+0.25 OU pediatric reading glasses

[smiegal]

I just witnessed, for the 3rd or 4th time, a child given +0.25 OU "reading glasses" by a local optom. None of them came from the same person or office. This particular child is 5 years old and clearly has congenital ptosis OU with a constant head tilt and palpebral fissure of 3 mm OU. They did not receive a cycloplegic refraction, as usual, and there was no acknowledgement of the ptosis.

Are any of you seeing this in your practice? How can some of these people live with themselves?

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[KHE]

I just witnessed, for the 3rd or 4th time, a child given +0.25 OU "reading glasses" by a local optom. None of them came from the same person or office. This particular child is 5 years old and clearly has congenital ptosis OU with a constant head tilt and palpebral fissure of 3 mm OU. They did not receive a cycloplegic refraction, as usual, and there was no acknowledgement of the ptosis.

Are any of you seeing this in your practice? How can some of these people live with themselves?

A couple of things about this:

I would bet $10 that each of those glasses had a small amount of prism in them that was not neutralized by whoever read the prescription. Virtually no OD would give +0.25 OU by itself.

But I think that this case presents a good opportunity to help bridge the divide a little bit between the two fields. I think it will also be a good academic exercise for people on both sides of this fence.

Put aside your gut reaction that the OD prescribed that simply as a way of generating a spectacle sale for a second because I know that's what you're probably thinking and I'll guarantee you that its not the case.

Try to think of a possible rationale for a prescription like that. Go ahead, just guess if you can't come up with something....

 

[Wolverine98]

A couple of things about this:

I would bet $10 that each of those glasses had a small amount of prism in them that was not neutralized by whoever read the prescription. Virtually no OD would give +0.25 OU by itself.

Put aside your gut reaction that the OD prescribed that simply as a way of generating a spectacle sale for a second because I know that's what you're probably thinking and I'll guarantee you that its not the case.

I'm not so sure. I've also seen this with both +0.25 and +0.50 for kids with no other apparent abnormalities; neutralized by multiple people on both manual and automatic machines (we checked because we were thinking the same thing you were). I've also seen a lot of young kids with glasses in the -0.25 to -0.50 range. Almost all of them come out of two optom offices.

While there are many good optometrists out there, there are also those who will recommend glasses in this range for the revenue.

Dave

 

[Ben Chudner]

While there are many good optometrists out there, there are also those who will recommend glasses in this range for the revenue.

These discussions are always so productive. I am sure that somewhere you might find an OD that prescibes a little too aggressively for the revenue, but you can't tell me that there are no OMD's that perform LASIK on questionable candidates, or remove cataracts that really do not need to be removed. Not only have I witnessed it for both procedures, but it is not hard to find LASIK cases that have resulted in litigation because of it. I am sure these doctors are motivated by revenue. When it comes down to it, which action has more potential risks? How can those surgeons live with themselves? Neither profession is immune from individuals that think about the bottom lime first and patient care second, but I truely believe that this is rare for both OD's and OMD's.

 

[KHE]

These discussions are always so productive. I am sure that somewhere you might find an OD that prescibes a little too aggressively for the revenue, but you can't tell me that there are no OMD's that perform LASIK on questionable candidates, or remove cataracts that really do not need to be removed. Not only have I witnessed it for both procedures, but it is not hard to find LASIK cases that have resulted in litigation because of it. I am sure these doctors are motivated by revenue. When it comes down to it, which action has more potential risks? How can those surgeons live with themselves? Neither profession is immune from individuals that think about the bottom lime first and patient care second, but I truely believe that this is rare for both OD's and OMD's.

Let's try to avoid going down this accusatory road.

We've all seen more than enough LASIK on marginal candidates. After managing a refractive surgery center, I believe that most of these cases are the result of the surgeons misplaced ego, not the result of some underhanded desire to make money.

Let's proceed on the assumption that 99% of OMDs and 99% of ODs honestly feel that they are doing what's best for the patient when they do things that other providers may feel are questionable.

That being said....what other possible rationales could there be for a low plus or minus rx?

 

[smiegal]

A couple of things about this:

I would bet $10 that each of those glasses had a small amount of prism in them that was not neutralized by whoever read the prescription. Virtually no OD would give +0.25 OU by itself.

But I think that this case presents a good opportunity to help bridge the divide a little bit between the two fields. I think it will also be a good academic exercise for people on both sides of this fence.

Put aside your gut reaction that the OD prescribed that simply as a way of generating a spectacle sale for a second because I know that's what you're probably thinking and I'll guarantee you that its not the case.

Try to think of a possible rationale for a prescription like that. Go ahead, just guess if you can't come up with something....

No prismatic component.

There is no reason to give this prescription that I can fathom, please enlighten me. Nip that patronizing tone in the bud, while you're at it.

Don't get me wrong, I know that there are questionable decisions being made re: cataract extractions that would be tough to defend from a risk/benefit perspective. This is not a demonize optoms thread. I am bringing up a specific questionable practice and wondering if anyone else has witnessed similar situations in their own practice.

 

[smiegal]

That being said....what other possible rationales could there be for a low plus or minus rx?

Quit the pimping, I am waiting with bated breath for your thoughts, KHE.

 

[stonegoat]

It's possible that a child may be prescribed glasses with a fairly low plus power if they have a convergence excess with a high AC/A. I doubt this is the situation most of the time. I worked in an awsome 4 Dr. practice for three years, and one of the Drs would occasionally Rx a very low plus to children "for reading". I assure you, it was money thing. It happens. I would feel ashamed and embarrased to do it.

JP

 

[EyeFormation]

Found this on an OD website...as a future pediatric ophthalmologist, I think it behooves me to attempt to find out the rationale for such actions...what are they actually trying to accomplish? I would agree that some are simply moneymakers, but some probably truly believe in a rationale for the prescription...the only way we as ophthalmologists can be truly advocates for our patients is to understand the arguments for things that we don't agree with, and then explain that to the patients in an intelligent, non-condescending way.

http://www.childrensvision.com/bifocals.htm

 

[smiegal]

Editorials are nice, but how about some research to support this theory of pediatric 0.25 readers.

 

[Wolverine98]

It's possible that a child may be prescribed glasses with a fairly low plus power if they have a convergence excess with a high AC/A. I doubt this is the situation most of the time. I worked in an awsome 4 Dr. practice for three years, and one of the Drs would occasionally Rx a very low plus to children "for reading". I assure you, it was money thing. It happens. I would feel ashamed and embarrased to do it.

It would be quite uncommon, IME, to use an add that was that low for a high AC/A. They're usually more in the at least +1.50 range.

Dave

 

[Wolverine98]

These discussions are always so productive. I am sure that somewhere you might find an OD that prescibes a little too aggressively for the revenue, but you can't tell me that there are no OMD's that perform LASIK on questionable candidates, or remove cataracts that really do not need to be removed. Not only have I witnessed it for both procedures, but it is not hard to find LASIK cases that have resulted in litigation because of it. I am sure these doctors are motivated by revenue. When it comes down to it, which action has more potential risks? How can those surgeons live with themselves? Neither profession is immune from individuals that think about the bottom lime first and patient care second, but I truely believe that this is rare for both OD's and OMD's.

I don't think that anything I wrote implied that I believe MDs are immune to this. There are several people in our area who are overly aggressive with refractive surgery and advertise heavily.

Maybe it is just ego, but I believe a fairly large portion of it is money, because some of it is being done on patients who are downright bad candidates (as an example, a 60 year-old with dry eyes, +4.00 hyperopia with about 3D of cyl, diabetic retinopathy, and cataracts who was booked for LASIK and then came to see me for a second opinion).

Dave

 

[PBEA]

Im an OD, and I have seen all of the above and more, from OD and OMD. There's a whole cadre of ODs and OMDs out there who are mislead by ignorance, money, power, or prestige. So whats your point smiegel? If you're grinding your axe then big deal, but it sounds like you are looking for a fight. You want to harp on misdiagnosis by an optom? You better take a long look in the mirror pal, because guess what? You WILL misdiagose/mistreat someone, get it?!? WILL it cause harm, hopefully not. Hell, a week does not go by in my office, w/o seeing some form of tx I do not agree with. Whether its the PCP treating iritis with abx, or the wallyworld refractor handing out crappy rxs to an amblyope, or the 20/25 nuclear sclerosis that "needed" to be removed by the cat surgeon. Last week I find a local school in my area has had a brown syndrome child with severe head tilt "working" with a school employed "vision therapist" (wtf is a "vision therapist"?, they are not OD or MD). The kid (13yo) has diplopia (except at his null point) and they are trying do what exactly? Im putting an occluder cl on and voila no more head tilt. If 4 or 5 "bad" rxs is all that you have seen that would qualify as mistreated then clearly you are just starting out, so buckle up dorothy because you are not in Kansas anymore. Maybe you could somehow enlighten us all as to how best to practice, but Im sure it will only end up in the funny papers, so dont waste your breath.

 

[Visionary]

Here's a nice study by Sean Donahue at Vandy about the higher likelihood of ODs prescribing lenses unnecessarily to preschoolers. Basically, 1.8% of kiddos were prescribed glasses following examinations by pediatric ophthalmologists, 11.7% following examinations by comprehensive ophthalmologists, but 35.1% following examinations by optometrists. Read for yourself:

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=15226721&dopt=Abstract

 

[KHE]

Here's a nice study by Sean Donahue at Vandy about the higher likelihood of ODs prescribing lenses unnecessarily to preschoolers. Basically, 1.8% of kiddos were prescribed glasses following examinations by pediatric ophthalmologists, 11.7% following examinations by comprehensive ophthalmologists, but 35.1% following examinations by optometrists. Read for yourself:

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=15226721&dopt=Abstract

That study is a perfect example of propaganda in this neverending war that gets thrown around:

Firstly, it is mainly used as an attack against proposed legislation mandating eye examinations by an eye doctor, not as a study of the number of unneeded prescriptions.

It also does NOT say that 35.1% of kids were prescribed glasses after a visit to an OD. It says that 35.1% of kids who FAILED A SCHOOL SCREENING were prescribed glasses. (which out of the total population is .1%)

I challenge any of you out there to throw on a pair of +0.75s (making them a -.075 myope) or a pair of -2.00s (making them a 2 diopter hyperope) on your kids (or even yourself) and let them run around with that and see how they do.

The study basically declares as "unneeded" any spectacles that did not relieve amblyogenic factors, which is something I can not disagree with more. Even the studies own auther backed off from that and clarified his position at a symposium hosted by ODs and OMDs shortly after that study was published.

But sadly, once again these forums have degenerated into useless namecalling on both sides, along with the usual partisan bickering and tired old rhetoric.

 

[smiegal]

That study is a perfect example of propaganda in this neverending war that gets thrown around:

Firstly, it is mainly used as an attack against proposed legislation mandating eye examinations by an eye doctor, not as a study of the number of unneeded prescriptions.

It also does NOT say that 35.1% of kids were prescribed glasses after a visit to an OD. It says that 35.1% of kids who FAILED A SCHOOL SCREENING were prescribed glasses. (which out of the total population is .1%)

I challenge any of you out there to throw on a pair of +0.75s (making them a -.075 myope) or a pair of -2.00s (making them a 2 diopter hyperope) on your kids (or even yourself) and let them run around with that and see how they do.

The study basically declares as "unneeded" any spectacles that did not relieve amblyogenic factors, which is something I can not disagree with more. Even the studies own auther backed off from that and clarified his position at a symposium hosted by ODs and OMDs shortly after that study was published.

But sadly, once again these forums have degenerated into useless namecalling on both sides, along with the usual partisan bickering and tired old rhetoric.

Again, I would like to know for which clinical scenario you (KHE or anyone else) would prescribe +0.25 OU readers for a child.

 

[Ben Chudner]

Again, I would like to know for which clinical scenario you (KHE or anyone else) would prescribe +0.25 OU readers for a child.

Without prism, I personally cannot think of a medical reason. Since none of us were in the room during the exam, we will never really know what the OD was thinking, but maybe there was a reason that we just can't think of. The point is, it doesn't really matter. There is little that can be done to prevent this from happening, just as we can't prevent 20/25 cataracts from being unneccesarily removed. This is not a widespread problem, as much as it appears you would like it to be. The article that was posted above is not evidence that OD's overprescribe as Ken points out. In fact, one could make the point that it shows OMD's tend to miss subtle refractive errors that, while they may not be amblyogenic, could inhibit learning in children.

 

[Visionary]

It also does NOT say that 35.1% of kids were prescribed glasses after a visit to an OD. It says that 35.1% of kids who FAILED A SCHOOL SCREENING were prescribed glasses. (which out of the total population is .1%)

Actually, the study referred to kids who, after picked up on a photoscreening, were found to not have amblyogenic refractive errors (i.e., false positives). The percentages relate to that SUBSET of kids who failed the photoscreening--less than 1% of the total picked up by the screening, I might add.

I challenge any of you out there to throw on a pair of +0.75s (making them a -.075 myope) or a pair of -2.00s (making them a 2 diopter hyperope) on your kids (or even yourself) and let them run around with that and see how they do.

The study basically declares as "unneeded" any spectacles that did not relieve amblyogenic factors, which is something I can not disagree with more. Even the studies own auther backed off from that and clarified his position at a symposium hosted by ODs and OMDs shortly after that study was published.

Again, let me correct you. Dr. Donahue mentioned the prescriptions given as ranging from -0.75 to +2.00D. The visual world of a child is inherently myopic, thus being -0.75 is in no way amblyogenic. As for the hyperopic correction, kids have an amazing degree of accommodation (>12D). To accommodate 2-3D would likely not even cause significant eyestrain in a youngster. With growth-related myopic shifts of 0.5-1.00D per year, such children would have outgrown their "need" for glasses in a relatively short amount of time.

Perhaps it IS a difference in philosophy; however, the pediatric ophthalmologists strangely do not cause amblyopia by not prescribing +2.00D lenses to youngsters. Interesting, eh?

 

[stonegoat]

All right OMDs....you're correct. ODs are crooks and theives. You are righteous and good. Satisfied?

Let this thread die.

JP

 

[DrEyeBall]

Last week I find a local school in my area has had a brown syndrome child with severe head tilt "working" with a school employed "vision therapist" (wtf is a "vision therapist"?, they are not OD or MD). The kid (13yo) has diplopia (except at his null point) and they are trying do what exactly? Im putting an occluder cl on and voila no more head tilt. .

Why are you using a contact lens? Why not consider surgery to treat his diplopia and allow him to use his eyes together and expand his field of single vision?

 

[DrEyeBall]

Without prism, I personally cannot think of a medical reason. Since none of us were in the room during the exam, we will never really know what the OD was thinking, but maybe there was a reason that we just can't think of. The point is, it doesn't really matter. There is little that can be done to prevent this from happening, just as we can't prevent 20/25 cataracts from being unneccesarily removed. This is not a widespread problem, as much as it appears you would like it to be. The article that was posted above is not evidence that OD's overprescribe as Ken points out. In fact, one could make the point that it shows OMD's tend to miss subtle refractive errors that, while they may not be amblyogenic, could inhibit learning in children.

I think there needs to be some solid scientific proof to show that low levels of hyperopia of myopia inhibit learning. To date, no such study exists.

I think what this study really showed was that people who are not well trained and experienced in children tend to over prescribe whether they are OD or MD. Justification for prescribing for these low levels of refractive error would be hard to find. Aphakic children are able to see fairly well at near without a reading add, how much less accommodation could this child have?

 

[PBEA]

Again, I would like to know for which clinical scenario you (KHE or anyone else) would prescribe +0.25 OU readers for a child.

Well, I would not call it a "clinical" scenario, but I have personally had somewhere between 50-100 different parents really desire just a "mild" reading rx. Even after I have explained that their kids do not show any measurable deficit in any areas of their vision. What do you think I should have done in that scenario? Rx +.50 or +.75 ? Rx plano? Yea, so they can come back and accuse me of lying to them? Or should I refuse? Maybe you would get up on a pulpit and proclaim that a near add is evil . Although that probably wont hold alot of water, considering that you can purchase anything up to +300 OTC. I've had people fill questionable tints in their kids glasses. Shiit I dont advise them on but that they desire. Ever consider that they just wanted a pair of glasses? What do you want to bark about now? Here is a little advice, unless you know wtf you are talking about I suggest you keep your nose in what matters! Like your pts. Id like to hear what you plan on doing with these pts, instead of your dire opinions about harmless spectacles. Hell, Ive measured -0.25 on more then one pair of OTC sunglasses, are you blaming that on ODs also? At this point I get dumber every time you post on this thread, so let it go.

 

[DrEyeBall]

Well, I would not call it a "clinical" scenario, but I have personally had somewhere between 50-100 different parents really desire just a "mild" reading rx. Even after I have explained that their kids do not show any measurable deficit in any areas of their vision. What do you think I should have done in that scenario? Rx +.50 or +.75 ? Rx plano? Yea, so they can come back and accuse me of lying to them? Or should I refuse? Maybe you would get up on a pulpit and proclaim that a near add is evil . Although that probably wont hold alot of water, considering that you can purchase anything up to +300 OTC. I've had people fill questionable tints in their kids glasses. Shiit I dont advise them on but that they desire. Ever consider that they just wanted a pair of glasses? What do you want to bark about now? Here is a little advice, unless you know wtf you are talking about I suggest you keep your nose in what matters! Like your pts. Id like to hear what you plan on doing with these pts, instead of your dire opinions about harmless spectacles. Hell, Ive measured -0.25 on more then one pair of OTC sunglasses, are you blaming that on ODs also? At this point I get dumber every time you post on this thread, so let it go.

This is actually a significant issue. I am not talking about the +0.25 readers per se but the issue you bring up about prescribing based on a parents desire.

I think we owe it to parents not to hand over a prescription when it is not needed. This goes for glasses as well as drops for "pink eye". SOme people claim that they do not want the patient or the family to leave and feel like something was not done for them.

If the child does not need the Rx and you do not give it to them, you HAVE done something worthwhile for them. You have a) given them your expert opinion about the situation and b) saved them money for something that is not needed.

the idea that these glasses are not harmful does not hold water. That is not a reason to prescribe them. I see a child like this several times a week. The parents might be happy to leave with glasses but I can not prescribe them only for that reason. If they end up going somewhere else to get them and feel better about that visit, so be it. I think it is the rare parent who, when told in a clear and well informed manner, will not be happy leaving knowing the glasses are not needed.

As for this specific situation, like every field of medicine or any other aspect of life, there are probably those who really believe they are helping with this Rx and those who are doing it for the money. These people exist in all walks of life. No one profession has a monopoly on them. When confronted with this issue and this Rx, I am diplomatic, non-accusatory and explain they probably do not help that much and can be discontinued. I explain that they probably will be fine without the glasses and could stop wearing them. That there is a difference of opinion about the usefulness of these glasses and I would not have prescribed them myself.

Why make the parent feel bad for wasting money on what they believed was the right thing to do for their child.

 

[PBEA]

Why are you using a contact lens? Why not consider surgery to treat his diplopia and allow him to use his eyes together and expand his field of single vision?

Holy cow, what a typical OMD response!!! You expect me to buy into strab sx for this browns kid? Do you think I would encourage/coerce a 13yo to undergo invasive eye sx with basically little to no expectation at fusion? I guess there always blind luck but then again. It definitely is a philosophical difference (as someone posted). Oh by the way the pediatric ophthalmologist she originally consulted did not recommend sx (surprise!), hoping for resolution no doubt. (or maybe the OMD recommended the "vision therapist" whatever that is ). If you think you can align these eyes close enough then all the power to you, Im just glad I dont agree. Although Im willing to argue about it some more. Especially the contact lens part, I dont see much in the literature.

 

[PBEA]

This is actually a significant issue. I am not talking about the +0.25 readers per se but the issue you bring up about prescribing based on a parents desire.

I think we owe it to parents not to hand over a prescription when it is not needed. This goes for glasses as well as drops for "pink eye". SOme people claim that they do not want the patient or the family to leave and feel like something was not done for them.

If the child does not need the Rx and you do not give it to them, you HAVE done something worthwhile for them. You have a) given them your expert opinion about the situation and b) saved them money for something that is not needed.

the idea that these glasses are not harmful does not hold water. That is not a reason to prescribe them. I see a child like this several times a week. The parents might be happy to leave with glasses but I can not prescribe them only for that reason. If they end up going somewhere else to get them and feel better about that visit, so be it. I think it is the rare parent who, when told in a clear and well informed manner, will not be happy leaving knowing the glasses are not needed.

As for this specific situation, like every field of medicine or any other aspect of life, there are probably those who really believe they are helping with this Rx and those who are doing it for the money. These people exist in all walks of life. No one profession has a monopoly on them. When confronted with this issue and this Rx, I am diplomatic, non-accusatory and explain they probably do not help that much and can be discontinued. I explain that they probably will be fine without the glasses and could stop wearing them. That there is a difference of opinion about the usefulness of these glasses and I would not have prescribed them myself.

Why make the parent feel bad for wasting money on what they believed was the right thing to do for their child.

All well and good, but for sure you have seen someone who just wants the cosmetic pair. If after you have done your due diligence why would you bother denying these people? If they want to flush their money down the toilet then what are you fighting for? Ive seen worse examples of "consumerism" why are harmless spectacles so different?

 

[PBEA]

Perhaps it IS a difference in philosophy; however, the pediatric ophthalmologists strangely do not cause amblyopia by not prescribing +2.00D lenses to youngsters. Interesting, eh?

I think the point KHE was making wasnt that -0.75 or +2.00 are necessarily amblyogenic but that they are sometimes symptomatic. With a chief complaint of reduced DVA with -0.75 ou, we all have a choice. I personally present it as an option, no harm, no foul. I would equally challenge (as KHE has done) anybody to walk around with the same myopic rx (about 20/30) and tell me that you dont have a problem. Some OMDs readily recommend lasik/prk for -1.00, but then hey it makes sense right, I mean why get those nasty, dangerous spectacles when you can have safe clear vision with eye surgery??!! Yeah whatever. I was at some conference awhile back and this OMD was describing the concept of 20/happy vision not 20/20 vision. I almost fell off my chair. Your right it is a difference in philosophy. Perhaps that is why I feel justified in acting in the best interest of my patients when I tell them to FORGET about surgery for their 20/25 cataract, etc.

 

[DrEyeBall]

If an adult wants a pair of glasses to make a fashion statement...fine.

I do not think this is the same issue when prescribing them for children. Most younger children come in complaining of decreased vision in order to get glasses. I have not seen an 8 year old come into the office asking for glasses to make a fashion statement. To give them a pair of glasses may just reinforce this behavior. Next time it could be the stomach ache to get out of school, the headache to avoid bedtime, etc.

I also think we went to school to not only prescribe glasses and medicines but to educate our patients. Having never given into a child's desire to wear glasses, I have found that parents are fine leaving without the glasses. Now maybe some of those parents go to the office that prescribed these +0.25 in this thread once they leave my office. If so, fine, I can live with that. I do not believe in prescribing for things that are not needed, no matter how "harmless" it may be. Why not just hand the prescription pad to the parents and let them decide what they need?

 

[DrEyeBall]

I think the point KHE was making wasnt that -0.75 or +2.00 are necessarily amblyogenic but that they are sometimes symptomatic. With a chief complaint of reduced DVA with -0.75 ou, we all have a choice. I personally present it as an option, no harm, no foul. I would equally challenge (as KHE has done) anybody to walk around with the same myopic rx (about 20/30) and tell me that you dont have a problem. Some OMDs readily recommend lasik/prk for -1.00, but then hey it makes sense right, I mean why get those nasty, dangerous spectacles when you can have safe clear vision with eye surgery??!! Yeah whatever. I was at some conference awhile back and this OMD was describing the concept of 20/happy vision not 20/20 vision. I almost fell off my chair. Your right it is a difference in philosophy. Perhaps that is why I feel justified in acting in the best interest of my patients when I tell them to FORGET about surgery for their 20/25 cataract, etc.

I think the difference here is that -0.75 will improve that person's vision and we all know that. It is not a question of whether it will or will not improve their ability to read the eye chart better. The question is whether or not it will make a big enough difference that someone will want to wear them some or all of the time. It is hard to argue prescribing this and telling the patient to decide for him or herself how often to wear them. Of course the next point is whether or not to Rx -0.50, -0.25, etc. Clearly at some point we would probably all agree the benefit is probably small. However, there is really no way you can justify a +0.25 Rx in any way. That is not to say that the people prescribing these are thieves. Some may have been taught this and never thought to question it. Way too many people practice based upon what someone said in a lecture at school and never critically think for themselves. On the other hand, there clearly are people who are doing it for the bottom line just like people doing 20/25 cataracts in patients with no complaints.

 

[PBEA]

Aphakic children are able to see fairly well at near without a reading add, how much less accommodation could this child have?

Id like to hear how this occurs exactly? I mean there really is very little escape from what we consider a fundamental physical property of light. In other words, unless these kids are overplussed for distance, then they would require a near add, right? Of course these kids probably have reduced BCDVA to begin with, and it might be easy to equate their reduced DVA with their reduced NVA and call it "fairly" good NVA. I guess so, but it might be easier still to find that with a near add they might exceed their reduced BCDVA (as is the case with many amblyopes) and have pretty darn good BCNVA. Or were you thinking of some fictional accomodative effect? I really would like you to put me in my place here and give me an explanation for your statement. Im always learning.

 

[DrEyeBall]

Id like to hear how this occurs exactly? I mean there really is very little escape from what we consider a fundamental physical property of light. In other words, unless these kids are overplussed for distance, then they would require a near add, right? Of course these kids probably have reduced BCDVA to begin with, and it might be easy to equate their reduced DVA with their reduced NVA and call it "fairly" good NVA. I guess so, but it might be easier still to find that with a near add they might exceed their reduced BCDVA (as is the case with many amblyopes) and have pretty darn good BCNVA. Or were you thinking of some fictional accomodative effect? I really would like you to put me in my place here and give me an explanation for your statement. Im always learning.

I have no idea how but I see it every day in my practice. Early on, these children are overplussed for their near world but then corrected for distance as they get older. When made emmetropic with an aphakic contact lens, they still can read J2 or J3 at near. Can I explain? No. Does it happen? Yes. Check the next pediatric aphake you have and see for yourself. many of these children do quite well and do not wear their reading Rx or bifocals until the print becomes fairly small. When you see it, if you figure it out, you can explain it to me.

This is also the case for many younger pseudophakic children as well.

 

[smiegal]

Well, I would not call it a "clinical" scenario, but I have personally had somewhere between 50-100 different parents really desire just a "mild" reading rx. Even after I have explained that their kids do not show any measurable deficit in any areas of their vision. What do you think I should have done in that scenario? Rx +.50 or +.75 ? Rx plano? Yea, so they can come back and accuse me of lying to them? Or should I refuse? Maybe you would get up on a pulpit and proclaim that a near add is evil . Although that probably wont hold alot of water, considering that you can purchase anything up to +300 OTC. I've had people fill questionable tints in their kids glasses. Shiit I dont advise them on but that they desire. Ever consider that they just wanted a pair of glasses? What do you want to bark about now? Here is a little advice, unless you know wtf you are talking about I suggest you keep your nose in what matters! Like your pts. Id like to hear what you plan on doing with these pts, instead of your dire opinions about harmless spectacles. Hell, Ive measured -0.25 on more then one pair of OTC sunglasses, are you blaming that on ODs also? At this point I get dumber every time you post on this thread, so let it go.

Well, in response to what I'd do for the aforementioned patient, I would perform a cycloplegic refraction (as for almost every kid I see the first time). Then, I would send them to have a frontalis sling.

These are confusing:

"What do you want to bark about now? Here is a little advice, unless you know wtf you are talking about I suggest you keep your nose in what matters! Like your pts."

"At this point I get dumber every time you post on this thread, so let it go."

 

[PBEA]

If an adult wants a pair of glasses to make a fashion statement...fine.

I do not think this is the same issue when prescribing them for children. Most younger children come in complaining of decreased vision in order to get glasses. I have not seen an 8 year old come into the office asking for glasses to make a fashion statement. To give them a pair of glasses may just reinforce this behavior. Next time it could be the stomach ache to get out of school, the headache to avoid bedtime, etc.

I also think we went to school to not only prescribe glasses and medicines but to educate our patients. Having never given into a child's desire to wear glasses, I have found that parents are fine leaving without the glasses. Now maybe some of those parents go to the office that prescribed these +0.25 in this thread once they leave my office. If so, fine, I can live with that. I do not believe in prescribing for things that are not needed, no matter how "harmless" it may be. Why not just hand the prescription pad to the parents and let them decide what they need?

Do you even have a dispensary? I thought you mentioned somewhere you did retina? I have no problem with your position that you "do not believe in prescribing for things that are not needed" but you are having a disconnect between a symptomatic child, who has no problem whatsoever with their eyes, and the fact that the child wants glasses because their friend has them, or whatever. It really shouldnt matter to your field (retina?) at all, but you are fighting for something that makes little sense. Here is another example, 14yo girl wants colored contacts, but is plano. Do you deny the plano rx? You mean only people with ametropia can wear colored contacts? Lord, say it isnt so Conversely only ametropes can wear a pair of "fancy" eyeglass frames? Of course none of that is true, and while I agree with your social assessment of these scenarios, I find no real harm in it provided that they were all educated about how unecessary (and sometimes silly) these things are.

 

[DrEyeBall]

Do you even have a dispensary? I thought you mentioned somewhere you did retina? I have no problem with your position that you "do not believe in prescribing for things that are not needed" but you are having a disconnect between a symptomatic child, who has no problem whatsoever with their eyes, and the fact that the child wants glasses because their friend has them, or whatever. It really shouldnt matter to your field (retina?) at all, but you are fighting for something that makes little sense. Here is another example, 14yo girl wants colored contacts, but is plano. Do you deny the plano rx? You mean only people with ametropia can wear colored contacts? Lord, say it isnt so Conversely only ametropes can wear a pair of "fancy" eyeglass frames? Of course none of that is true, and while I agree with your social assessment of these scenarios, I find no real harm in it provided that they were all educated about how unecessary (and sometimes silly) these things are.

No, I do not do retina. I think in some previous post we were discussing something to do with retina though.

I will repeat what I said before ... I think these are two difference sets of patients. The teenager who wants contacts to change their eye color is not the 8 year old faking poor vision to get glasses. The former comes in and states what they want and why. Forget the issue about wearing contacts for a non-medical reason. Although I wold not prescribe these, that is not the issue. The point is that this person comes in and asks for something for a specific reason and this can be addressed as such. You can educate the parents about the potential dangers of contact lenses but if they feel that risk is small and the benefit is high, it may make sense to them.

The latter situation involves a child who is pretending to have a problem in order to get something they want. Prescribing in this situation may increase the chance that this pattern of behavior will occur again because it has been rewarded. I have never found a parent who still wants these glasses when told they are not needed and why I choose not to prescribe them.

I do not think you can compare these two situations and call them similar

 

[DrEyeBall]

Do you even have a dispensary? .

That is a curious question. Why do you ask? Do you think having one or not having one would influence your decision to prescribe this for the reasons you give?

 

[PBEA]

Well, in response to what I'd do for the aforementioned patient, I would perform a cycloplegic refraction (as for almost every kid I see the first time). Then, I would send them to have a frontalis sling.

These are confusing:

"What do you want to bark about now? Here is a little advice, unless you know wtf you are talking about I suggest you keep your nose in what matters! Like your pts."

"At this point I get dumber every time you post on this thread, so let it go."

Well, well, if it isnt the inflammatory op. "frontalis sling"? I presume thats sx talk for lid repair, 3mm apertures! sounds pretty severe, hard to imagine anybody missing that. I mean they must have zero field of vision, or just zero vision.

Question for you, at what age would you stop doing routine cycloplegia? I only use it in higher risk or suspicious cases. Otherwise, I just do quick wet retinoscopy with regular mydriasis to double check. I doubt ive missed anything that way, and its much faster.

Your confused about my other comments? Do I really need to clarify? You jump started this mud-slinging thread, so I have no qualms about setting you straight. Still dont get it?

 

[PBEA]

That is a curious question. Why do you ask? Do you think having one or not having one would influence your decision to prescribe this for the reasons you give?

No, but from your posts, I get the feeling you dont see many "routine" exams (or people seeking spectacles), and as such, dont see how common some of these scenarios can be.

 

[PBEA]

No, I do not do retina. I think in some previous post we were discussing something to do with retina though.

I will repeat what I said before ... I think these are two difference sets of patients. The teenager who wants contacts to change their eye color is not the 8 year old faking poor vision to get glasses. The former comes in and states what they want and why. Forget the issue about wearing contacts for a non-medical reason. Although I wold not prescribe these, that is not the issue. The point is that this person comes in and asks for something for a specific reason and this can be addressed as such. You can educate the parents about the potential dangers of contact lenses but if they feel that risk is small and the benefit is high, it may make sense to them.

The latter situation involves a child who is pretending to have a problem in order to get something they want. Prescribing in this situation may increase the chance that this pattern of behavior will occur again because it has been rewarded. I have never found a parent who still wants these glasses when told they are not needed and why I choose not to prescribe them.

I do not think you can compare these two situations and call them similar

My example wasnt perfect but it conveys the message. Point is you are holding out your opinion on these scenarios as the ideal, and refuse to consider other possibilities as reasonable. I wonder, how do you feel about refractive sx?

 

[DrEyeBall]

No, but from your posts, I get the feeling you dont see many "routine" exams (or people seeking spectacles), and as such, dont see how common some of these scenarios can be.

You would surprised how many parents come for second opinions on these too but I do see these patients as well. I can tell you that if people are prescribing these purely for cosmetic reasons, the parents are not telling people that when they go for their second opinion. That is why I would also steer clear of this practice. I really would not want my name associated with that Rx when the parents go to the next doctor.

I suspect having your own shop lowers the threshold for some people to do this. I was told by one MD that he stopped telling patients that the OTC readers were just as good as prescription readers or that -0.50 was "very weak" the day he put in his optical shop. The same can be said for those who perform surgery when not needed. the risk/benefit ratio may be higher than prescribing glasses that are not needed, but it is all just a different degree of the same thing. You have to draw the line somewhere.

 

[DrEyeBall]

My example wasnt perfect but it conveys the message. Point is you are holding out your opinion on these scenarios as the ideal, and refuse to consider other possibilities as reasonable. I wonder, how do you feel about refractive sx?

I would not have it done on me but that does not mean it is not a good procedure for people who want it. As eye care professionals, it is our job to educate patients on risks, benefits and alternatives and allow them to decide what they want.

 

[KHE]

Actually, the study referred to kids who, after picked up on a photoscreening, were found to not have amblyogenic refractive errors (i.e., false positives). The percentages relate to that SUBSET of kids who failed the photoscreening--less than 1% of the total picked up by the screening, I might add.



Again, let me correct you. Dr. Donahue mentioned the prescriptions given as ranging from -0.75 to +2.00D. The visual world of a child is inherently myopic, thus being -0.75 is in no way amblyogenic. As for the hyperopic correction, kids have an amazing degree of accommodation (>12D). To accommodate 2-3D would likely not even cause significant eyestrain in a youngster. With growth-related myopic shifts of 0.5-1.00D per year, such children would have outgrown their "need" for glasses in a relatively short amount of time.

Perhaps it IS a difference in philosophy; however, the pediatric ophthalmologists strangely do not cause amblyopia by not prescribing +2.00D lenses to youngsters. Interesting, eh?

No one is suggesting that -0.75 or +2.00 refractive errors are amblyogenic, or that pediatric OMDs are inducing amblyopia by not prescribing in that range.

But the author of the study basically makes the blanket statement that any prescrption in that range is not needed, and the underlying implication that he makes is that people who do it only do it for the money.

Rest assured there are plenty of symptomatic -0.75 people running around. There are also plenty of symptomatic +2.00 children. Even if they have large amplitudes of accommodation (a monocular reading) and can accommdate 12 diopters, that still means that a +2.00 hyperope would have to use 4-5 diopters of accommodation to read. I can lift 100 pounds but I'm not going to be too happy carrying around 40 pounds all day. None of this even considers phoria measurements or effects on the vergence system that all this accommodation has.

 

[KHE]

I will repeat what I said before ... I think these are two difference sets of patients. The teenager who wants contacts to change their eye color is not the 8 year old faking poor vision to get glasses. The former comes in and states what they want and why. Forget the issue about wearing contacts for a non-medical reason. Although I wold not prescribe these, that is not the issue. The point is that this person comes in and asks for something for a specific reason and this can be addressed as such. You can educate the parents about the potential dangers of contact lenses but if they feel that risk is small and the benefit is high, it may make sense to them.

The latter situation involves a child who is pretending to have a problem in order to get something they want. Prescribing in this situation may increase the chance that this pattern of behavior will occur again because it has been rewarded. I have never found a parent who still wants these glasses when told they are not needed and why I choose not to prescribe them.

I do not think you can compare these two situations and call them similar

Sorting out which patients have a true problem and which ones are just looking for glasses is relatively easy. Any first year optometry student can do it. In all my years, I have never encountered any practitioner who prescribed prescription eyewear to a child just because they wanted it knowing full well the childs motivation.

As eyewear becomes more fashionable I have however seen some adults request plano lenses be put into fashionable frames for cosmetic reasons. This seems to be rare however. Frames that are even remotely fashionable can get pricey quickly and my experience is that most women (its always women) would rather spend the money on shoes and bags.

 

[PBEA]

I would not have it done on me but that does not mean it is not a good procedure for people who want it. As eye care professionals, it is our job to educate patients on risks, benefits and alternatives and allow them to decide what they want.

Dont you see that you are talking on both sides of this debate? You will "educate patients on risks, benefits and alternatives and allow them to decide what they want" with regard to invasive eye surgery, but when it comes to spectacles or colored contacts you draw the line? C'mon, gimmee a break, you have to see that!!

Another example, new pt, 25yo wearing bifocals for no apparent reason other then thats what he's been wearing for a long time. Pt does not need the bifocal (shown to him with simple demonstration), but really, really, really wants to keep wearing bifocals. You are telling me you will not give this guy the rx? Even after you "educate patients on risks, benefits and alternatives and allow them to decide what they want" still no rx? Your like the spectacle nazi!!! just kidding, anyway its been fun im going to bed, g'night

 

[DrEyeBall]

Dont you see that you are talking on both sides of this debate? You will "educate patients on risks, benefits and alternatives and allow them to decide what they want" with regard to invasive eye surgery, but when it comes to spectacles or colored contacts you draw the line? C'mon, gimmee a break, you have to see that!!

Another example, new pt, 25yo wearing bifocals for no apparent reason other then thats what he's been wearing for a long time. Pt does not need the bifocal (shown to him with simple demonstration), but really, really, really wants to keep wearing bifocals. You are telling me you will not give this guy the rx? Even after you "educate patients on risks, benefits and alternatives and allow them to decide what they want" still no rx? Your like the spectacle nazi!!! just kidding, anyway its been fun im going to bed, g'night

The same can be said for surgery. There are patients who want a surgery that makes no sense to me and I can not in good faith perform it. If an adult wanted those colored contacts, fine i would prescribe them but not a child. Those glasses for children are still a different story to me.

As for the bifocal. This happens fairly frequently. I do rewrite the Rx in that situation.

I guess the bottom line is that there are many ways to treat patients. There are some ways we can all agree are right, some we can all agree are wrong and some that we will not agree with each other. What we need to see is that this is not an OD vs MD thing. There are plenty of good people in both professions. We also each have our share of questionable people. We can have these discussions without accusing the etntire group or the other of being greedy pigs or being stupid.

 

[PBEA]

Sorting out which patients have a true problem and which ones are just looking for glasses is relatively easy. Any first year optometry student can do it. In all my years, I have never encountered any practitioner who prescribed prescription eyewear to a child just because they wanted it knowing full well the childs motivation.

As eyewear becomes more fashionable I have however seen some adults request plano lenses be put into fashionable frames for cosmetic reasons. This seems to be rare however. Frames that are even remotely fashionable can get pricey quickly and my experience is that most women (its always women) would rather spend the money on shoes and bags.

Im playing devils advocate for these scenarios as I do not prescribe that low a plus rx for anyone, but thats not the point. In all the +0.25 spectacles ever prescribed, your saying that there was a functional reason for it? I doubt it, more likely the pt or parent requested it and the doc allowed it, because what difference does it make? I have worked with a few ODs who have rxd some low plus and although I never asked them why, I tend to think my above assumptions explain it.

 

[Wolverine98]

Im playing devils advocate for these scenarios as I do not prescribe that low a plus rx for anyone, but thats not the point. In all the +0.25 spectacles ever prescribed, your saying that there was a functional reason for it? I doubt it, more likely the pt or parent requested it and the doc allowed it, because what difference does it make? I have worked with a few ODs who have rxd some low plus and although I never asked them why, I tend to think my above assumptions explain it.

Actually, from the offices I'm thinking of, the parents were told that the children HAD to wear them, or they were at risk of going blind. This is also in a patient population that is not buying things for cosmetic reasons. They're giving up clothing and food for themselves to buy their kids these "necessary" +0.25 glasses. If it happened once or twice, I would just assume that the parents misunderstood, but when several people are saying the same thing, it gives you pause.

In all the degeneration of this thread, I still have yet to see a good explanation for why +0.25 glasses would be medically needed. I've seen a few (IMO iffy) reasons for doing so, but no necessary ones. We've jumped to talking about -0.75 and +2.00, which are both different issues.

As I see it, kids (or parents asking for them) wanting glasses just to have glasses is akin to patients demanding antibiotics for colds. From that individual patient's standpoint, there's not a lot of harm in taking them, but it's really not in their best interest for multiple reasons (some of which have already been touched on).

The cosmetic contact debate is probably a whole other thread in itself. I've seen two patients in the last 6 months who are now bilaterally in the 20/200 BCVA range thanks to these (gotten from gas stations, which is, again, a whole other issue).

BTW, I should say that my initial response was not to say that ODs are evil greedy bastards by nature (because, as mentioned there are plenty of those among both ODs and OMDs). It was simply to point out that this does happen, in response to those who said this couldn't be going on.

Dave

 

[f_w]

I still have yet to see a good explanation for why +0.25 glasses would be medically needed.

And you won't get one here. Once the OD police gets a choke-hold on a thread, specialty related questions fall by the wayside.

As I see it, kids (or parents asking for them) wanting glasses just to have glasses is akin to patients demanding antibiotics for colds. From that individual patient's standpoint, there's not a lot of harm in taking them, but it's really not in their best interest for multiple reasons

I'm just glad that glasses rarely kill or take your kidneys out.

BTW, I should say that my initial response was not to say that ODs are evil greedy bastards by nature

That sounds so harsh. I prefer crafty businesspeople with the 'can do' customer service attitude.

 

[Visionary]

No one is suggesting that -0.75 or +2.00 refractive errors are amblyogenic, or that pediatric OMDs are inducing amblyopia by not prescribing in that range.

But the author of the study basically makes the blanket statement that any prescrption in that range is not needed, and the underlying implication that he makes is that people who do it only do it for the money.

Rest assured there are plenty of symptomatic -0.75 people running around. There are also plenty of symptomatic +2.00 children. Even if they have large amplitudes of accommodation (a monocular reading) and can accommdate 12 diopters, that still means that a +2.00 hyperope would have to use 4-5 diopters of accommodation to read. I can lift 100 pounds but I'm not going to be too happy carrying around 40 pounds all day. None of this even considers phoria measurements or effects on the vergence system that all this accommodation has.

Symptomatic is one thing. Have I prescribed +1.50D specs for symptomatic kiddos? You bet. What I cannot make sense of from the study data is why there is such a disparity among the different eye care professionals. You can't tell me that the ODs saw that many more symptomatic kiddos than the OMDs, can you? Or even that the general OMDs saw more than the pediatric OMDs?

And I am not saying that it's about money. There's enough money-grubbing to go around in both our professions, so let's drop that angle. It may simply be, as stated by DrEyeBall, a difference in educational philosophy. Regardless, there is a clear difference.

 

[DrEyeBall]

Symptomatic is one thing. Have I prescribed +1.50D specs for symptomatic kiddos? You bet. What I cannot make sense of from the study data is why there is such a disparity among the different eye care professionals. You can't tell me that the ODs saw that many more symptomatic kiddos than the OMDs, can you? Or even that the general OMDs saw more than the pediatric OMDs?

And I am not saying that it's about money. There's enough money-grubbing to go around in both our professions, so let's drop that angle. It may simply be, as stated by DrEyeBall, a difference in educational philosophy. Regardless, there is a clear difference.

This is something that should be examined. There are differences of practice that just can not be based upon or explained by one "type" of pateint seeing an OD or MD. Does every +1.50 hyperope with asthenopia just happen only to see ODs and all the asymptomatic ones go to MDs? Probably not. More importantly, people can learn from the experience of others. It bothers me when I see a child who has been "weaned into" a high plus prescription with multiple Rx's. I do not think someone has done this to sell multiple glasses. I think someone told them in school that is the way it is done and they never question that practice. When I discuss these patients with the referring doctor, they tell me that children never accept their full plus. It is frustrating that after I tell them I, and most other people I know, prescribe the full CR on the first exam and the children have no problem wearing it, they continue to prescribe in their old way. Do they not trust the advice, do they even bother to try it to see if it might be true? These difference in practice pattern should be examined and discussed openly.

 

[KHE]

This is something that should be examined. There are differences of practice that just can not be based upon or explained by one "type" of pateint seeing an OD or MD. Does every +1.50 hyperope with asthenopia just happen only to see ODs and all the asymptomatic ones go to MDs? Probably not. More importantly, people can learn from the experience of others. It bothers me when I see a child who has been "weaned into" a high plus prescription with multiple Rx's. I do not think someone has done this to sell multiple glasses. I think someone told them in school that is the way it is done and they never question that practice. When I discuss these patients with the referring doctor, they tell me that children never accept their full plus. It is frustrating that after I tell them I, and most other people I know, prescribe the full CR on the first exam and the children have no problem wearing it, they continue to prescribe in their old way. Do they not trust the advice, do they even bother to try it to see if it might be true? These difference in practice pattern should be examined and discussed openly.

That's a legitmate question. I only practice part time right now, but throughout my training I encountered people who advocated full cycloplegic Rxs and those that advocating the "weaning" that you describe.

I've done it both ways and more often than not, I go with the "weaning" method because I have encountered far more problems with the full cycloplegic Rx.

If you are used to seeing the world a certain way, and someone throws on a pair of +5.00-3.50x 45s the huge jump in accommdative and convergence demand as well as your spatial perception is not going to make you too happy.

I've seen enough parents who saw practitioners who do the full cycloplegic right away tell me that the child has never worn the glasses and constantly pulls them off their face. And these aren't kids who are just refusing glasses because I have found that in these cases, starting with a lower Rx (usually the dry refraction) and working up usually creates more acceptance in these patients, especially if large amounts of cylinder are involved and especially since someone with a dry refraction of +3.50 and a wet refraction of +5.50 is essentially running around as a +3.50 hyperope when they are not cyclopleged.

So again, more art than science I guess.

 

[smiegal]

Well, well, if it isnt the inflammatory op. "frontalis sling"? I presume thats sx talk for lid repair, 3mm apertures! sounds pretty severe, hard to imagine anybody missing that. I mean they must have zero field of vision, or just zero vision.

Your confused about my other comments? Do I really need to clarify? You jump started this mud-slinging thread, so I have no qualms about setting you straight. Still dont get it?

I truly wish I could post a photo of this child. She has a constant chin-up head tilt with 3 mm fissures OU. I shouldn't have included that info in my initial post because I really wanted to discuss +0.25 OU pediatric reading glasses (but it is one of the most bizarre missed diagnosis cases I've ever seen). It probably just annoyed people and set a bad tone for the discussion.

The issue truly does frustrate me, though, and I still can't think of a good reason to ever give a kid +0.25 OU other than $. If people think differently, I'm interested in their opinion.

As for you, PBEA, what's all this "setting you straight" and "you don't know wtf you're talking about" stuff in your posts? All you've demonstrated thus far is that you're very angry and defensive.