little four eyes

It took me a very long time before I could spell ophthalmologist right on the first try.  I guess one of the perks of a kid in glasses is that I can now type it quickly with no problem.  So I had to laugh when I this tweet from FakeAPStylebook (absolutely worth following if you enjoy funny tweets, it probably goes without saying that it has nothing to do with children’s eye issues):

Glasses – Check

Occlusion – Check

Surgery – Check

Prism Adaptation – Check

Hmmm… is there something related to little ones in glasses that we haven’t tried yet????   Not that I know of!  We went to the ophthalmologist on Friday due to Elliana’s eyes becoming more over corrected. (major bummer) It appears that she is reacting atypically.  As time progresses her eyes are turning in more rather than becoming straighter as traditionally happens.  She now has a Fresnel prism placed on her glasses.  My first question was, “What is that?”  I understand that it similar to the prisms used in the exams.  I asked how it is different than a lens.  It does not affect the distance at which the light focuses on the back of the eye, rather bounces light in a different way (sorry, still not sure on this.)  Googling Fresnel Prisms on glasses has me just  about as confused.  The article Management of Strabismus and Amblyopia: a Practical Guide byBy John A. Pratt-Johnson, Geraldine Tillson says that “Occasionally, a patient with an acquired esotropia and the full optical correction in place may have a much larger angle esotropia on the prism cover test than appears to be present at a casual glance…the prism estimated as needed to neutralize the deviation is inadequate and more and more prism is required.”  It sounds like this treatment is rare.  We pretty much put a stick on prism over her strong eye because it may act as an occluder.  We go back on Friday for more tests and the article says something about testing for fusion with a synoptophore or the Whorth four-dot test. None of which I know anything about.  Unfortunately, we also have to put atropine drops in both of her eyes for the next 3 days in order to get a good read on her vision this Friday.  Since she is older and more verbal about her eyes – she is NOT a happy camper and has expressed her distaste for the eye drops and has screamed all morning.  2 more mornings of drops.  Wish me luck and let me know if you know anything else about the prisms!

I’m reposting this comment from Stacy in hopes that others will have information for her. -Ann Z

I have a 15 month old son, Ethan, and we just had our first visit with a pediatric ophthalmologist. I feel very disappointed, frustrated and scared after this appointment. We took our son to the ophthalmologist because his left eye turns in. I was not terribly worried because I had amblyopia as a child and anticipated that at the most we would be patching our son’s eye. The eye doctor told us that Ethan’s right eye has 20/20 vision, but his left eye is extremely nearsighted and that he had something called “myelinated retinal nerve fibers.” The eye doctor told us we would need to patch his right eye and that he would need to wear glasses with a Rx of -8.5 in the left lens. He told us we could “read up” on these myelinated retinal nerve fibers as it is a rare condition. He also said that with patching and glasses (6-8 hours a day) that a reasonable vision expectation for Ethan would possibly be 20/50. I feel lost. All I can find on “myelinated retinal nerve fibers” are medical journals full of jargon that I do not understand!!! I’m still unclear as to what Ethan’s actual diagnosis is or how long we will need to patch and wear glasses. All I know is that I am to return in 2 months to check his vision again. We are seeking a second opinion. But has anyone been told their child has “myelinated retinal nerve fibers?” Any help would be soo appreciated! I feel defeated.

Edited on 26-Jan-10 to correct the errors that Dr. Bonilla-Warford pointed out (thanks Nate!) – Ann Z

Glasses prescriptions can be confusing – lots of numbers and abbreviations that aren’t necessarily easy to figure out, or at least, they weren’t when I first tried to understand Zoe’s prescription.  And in fact, I thought I understood what all the numbers meant, but after doing more research for this post, I found it to be far more complex than I’d originally thought. (On that note, if any eye doctor types read this and catch any mistakes, please, please let me know and I’ll correct them – thanks Nate!).

Before we get too far into what a prescription is, I thought it might be worthwhile to mention what a prescription isn’t.   It will not tell you:

• what your child’s diagnosis is.  You can tell whether glasses will correct for nearsightedness or farsightedness, but that doesn’t tell you what the cause of the vision problem is.
• if your child has amblyopia, it will not tell you what his or her actual visual acuity is.
• if your child has strabismus, it will not tell you how much his or her eyes are turning in or out.
• how well your child’s eyes work together, and whether or not he or she has stereoscopic vision.
• how advanced your child’s cataracts or glaucoma is, and how that affects their vision.
• anything that is not related to how glasses or contacts should be made in order to correct your child’s refractive errors (that is, due to the shape of the eye not being able to focus light correctly).

Okay, so back to the eyeglasses prescription then, and what it can tell you.  Prescriptions have a lot of different components, and I’ve seen them written a number of different ways, but they do have common elements at the core.  I’ll go into more detail on each piece, but I tried to put together something of a “cheat sheet” here:

Which eye are we talking about?

Since we’re nearly always looking at prescriptions for two eyes, you’ll nearly always see two sets of numbers, one for the left eye, and one for the right.  I’ve seen some prescriptions that label them “left” and “right” or “l” and “r”, which even I can figure out on my own.  But more often, I’ve seen “O.D.” and “O.S.”.  These are abbreviations for the Latin words for left eye and right eye.  For the record:

• O.D. : right eye
• O.S. : left eye
• O.U. (which I’ve never seen before, but found this information so figured I’d include it) : both eyes

Sphere

Sphere, often abbreviated as “sph” is the spherical refractive error, or nearsightedness or farsightedness.  It’s pretty much what I think of when I think of an eye glasses prescription.  Then again, I’ve never really had to deal with astigmatism (for me or Zoe).  The first part of this number will be a plus or minus sign:

• + : farsighted, or longsighted prescription: hyperopia.
• - : nearsighted, or shortsighted prescription: myopia.
• 0, Pl, or Plano : no error

How bad is the spherical prescription?

The number is in “diopters” but we don’t need to know too much about that (read about it on Wikipedia here), it’s a measure of how much the curvature of the eye  is off from normal.  Basically, the higher the number (ignoring the plus or minus), the worse the prescription.

Myopia (-)

• 0.00 to -3.00 : mild myopia
• -3.00 to -6.00 : moderate myopia
• -6.00 and higher : high myopia

Hyperopia (+)

• 0.00 to +2.25 : mild hyperopia
• +2.25 to +5.00 : moderate hyperopia
• +5.00 and higher : high hyperopia

Cylinder

Cylinder is the measure of astigmatism.  Astigmatism is when there’s an irregular shape to the cornea, often described as a football shape.  It causes blurriness at any distance.  There are two measurements that go along with astigmatism, the first, cylinder, is a measure of how severe the astigmatism is.

How bad is the cylinder prescription?

Like the spherical error, the cylinder number is measured in diopters.  The thing you want to pay attention to is the number.  It may be written as a plus or a minus, but that doesn’t actually make any difference in how bad the prescription is, ophthalmologists use a “+”, optometrists use a “-” (see Dr. Bonilla-Warford’s comment for more explanation of that).   The higher the number after the plus or minus, the more severe the astigmatism.

• 0.00 to 1.00 : mild astigmatism
• 1.00 to 2.00 : moderate astigmatism
• 2.00 to 3.00 : severe astigmatism
• 3.00 and higher : extreme astigmatism

Axis

The axis tells you whish way the astigmatism is oriented on your child's eye

If you think of astigmatism as a football shape, it makes sense that the football might be turned any direction.  The axis number then, tells you the orientation of the astigmatism.  The number is in degrees, it doesn’t have anything to do with how severe the astigmatism is, just how it is situated on your child’s eye.

Add

If your child needs bifocals, you will likely see a number here.  This tells you how the prescription should be changed for close up.  Let’s say your child has a regular glasses prescription of +3.00, if the add number is +1.00, then the near distance prescription will be +3.00 + 1.00, which equals +4.00 (3+1=4).  In the same vein, if your child is nearsighted, say -4.00, but has an add of +2.00, then the  near distance part of the bifocals will have a prescription of -4.00 + 2.00, which equals -2.00.

Sometimes, you don’t have an “Add” part of the prescription, and instead you’ll just see a prescriptions for distance vision and a separate prescription for near vision.

But what does that mean for how my child sees?

If you’re wondering what your child’s prescription means in terms of how they can see, there are a couple of places online where you can plug them in to see how blurry things appear.  Keep in mind that an eyeglasses prescription is not the final word in how well a child sees.  For instance, it will not tell you how your child’s weak eye is seeing if your child has amblyopia, or how your child might be seeing if he or she has cataracts or glaucoma.

Online vision simulators:

• Eyeland Web Tools – this site has one tool for myopia, and a different one for hyperopia, and one for astigmatism.  All three show you a scene that you might see while driving a car.  So hopefully not a scene that your child would necessarily see, but it still helped me visualize how the world might look with Zoe’s prescription.  Simulates prescriptions from +9 to -9 for the spherical error, and up to -8 for the astigmatism.
• Eli Billauer’s blur simulator – I’ve mentioned this site before on Little Four Eyes.  Enter your child’s prescription (sphere, cylinder and axis) for each eye, and it will show you two Snellen charts (the one’s with the big E at the top), one for each eye, that simulates how your child might see it.  Simulates prescriptions from +5 to -5 for the spherical error and +5 to -5 for astigmatism.
• Wolfram Alpha – this is a weird search engine that tries to answer your questions, and calculate equations that you enter.  You can enter your child’s eyeglasses prescription, and it will give you information about it, including a simulation of looking at the Snellen chart, and the far or near point for clear vision.  You will only see the Snellen chart if the simulator thinks one of the lines would be visible, which is +2.5 to -2.5.   You need to enter the prescription this way:

  OD +4.25 cyl 0.5 x 90

  (the number after the “x” is the axis for astigmatism, you can leave off the astigmatism numbers if they don’t apply).

Melissa from Children’s Hospital Boston’s pediatric blog, Thrive, wrote about a baby undergoing a new surgical procedure, called keratoprosthesis to replace her damaged cornea with an artificial one.  It’s an interesting story with a hopeful ending.  I have to say, writing this blog has given me a new appreciation for vision, and how fragile it can be, and some of the amazing advances in medicine.  I feel like I’m forever learning more and more (that’s a good thing).

In Tami’s story, her daughter Lilly passed the vision screening that their school system required for kindergarten, but was found to have amblyopia at an eye exam at an ophthalmologists   (read the whole story) .  As I was looking in to this, I was surprised to learn that this isn’t all that uncommon.  Children can and do pass the quick vision screenings at their doctors or at school, when in fact, they do have vision problems that need to be treated.  In the United States, most states require some vision screening before a child starts school (though 16 states have no requirement at all), only 3 states require a comprehensive eye exam.  I’d love to hear from readers in other countries about whether they have any vision screenings or exams that are required of children before they start school.

What’s the difference between a vision screening and a comprehensive eye exam?  A comprehensive eye exam is performed by an opthalmologist or optometrist and includes a visual acuity test using one eye, and then the other, cover testing, and then dilating drops and retinoscopy (if you’re reading this because your child wears glasses, this would be the very familiar eye exam).  The screenings, on the other hand, vary from place to place, but most typically involve reading an eye chart or vision acuity cards, though some use refractors that measure the refractive error of the eye without dilating the eye first.  Screenings may be done by pediatricians, school nurses, technicians or trained lay persons.  There is no question that the full comprehensive eye exam is necessary to get the complete picture of a someone’s vision needs.  The question is whether a screening can identify kids with vision issues and get them to an eye exam to figure out exactly what treatment is needed.

The Report of the National Commission of Vision and Health on Children’s Vision that was released this summer does a nice job of compiling and explaining studies that have been done to compare vision screenings to vision exams (the report is here, start on page 9 for the section on screenings and exams).  Vision in Preschoolers, or VIP, is one such study, conducted in 2001-2004, by the National Eye Institute, which compared 11 vision screening tests to see which were the most accurate.  The three best tests still missed more than 30% of kids with vision problems (though they did identify 90% of children with the most severe vision problems).

At least one study cited in the report found that the additional cost of having all children go through a comprehensive eye exam is easily offset by the increase in the number of children whose amblyopia could be detected earlier and treated successfully, compared with the numbers detected and treated with a vision screening program (full text of that study is here).

I know that I’m preaching to the choir here at Little Four Eyes, but please encourage friends and family to have their children’s vision checked out at a full eye exam, rather than relying on vision screenings.  Programs such as InfantSEE (at infantSEE.org) provide exams at no cost for infants, and many insurance programs cover comprehensive eye exams once a year or once every two years.

Tami sent me this story about her experiences in getting her daughter diagnosed.  I have more to write about the importance of vision exams over vision screenings, but there is so much good advice in this story, that I wanted to publish it on its own.  -Ann Z

My daughter, Lilly, turned 5 in June. During her annual check up we were sent to the optometrist’s office to read the eye chart. That is the only thing that is required by our school system for kindergarten entrance. There was no specific line for her to stand on, the lady just told us to stand in an approximate spot about 4 feet from the chart and read as many lines as possible with both eyes. Next she was told to cover her left eye with her hand and read as many lines as possible. Then the same with the right eye covered. We were handed a slip of paper saying she had 20/20 vision.

I knew our health insurance covered one eye exam a year as long as we saw an ophthalmologist. We don’t have vision insurance and I have been wearing corrective lenses since I was 10 so I always take advantage of that. I had also taken Lilly in before she started preschool when she was 3. He didn’t find any problems at that time. Her preschool also had the Lion’s club in doing eye checks and there were not problems found.

I had an exam already scheduled for her the next week after her annual pediatrician’s exam (June 30th). I figured it was a good idea to get her in before she started kindergarten, just to be sure there were no problems.

After going back to the office she sat in the exam chair and was told by the nurse to read the chart with both eyes, no problem. Then the dr came in. He had her read the chart with both eyes, no problem at all. Then asked her to cover her left eye with the plastic thing, no problem. Next he told her to cover her right eye, she sat there for a moment, then started moving the plastic thing and cheating. I could tell the dr was getting annoyed by it so I went over and covered her eye. To my complete shock, she could not read it! Not even the top line. My heart sank. How could I not know that my baby couldn’t see out of one eye?

Next the dr put dilating drops in and asked us to wait in the hall for a few minutes. When we went back in he did all the usual things optometrists and ophthalmologists do with adults. Looking into her eyes, changing lenses to find the right prescription the reading the charts again.

Sadly this dr was not very good about explaining her situation. He told me she had good vision in the right and bad vision in the left along with an astigmatism. She would need glasses and I would need to put atropine drops in the good eye every day. That was about it. As soon as I left the office I was on the phone leaving a message with a friend who’s daughter also wears glasses, just to get  some general information from her such as a good place to buy glasses.

After a night of stewing, not sleeping and worrying about how we were going to pay for all of this with no vision insurance I talked to the nurse and she informed me that it was called Amblyopia and that our health insurance would probably pay for it. So, I called the insurance company, they told me that yes it was a medical diagnosis so insurance would pay for exams, but not glasses. I find that crazy. If you break a bone your insurance pays for getting a cast put on!

I was talking to the mother of one of Lilly’s t-ball teammates. Her daughter had amblyopia also and they had a wonderful pediatric specialist that they really liked in another city about 45 minutes away. I decided we’d go back for her re-check the next month and see what the dr said.

A month later (August 6) we had to go back for a re-check. After reading the eye chart and looking at her eyes he tells us that she’s had tremendous improvement and we could stop the drops, continue wearing the glasses and come back in a year.

After all that I had read on the internet, I didn’t like what I heard. So I called the specialist I had been told about, and actually had heard his name from a few other people too. It was hard to get an appointment (September 6) and I had to take Lilly out of school for half the day, but I had no choice unless I wanted to wait until January.

I am totally sold on the pediatric ophthalmologist! When we were called back into the exam room the assistant asked us what brought us there and I explained everything up until that point. That place is fantastic. What a difference going to a place that is geared toward children! The staff is so much more patient and they have so many tricks to making the kids cooperate. In the first room Lilly read the eye chart with her glasses on and the lady took her glasses for a bit to check them. Then she dilated both her eyes and sent her into the waiting room filled with toys and a Disney movie playing.

After a few minutes we were sent into a different room to wait for the dr. When he came in he asked us to again tell him the story of what brought us to his office. He seemed very irritated by us being told that everything was fine after a month. He told us that treating amblyopia can take many months and even years to treat. He did all the same things as the other dr, but he was much more patient with her and had the tools to get her to cooperate for him, such as animals and movies to draw her attention.

At the end of the exam he told us that she definitely needed to return to treatment and gave us the option of doing the drops again or try patching. She also needed new lenses in her glasses, a stronger prescription for the bad eye. He told us that if the drops didn’t make enough improvement we would have to start patching and also warned us that it was possible that she would need surgery if the the patching didn’t work. He asked if we had ever noticed the lazy eye , which we hadn’t, so he made her eye drift off so we could see what was going on. He was also very thorough about telling us all about the condition, such as most of the time children have it from birth and how often it goes undiagnosed. He waited to see if we had any more questions for him before he left too. Nothing is worse than a dr that darts out of the room before you have a moment to think about things.

I walked out of that office feeling much better about the situation than I ever had. I will NEVER deal with someone who is not a pediatric specialist for anything again. The original dr is a good dr for me, but not for her!

We go back next month (November 5th) to see if she’s improving with the drops.

I just read a fantastic post over at Christopher’s Eyes that I wanted to pass along. Christopher is three, and has congenital glaucoma, which means many, many appointments to check his eye pressure.  For young kids, this means an exam under anesthesia (EUA), which is a huge production requiring a trip to a hospital and a lot of preparation, because the child will be put under anesthesia.  Most doctors will say that EUA’s are needed until a child is at least 6 because no child will sit still enough for the adult pressure checks.  Christopher’s Dad talks in great detail about  the process they went through to help Christopher feel comfortable at the doctor’s office, and to understand what was going on, and to sit still for successful eye pressure checks at the doctor.

Even if your child won’t need an EUA, the post is a good one for thinking about compassionate and helpful ways to help your child feel comfortable in exams or with unfamiliar procedures.

I just ran across a press release today announcing promising early results of a study named the Stabilization of Myopia by Accelerated Reshaping Technique (SMART) Trial -  The study is a five-year trial of a treatment called overnight orthokeratology (also known as corneal refractive therapy or vision shaping treatment).  In this treatment, patients wear a rigid, specially designed contact lens at night which reshapes the cornea leading to clearer vision during the day.   This treatment was approved in 2002 for use in the USA to treat myopia (or nearsightedness), and I believe it has been used elsewhere, particularly in Japan, for longer.  It is worth noting that the treatment does not cure nearsightedness; like glasses, it only treats it.  When patients go for a few nights without wearing the lenses, their vision will go back to their normal prescription.

The exciting thing about this trial, though, is that it is looking at whether overnight orthokeratology can actually slow or even stop the progression of myopia in children.  Myopia tends to get worse through childhood, and for parents with young children who are already significantly myopic, the idea of their vision worsening is very concerning.   As mentioned above, the SMART trial is a 5-year trial that will follow 300 children aged 8 – 14.  The trial is only one year in, however, the early results appear promising.  The children wearing the overnight orthokeratology lenses showed little to no change in their myopia, compared with those who wore soft contact lenses during the day whose nearsightedness got progressively worse.  It is worth noting that these results are coming from a press release, and nothing has been published in a peer reviewed journal yet – this isn’t surprising as the study isn’t finished – but it is building on existing studies which have shown similar results.   It will be very interesting to watch this study and see how the results look at the end of the trial, but the possibility of arresting the progression of nearsightedness is very exciting!

If you’d like to learn more, you can read more about the treatment and study in this article: Nighttime contact lenses show promise in controlling nearsightedness,  or see a video of two young girls using the lenses at Bright Eyes News.

This story comes from Dina, the author of the blog Frazzled Working Mom.  Her older child has since been diagnosed on the autism spectrum and is legally blind; as a result, Dina has become an expert in navigating through the special education system to successfully advocate for him. She’s sharing the story of her son’s vision problems in two parts.  Watch for part 2 coming soon. – Ann Z

I was delighted to be invited as a guest writer this week on the “Little Four Eyes” blog. I write my own blog covering topics about the juggle on managing work and life, and Ann and I met in the blogosphere over our common thread of having a child with glasses. Though my story starts 9 years ago when I easily conceived my first child, and I thought that things were too good to be true. I quickly learned that they were.

After just 5 months and 4 days of being pregnant, my son was born after a 2 hour labor, which the doctors were unable to stop. Weighing about a pound and a half, my son spent five grueling months in the newborn ICU. Like many preemies, he was diagnosed with “Retinopathy of Prematurity” – simply called – ROP. Preemies are at risk of blood vessels in the eye growing “out of control” and causing damage to their retinas. In some extreme cases, retinal detachment can occur.

When my son was two months old (though still many weeks shy of his due date), we enrolled him in a study and he qualified for surgery much earlier than when it was typically called for. The study would “test” out this early treatment, but only in one eye. It was a study we almost opted out of because of his overall precarious health. I will be grateful for the rest of my life that we enrolled him in it, and if given the chance, I would stand up in Times Square and shout my endorsement of clinical studies. My son would be completely blind had he not been enrolled in this study.

The eye that did not qualify for the study (“the control” treatment) ended up having a retinal detachment; he was transferred by ambulance to the only hospital in Boston with a pediatric retinal surgeon for reattachment surgery. Despite close follow-ups, the doctor didn’t call the surgery a failure until several months later, and he gave us a “last resort” to save his vision. We drove a third of the way across the country to go to the #1 ranked pediatric retinal surgeon in the country. A long shot, but our only shot. It didn’t work.

So, the decision to put him in the study was thus far the best decision of my life. And the treatment from the clinical study is now the standard treatment; my son’s doctor told me that there is now a much lower incidence of blindness in pre-term babies because of this. So while my son lost his sight in that eye, he at least helped to save others who followed behind him.

My son is near-sighted in his “good” eye, and he wears glasses every waking moment to protect that eye as well. He wouldn’t be who he is without the glasses. They’ve been a part of him ever since he learned to walk.

He is considered legally blind, which makes life hard in many ways. But at least he can see out of one eye. I know a family from the NICU who didn’t participate in that study, and their child is completely blind. I haven’t talked to them in years, but I think of them frequently.

So while I wish we didn’t go through any of this, and our whole pre-term saga has many other layers to it, it has at least made us all stronger for having been down this windy road.

Read Part II.

You can read more of Dina’s writing at Frazzled Working Mom, which explores topics covering work/life balance and offers tips for handling the chaos in life.