Guidelines for

correction of refractive
errors
🙢
By
Ambica and Ritika
B.optom 2nd year
BV(DU)MC, SCHOOL OF OPTOMETRY, PUNE
• Guildlines: Hypermetropia
• Guidelines:Myopia
• Guidelines: Astigmatism
 Guidelines: Hyermetropia
🙢
🙣 INFLUENCE OF AGE:
🙣 The hyperopic state is normal in the newborn and in young children and to
handle this simple refractive error, their accommodation is ordinarily more than
adequate which continues for years
🙣 So, When is it necessary to prescribe glasses for the hyperopia?
🙣 Answer will depend in the age of the patient, in which we will examine several
groups separately like below
 Below Age 6 years
🙢
🙣 A hyperopic youngster will come to your attention when
(a) A routine preschool evaluation or visual screening has picked up some
decrease in visual acuity
(b) A nursery school teacher, parent, grandparent, or friend has noted a strabismus
(c) A strong family history of strabismus begins to concern the parents
(d) Nystagmus, head tilt, or other evidence of visual deficiency alerts the parents
to seek help
🙣 Headache, a major symptom of uncorrected hyperopia in adults, is almost never
a problem in this preschool age group.
1. The high Hyperope(approximately +5.00D or more) with refractive amblyopia(reduced acuity for his or her
age)
-Early correction is likely to accelerate development of maximal
vision.
-Occlusion of the better eye with spectacle correction in case of one
eye more amblyopic than the other.
-Hyperopia accompanied by an astigmatic error- spectacle correction
more important
-High hyperope who has normal uncorrected acuity does not require
glasses but should be reevaluated at regular interval of times.
(Should be considered in case of symptomatic)
2. The Esotrope
-Using Atropic cycloplegia elicit the total hyperopia, then give the
full hyperopic correction
-The full correction, by eliminating all accommodative effort and
thereby reducing the excess accommodative convergence, will
produce a maximum effect on the muscle imbalance.(Although
other cycloplegic drops are also used often, atropine is superior in allowing the full hyperopic refractive error to
be uncovered)
3. The hyperope who has bilateral subnormal vision due to pathology of the cornea, lens, optic nerve, or
retina. This child will usually exhibit clinical manifestations, such as a searching nystagmus or variable,
eccentric fixation
- Full cycloplegic correction can serve a hyperope as a partial “low vision aid”.
-Greater magnification is achieved by bringing the objects closer(in case of more
magnification additional plus lenses are prescribed)
4.The hyperopic anisometrope(one eye more hyperopic than the other)
-Correction will be based on the visual acuity findings(in case of absence of
strabismus and the child is old enough to allow a reasonable estimate of VA)
For example:
A 4 year old girl is brought in for a routine eye examination with the following
findings:
WITHOUT CORRECTION WITH CORRECTION
OD 20/30+ +2.50 20/30+
OS 20/70- +4.75 20/40+
What do you think, will you prescribe the glasses in above condition?
5. The child with external ocular infections
-No evidence to support a relationship between refractive errors and such external
ocular conditions as blepharitis, styes, chalazia, or non infectious conjunctivitis.
 Age 6 to 20 years
🙢
- Hyperopia generally decreases in pre-pubertal years.
- Don’t get mislead that teens will pose fewer problems for the hyperope.
- > importance of near work & demands of accommodation, asthenopic symptoms may appear & thus
refractive correction may be required.
- Important to unmask all the hyperopia at this stage.
- High hyperopia, eso-deviations & excessive accommodative effort are intertwined in youngsters.
- Few persons with high degrees of hyperopia will have escaped detection and treatment by the age of 10-20
years.
- Visual stress and decreased visual acuity are likely in such patients, who must rely on optical correction.
- The wide spectrum of philosophies concerning appropriate treatment ranges from providing minimal plus
lenses that may alleviate symptoms to prescribing full plus correction to relax accommodation.
- Clinicians may base prescription decisions on the power required to provide optimal visual acuity and
normal accommodative and binocular function.
- Patients often become quite dependent upon this above correction.
Esophorias of 6▲or more are usually significant in older children, and lesser deviations may be significant when
divergence reserves are small.
Prescription for a hyperopic refractive error, or of additional plus power for near, is usually a straightforward
treatment for esodeviations.
Vision training may be indicated for some patients.
The amount of plus for comfortable vision can usually be predicted by the AC/A ratio and refined in the office using
the trial frame.
Little 7-year old Mavis B. was examined by 2 doctors several months ago, & both agreed she needs glasses. These
were prescribed as:
OD +5.00 DS/+1.00DC * 180 20/25 –
OS +5.00 DS/+1.00DC * 10 20/20 –
Doctor A: Little mavis was cross-eyed and despite the glasses, needs the strabismus surgery promptly.
Doctor B: Eso-deviation was accommodative & that the existing glasses were adequate.
Manifest refraction same as PGP. Muscle balance measurement:
With Glasses (at 6 m & 38 cm): ‘15▲ esophoria’ & ‘25▲ esotropia OD’ respectively.
With +2.50 D adds (at 6 m & 38 cm): None & 10▲ esophoria.
Cycloplegic refraction: no additional plus. Bifocals prescribed and top of the seg raised to a level just below the
pupillary centers.
Rebecca C., 11 years old, was brought in for eye exam after her school teacher reported to her parents that she was
losing her classroom enthusiasm. She also complained (minimally) that her eyes became tired during reading tasks.
Rebecca’s unaided distance visual acuities were 20/30 OD and 20/40 OS, & her accommodative amplitudes using
the prince rule were 7 D OD & 6 D OS.
Cover testing revealed low esotropia at distance and 7▲esophoria at near.
Cycloplegic refraction: OD +2.00DS/-0.50DC * 180 20/20
OS +3.25DS 20/20
Single vision spectacles with the full cycloplegic findings for use during indoor activities.
Sometimes even vague symptoms warrant attention & sometimes treatment.
 Age 20years
- In middle decades the hyperope is likely to become symptomatic,developing headache & asthenopia.
- Primary cause: Ciliary spasm & a progressive decrease in accommodative reserve.
- By the age of 30-35 years, most previously asymptomatic, uncorrected patients begin to experience blur at near
and visual discomfort under strenuous visual demand.
- Facultative hyperopia can no longer be sustained comfortably, due to decreasing accommodative amplitudes.
- A prescription for the distance manifest (noncycloplegic) refraction for the patient to wear as needed (i.e., part
time) often suffices.
With increasing age and visual demands at near, the patient may require additional correction.
Before prescribing a permanent pair of spectacles, the optometrist may lend the patient a pair of spectacles (i.e.,
over-the-counter reading glasses) to demonstrate the potential benefits of optically correcting latent hyperopia.
Sherry B., a 28 year old waitress who had worn glasses since age 14,began have their near problems. She tended to
fatigue easily & noted that print blurred after she/eye read for a few minutes.
Present Glasses: OD: - 0.50DS/+3.75DC *105 20/30
OS: +1.00DS/+0.50DC *10 20/20-
Manifest Refraction: OD: +1.75DS/+3.00DC *105 20/20
OS: +2.00 DS/+1.00DC *90 20/20+
With this hyperopic lens correction she had an accommodative amplitude of 4.75D OU.
Normally at this age amplitude is 9D ± 2D, so search for missing accommodation is on!
Cycloplegic Refraction: OD: +4.00DS/+3.00DC *105 20/20
OS: +4.25DS/+0.75DC *90 20/20+
Case of wayward accommodation solved.
A new problem arises! ‘A post cycloplegic blur that is well beyond average’.
A pair of 2.50D clip ons supplied to eliminate the blur.
2.50D clip ons: often used after cycloplegia, when a patient needs to resume the reading without a delay
 Patients of pre-presbyopic years(35-40
years)
- waning accommodation.
- 1.50 D hyperopes who previously get along without wearing the correction suddenly finds they cannot.
- Watch TV with glasses that were prescribed years ago for ‘reading’.
- AA decreases: latent hyperopia becomes manifest: Patients at this stage find their old, unused lenses
necessary.
- Do not prescribe bifocals prematurely without doing cycloplegia.
- It’s true that majority of patients who receive bifocal prematurely accepts it unflinchingly, secure that you as
an expert knows what you are doing.
- Don not jump to bifocals without evaluating hyperopia with a cycloplegic agent.
 Age 40 + years
With the onset of presbyopia, changing focus becomes progressively more difficult, especially in poor illumination.
Increased blur at near necessitates correction for near and often for distance as well.
Prescribing an optical correction for most or all of the distance manifest refraction, along with a near addition, can
greatly improve the patient’s vision and comfort.
Hyperopia equal to or greater than 1.00-1.50 D generally requires full-time distance correction, with a near addition
for patients over about age 45.
As facultative hyperopia becomes absolute, more plus power at distance is required.
Progressive multifocal lenses enable clear focusing at a range of finite distances.
A monovision, bifocal, or multifocal contact lens prescription is an option for some patients.
Glasses which become inadequate for near vision: Bifocals needed.
Patient can say no for bifocal but its upto you how you are going to convince the patient for it.
Potential for an unhappy person is great.
If patient requires distance correction, the alternatives are limited.
Must continue to provide that distance correction as the patient has already adapted to it.
If proceeded with separate pairs for distance and near, so it will be clumsy one & will result in displeasure.
Success of 1st time presbyopic correction:
- Selection of proper add design.
- If seg are prescribed, then appropriate size, height and style required.
Improvise if you successfully convinced the patient but when worn didn’t adapt well.
Patience, Knowledge & Foresight!
The Intermediate range:
Accommodative power diminishes(age wise) – latent hyperopia becomes manifest: Distance lens correction
changes frequently.
Helps alleviating any reading difficulties as well.
Increase in plus distance correction stimulates total power of the near correction.
Don’t get tempted to prescribe trifocal.
John G., age 47, wears 3-years old glasses & complains of ‘blurry vision’ at distance & near.
Present Glasses: OU: +1.00 20/40
Add OU +1.50 6-point type at 65 cm.
Manifest Refraction and Rx: OU: +2.00 20/20
Add OU +1.50 6-point type at 40 cm.
No intermediate help required.
But as he ages, will require the intermediate help, Consider for progressive or trifocal then!
 BASIC NOTE: GUIDELINES OF HYPEROPIA
🙢
🙣 The Spectacle correction: i) Overcorrection at infinity ii) Lens design.
🙣 Optical correction should be based on both static and cycloplegic retinoscopy,
accommodative and binocular assessment, AC/A ratio, and the correction should
be modified as needed to facilitate binocularity and compliance.140
🙣 Careful followup is essential, and frequent lens changes may be needed.
🙣 A significant increase in hyperopia is not unusual after the patient has worn
optical correction for even a short time, due to the manifestation of latent
hyperopia.
🙣 When compliance proves difficult, the clinician may encourage acceptance of the
prescribed treatment by using cycloplegic agents to blur uncorrected vision.125
🙣 Contact lenses may be a good alternative for patients who do not comply with
prescriptions for spectacle wear, especially those with anisometropia, high
hyperopia with or without nystagmus, and hyperopia with accommodative
esotropia.
 GUIDELINES: MYOPIA
🙢
🙣 There is nothing simpler in the field of refraction than the symptomatology of
myopia, which is, in its entirety, blurred distance vision.
🙣 Asthenopic symptoms are created not only by myopia but rather by associated
conditions –
🙣 Astigmatism
🙣 Muscle imbalance
🙣 Anisometropia –
🙣 Or by the way myopia is managed.
The Young Child:
- When to prescribe those first glasses for myopia is an important question????!!!!!
- Whether or not to inflict spectacles on to small children should be determined by the evidence that their blurred
distance is severe enough or not.
- Asymptomatic myopes do not usually need lens correction but some exceptions:
* A child: completely symptom free but has a visual acuity of 20/200 OU & - 2.00 D OU refractive error.
* Require glasses to improve classroom performance.
* Only symptoms does mean glasses are required.
Myopia is rare in preschool or early school-age children unless there is a history of premature birth,
neurodevelopmental delay, or a family history of degenerative myopia.
Myopia of more than 1.00-2.00 D in preschool children can be corrected with minus lenses, when the children's
interactions involve persons and objects at intermediate distances.
If the myopia is left uncorrected, the preschool myopic child should be examined at 6-month intervals.
Optical correction should be prescribed if the myopia reaches a higher degree, thus making distance viewing more
difficult, or if the child appears to have adverse behavioral effects caused by not being able to see clearly at far or
intermediate distances.
Demands on both distance and near vision increase as children enter and progress through school. Vision screening
programs often use distance visual acuity of 20/40, or 1.00 D of myopia, as the criterion for referral during children's
first few grades in school.
It may be prudent for clinicians to use one or both of these criteria as a guide in correcting myopia in children.
Adolescent & Adult cases: Most clinicians will proceed to correct any significant degree of myopia to improve
distance visual acuity in the adolescent or adult patient.
- Persons who are more precise and discriminating than others are more likely to have visual complaints pertaining to
very low refractive errors thus they are likely to benefit from the optical correction of a very small degree of myopia.
- In cases of high exophoria or intermittent exotropia, a prescription for fulltime wear of the full refractive correction
for myopia is warranted.
- In cases of esophoria at near or accommodative insufficiency, a plus lens addition for near may be appropriate.
- An option for the patient with very low ametropia is to try to improve the visual environment before prescribing
lenses.
* For example, an option to present to the parents of a grade school child with 0.50 D of myopia who complains of
difficulty seeing the chalkboard from the back of the classroom is to ask the teacher to move the child toward the
front of the room.
Muscle Imbalance: Prescribing glasses for a myope with a low refractive error are justified if the lens are to play the
role in the management of a muscle imbalance.
- Patient has a tropia or no fusion capability: Cosmetic defect can be reduced (minus lens prescription).
- Patient has a phoria: Glasses can make significant impact.
- The higher the ratio, more the influence.(degree of influence dependent on patient’s AC/A ratio).
The following case will illustrate how a failure to take AC/A ratio into account can create problems for the
refractionist & for the patient:
MW. Jr was brought into our office by physician-father with a chief complaint not unusual for a 12 yr-old: he had
lost his glasses. The fathers complaint was also not unusual: those glasses were only six months old. Actually, juniors
had been wearing glasses ‘for nearsightedness’ for about 1.5 years & had been completely comfortable with them. He
had no symptoms without them either, apart from a moderate blurring of a distance vision. Juniors mother felt that
his eyes crossed with glasses on but his father was certain that they did not. The difference of opinion caused us to
take careful look at juniors phoria and vergence measurement along with his refraction.
Uncorrected vision: OU 20/70
Screen-Cover Testing (without glasses): At 6 meters: Orthophoria & At 33 cm: 3▲esophoria.
Manifest refraction: OD: -1.75DS/+0.25DC * 15 20/15
OS: -1.75DS/+0.25DC * 165 10/15
Vergence (with manifest correction): At 6 m: Conv. 8▲BO blur & 3▲BO recover, Div: 4▲BI blur & 1▲BI
recover.
At 33 cm: Conv: 26▲BO blur & 16▲BO recover, Div: 20▲BI blur & 10▲BI
recover.
STEREOPSIS: Fused the Polaroid fly & all 9Wirt circles.
Cycloplegic refraction: OD: -1.50DS/+0.25DC*30 20/15
OS: -1.50DS/+0.25DC*165 20/15
First confidently prescribed manifest Rx to replace the lost glasses but within 2 months junior was back with the
complaint: New glass: Watery eyes, headache while reading and had not experienced this symptom in his previous
pair.
So, We repeated phoria measurement, this time with or without glasses:
Screen Cover With Glasses Without Glasses
At 6 meters Ortho Ortho
At 33 cm 15▲E 4▲E
Junior was given a new pair of bifocals this time without a delay:
Rx: OD: -1.75DS/+0.25DC * 15
OS: -1.75DS/+0.25DC * 165
Add: +1.50 OU. Symptoms promptly disappeared.
Quasi-Myopic progression: Blurring of vision always doesn’t mean that the myopia is progressing.
- Instead Vertex distance problem could be there.
- When writing a lens prescription for any high refractive error: essential to note the Vertex distance at which the
refraction is performed.
- Steve. F., age 12 had been under semi-annual observation because of rapidly increasing myopia. When he broke
his eye glass frames(again), we refracted him and wrote a lens Rx:
OD: -7.00DS/+1.50DC*130 20/20+
OS: -8.00DS/+2.00DC*60 20/20+
Vertex distance: 15mm OU
Four months later school referred him back to us as his vision was found out to be 20/30 OD & 20/40 OS.
We thought myopia would have progressed, so refracted again but found no refractive change.
Second step: Checking Vertex distance of the glasses, found out 22 mm instead of earlier 15 mm.
This increase created undercorrection.
Lens correction increased by - 0.25 D OD & - 0.50 D OS & thus acuities in ‘BE’ returned to 20/20.
Pathological myopia: Management of pathological myopia – close to nothing is there which could influence or slow
the increase in refractive error or impede the progression of the degeneration.
- Low vision services can be provided when best corrected visual acuity levels are significantly reduced.
- Can help low vision myope by undercorrecting.
- Undercorrection allows reading material to be held closer: increases angular magnification.
- Young patient (excellent AA): their accommodation markedly supplement the ‘add’ given by the undercorrection.
- Myopes learn quickly that they can see better at near by simply taking off their glasses.
- An ultimate undercorrection: takes full advantage of high plus power created by myopia itself & of available
accommodation to gain significant magnification.
Unilateral myopia: Gary B., is a 7 yr-old asymptomatic child who has an uncorrected refractive error:
OD Plano 20/15
OS -0.75 20/15
What you will do he is asymptomatic? Obviously you will sit tight.
But what if the patient returns a year later with being same asymptomatic but with a change in its manifest
refraction: OD: Plano 20/15
OS: -1.75 20/15
What would you have done if he were a bilaterally myopic anisometrope? Obviously prescribed glasses.
But he is unilateral myope, then it is completely different challenge.
Its upto you at what point you will prescribe glasses. But for now, No symptoms, No glasses!
Will he develop refractive amblyopia by with-holding the glasses? The answer is no.
In cases where, Fusion is adequate: Observe the patient but don’t give any correction.
In cases where, Fusion is inadequate or asthenopic symptoms: Correction is clearly indicated.
Patients with antimetropia: Decision of correction depends on:
a) the symptoms, b) the fusion capability without lens correction, c) best visual acuity attainable by the hyperopic
eye.
In every instance of prescribing glasses for anisometropia, the amount of aniseikonia induced by corrective lenses
must be measured.
Compensation for it is unnecessary in children but necessary in adults.
Pseudomyopia & Cycloplegia: Making our continuing pitch for cycloplegia, here we are again – yes, even in myopia.
- Cases of Pseudomyopia won’t be uncovered if it were not of cycloplegia.
- The goal of treatment for pseudomyopia is to relax the patient’s accommodation.
- The full minus lens power from the manifest refraction should not be prescribed for long-term use. Although this
minus power may improve the patient's distance visual acuity, it will not aid in reducing accommodative response.
- Treatment to reduce accommodative dysfunction may include one or a combination of the following:
• Vision therapy
• Instillation of a cycloplegic agent to eliminate accommodative spasm
• Nearpoint plus lens addition
• Instruction in visual hygiene.
Night myopia: When nocturnal myopia is diagnosed, the prescription for minus lenses for use only at night or in
darkened conditions can be based on an arbitrary increase in minus power or possibly the results of the dark room
retinoscopy procedure.
- For patients who require spectacle correction of myopia under normal illumination, the prescription for a second
pair of glasses for nighttime seeing can incorporate the additional minus power.
- Optical correction: to determine its amount, i.e. the position of far point.
- Correction of night myopia cannot be based on conventional refraction techniques performed at low luminances.
- Asymptomatic night myopia: No correction
- Symptomatic night myopia: Correction required & determined by dark retinoscopy.
- Not necessary to use standard clip-ons - 1.25D for everyone.
Pre-presbyopia & Presbyopia: Myopes do not usually requires bifocals until a later age than their hyperopic peers.
- Factors for myope’s delayed need for a presbyopic correction:
* Mild myopes can compensate for the accommodation demanded by the close work merely by removing their
glasses.
* Myopes can slide their glasses down their noses to read.- an optical trick: reduces accommodation required.
* The spectacle wearing myope, even when not undercorrected, needs to use less accommodation for any given
task than the corrected hyperope.
* For the patient whose myopia is actually increasing at late 30s, prescribing more minus for distance is not
useful. Allow slight distance blur until assistance of reading add comes into play.
* At this time full distance Rx may be given along with the bifocal add.
When to consider prescribing What to prescribe

a. < -5.00 D, during the first year a. Reduce by 2.00 D. Undercorrect because
emmetropization does occur for myopes.
b. < -2.00 D myopia from one year or when b. Reduce by 0.50 D or 1.00 D until school
child is walking age. Undercorrect because some
emmetropizationis still occurring.
c. 4 years to early school years c. < -1.00 D or lower amoungsif it improves
VA and thechild appreciates it. Can give full
correction at this age.
d. School age myopia d. Prescribe full correction.

Ref: Leat, S. To prescribe or not to prescribe? Guidelines for spectacle prescribing for infants and
children. ClinExpOptom2011;94: 6: 514-527.
 GUIDELINES: ASTIGMATISM
🙢
🙣 The subject of astigmatism tends to make even the most level-headed refractionists a bit paranoid.
🙣 Most patients presented with choice: Sharp vision or Comfort one: Usually will choose comfortable
lens prescription.
🙣 Any doubt?? – acceptance : first time correction or a large change in correction: do trial framing of
the prescription.
🙣 Time or Circumstance not on your side: Prescribe sharp vision first.
🙣 Modification of your prescription – When adaptation difficulty to the full astigmatic correction.
Indications for lens correction: ….. To correct astigmatism: degree of visual impairment or asthenopia.
A substantial amount of astigmatism????? –
Your decision(based on the corrected visual acuity).
Brought upto 20/20 with lens correction – Justifiable to temporize.
Best corrected vision no better than 20/40 – prescribe the correction to sharpen the retinal image.
Joseph P., age 8years, is the little brother of our secretary. He handed the referral from his school which indicated:
‘Vision: below normal’.
Findings: 20/100 OU, Yet the patient says he is not having any symptoms or problem seeing chalkboard.
Manifest refraction: OD: -3.50DS/+3.50DC * 105 20/60
OS: -3.00DS/+3.00DC * 75 20/70
Keratometery: 4.75D of corneal astigmatism OU.
Cycloplegic refraction: OD: -1.25DS/+4.50DC * 120 20/40
OS: -1.00DS/+4.50DC * 60 20/50
Cycloplegic refraction finding was prescribed & 4 months later V/A with these glasses improved to 20/25 OU.
So, what does the Joe’s case demonstrate????
No hard & fast rule can be made.
Each problem must be resolved according to patient’s symptoms & needs & your assessment of your overall
situation.
Refracting the astigmat at near: Cylinder power is substantial – measure the axis and power of the cylindrical error.
Recently examined Margaret. J., a 30- year old woman whose chief complaint was ‘migraine’ headaches since
childhood. She also worn worn glasses since childhood and was now wearing a 2- year old prescription.
Present Glasses: OD: +1.75DS/+4.00DC * 90 20/50
OS: -1.25DS/+3.75DC * 125 20/40
Manifest Refraction: OD: +2.50DS/+4.00DC * 90 20/40
OS: -1.75DS/+3.75DC * 120 20/25
Cylinder was high, so performed a refraction at near!
Manifest at 40 cm: OD: +2.00DS/+5.00DC * 90
OS: -2.00DS/+4.50DC * 115
When the patient worn distance correction at near, she could read type no smaller than 6 point.
With proper near correction, she could read 4-point type with ease.
Before giving different prescription for distance and near, give patient the opportunity for a prolonged reading
trial.
Cutting the cylinder power & Rotating the axis: Used to alleviate the distortion & the symptoms created by high
cylindrical correction: reducing the cylinder power, maintain the axis & alter the sphere so that the spherical
equivalent remains unchanged.
For example: OU +1.00DS/+4.00DC * 70, you might opt for an Rx OU +2.00DS/+2.00DC * 70, maintained +3.00
D same SE.
Do not go for cylindrical manipulation until after the patient shown an inability to adapt to full cylindrical
correction.
Initially full cylindrical should be prescribed & the above method should be reserved for those who failed to adapt.
Accuracy of axis: You are doing routine inspection & you got with the axis different from that which you
prescribed…
what will we should do then?
Changes in cylinder power and axis:
1) Change with age 2) Changes in children 3) Post-Surgical changes
Ciliary spasm: It may be the presenting problem in some individual with uncorrected astigmatism.
Clinical experience has shown that initial manifest refraction will not be able to uncover all the astigmatic error.
Cycloplegia needed!
When Diane Q., was first examined at the age 17, she had headaches & pain in the eyes two or three days a week.
She was wearing a two year old glasses, prescribed without the benefit of cycloplegia.
Present Glasses: OD: -4.25DS/+4.00DC * 125 20/25+
OS: -2.75DS/+4.25DC * 55 20/30
Manifest refraction was same as above but Cycloplegia not.
Cycloplegic refraction: OD: -2.50DS/+3.50DC * 120 20/20
OS: -1.00DS/+3.50DC * 60 20/25
 At post-cycloplegic refraction, promptly reverted back to her old glass prescription, Nevertheless, it was found we
could push +1.00 D more upon each eye.
Rx: OD: -3.25DS/+3.50DC * 122
OS: -2.00DS/+4.00DC * 60
Diane was completely symptom free, & her vision with glasses was an acceptable one OD: 20/20, OS:
20/30. 2 yrs later successfully initiated into contact lens mystique.
Influence of medical problems: Diabetes frequently present a peculiar refractive problem.
Diabetic lens changes ocassionally produce substantial astigmatic errors.
Don’t neglect the possibility of metabolic basis for change in vision
James R., age 58 arrived at the office complaining of blurred vision at both distance and near for the preceding year.
Careful history revealed that he had been taking gold injections for arthritis and that he was currently on diuretic and
sedative medications. His complaint was confirmed when his vision was tested with his one-year old glasses.
Present Glasses: OD: -1.50DS/+1.75DC * 180 20/60
OS: -1.50DS/+1.75DC * 10 20/60
Add OU +2.50 10-point type at 37 cm.
Morphologic examination of eye was uneventful
Manifest refraction: OD: -1.50DS/+4.25DC * 172 20/20
OS: -0.75DS/+4.75DC * 9 20/20
Add OU +2.25 6-point type at 35 cm
But missed the fact that the astigmatism was lenticular.
Keratometery: OD: 42.50 @ 180/42.25 @ 90 & OS: 42.75 @ 6/42.00 @ 96
Prescribed the manifest refraction findings but ignored the fact which costed.
One month later Mr. R was back, stating that he could see nothing with his new glasses. Checked and found that the
vision has been dropped to 20/70 OU. Repeated the refraction & now the correction has been reverted almost back
to same as the year old glasses.
Manifest refraction: OD: -1.50DS/+1.75DC * 180 20/20
OS: -1.50DS/+1.75DC * 10 20/20
Add OU +2.25 6-point type at 37 cm.
History was taken again: 1) Mr. R., has reduced his ethanol intake from 20 bottles per day to 5 bottles.
2) Enlarged liver(no big surprise)
3) Under observation for suspected diabetes.(a big surprise)
Asked for diabetes test and it was confirmed the patient was having it.
Manifest refraction: OD: -1.50DS/+1.50DC * 180 20/15
OS: -1.25DS/+1.50DC * 5 20/15
Add OU +2.00
Refraction has been stable for a year.
Children <5 YO
–Priority placed on avoiding amblyopia
Children age 5-10
–Full correction
–Children can adapt to cylinder a lot easier than adults
Older children –10 YO –> teenage
–Full correction, but be wary of spatial distortions and issues with adaptation
Adults
–Must consider spatial distortions and adaptation
–May need to give reduced amount of cylindrical correction
–Trial frame!
Reduce the amount of cylinder, keeping the spherical equivalent
Increase the amount of cylinder over time
Move the axes toward 180 or 90, if possible
Keep habitual axis and modify the power
When to consider prescribing
• > 2.50 at 15 months of age upwards
• ≥2.00 D at 2 years of age upwards
• ≥ 1.50 D at 4 years upwards
• Correct oblique astigmatism ≥1.00 D from
1 year onwards
• ≥0.75D at school age without symptoms
What to prescribe
• Give partial correction up to 3 to 4 years
by which time emmetropization is largely
completed.
• Give partial cylinder up to 3 to 4 years,
after which give full cylinder
• Give full cylinder. although in cases of
previously uncorrected high astigmatism, a
reduced prescription may be given
initially, to allow the child to adapt.
• Clinical instinct of the author would be to
correct approximately ¾ to the age of 2,
then full.
• Give full cylinder and d0 as same as said
in 4 yrs.
REFERENCES:
-The fine art of prescribing glasses- By Benjamin Milder, MD and Melvin L. Rubin,
MD, MS
-Journal of clinical and biomedical sciences
-AOA
-Guildlines for spectacles prescribing for infants and children, ClinExoptom2011;94: 6:
514-527