CHALLENGES IN

PEDIATRIC REFRACTION

Sarbind Kumar Yadav

M.Optom, CLEP (J &J Vison care, India)
Senior Consultant Optometrist
Ramlal Golchha Eye Hospital Foundation, Biratnagar
Introduction
 what is required in pediatric refraction??

• This technique must be appropriate for non-verbals, un-

cooperatives, non-communicatives in child’s parts.
• This technique must provide important information in
refractive state of eye repeatably and reliably in instrumental
part.
• Must be understandable, easily assessable and accessible.
• Practitioner must be competent enough to deliver a perfect
judgement.
 How is it different from normal refraction???

• Objective refraction is usually used to determine refractive

status of infants and preverbal children.
• Meticulously and accurately done
• Great expertise is necessary
• Should understand emmetropization and relation between
state of BSV and refractive status of child
• Techniques must me easily understandable
• Cycloplegic refraction is preferable due to active
accommodation in child
 Pediatric vision development
Age Visual characteristics Stereoacuity
Birth – 4 months Conscious fixation on near Not present
object
Development of sensory
and motor fusion
5 – 8 months Good colour vision Begins at 5 months
Fovea well developed
Some sensory & motor
fusion
9 -12 months Able to grasp objects Can judge distances fairly
Sensory and motor well and throw things with
fusions well developed precision
1 – 2 years Highly interested in Well developed
exploring their
environment looking and
listening
 Emmetropization
“ The total emmetropization process occurs mostly during the first 4 -5 years of life
with both initial myopia and hyperopia converging on low hyperopia and by 6
years, 80% of children are found to be emmetropic”
Thorn B, Bauer J et al, 1996

“ At birth, the average amount of astigmatism is predicted to be 2.98D, decreasing to

0.50D by 2.5 – 5 years of age”
Mohindra I ,Held R, 1991

Active process Passive process

Regulated by retinal image Physical and genetic
Visual deprivation causes the determinants of normal eye
eye to elongate growth
“development of high
ametropia, usually because of
genetic inheritance”
Sorby et al 1998
 TYPES OF PEDIATRIC REFRACTION
Objective Refraction

Dyanamic
Static Retinoscopy
Retinoscopy

Manifest Cycloplegic

MEM Bell BOOK Chromoretinoscopy

Subjective Refraction with/without cycloplegic

CHOICE OF REFRACTION FOR DIFFERENT AGE GROUPS

Mohindra retinoscopy
infii
Infants Retinoscopy with/without cycloplegic
Photorefraction

Keratometry
Retinoscopy with/without cycloplegic
Preschool
MEM retinoscopy
Subjective refraction
Book retinoscopy

Keratometry
Manifest / cycloplegic retinoscopy
School Aged
Dyanamic retinoscopy
Subjective refraction
Indication of Cycloplegic Refraction
Uncooperated patients (8 years or
younger)

With strabismus

Indications
Latent hyperopia

Pseudomyopia

Inconsistent end point of

refraction
 Additional Indication

• Every nonverbal and non communicative children

• Patient with high heterophoria
• Accommodative esotropia ( atropine is the best
choice)
• Accommodative asthenopia
• Poor reliability between dry retinoscopy objective
finding with subjective finding
 `

History
Visual Acuity
Medical Hyperemia in
Allergic conjunctiva
(near /distance)
Emotional

MEASUREMENTS TO BE Accommodation and

Pupillary reflex and Binocular
DONE BEFORE INSTILLING
Size under room Status
CYCLOPLEGICS
illumination

Manifest AC angle and AC/A

refraction IOP Ratio
 Guidelines for Cycloplegic agents

• Atropine cycloplegic refraction is advised in the

younger than 5 years
• Atropine is advised in esotropic children
(accommodative type) up to 4 years
• After 5 years, cyclopentolate is advised up to 25 – 30
years.
• Above 30 years of age, amplitude and lag of
accommodation is checked and cycloplegic refraction
is advised
 WHY CYCLOPLEGIC REFRACTION??
• To stop eye’s ability to auto focus or accommodate in order to
determine true prescription.
• When the eye contracts and relaxes, the lens shape changes
its shape.
• Cycloplegics paralyses ciliary muscle and the lens can no
longer change its shape and hence there is no chance of
accommodation.
• In children they have the great ability to vary their
accommodation.
Contraindications

 Narrow angle glaucoma

 Hyper sensitivity to specific
cycloplegic drugs

 Blurred Vision
 Photophobia
 Systematic side effect except
tropicamide

Adverse Effects
 Caution
Cyclopentolate may produce
oedma, follicular conjunctivitis &
dermitis in some patients

Cyclopentolate may produce

exaggerated seizure in children’s with
epilepsy

Overdose of cycloplegic agent has to be avoided in children with Down’s

syndrome or other affected cerebral plasy, trisomy 13 & 18, and other
central nervous system (CNS) disoders because it produces hallucinogenic
effect
 Subjective Refraction

cooperated patients (8 yrs &

older)

Indications Without strabismus

Consistent BCVA
 5 W’s of Refraction
 Who
 What
 Where
 When
 Why
Difficulty in retinoscopy
Possible causes Solutions
Opaque / hezy ocular media In most cases, it is overcome by use of
mydriatics*
Small pupil size Use of mydriatics*
High degree of refractive errors Follow up case: check PGP to get a rough
estimation
First examination: if reflex is dull, try -7
first and then +7. if reflex is still dull
proceed to 15D or 20D , untill the reflex is
visible and proceed from there

*Perform all the indicated investigation and rule out contraindication before dilating
Possible causes Solutions
Wandering fixation Give a specific fixation target
Abnormally active accommodation Fogging technique
Cycloplegic refraction may be
required
Possible causes Solutions
High astigmatism Rotate the retinoscopic beam to find
angle where scissor reflex is minimum
Nebular corneal opacity Increase retinoscopic illumination to
decrease pupil diameter.
Spot retinoscopy may be helpfull
Possible causes Solutions
Irregular astigmatism Do keratometry and prescribe
minimum power that gives maximum
visual acuity. Subjective refraction
may also be done in school going
children.
Keratoconus Relate refraction to visual acuity
Perform corneal topography
Perform keratometry
Possible causes Solutions
Positive aberration (in normal Increase retinoscope illumination to
accommodating lens) decrease pupil diameter
Concentrate on the centrral bright glow
and ignore the peripheral glow
Negative aberration (more in lenticular Increase retinoscopic illumination
nuclear sclerosis Perform cycloplegic refraction
What is the greatest challenges to pediatric refraction

• A great ability of a child to maintain wide range of

accommodation
• Un-cooperation
• Greater range of accommodation
• Difficulty in quantifying visual status
• Risk of visual deprivation
• Difficulty in making a child understand to wear glass.

so, cycloplegic refraction must be carried out in every patient with or without strabismus
 Additional challenges of pediatric refraction

• Nystagmus
• Strabismus
• Aphakia
• Small pupil
• Cataract
• Corneal opacity
• Faint retinoscopic reflex
• In case of nystagmus, retinoscopy should
performed in the null zone if such is present
• In case of strabismus, the child is asked to alter
gaze to another fixation (or close to eye) so that
the tested eye is better positioned
• And should perform retinoscopy slightly off axis
• In case of aphakia, the retinoscopy should
performed after dilatation
 Redical retinoscopy
• This technique is applied in case of small pupils,
cataract, media opacity and faint retinoscopic reflex
• Instead of performing at usual working distance, the
examiner move closer to the patient. So, that
observable reflex can be obtained
• May involve working distance as close as 20 cm or 10
cm
• Finally, the dioptric poer of the WD is deducted from
the retinoscopic value
• Example – the retinoscopy value = +3.00DS/
-1.50X 90
Working distance = 20cm i.e. +5.00D
Net retinoscopy value = - 2.00DS/ -1.50X90
 GUIDELINES FOR PRESCRIPTION IN HYPEROPIA

Infants (0 -1 yrs)
Isometropic Hyperopia

Deviation + ce
(eso) Deviation –ce

Full cycloplegic correction Prescribe only when error is

given when error is (>or = 2D) (>= 5D ) i.e. partial or or 3/3 rd
and regular F/U for error prescription is advised
bellow this
 Cont….
Infants (0 – 1 yrs) Hyperopic anisometropia

<2.50D > Or = 2.50D

Partial Full prescription

No prescription needed prescription (no (esodeviation + ce)
( follow up 3 - 6 deviation)
monthly
 Cont…..
Toddlers (1 – 3 yrs)

Isometropic Hyperopia

Deviation +ce Deviation -ce

(eso)

Full cycloplegic correction given Prescribe only when error is (> or

when reeor is (> or = 2D) and = 3.5 D i.e. 3/3rd prescription is
regular F/U for error below this advised
 Cont….
• Toddlers (1 – 3 yrs)
Hyperopic anisometropia

< 2.00 D > Or = 2.00 D

No prescription is required Partial prescription Full prescription ( eso

( F/U 3-6 monthly) ( no deviation) deviation +ce)

Note: if exodeviation is associated plus correction must be reduced

 Cont…
• Preschool (3 – 6 yrs)
Isometropic hyperopia

Deviation +ce
(eso) Deviation -ce

Full cycloplegic correction given Prescribe only when error is ( > or = 2.50
when error is D) i.e. partial or 2/3rd prescription is
(> or = 1.5 D) and regular F/U for advised
error below this
 Cont…
• Preschol (3 – 6 yrs)
Hyperopia ( Anisometropic)

< 1.50 D > Or = 1.50 D

Full prescription
No prescription Partial (esodeviation
required ( F/U 3-6 prescription (no +ce)
monthly) deviation)

Note: if exodeviation is associated plus correction must be reduced

 School age ( above 6 years)
• Cycloplegic refraction is always recommended when hyperopia is present
in initial retinoscopy.
• Science good vision is necessary for both near and distance, proper
correction is needed for better academic performance.
• At school age children are expected to be nearly emmetropic.
• Isometropic error (> or = 1.00 D) without symptoms is indicated for
correction.
• A full or near full correction may be given at this age, as emmetropization
ended.
• Hyperopic anisometropia (> or = 1.00 D) needs full correction
 Guidelines for prescription in myopia

Infants (1 – 3yrs )
 Infants with low to moderate myopia may not need prescription.
 Because they don’t need to view things in fine details.
 But AAO gives prescription guidelines in such condition as:-

Not required to prescribe

< - 5.00 D
( constant monitoring)

Isometropic Myopia

> Or =
Required prescription
-5.00 D
( reduced by 1-2 D)

 AAO suggests prescription of glasses when myopic anisometropia is (> or = 2.50 D) in infants to
reduce chances of amblyopia.
High amount of myopia at birth is likely to produce esotropia becoz far point is very close to eye.
 Toddlers ( 1 – 3 yrs)

 No prescription is given for low myopia in toddlers but given for moderate and high myopia.
 Prescription guidelines as per AAO

No need to precribe
< - 4.00 D ( constant monitoring)

Isometropic myopia
Needs prescription ( reduced by 1- 2
> Or =-4.00
D)
D
( Fr no deviation)

Example : highly myopic children appear to do well without correction and cannot always
tolerate their full prescription. A 1.5 year myope requiring -10.00 D may cope better with
-7.00 D for a few months before, gradually increasing the prescription.
 For muscle imbalances
For eso deviation : minimum minus for clear vision
For exo deviation : maximum minus for clear vision

AAO suggests anisometropic Mypia of > = 2.50 D needs prescription in

toddlers to prevent probable chance of amblyopia & deviation
 Preschool age (3 - 6 yrs)

No need to prescribe
< - 3.00 D
(costant Monitoring)

Isometropic
Myopia

> Or = -3.00D Needs prescription

(reduced by 1-2 D)
For no deviation
 for muscle imbalances
For eso deviation : minimum minus for clear vision
For exo deviatio : maximum minus for clear vision

AAO suggests anisometropic myopia > or = 2.00D needs prescription in

preschool to prevent probable chance of amblyopia an deviation.
Similarly if amblyopia is associated with myopia but no strabismus 2/3rd of
cycloplegic correction can be given for children’s below 6 yrs.
 School age (above 6 years)
• Full prescription must be given to abolish amblyopia, deviation & avoid
symptoms like squinting eyes.
• Over correction must be avoid becoz overcorrecting myopia can be
determined and may cause accommodative spasm leading to severe
asthenopia and esotropia.
• Slight under correction is done in esophoric children of more than 6 yrs.
• In high myopia (> or = 10.00) full correction can be can not be tolerated so
under correction is recommended.
for muscle imbalances
For eso deviation: minimum minus for clear vision
For exo deviation: maximum minus for clear vision

Similarly in anisometropic myopia (> or = -3.00D ) must be prescribed

to prevent amblyopia.
 Guidelines for prescription in Astigmatism
Infants (0 – 1 yrs) Not required prescription
< 3.0D
(constant monitoring)
Isometropic
Astigmatism

> or=3D Required prescription i.e. 3/4th

can be given (prefer to monitor
in F/U)

<2.50 Not required to prescribe

D (constant monitoring)
Anisometropic
Astigmatism > Required prescription
Or=2.5 Prescribe only after monitorung
D and without hampering
emmetropization
 Toddlers (1 – 3 yrs)
Not required prescription
<
(constant monitoring)
2.50D
Isometropic
Astigmatism Required prescription
> or = 2.5 D i.e. 3/4th can be prescribe

< Not required prescription

2.00D (constant monitoring)
Anisometropic
Astigmatism
>Or =
Required prescription
2.00D
Prescribe full if amblyopia is present
 Preschool (3 – 6 yrs)
< Not required to prescribe
1.50D (constant monitoring)

Isometropic
Needs full prescription (reduced
Astigmatism
prescription can be given first to
> Or = 1.5 D
adapt)

Not required prescription (constant

< 1.50D monitoring and F/U)
Anisometropic
Astigmatism
>or= Needs full prescription if amblyopia
1.5D is present & if no amblyopia, partial
can be given shifting later to full Rx
 School going children
Not required to prescribe
<
(constant monitoring)
0.75D
Isometropic
Astigmatism >or= Needs full prescription
0.75D (prescribe if symptomatic)

Not required to prescribe

<1.50 (consatant monitoring & F/U)
Anisometropi D (Prescribe if symptomatic)
c Needs full prescription if amblyopia
Astigmatism >or= & if
1.50D No amblyopia prescribe partially
later shift to full Rx
 Guidelines for prescribing aphakic children

 In first few months overcorrected by (2D to 3D), becoz the

child’s worlds in near.
 Later at about 1 yrs of life overcorrection is reduced to (1D to
1.5D) to single vision intermediate add.
 After 1 yrs of age (preschool age) bifocal prescription can be
considered.
 Laurence gave a formula to predict spectacle power in aphakic
children’s
F apakic = +11.00D+1/2(F preoperative)

Example: A child is B/L hyperopic by 3.00D before surgery and power

must be given to him after surgery is +12.5D
 Conditions for prescribing bifocals in pediatrics

• Accommodative Esotropia
• Constant Esotropia or IET
• Congenital Aphakia
• Down’s Syndrome
• Esophoria
• Pseudophakic child
 Commonly Encountered conditions in pediatric
clinic with type of refractive errors seen in those
• Albinism – astigmatism in all subtypes (myopic or
hyperopic)
• ROP – high myopia
• Down’s Syndrome – hyperopia with or without
WTR astigmatism
• Nanophthalmos – high hyperopia upto +20D
• Sclerocornea & cornea plana – high hyperopia
• Congenital defects like Marfan’s syndrome,
homocystinuria – myopic error (most commonly).
References
 Primary care optometry, Theodorer P. Grosvenor, 3 th edition
 Borish’s clinical refraction, William J.Benjamin, 2 nd edition
 Optometric Clinical Guidelines for pediatric eye and vision examination; American optometric Association
 Clinical pediatric optometry, Leonard J. Press, Bruce D. Moore, 2 nd edition
 Principles and practice of pediatric optometry, Alfred A. Rosenbloom, Meredith W. Morgan
 Essential of pediatric optometry, Goutam Dutta
 Comprehensive pediatric eye and vision examination, American optometric Association
 Pediatric optometry, David Taylor
 A Textbooks for optics and refractive Anomalies, AK Jain
Thank You