Pediatrics, Presbyopia Denial, Blur simulator

Common Children's Eye Care Question

i get the following question asked to me several times a month either in person, on a message board, email, FACEBOOK, etc etc. the answer is a lengthy one so when i had it asked to me most recently...well i figured it might be nice to post it here. 1st is the (long) question, then my answer:

"My 5 year old has never expressed any her eyes or seeingnor have we noticed her squinting or moving a book around to get it in focus. She was stopping by the nurses office at the school and the school nurse gave a simple eye chart test and recommended she see an eye doctor, because she seemed a little near sighted.

The eye doc gave her a prescription that was very strong for far sighted at 2.5 and 3.0. When she put them on we could tell that she was looking around them to see things but she wanted to wear them because they were Hannah Montana glasses. After a while we got her out of the glass and have kept them out of sight and out of mind.

My wife asked my daughters' teacher to watch her for any signs of vision problems and we have done the same. The teacher is acutely aware of signs to watch for because she just put her own 5 year old in glasses and has not noted any of the symptons with our child. It should be noted that the teacher would actually watch for signs because my wife is the principal.

I told my wife that my daughter probably misinterpreted what the eye doctor was doing during the exam and just flat out told him what she thought he wanted to hear during the test to get it over with. we should knock this whole episode up to experience and move on. She only wore those glasses the one day and I have told my wife that if she shows any signs of vision problems in the future that we will take her to a different eye doc.

My question is do you think I am wrong here."

Now my (also lenghty) response:

where to start on this one? this is a topic i'm really opinionated on.

1st of all, an ophthalmologist is a SURGEON. if you think your kid needs surgery then by all means go to an ophthalmologist. but the people who advocate taking your kid (or anyone) to an ophthalmologist over an optometrist in a non-surgical case...i think thats wrong

2ndly...anyone who sees any amount of peds (our office sees a ton)...the techs and the docs dont put much stock in the subjective testing. parents and nurses get hung up on a 5 year old or 7 year old picking #1 over #2 and/or "reading" 20/20 etc etc. if the doc knows what he or she is doing none of that will make ANY IMPACT on the Rx given. ZERO. whether or not your kid needs glasses at all and what that Rx is *IS NOT* determined by A-N-Y-T-H-I-N-G the kid says during that exam. its all done by very accurate OBJECTIVE testing (read: tests that dont involve responses). no 5 year old or 7 year old can ever "follow" what the doc means during subjective refraction. i skip it all the time in those patients. occasionally i feel like i have to do it just as a show for the parents, but it doesnt ever sway what i do.

"I told my wife that my daughter probably misinterpreted what the eye doctor was doing during the exam and just flat out told him what she thought he wanted to hear during the test to get it over with" NO. i can definitively say that did not happen. what she said or didnt say made no impact whatsoever. as a rule most people dont understand subjective refraction. its way, way more complicated than just asking you what you want to look thru. and all farsighted people of all ages always choose "less" Rx. they'd all choose zero if it was up to them...and they'd all be cross-eyed (eso). no eye doctor would leave it up to a 5-year old's discretion as to wheter or not they need glasses.

3rdly most optometrists, contrary to popular belief, dont WANT your 5 year old in glasses. we'd prefer not. glasses cause nearly as many problems as they solve: breaking glasses, scratching glasses, keeping up with glasses, making your kid wear me we're all REALLY conservative when it comes to peds glasses. we're erring on the side of NOT Rx'ing glasses for your 5-year old, not the other way around. if the doc rx'd glasses to a 5-year old...its b/c said 5-year old REALLY NEEDS THEM. not b/c the doc wants to make a few bucks or feels like they have to "do something" b/c the nurse said there were problems or whatever.

4thly most nurses & parents of a 5 year old are hung up on nearsightedness. they think that if the kid "reads" 20/20 at x-distance then he/she is FINE and if they cant read 20/20 then they might need glasses. well w/o getting into a LENGTHY explanation (maybe later but not right now)...i usually dont care much if a 5 year old is slightly nearsighted. so they cant read the captions on the tv? so what? what i'm worried about is the +2.00 and UP *FARSIGHTED* KIDS. why is that? b/c uncorrected farsightedness causes esotropia and leads to refractive amblyopia nearly 100% of the time. its an "amblyogenic factor". google all this stuff. i see this all the freakin' time. a +3.00 farsighted kid DEFINITELY DOES need glasses, and you could be doing your kid a BIG, BIG disservice by not making her wear those +3.00's. the problem, of course, is that a +3.00 kid will never, ever, EVER complain that anything is "blurry" at any distance. they wont EVER squint or move a book back and forth...NONE OF THAT. those are all NEARSIGHTED complaints. farsighted kids wont complain AT ALL, & will "pass" the vision screen at school 75% of the time, unless the nurse REALLY knows what they're doing, which is unfortunately rare. its a long story as to why, but they can basically compensate for their farsightedness. so why not just let them compensate for it? whats the big deal? the answer is b/c the "compensation" is the following sequelae:

accommodation--->accommodative esotropia--->diplopia--->suppression--->r efractive amblyopia (permanent vision loss)

5: almost never do any of us who are doing peds eye exams prescribe the full amount. we're all conservative (see #3) and we will Rx the minimum possible about to prevent accommodative esotropia...and thats it. no more. so if your kid was Rx'd +2.50 and is HIGHLY, HIGHLY likely that she's really +5.00. the +3.00 is just the minimum amt to prevent vision loss from esotropia/amblyopia.

6: no farsighted kid ever wants to wear glasses at the beginning. this is one of the many reasons we dont like Rx'ing it. they all want to look over it, look around it, etc etc yadda yadda yadda. its a suckie job but its the parents job to make the kid wear it as written. the parent has to be the enforcer. its just like potty training or anything else with kids: the kids hate it and the parents hate it but its just one of those things you gotta do.

get a 2nd opinion...thats a great idea. see an ophthalmologist if you want to (although i dont know why anyone would in this case). but if the kid really got rx'd +3.00, then they're really probably +4.00 or +5.00...and thats going to get rx'd every time by every eye doc on the planet. no one is going to skip that type of rx in a 5-year old. no one who knows what they're doing anyway. sorry, probably not what you wanted to hear. most 5 year olds who are over +2.00 need some amount of correction to avoid esotropia

"we should knock this whole episode up to experience and move on" no, i wouldnt.

"if she shows any signs of vision problems in the future that we will take her to a different eye doc" she wont show any more signs than she has shown now. by the time she shows signs or complains it could literally be too late.

having the teacher "watch for signs" is...not a good idea. wear the glasses or get a 2nd opinion. the kid doesnt know enough to complain, the nurse wont catch it, the teacher cant see any "sign" of it.
Tags: amblyopia, children, strabismus, amblyogenic, esotropia, accommodative | Edit Tags
Friday February 13, 2009 - 02:26pm (CST) Edit | Delete | Permanent Link | 0 Comments
"Presbyopia Denial" or...Presbyopic & Mad as Heck
So I just had another one of happens every few weeks:

...a presbyopic person who is just mad at the world. They used to see great at all distances, now they're 55 and need bifocals., and they're very upset. They want LASIK or contacts or ANYTHING to not wear glasses. LASIK won't work for presbyopia and contacts sacrifice acuity to gain reading.

It always surprises me how vitriolically peeved some of these people are. They are in "presbyopia denial" as I call it...probably really just age denial. There's no great way to handle these patients. They try contacts...and they're mad that they don't see well thru them. There's just nothing for it except at least occasional glasses wear, which they perceive as making them "old" or "weak" or whatever.

Tough poop. "Getting old ain't for sissies", as Betty Davis famously said. Believe me we optometrists don't ENJOY selling you glasses, but if you want to see and see well, sometimes (most of the time when you're over 50) at least occasional glasses wear is usually unavoidable.

I'm also frequently surprised at how a few patients we see have NEVER heard of this. Kind of amazing since it happens to literally every mammal. But we still get one or two every few months who literally think they're "going crazy" b/c now they're 50+ and can't read. So interesting...
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Wednesday February 11, 2009 - 11:01am (CST) Edit | Delete | Permanent Link | 0 Comments
Blur Simulator
I found this website today while preparing for my weekly in-office staff education talk (lecture?) tomorrow entitled "Prism Break" (heheh).

This website is unrelated to prisms, but sure is cool! It shows you a simulation of your vision through whatever Rx you type in. No Rx, wrong Rx, etc. For example if a parent wants to know what their child sees like, they can type in their child's Rx and view a simulation of it! Pretty cool.


Its not perfect, and thats not the fault of the website creator. Not all refractive conditions can be accurately simulated. For example a young, healthy hyperope usually has NO blur. ZERO. So if your 4-year old's Rx is +5.00 and you type in +5.00, you'll get a blurry image...but I can assure you that a +5.00 nonamblyopic 4 year old DOES NOT perceive blur. They have OTHER problmes like accommodative esotropia and diplopia and others...but not blur.

The website is still cool, tho. Kudos to the creator!


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