1. BV MEETING September 2007 LIONEL KOWAL

2. To Emmetropize or Not to Emmetropize? The Question for Hyperopic Development MUTTI, DONALD Ohio American Academy of Optometry Volume 84(2),February 2007pp 97-102 Emmetropization is usually rapid, occurring in the first year of life. Failure to emmetropize leaves 2-8% of children with potentially clinically significant hyperopia after infancy. Uncorrected hyperopia in childhood has a negative impact on distance acuity and the accuracy of the accommodative response for an unknown number of children. The clinical gray zone for these problems as judged by distance refractive error alone begins around +2 to +3 D.

3. To Emmetropize or Not to Emmetropize? The Question for Hyperopic Development Refractive correction seems to improve distance acuity and the accuracy of accommodation. Reluctance to prescribe hyperopic corrections to children to improve visual performance might be unwarranted. If emmetropization is largely complete, if defocus has only a minor effect on the development of refractive error in infancy or childhood, and if the hyperopic eye is already growing longer but not moving toward emmetropia, then there may be little reason to either wait or be concerned about interfering with emmetropization that may never happen. The immediate visual benefit may outweigh these concerns.

4. To Emmetropize or Not to Emmetropize? The Question for Hyperopic Development LK comment: Normal population, not a strabismus population. Does a strabismus population consistently emmetropise <12 mo of age? Abrahamsson : non- emmetropization  strabismus

5. Infant Hyperopia: Detection, Distribution, Changes and Correlates. Outcomes From the Cambridge Infant Screening Programs ATKINSON, J; BRADDICK, O; et alii. London & Oxford American Academy of Optometry Volume 84(2),February 2007,pp 84-96 2 screening programs to detect significant refractive errors in >8000 8-9 mo infants, examine the sequelae of infant hyperopia, and test whether early partial spectacle correction improved visual outcome (strabismus and acuity). 2nd program: also examined whether infant hyperopia was associated with developmental differences across various domains such as language, cognition, attention, and visuomotor competences up to age 7y.

6. Infant Hyperopia: Detection, Distribution, Changes and Correlates. Outcomes From the Cambridge Infant Screening Programs #1: orthoptic examination and isotropic photorefraction, with cycloplegia. #2: no cycloplegia. Hyperopic infants (≥+4D) were followed up alongside an emmetropic control group, with visual and developmental measures up to age 7y, and entered a controlled trial of partial spectacle correction.

7. Infant Hyperopia: Detection, Distribution, Changes and Correlates. Outcomes From the Cambridge Infant Screening Programs RESULTS #2 : accommodative lag with a target at 75 cm (focus ≥+1.5 D) was a marker for significant hyperopia. In each program, prevalence of significant hyperopia at 9 to 11 mo was around 5% Infant hyperopia : increased strabismus at 4y. Manifest strabismus was 0.3% at 9 mo and 2% by school age. Infant hyperopia : poor acuity at 4y. The hyperopic group showed poorer overall performance than controls between 1 - 7 y on visuoperceptual, cognitive, motor, and attention tests …… no consistent differences in early language or phonological awareness.

8. Infant Hyperopia: Detection, Distribution, Changes and Correlates. Outcomes From the Cambridge Infant Screening Programs RESULTS….continued Spectacle wear by infant hyperopes : better visual outcome than in uncorrected infants. Improvement in strabismus with spectacle wear was found in the first program only... did not affect emmetropization to 3.5y. Both corrected and uncorrected groups remained more hyperopic than controls in the preschool years. Conclusions. Photo/videorefraction can successfully screen infants for refractive errors Visual outcomes may be improved by early refractive correction. Infant hyperopia is associated with mild delays across many aspects of visuocognitive and visuomotor development.

9. Eye advance online publication 2 February 2007 Ethnic differences in refraction and ocular biometry in a population-based sample of 11–15-year-old Australian children J M Ip 1, …. P MitchellSydney 2353 students (75% response) from a random cluster-sample of 21 secondary schools across Sydney. Examinations included cycloplegic autorefraction, and measures of Ks, anterior chamber depth, and axial length.

10. Ethnic differences in refraction and ocular biometry in a population-based sample of 11–15-year-old Australian children Participants mean age was 12.7 y (range 11- 14); 49% female. 60% European Caucasian ethnicity, 15% East Asian, 7% Middle Eastern, and 5% South Asian. The most frequent refractive error was mild hyperopia (59%), [SE +0.50 - +1.99D]. Myopia (≤-0.5D) was found in 12%, Moderate hyperopia (+2D) in 3.5%.

11. Ethnic differences in refraction and ocular biometry in a population-based sample of 11–15-year-old Australian children Myopia prevalence was lower among European Caucasian children (5%) and Middle Eastern children (6%) than among East Asian (40%) and South Asian (32%) children. European Caucasian children had the most hyperopic mean SE (+0.8D) and shortest mean axial length (23.2mm). East Asian children had the most myopic mean SE (-0.7D) and greatest mean axial length (23.9mm). Conclusion The overall myopia prevalence in this sample was lower than in recent similar-aged European Caucasian population samples. East Asian children in our sample had both a higher prevalence of myopia and longer mean axial length.

12. Prevalence of Hyperopia and Associations with Eye Findings in 6- and 12-Year-Olds Jenny M. Ip, MBBS, 1 … Paul Mitchell, MD, PhD 1 Ophthalmology 2007;xx:xxx © 2007 by the American Academy of Ophthalmology. Purpose: To describe the prevalence of hyperopia and associated factors in a representative sample of Australian schoolchildren 6 and 12 years old. Participants: Schoolchildren ages 6 (n 1765) and 12 (n 2353) from 55 randomly selected schools across Sydney. Methods: Detailed eye examinations included cycloplegic autorefraction, ocular biometry, cover testing, and dilated fundus examination. Information on birth and medical history were obtained from a parent questionnaire. Main Outcome Measures: Moderate hyperopia defined as spherical equivalent refraction of 2D), and eye conditions including amblyopia, strabismus, astigmatism, and anisometropia. Results: Prevalences of moderate hyperopia among children ages 6 and 12 were 13.2% and 5.0% respectively It was more frequent in children of Caucasian ethnicity (15.7% and 6.8%, respectively) than in children of other ethnic groups.

13. Prevalence of Hyperopia and Associations with Eye Findings in 6- and 12-Year-Olds…2 Compared with children without significant ametropia, the prevalence of eye conditions including amblyopia, strabismus, abnormal convergence, and reduced stereoacuity was significantly greater in children with moderate hyperopia (all Ps 0.01). Maternal smoking was significantly associated with moderate hyperopia among 6- year-olds (P 0.03), but this association was borderline among 12-year-olds (P 0.055). Early gestational age ( 37 weeks) and low birth weight ( 2500 g) were not statistically significant predictors of moderate hyperopia in childhood. Conclusions: Moderate hyperopia was strongly associated with many common eye conditions, particularly amblyopia and strabismus, in older children. Birth parameters did not predict moderate hyperopia.

14. Management of hyperopia in children Jeddi Blouza A, ….. Tunis, Tunisia. J Fr Ophtalmol. 2007 Mar;30(3):255-9. Jeddi Blouza A….J Fr Ophtalmol. To study the prevalence of hyperopia in school- aged children and to analyze the factors that increase the risk of squint or amblyopia in a retrospective study. 300 eyes of 150 children with hyperopia who did not have anisometropia ≥ 1.5 D. Hyperopia : spherical equivalent ≥ +0.5 D. Amblyopia was screened and treated by patching therapy and then penalisation. Complete spectacle correction for children ≥+3.5D or in presence of squint or amblyopia.

15. Hyperopia in Tunisian children RESULTS 1 RESULTS Mean age 9.5+/-2.7 y. Mean overall refraction +2 D (+/-1.65). Hyperopia ≥ +3.5D: 19% of children; latent in 35%. Strabismus in 7%, accommodative in 25%. ET most prevalent deviation (73%). Prevalence of amblyopia 12%. Mean sphere in amblyopic children was 5.7 D (+/-1.64 D). Initial depth of amblyopia was mild to moderate and 98% of the children achieved iso-acuity after patching therapy.

16. Hyperopia in Tunisian children RESULTS 2 RESULTS Correlation between high +, amblyopia, and squint statistically significant. ≥ + 3.5D: Risk ratios of squint 5.2, amblyopia 3.7. CONCLUSION: Children ≥ +3.5 D have an increased risk of amblyopia and squint that threatens their visual function. Hyperopic correction should be prescribed even if no strabismus or amblyopia is detected in order to prevent this risk.

17. Hyperopia in Tunisian children COMMENT COMMENT Tunis: Hyperopia ≥ +3.5D: 19% of children; latent in 35%. Sydney Middle Eastern children ≥+2D: 8% of 6y, 7% of 12y

18. Longitudinal changes in the spherical equivalent refractive error of children with accommodative esotropia S R Lambert…. Atlanta, GA, USA British Journal of Ophthalmology 2006;90:357-361 Longitudinal changes in spherical equivalent (SE) refractive errors of children with accommodative esotropia as a function of the age when glasses were prescribed. 126 children with accommodative ET followed longitudinally for 4.4 (SD 2.5) years. Cycloplegic refractions were performed using autorefractor for older children and retinoscopy for younger children. The refractive data were analysed for three groups of children based on their age at the time spectacles were prescribed.

19. Longitudinal changes in the spherical equivalent refractive error of children with accommodative esotropia RESULTS….. The initial SE refractive error was age dependent <2y+5.1 (1.9) D 2- <4y +4.2 (1.9) D 4-8y, +3.8 (1.7) D. All ages : initial increase in refractive error, followed by later decrease. Greatest decrease in oldest age group. Refractive error peaked 1y after glasses prescribed for children 4-8y vs...... 6y after glasses prescribed for children < 2y. Conclusion: Longitudinal changes in refraction for children with accommodative ET vary as a function of age when glasses wear is initiated.

20. Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective COTTER, SUSAN A. California American Academy of Optometry Volume 84(2),February 2007, pp 103-109 Variations in prescribing patterns for childhood + occur within optometry & within ophthalmology. Differences : due to a greater level of concern among optometrists about associated vision functions such as accommodation, vergence, & stereopsis, & potential impact of uncorrected + on reading & school performance. Conclusions. If indications for prescribing spectacles for children with hyperopia are to be validated, randomized controlled trials need to be performed.

21. Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective Survey 1: Prescribing for bilateral asymptomatic + in young children 65% of pediatric optometrists use +3 D of bilateral hyperopia as their prescribing threshold for 2yo. 28% used a higher threshold with 25% using +5 D as their threshold. Pediatric ophthalmologists: 66% use +5D as their threshold. 25% use a +3D threshold.

22. Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective Survey 2: What magnitude of + in asymptomatic children should be referred in a vision screening because it is worrisome College of Optometrists in Vision Development (COVD) & American Association of Pediatric Ophthalmology and Strabismus (AAPOS) AAPOS: worrisome level of hyperopia was +5D from 0 - 6 mo; +4D for 6- 48mo. COVD : +3.50 D at 0- 6 mo; +3 D from 6 - 24 mo, +2.50 D from 24 -30 mo, and +2D 30- 48 mo.

23. Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective Hyperopic children who have strabismus and/or amblyopia Views of Donders (1864) and Worth (1903) used similarly within both professions - maximum + to produce alignment in ET, full amounts of correction for anisometropia and astigmatism to provide equal retinal image clarity between the eyes, symmetrically reduced + prescriptions when needed to ensure or promote acceptance of spectacles. Greatest prescribing variability: children ≤12 y who have approximately equal + in the 2 eyes with neither strabismus nor amblyopia.

24. Ocular Dominance Diagnosis and Its Influence in Monovision Olga Seijasa … Pilar Gomez de Liano, Rosario Gomez de Liano, … American Journal of Ophthalmology Volume 144, Issue 2, August 2007, Pages 209-216 9 different tests were carried out in a group of 51 emmetropic subjects to determine both motor and sensory ocular dominance. For analysis, patients were divided into 2 groups according to age. Normal ophthalmologic examination results were the inclusion requirement, with normal binocular vision and good stereoacuity.

25. Ocular Dominance Diagnosis and Its Influence in Monovision RESULTS A significant % of uncertain or ambiguous results in all tests performed was found, except in the hole-in- card and kaleidoscope tests. When the tests were compared, two by two, the correlation or equivalence found was low and was much lower if tests were compared three by three. No clear ocular dominance was found in most studied subjects; instead, there must be a constant alternating balance between both eyes in most emmetropic persons, but not in those with pathologic features. This fact would explain the great variability both between and within different kinds of tests.

26. Ocular Dominance Diagnosis and Its Influence in Monovision RESULTS Also, it would explain why monovision technique is well tolerated in most patients, with unsuccessful results only in those patients with strong or clear dominance. …. it seems appropriate to evaluate patient’s dominance before monovision surgery to exclude those individuals with clear dominance.

27. Association between fixation preference testing and strabismic pseudoamblyopia Hakim OM Saudi Arabia J Pediatr Ophthalmol Strabismus. 2007 May-Jun;44(3):174-7 Hakim OM J Pediatr Ophthalmol Strabismus... to evaluate the strength of the association between fixation preference and strabismic amblyopia. 80 pts (3 to 8y) with manifest strabismus and ability to do a Snellen E test …. Fixation preference was graded from 0 (free alternation) to 3 (strong uniocular fixation). We compared acuity and the grade of fixation preference.

28. Association between fixation preference testing and strabismic pseudoamblyopia RESULTS RESULTS 60 pts had strong uniocular fixation (grade 3). Of these patients, 50 had no amblyopia and only 10 had deep amblyopia. 10 pts had moderate fixation (grades 1 and 2). Of these patients, 5 had no amblyopia and 5 had moderate amblyopia. 10 patients had free alternation (grade 0). These patients had equal vision. CONCLUSION: Treatment of strabismic amblyopia on the basis that the sound eye will show strong fixation preference can be hazardous. Fixation preference could be a severe form of eye dominance, and better methods for testing visual acuity in preverbal children are required.

29. Ocular findings in individuals with intellectual disability. Karadag R, …. Can J Ophthalmol. 2007 Oct 4;42(5) Karadag R Can J Ophthalmol. Random sample of 180 intellectually disabled children and adults aged 9 - 50 Refractive error in 56 of 166 patients. Strabismus 2nd most frequent abnormality. Eyelid abnormalities in 30 patients. Cataract inc. congenital lens opacity was 4th most frequent pathology Posterior segment findings were detected in 23 of 166 patients.

30. Age at strabismus diagnosis in an incidence cohort of children. Mohney BG, …. Mayo Clinic Rochester, Minnesota Am J Ophthalmol. 2007 Sep;144(3):467-9 Mohney BG Am J Ophthalmol. Medical records of all Olmsted County, Minnesota, residents < 19 y diagnosed with ET, XT or hypertropia from January 1985 to December 1994 reviewed. The median age at diagnosis of esotropia (n = 380) : 3.1y exotropia (n = 205): 7.2y hypertropia (n = 42) : 6.1y(P =.001).

31. Age at strabismus diagnosis in an incidence cohort of children. Mohney BG, …. Mayo Clinic Rochester, Minnesota Am J Ophthalmol. 2007 Sep;144(3):467-9 Mohney BG Am J Ophthalmol. First 6 y, ET had highest incidence XT predominated age 7-12. Each form similarly likely to occur 13 -18 y P =.001

32. Common forms of childhood strabismus in an incidence cohort. Mohney BG. Mayo Clinic Am J Ophthalmol. 2007 Sep;144(3):465-7. Mohney BG Am J Ophthalmol. Medical records of all Olmsted County, Minnesota, residents < 19 y with ET, XT or hypertropia 1985 - 94. 627 new cases of childhood strabismus identified ET 380 (60%) accomm 28%, nonaccomm 10%, neurological 7%, XT 205 (33%) I-mitt 17%, convergence insufficiency 6% Hypertropia 42 (7%).