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Medical Forum / General / Vision / October 2006Glasses for 5 year-old twins
Our twins finally got a 2nd opinion from the opthamologist after being told by an optometrist that they needed glasses. To recap, one of our twins was (under drop, the term used by the opthamologist) -1.50 in each eye, while the other was -2.00 and -2.75. The opthamologist said the following: 1) Children under-9 should NOT normally be given corrective lenses if they are hyperopes and within 2-3 diopters, provided they seem to be able to function well visually. He mentioned something about young children having lots of "reserve". 2) Although optometrists in Ontario fought for years for the right to administer cytoplegic (?) drops, few actually use them and it's virtually impossible to accurately measure a child's refraction without them (e.g. with an auto-refractor). 3) He is currently doing about 20 second opinions each week (he had done 4 by noon today when he called me back) and reversing virtually all the recommendations received from optometrists for prescriptions given to young children. As a result, there must be thousands of young children out there wearing glasses unnecessarily. For us, that makes twice in 3 years that the OD has overruled the optometrist. We're going to follow his recommendation. -Pat On 10/17/06 7:08 PM, in article 45358c42$0$5567$c3e8da3@news.astraweb.com, > For us, that makes twice in 3 years that the OD has overruled the > optometrist. We're going to follow his recommendation. I thought OD meant optometrist. Did you mean ophthalmologist? Bill -- Fermez le Bush Yes. > On 10/17/06 7:08 PM, in article 45358c42$0$5567$c3e8da3@news.astraweb.com, > [quoted text clipped - 7 lines] > Bill > -- Fermez le Bush If they are hyperopes, the numbers must be (+) not (-). Minus is myopic. On 10/17/06 7:08 PM, in article 45358c42$0$5567$c3e8da3@news.astraweb.com, > Our twins finally got a 2nd opinion from the opthamologist after being > told by an optometrist that they needed glasses. [quoted text clipped - 22 lines] > > -Pat > 2) Although optometrists in Ontario fought for years for the right to > administer cytoplegic (?) drops, few actually use them and it's virtually > impossible to accurately measure a child's refraction without Cycloplegic drops should be administered by medical doctors and optometrists are NOT medical doctors. > For us, that makes twice in 3 years that the OD has overruled the > optometrist. We're going to follow his recommendation. The OD stands for the optometrist. An ophthalmologist is an MD who specializes in the eye. Your twins need to see a pediatric ophthalmologist, not a general optometrist. > > 2) Although optometrists in Ontario fought for years for the right to > > administer cytoplegic (?) drops, few actually use them and it's virtually [quoted text clipped - 9 lines] > specializes in the eye. Your twins need to see a pediatric ophthalmologist, > not a general optometrist. Actually, optometrists *are* allowed to use "drops" to dilate the pupil and administer a cycloplegic refraction. I believe they can also prescribe some types of medicine and eyedrops, such as used for dry eyes. What they *cant* do is surgury, although I heard theres a waiver for PRK(not lasik!) anyway if your children are hyperopic, they dont need glasses if theres no symptoms. If they are myopic, Otis can offer advice to help them clear their vision to 20/40 or better. > > 2) Although optometrists in Ontario fought for years for the right to > > administer cytoplegic (?) drops, few actually use them and it's virtually > > impossible to accurately measure a child's refraction without > > Cycloplegic drops should be administered by medical doctors and optometrists > are NOT medical doctors. Your reasoning here is? Using that argument, dentists should not be allowed to administer anesthetics or give injections, nor should podiatrists, because neither are "medical doctors." I have a thriving pediatric section to my practice, and have been using cycloplegic drops routinely on children from 2 years and up for the past 20+ years. > > For us, that makes twice in 3 years that the OD has overruled the > > optometrist. We're going to follow his recommendation. Studies show that uncorrected hyperopia is the vision condition most responsible for reading-related learning disorders in children. Uncorrected hyperopia is also more likely to be associated with lazy than any other refractive condition. > The OD stands for the optometrist. An ophthalmologist is an MD who > specializes in the eye. Your twins need to see a pediatric ophthalmologist, > not a general optometrist. An OD specializes in vision and the diagnosis and correction of vision problems in adults and children. DrG "Dr. Leukoma" <drg@leukoma.com> wrote in news:1161175798.987539.309500 @b28g2000cwb.googlegroups.com: > dentists should not be > allowed to administer anesthetics Actually, a friend of mine is an anesthesiologist with a dental anesthesia practice. Dentists and oral surgeons hand him money like he's doing them the biggest favor in the world--and in fact, it is close. Dollars to donuts, if I ever require a general during a dental procedure, this would be the arrangement I'd use. It's safer. That's not to say that this has anything to do with cycloplegic agents, of course, but the risks of using these agents are not the same as those of general anesthesia during a dental procedure.  SignatureScott Reverse name to reply > That's not to say that this has anything to do with cycloplegic agents, of > course, but the risks of using these agents are not the same as those of > general anesthesia during a dental procedure. I wasn't even thinking of general anesthetics. I was thinking of locals. I don't have a problem with my dentist administering light sedation with nitrous, but I have never used it. DrG >> That's not to say that this has anything to do with cycloplegic >> agents, of course, but the risks of using these agents are not the [quoted text clipped - 5 lines] > > DrG But it does make you wonder. Every day, people receive general from oral surgeons-- and its fine, until something goes wrong, in which case, you really wish an anesthesiologist were around. FWIW, its my understanding that its the malpractice discount that pushes dentists towards services like that my friend offers. SignatureScott Reverse name to reply > But it does make you wonder. Every day, people receive general from oral > surgeons-- and its fine, until something goes wrong, in which case, you > really wish an anesthesiologist were around. FWIW, its my understanding > that its the malpractice discount that pushes dentists towards services > like that my friend offers. I have no problem with an anesthesiologist administering general anesthesia, because I am somewhat frightened of it. I have had several extractions by oral surgeons in my lifetime that involved the injection of sodium pentothal. The problem is that I am not in any position to debate the training of oral surgeons in that area, and I have always just assumed that it was quite extensive. I know of quite a few eye surgeons who utilize nurse anesthetists instead of anesthesiologists, and have seen a few of them administer pentothal induction before giving the peribulbar injection. DrG > Studies show that uncorrected hyperopia is the vision condition most > responsible for reading-related learning disorders in children. > Uncorrected hyperopia is also more likely to be associated with lazy > than any other refractive condition. That should read "lazy eye." But, look, certainly if a child is symptomatic the prescription is given. The key is in determining whether the child is symptomatic, or rather if there are signs of a problem. Signs of a problem would include reading ability or performance on nearpoint tasks. Beyond that, there is a threshold beyond which glasses should be prescribed simply because the burden on the accommodative/convergence system is too much even in the absence of any "demonstrable" signs or symptoms, and this "threshold" is not something all doctors are going to agree upon. There is also the question of whether the hyperopia -- regardless of magnitude -- is bilateral and relatively equal between the two eyes. Also, and perhaps more importantly, what are the visual acuities? With respect to pediatric OMD's vs. optometrists: Can you say "turf war"? DrG Subject: Ophthamologist versus optometrist With respect to pediatric OMD's vs. optometrists: Can you say "turf war"? Otis> I think the correct term would be majority-opinion versus second-opinion. Otis> Thus the medical doctor would not put a child (who has good visual acuity) into a strong plus for a refractive STATE of +1.74 diopters, versus the second-opinion optometrist would do that. Otis> Patrick has the right to understand that: 1. His children have visual acuity comparable for a child of their age and: 2. The second-opinion is that a child with a refractive STATE of +1.5 diopters -- should not be wearing a +1.5 diopter lens at that age. That is the reason for an informed, competent second-opinion on putting a child into a plus lens. It is a parents right to be informed of this issue -- as we are doing on sci.med.vision. Best, Otis DrG > > Studies show that uncorrected hyperopia is the vision condition most > > responsible for reading-related learning disorders in children. [quoted text clipped - 20 lines] > > DrG [sarcasm]That sure added clarity.[/sarcasm] > Subject: Ophthamologist versus optometrist > [quoted text clipped - 54 lines] > > > > DrG >> 2) Although optometrists in Ontario fought for years for the right to >> administer cytoplegic (?) drops, few actually use them and it's virtually >> impossible to accurately measure a child's refraction without > >Cycloplegic drops should be administered by medical doctors Do you mean "only administered" by MDs? I really don't care about your political views. You might as well state "women should not be allowed to vote" or "black people should ride in the back of the bus." The cold hard fact of the matter is that optometry is a *licensed profession* and in the USA, state law decides who can/should do what. And every state in the USA permits ODs to administer cycloplegic drops. And the reason this is the case is that this is in the best interests of the public health in America. So your lame *political view* is out of touch with mainstream America. >and optometrists are NOT medical doctors. So what? Sounds like "MD snobbery" to me. General medical doctors are not ODs nor OMDs and shouldn't be allowed to prescribe ophthalmic medications, spectacle/contact lens prescriptions nor diagnose eye disease. How's that? Just an opinion from an optometrist. > The opthamologist said the following: > > 1) Children under-9 should NOT normally be given corrective lenses if > they are hyperopes and within 2-3 diopters, provided they seem to be > able to function well visually. He mentioned something about young > children having lots of "reserve". Why under 9? Why not 10? There is no logic here. 2-3 dioptres is not a good level to read with even with "plenty of reserve". > 2) Although optometrists in Ontario fought for years for the right to > administer cytoplegic (?) drops, few actually use them and it's > virtually impossible to accurately measure a child's refraction without > them (e.g. with an auto-refractor). This is a total load of crap!!! I will pit my retinoscope up againt your ophthal any day. Cycloplegics don't give you much difference in result and you are assessing an unnaturally altered system. I always base my scripts off my ret, even having done a cyclo refraction. Also autorefractors are for clowns that can't use a ret, and for what it is worth, the good autorefractors these days will get the result without using cyclo. > 3) He is currently doing about 20 second opinions each week (he had done > 4 by noon today when he called me back) and reversing virtually all the > recommendations received from optometrists for prescriptions given to > young children. As a result, there must be thousands of young children > out there wearing glasses unnecessarily. Yes, but I see 20 second opinions from ophthals a week, most have been given wrong prescriptions or no prescription. That your ophthal says not to get glasses does not make him right. The major difference between optoms and ophthals is that we deal with systems that function in the real world, not the hypothetical of "plenty of reserve". The requirements of children at school these days is very different than when you were at school. The worst case scenario of your children getting glasses is that they would be of no benefit. They would not cause problems, worsening or anything else. > For us, that makes twice in 3 years that the OD has overruled the > optometrist. We're going to follow his recommendation. That may be a wise decision or it may be not. Having not tested your children, I can't say one way or another, but for what it is worth, an ophthal does not know more about eyes than an optom, he may know more about surgery, but your children don't need that. Optoms are much better than an ophthal at what they do, which is prescriptions and glasses and contacts. I will happily put my refraction skills against an ophthal. What I look for in cases such as your children is how they are functioning, which your ophthal can't assess as he has stuck cycloplegic in their eyes. How has he assessed their focussing and convergence skills? What is their AC/A ratio? How much lag is there when they read? Can they clear minus lens with ease? What are their accommodative and vergence reserves? I bet these were not tested, but I wouldn't be making any recommendation to you without these results as they tell me how your kids eyes work. Once I have this, I have a baseline to compare against at a later date. dr grant >> 2) Although optometrists in Ontario fought for years for the right to >> administer cytoplegic (?) drops, few actually use them and it's [quoted text clipped - 10 lines] > using cyclo. > Well, in the opinion of the opthamologist, you can't get a proper reading from young children without them. In fact, I think I said that they can't even bill unless the drops have been administered. > >> 3) He is currently doing about 20 second opinions each week (he had done [quoted text clipped - 37 lines] > > dr grant > Well, in the opinion of the opthamologist, you can't get a proper > reading from young children without them. In fact, I think I said that > they can't even bill unless the drops have been administered. Who said your ophthal is right? He is restricted by his ability. If he does not know how to use a retinoscope, of course he will say this. It does not go to prove that he is correct in any way, maybe that he is ignorant or incompetent. The most effective way to treat your children is to evaluate the way the visual system operates, and you may want to think about the word system here. It means all the bits operating together. How can your ophthal assess anything about your children's eyes when he has deliberately taken one part out of the system? He is looking at a prescription, not how your children's eyes are working. You do not need to use a cyclo on all children. You especially don't need it at your kids levels of +1.5 to +3.00 and you need to consider what effects there may be in the long term. dr grant On 10/18/06 2:34 PM, in article 1161207296.545081.164820@m7g2000cwm.googlegroups.com, "CatmanX" <drgrant@ozemail.com.au> wrote: >> Well, in the opinion of the opthamologist, you can't get a proper >> reading from young children without them. In fact, I think I said that [quoted text clipped - 17 lines] > > dr grant IF the refraction WERE 1.50 - 3.00 - but I have seen enough cases where the lack of a cycloplegic hid the fact that they were much more hyperopic, or anisometropic. I think testing BOTH ways is important, once, at least, when starting out, so you have all the information. BTW, what "effects there may be in the long term" are you talking about? I can't think of any in particular resulting from a cycloplegic exam that I have seen. And none that I know about other than a temporary allergic reaction or such (rare). > IF the refraction WERE 1.50 - 3.00 - but I have seen enough cases where the > lack of a cycloplegic hid the fact that they were much more hyperopic, or > anisometropic. I think testing BOTH ways is important, once, at least, when > starting out, so you have all the information. I certainly don't disagree there David. My disagreement was that there is no assessment from the ophthal regarding accommodative status and can be none until the cyclo has worn off. Also a well performed ret will garner much the same result as a cyclo. I do both regularly. > BTW, what "effects there may be in the long term" are you talking about? I > can't think of any in particular resulting from a cycloplegic exam that I > have seen. And none that I know about other than a temporary allergic > reaction or such (rare). By long term, I am talking about reading performance, comprehension and the likes. My mnajor dealings with kids pertain to reading issues and is always the first thing that crosses my mind. +3.00 with reading issues is a poor combination. Glases can be very helpful here. What I am concerned about here is optoms pushing glasses, as well as ophthals pushing no glasses. It would appear neither camp in this case is looking at the kids, merely their personal bias. I try to make each judgement based upon the test results, the childs performance in class and how all this impacts upon the child and family. The ophthal here appears to be against glasses period. The optoms either are pushing glasses or not doing a good job explaining to the parents that the glasses are worthwhile. grant I also routinely perform retinoscopy, and in most cases it does an adequate job. However, it is not unusual to underestimate the amount of total hyperopia without using a cycloplegic agent. In fact, I can recall more an instance or two where both methods failed to reveal hyperopia. I think there are other important reasons to use a cycloplegic, if for no other reason than facilitating a better fundus examination and for medico-legal reasons. DrG > > IF the refraction WERE 1.50 - 3.00 - but I have seen enough cases where the > > lack of a cycloplegic hid the fact that they were much more hyperopic, or [quoted text clipped - 25 lines] > > grant "CatmanX" <drgrant@ozemail.com.au> wrote in news:1161261220.182611.326790 @b28g2000cwb.googlegroups.com: > The ophthal here > appears to be against glasses period. The optoms either are pushing > glasses or not doing a good job explaining to the parents that the > glasses are worthwhile. From an earlier post from the OP "I'm a bit reluctant to have them start wearing glasses and will probably get a second opinion again." It almost seems to me that there's been some doctor shopping here, and the no-glasses approach might have been actively sought out. Perhaps this isn't the best case study over which to discuss the OD vs OMD approach. It's hard for me to believe that both types of practices would usually arrive at nearly the same treatment path nearly all of the time. SignatureScott Reverse name to reply > By long term, I am talking about reading performance, comprehension and > the likes. My mnajor dealings with kids pertain to reading issues and [quoted text clipped - 8 lines] > glasses or not doing a good job explaining to the parents that the > glasses are worthwhile. I don't call recommending glasses for a +1.75 hyperope age 5 years as "pushing" glasses. Anything less than 1.00 diopter? Probably. Most parents have a strong antipathy towards eyeglasses for their children, and such a recommendation is never made lightly. It helps if there is a behavioral basis for the decision, such as poor concentration, poor attention span for close work, headaches, squinting, rubbing the eyes, etc., etc. But, I think that +1.75 or +2.00 in a 5 year/old is a prescribable amount, and I wouldn't be acting the apologist. What I do find fault with is the manner in which the second opinion doctor disparaged a perfectly legitimate recommendation. Even the great authority on these matters, GK Van Noorden, states that prescribing for hyperopes is highly variable across practitioners. DrG On 10/19/06 5:33 AM, in article 1161261220.182611.326790@b28g2000cwb.googlegroups.com, "CatmanX" <drgrant@ozemail.com.au> wrote: >> IF the refraction WERE 1.50 - 3.00 - but I have seen enough cases where the >> lack of a cycloplegic hid the fact that they were much more hyperopic, or [quoted text clipped - 25 lines] > > grant Yes, kids are all individuals, and neither "side" should be pushing one of the other - they should push inwhatever direction the individual child needs (or doesn't need) help. The accommodation needs to be measured, obviously, before the cycloplegic retinoscopy. Can't start with that. It is true, I have been amazed to see new patients come to the ophthalmologist's office already dilated at home before they have ever been seen. This is in kids to rule out strabismus, amblyopia, reading problems, etc., none of which can be done it they are seen for the first time already dilated!! > 3) He is currently doing about 20 second opinions each week (he had done > 4 by noon today when he called me back) and reversing virtually all the > recommendations received from optometrists for prescriptions given to > young children. As a result, there must be thousands of young children > out there wearing glasses unnecessarily. What a hero. My take is that there are thousands of young children out there who are potentially being deprived of proper treatment and good vision in the critical learning years. DrG Leuk> What a hero. My take is that there are thousands of young children out > there who are potentially being deprived of proper treatment and good > vision in the critical learning years. Otis> Good Vision? There was no statement about visua acuity, and a refractive STATE of +1.75 diopters is normal for a five year-old child. The optical medical doctor was correct. There is no good reason why the child should be put into a +1.75 diotper lens. But that is the second-opinion, and you fail to understand the concept, not to mention the right of the parent to informed choice in this matter. Best, Otis > > 3) He is currently doing about 20 second opinions each week (he had done > > 4 by noon today when he called me back) and reversing virtually all the [quoted text clipped - 7 lines] > > DrG > Otis> Good Vision? There was no statement about > visua acuity, and a refractive STATE of +1.75 diopters [quoted text clipped - 5 lines] > mention the right of the parent to informed choice > in this matter. Don't lecture me on vision. There is more to it than a Snellen chart at 20 feet. DrG > > Otis> Good Vision? There was no statement about > > visua acuity, and a refractive STATE of +1.75 diopters [quoted text clipped - 10 lines] > > DrG You do know young hyperopes are still undergoing emmetropization. That +2 hyperope could very well become +.5 in a few years. Why interrupt it with a plus lens if he sees well and has no symptoms of eyestrain? I do recall the OMD mentioning that their refraction will continue to change over the next few years. Since they seem to see perfectly right now without straining, I'm willing to wait and see. > You do know young hyperopes are still undergoing emmetropization. That > +2 hyperope could very well become +.5 in a few years. Why interrupt it > with a plus lens if he sees well and has no symptoms of eyestrain? Dear Pat, If an OD explains WHY he thinks a child with a refractive STATE of +2 diopters (no symptoms of anything -- visual acuity normal), and you BELIEVE him, then you should be requested to sign a statement to the effect that the "plus" in this instance is not "standard" and you understand that issue. But let me be clear about this issue. There is SCIENTIFIC evidence that a +2 -- worn all the time as was the OD's intention -- will result in: 1. The child's refractive STATE remaining at +2 diopters, or 2. The child's refractive STATE moving more positive, perhaps to +2.5, 3.0 (and if the strength is increased to +3 diopters, then on to +4 diopters.) 3. When this scientific experiment is done as pure science, then indeed the natural eye's refractive STATE will "follow" the +2 diopter lens in this manner. This is intuitively with the ophthamologist understands (I hope), and the reason that is it stated that a +2 diopter lens will "interfere" with "emmetropization". This is why I also suggest you be cautioned about using the "plus" in this manner -- so you understand the risks of it. Best, Otis > I do recall the OMD mentioning that their refraction will continue to > change over the next few years. [quoted text clipped - 5 lines] > > +2 hyperope could very well become +.5 in a few years. Why interrupt it > > with a plus lens if he sees well and has no symptoms of eyestrain? Pat may be interested in this article: British Journal of Ophthalmology 2005;89:542 © 2005 BMJ Publishing Group Ltd -------------------------------------------------------------------------------- ECHO Long sight reduces learning in young schoolchildren Children are failing educationally because long sight is not seen as a problem, say doctors in South Wales who have studied more than a thousand schoolchildren. Scores for national tests-proficiency in reading and writing English and progress in the national curriculum in English, mathematics, and science-were significantly lower for the children who had been referred to an optometrist and were the most long sighted (>+3D for both eyes or 1.25 for best eye) than for those who were less affected (+3D) and for those who had not been referred. Thirteen per cent of the total cohort had been referred to an optometrist after failing a test for long sight, and half of them needed glasses or a referral to an educational psychologist, or both. Many of those referred to the psychologist scored poorly in the tests. The local community paediatric service screened almost 1300 children aged 8 years with a standard vision screening protocol changed to include a fogging test for long sight. Children failing this test or others were referred to an optometrist for treatment and possible further referral to an educational psychologist. Educational test results were obtained for consenting children. > Dear Pat, > [quoted text clipped - 40 lines] > > > +2 hyperope could very well become +.5 in a few years. Why interrupt it > > > with a plus lens if he sees well and has no symptoms of eyestrain? Pat may be interested in this article: British Journal of Ophthalmology 2005;89:542 © 2005 BMJ Publishing Group Ltd So what you are telling Pat, is that his 5 year old kids with a normal refracitve STATE of +1.5 diopters have: 1. Reading problem. 2. Psychological problem or 3. Both, And that justifies putting the child into a +1.5 diopter lens with NO DISCUSSION of any of these "issues" the OD "assumed" were true because of the normal refractive STATE of +1.5 diopters. Seems to me that the OD should have discussed these issues BEFORE a +1.5 diopter lens was prescribed. Or perhaps, the OD does not understand the right of a person to an informed choice in this matter. >From Pat's statement, the OD just "prescribed" a +1.5 diopter for the kid, and sent Pat out to the "desk" to order the +1.5 -- to be worn 16/7. Jeeze! Otis > Pat may be interested in this article: > [quoted text clipped - 71 lines] > > > > +2 hyperope could very well become +.5 in a few years. Why interrupt it > > > > with a plus lens if he sees well and has no symptoms of eyestrain? > Pat may be interested in this article: > [quoted text clipped - 9 lines] > > 3. Both, Is this the conclusion you drew from the article? > Jeeze! That's for sure! LOL! DrG > But let me be clear about this issue. > > There is SCIENTIFIC evidence that a +2 -- worn all the time > as was the OD's intention -- will result in: Prove it. Provide one single citation of peer-reviewed research that supports your ridiculous claim. Go ahead. Or get the hell out of here. LB > You do know young hyperopes are still undergoing emmetropization. That > +2 hyperope could very well become +.5 in a few years. Why interrupt it > with a plus lens if he sees well and has no symptoms of eyestrain? What makes you think that correcting a +2 hyperope for reading will interrupt emmetropization? How do you measure eyestrain? Do you ask the child if it matters to them if they need to accommodate twice as much as an emmetrope? Or, do you just muse about the marvels of accommodation and convergence and the ability of young children to "compensate" and "cope," and the virtues of necessity over prudence? Or, would you give the child the opportunity to not have to work so hard to accommodate and determine for themselves if the glasses are beneficial? They'll tell you by how often they use them. Don't you think the child has that right? I think before I provided a "knee-jerk" second opinion condemning the hyperopic correction, I would put the child's interests first and have this discussion with the parent. DrG Dear Pat, I think that the ophthamologist is correct. A positive refractive STATE is called "hyperopia", and the un-necessary prescription would be +1.5 diopters and +2 diopters. Refractive STATES are normal. It would be of value to establish the child's approximate Snellen reading. If the child were at -2.0 diopters, his Snellen would be about 20/70 to 20/100. I do not think this is the case. Best, Otis To recap, one of our twins was (under drop, the term used by the opthamologist) -1.50 in each eye, while the other was -2.00 and -2.75. > Our twins finally got a 2nd opinion from the opthamologist after being > told by an optometrist that they needed glasses. [quoted text clipped - 22 lines] > > -Pat ...you can always believe [DR]Brown. Oh, and by the way, a refractive error of +2.00 on a five year/old is not normal...statistically speaking. > Dear Pat, > [quoted text clipped - 43 lines] > > > > -Pat I find it difficult to believe that Otis Brown was a myopic child. Myopic children are typically much more intelligent. Hyperopic children, on the other hand, have a much higher rate of reading-related learning disabilities. Possibly Otis was a hyperope who underwent a radical myopic shift. DrG > Dear Pat, > [quoted text clipped - 43 lines] > > > > -Pat > A positive refractive STATE is called "hyperopia", and > the un-necessary prescription would be +1.5 diopters [quoted text clipped - 5 lines] > about 20/70 to 20/100. I do not think this is the > case. Dear Pat, Please disregard Otis's postings. He is not in the medical profession nor in any position to give medical advice. Thank you. Allen No, Allen, I do not give "medical advice". I just suggested to Pat that he become knowledgeable of the second-opinion, that refractive STATES of the fundamental eye run between zero to +2 diopters for a child of that age, and that a MEDICAL DOCTOR recommended that the child NOT be put into a plus. Pat has a right to understand that issue and make a choice between forcing his child to wear a +1.75 diopter 16/7, or wear no plus at all. Best, Otis > > A positive refractive STATE is called "hyperopia", and > > the un-necessary prescription would be +1.5 diopters [quoted text clipped - 14 lines] > > Allen > No, Allen, I do not give "medical advice". As usual Otis WRONG AGAIN. >> > If the child were at -2.0 diopters, his Snellen would be >> > about 20/70 to 20/100. I do not think this is the >> > case. The above are YOUR WORDS which sure appears to be medical advice. Allen > I just suggested to Pat that he become knowledgeable > of the second-opinion, that refractive STATES of > the fundamental eye run between zero to +2 diopters > for a child of that age, and that a MEDICAL DOCTOR > recommended that the child NOT be put into > a plus. Pat has right to a second "qualified" opinion. This, of course, excludes yours. DrG > Pat has right to a second "qualified" opinion. This, of course, > excludes yours. > > DrG Otis> And, it is obvoius, you would also "omit" telling Pat about the highly qualified judgment of an Ophthamologist, who recommends that a child with good visual acuity NOT wear a plus lens for a refractive STATE of +1.75 diopters. Otis> That is WHY there is a second-opinion -- and why it must exist and be understood by Pat. If I had a choce between a highly qualified MEDICAL opinion, and your OD opinion -- I would suggest that hte ophthamologist is more qualified than your are. Otis > > I just suggested to Pat that he become knowledgeable > > of the second-opinion, that refractive STATES of [quoted text clipped - 7 lines] > > DrG I would suggest > that hte ophthamologist is more qualified than > your are. The fact is that optometrists have more theoretical and didactic training in refraction and binocular vision and the treatment consequences of related problems. By far. I would say that the only o.m.d.s that could pass the refraction, optics and binocular vision parts of the National Board of Optometry Exams are those few who were first optometrists, then decided to be ophthalmologists. There are a handful of those in the U.S. Having said that, some of my best freinds are ophthalmologists, and they are certainly the best in surgery and treating difficult pathology cases. This thread is not about those cases. w.stacy, o.d. WS> ...and didactic training Otis> didactic -- fitted or intended to tach; prescriptive, Pedagogy; art of teaching; systematic instruction. Otis> and yes, you do receive training -- but fail to discuss the seecond opinion when a child has a refractive STATE of +1.5 diopters, and the second-opinion is that the child should not be wearing the "plus" at that time. What you need to do is to be "didactic" with Pat, and explain EXACTLY why you think a child at +1.5 diopters should be wearing that plus -- when other highly qualified experts think (for didactic reasons) that the child should NOT be wearing a +1.5 diopter as the age of five. Otis> You need to "clean up" you "reasons why" at this point. (I do accept that there CAN BE reasons-why, but you have not been very articulate about them.) Otis> Maybe you can make the case FOR the +1.5 diopters to Pat so we can truly understand the "reasons why". That is what sci.med.vision is all about. Best, Otis The fact is that optometrists have more theoretical and didactic training in refraction and binocular vision and the treatment consequences of related problems. By far. I would say that the only o.m.d.s that could pass the refraction, optics and binocular vision parts of the National Board of Optometry Exams are those few who were first optometrists, then decided to be ophthalmologists. There are a handful of those in the U.S. > I would suggest > > that hte ophthamologist is more qualified than [quoted text clipped - 13 lines] > > w.stacy, o.d. > Otis> and yes, you do receive training -- but fail to discuss > the seecond opinion when a child has a refractive STATE of [quoted text clipped - 5 lines] > experts think (for didactic reasons) that the child should > NOT be wearing a +1.5 diopter as the age of five. The reasons for doing something (as opposed to doing nothing) have been explained. Can't you read? > Otis> You need to "clean up" you "reasons why" at this point. > (I do accept that there CAN BE reasons-why, but you [quoted text clipped - 3 lines] > to Pat so we can truly understand the "reasons why". > That is what sci.med.vision is all about. I have made the case, which is that moderately hyperopic children tend to have a higher incidence of reading-related learning problems....even if they can pass the DMV exam. As was mentioned, it would appear that the OP was shopping for the advice they wanted to hear. DrG Dear "L", Using non-standard methods on a child -- with no discussion with the parent about the alternative. Effectively restraint of information that is crucial to understand your "preferred" alternative. A 5 year-old child has a refracive STATE of +1.5 diopters and visual acuity that is comparable to most 5 year olds. There is no overt indication of any problem. Pat did was not told of any problem AT ALL. The +1.5 diopter was an OPINION of the OD who was going to put the child into a +1.5 diopter lens. While I would be willing to support that type of "approach", I think Pat should have been given sufficient information to understand that: 1. That is your second-opinion. 2. Standard practice is to NOT put a +1.5 diopter lens on a child that has a natural and normal refractive STATE. If you wish to do this, you need to explain this in detail and get the written permission from Pat that you recommend a non-standard method -- and the reasons for it. Pat might "buy into" your "reasons". But anything less than that is not being completely fair to Pat -- and he had to go to a "majority opinion" ophthamologist to find this out. I would in fact be WILLING to support the use of the plus in the manner -- but ONLY if the parent is fully informed as to the the reasons, and has the ability to understand that putting a child into a +1.5 diopter with good vision -- is at best the "second-opinion". Best, Otis > Otis> You need to "clean up" you "reasons why" at this point. > (I do accept that there CAN BE reasons-why, but you > have not been very articulate about them.) > Otis> Maybe you can make the case FOR the +1.5 diopters > to Pat so we can truly understand the "reasons why". > That is what sci.med.vision is all about. I have made the case, which is that moderately hyperopic children tend to have a higher incidence of reading-related learning problems....even if they can pass the DMV exam. Otis> Funny, but Pat was not told of your second-opinion. Further, he should have been told that this was YOUR OPINION, and not standard practice. Otis> Your failure was one of arrogance -- to ASSUME that Pat "wanted" a +1.5 diopter -- and to prescribe it with no informed concent. Best, Otis As was mentioned, it would appear that the OP was shopping for the advice they wanted to hear. DrG > > Otis> and yes, you do receive training -- but fail to discuss > > the seecond opinion when a child has a refractive STATE of [quoted text clipped - 25 lines] > > DrG "otisbrown@pa.net" <otisbrown@pa.net> wrote in news:1161292886.755681.94300 @b28g2000cwb.googlegroups.com: > I would in fact be WILLING to support the use of > the plus in the manner -- but ONLY if the parent is > fully informed as to the the reasons, and has > the ability to understand that putting a child > into a +1.5 diopter with good vision -- is at > best the "second-opinion". Excuse me????? Sure likes medical advice since you SUPPORT it. Where is your medical practitionaire license????? Hey Neil, Maybe the PA state board would be intrigued by the above medical advice? Allen > Dear "L", > > Using non-standard methods on a child -- with no discussion > with the parent about the alternative. Effectively restraint > of information that is crucial to understand your "preferred" > alternative. Are you privy to what was discussed? I am not. > A 5 year-old child has a refracive STATE of +1.5 diopters and > visual acuity that is comparable to most 5 year olds. A refractive error of +1.5 in a five year old is not normal. Can't you get that through your thick cranium? > There is no overt indication of any problem. Again, I am not privy to that information. Are you? > Pat did was not told of any problem AT ALL. I'm sorry. I don't recall where that was stated. Do you? > The +1.5 diopter was an OPINION of the OD who was > going to put the child into a +1.5 diopter lens. It was the recommendation of the optometrist, yes. > While I would be willing to support that type of "approach", > I think Pat should have been given sufficient information > to understand that: > > 1. That is your second-opinion. The OD was not consulted for a second opinion. The OMD was. > 2. Standard practice is to NOT put a +1.5 diopter lens > on a child that has a natural and normal refractive STATE. You have no idea what standard practice is. No idea whatsoever. > If you wish to do this, you need to explain this in detail > and get the written permission from Pat that you > recommend a non-standard method -- and the > reasons for it. If this is a non-standard method, then Pat should inform the licensing board. > Pat might "buy into" your "reasons". But anything > less than that is not being completely fair to Pat -- and > he had to go to a "majority opinion" ophthamologist > to find this out. On three separate occasions, no less. > I would in fact be WILLING to support the use of > the plus in the manner -- but ONLY if the parent is > fully informed as to the the reasons, and has > the ability to understand that putting a child > into a +1.5 diopter with good vision -- is at > best the "second-opinion". No. The second opinion was from the OMD, who disagreed with the first opinion. Is your reasoning impaired? DrG Dear "G", I know that you believe that all refractive STATES are ERRORS. That is what they teach you in OD school, facts and concept to the contrary. But let us be clear about natural refractive STATES of primates in the wild. (Data taken from Rhesus from the wild. >From 600 plus eyes, the statistics were (rounded off SLIGHTLY) Average refractive STATE (+0.7 diopters) Standard Deviation +0.7 diopters. This means that 68 percent of the population had refractive STATES running from zero to +1.4 diopters. At the 2 sigma level, the natural refractive STATE ran between -0.7 diopters to +2.1 diopters. I consider these to be natural refractive STATES of the fundamental eye. Obviously you love to call them "errors" from you antique theory that calls a refractive STATE of exactly zero -- the only "normal" state. By your theory, about 1 percent of these monkeys have "normal" eyes. All the rest are "defective". I can NOT agree with your wording, nor description of the refractive STATES of all natural eyes. A refractive error of +1.5 in a five year old is not normal. Can't you get that through your thick cranium? Otis> Can't you get the idea that the natural eye can have refractive STATES (not errors) and be normal? Otis > > Dear "L", > > [quoted text clipped - 63 lines] > > DrG Those of us in the "biz" call them refractive errors. You can call them what you wish. DrG > Dear "G", > [quoted text clipped - 110 lines] > > > > DrG > Dear "G", > But let us be clear about natural refractive STATES > of primates in the wild. (Data taken from > Rhesus from the wild. Why are you discussing monkey data again? Is this not a HUMAN discussion? > I consider these to be natural refractive STATES > of the fundamental eye. No one care what you consider. And what the hell is a "fundamental eye"? >Obviously you love > to call them "errors" from you antique > theory that calls a refractive STATE of > exactly zero -- the only "normal" state. Obviously you love to make up terminology and quote statistics that have no relation to the discussion. Boring old man. You contribute nothing to the body of knowledge. I'd guess you're only read for amusement. Doesn't that just eat you up inside? LB > > I consider these to be natural refractive STATES > > of the fundamental eye. > > No one care what you consider. And what the hell is a "fundamental > eye"? You need to pay more attention, Larry. It's Thursday, so it's the "fundamental" eye day. If it was Wednesday, then it would be the "natural" eye day. Besides, he already used "natural" in the sentence, so he couldn't very well use it again. > Boring old man. You contribute nothing to the body of knowledge. I'd > guess you're only read for amusement. Doesn't that just eat you up > inside? His posts are quite interesting. Nobody else uses all caps to anywhere near the extent he does. SignatureDan Abel dabel@sonic.net Petaluma, California, USA He's obviously up to his "monkey business" again. Also, the new paradigm dictates plus for myopes to retard myopiagenesis and minus for hyperopes to stimulate emmetropization. Haven't you heard.....? DrG > > Dear "G", > [quoted text clipped - 24 lines] > > LB Dear "L", Using non-standard methods on a child -- with no discussion with the parent about the alternative. Effectively restraint of information that is crucial to understand your "preferred" alternative. A 5 year-old child has a refracive STATE of +1.5 diopters and visual acuity that is comparable to most 5 year olds. There is no overt indication of any problem. Pat did was not told of any problem AT ALL. The +1.5 diopter was an OPINION of the OD who was going to put the child into a +1.5 diopter lens. While I would be willing to support that type of "approach", I think Pat should have been given sufficient information to understand that: 1. That is your second-opinion. 2. Standard practice is to NOT put a +1.5 diopter lens on a child that has a natural and normal refractive STATE. If you wish to do this, you need to explain this in detail and get the written permission from Pat that you recommend a non-standard method -- and the reasons for it. Pat might "buy into" your "reasons". But anything less than that is not being completely fair to Pat -- and he had to go to a "majority opinion" ophthamologist to find this out. I would in fact be WILLING to support the use of the plus in the manner -- but ONLY if the parent is fully informed as to the the reasons, and has the ability to understand that putting a child into a +1.5 diopter with good vision -- is at best the "second-opinion". Best, Otis > Otis> You need to "clean up" you "reasons why" at this point. > (I do accept that there CAN BE reasons-why, but you > have not been very articulate about them.) > Otis> Maybe you can make the case FOR the +1.5 diopters > to Pat so we can truly understand the "reasons why". > That is what sci.med.vision is all about. I have made the case, which is that moderately hyperopic children tend to have a higher incidence of reading-related learning problems....even if they can pass the DMV exam. Otis> Funny, but Pat was not told of your second-opinion. Further, he should have been told that this was YOUR OPINION, and not standard practice. Otis> Your failure was one of arrogance -- to ASSUME that Pat "wanted" a +1.5 diopter -- and to prescribe it with no informed concent. Best, Otis As was mentioned, it would appear that the OP was shopping for the advice they wanted to hear. DrG > > Otis> and yes, you do receive training -- but fail to discuss > > the seecond opinion when a child has a refractive STATE of [quoted text clipped - 25 lines] > > DrG Read and enjoy: Hyperopia and educational attainment in a primary school cohort W R Williams1, A H A Latif2, L Hannington3 and D R Watkins4 1 School of Care Sciences, University of Glamorgan, UK 2 The Children's Centre, Royal Glamorgan Hospital, UK 3 Dewi Sant Hospital, Pontypridd, UK 4 Taff Street, Pontypridd, UK Correspondence to: Dr A Latif The Children's Centre, Royal Glamorgan Hospital, Llantrisant, CF72 8XR; Abbas.latif@pr-tr.wales.nhs.uk Accepted for publication 7 July 2004 Background: Vision screening addresses the visual impairments that impact on child development. Tests of long-sightedness are not found in most school screening programmes. The evidence linking mild-moderate hyperopia and lack of progress in school is insufficient, although strengthened by recent findings of developmental problems in infants. Aims: To report on the relation between hyperopia and education test results in a cohort of primary school children. Methods: A total of 1298 children, aged 8 years, were screened for hyperopia on the basis of fogging test results. School test results (NFER and SATs) were compared between groups categorised by referral status and refractive error. Results: A total of 166 (12.8%) fogging test failures were referred for ophthalmic assessment. Ophthalmic tests on 105 children provided an accurate diagnosis of vision defects, for reference to their education scores. Fifty per cent of the children examined by optometrists required an intervention (prescription change, glasses prescribed, or referral). Mean (95% CI) NFER scores of children with refractive errors (summed for both eyes) >+3D (98.4, 93.0-103.8, n = 32) or >+1.25D (best eye) (99.3, 93.0-105.6, n = 26) were lower than the respective scores of children with a less positive refractive state (104.8, 100.7-108.9, n = 43) (103.6, 99.7-107.4, n = 49), the non-referred group, and total sample. The SATs results followed a similar trend. A high proportion of the fogging test failures (16%) and confirmed hyperopes (29%) had been referred to an educational psychologist, and the latter group contributed substantially to the poor education scores. Conclusions: The results of this study provide further evidence for a link between hyperopia and impaired literacy standards in children. ================================================================== Optom Vis Sci. 2004 Apr;81(4):233-7. A survey of clinical prescribing philosophies for hyperopia. Lyons SA, Jones LA, Walline JJ, Bartolone AG, Carlson NB, Kattouf V, Harris M, Moore B, Mutti DO, Twelker JD. The New England College of Optometry, Boston, Massachusetts, USA. BACKGROUND: Prescribing philosophies for hyperopic refractive error in symptom-free children vary widely because relatively little information is available regarding the natural history of hyperopic refractive error in children and because accommodation and binocular function closely related to hyperopic refractive error vary widely among children. We surveyed pediatric optometrists and ophthalmologists to evaluate typical prescribing philosophies for hyperopia. METHODS: Practitioners were selected from the American Academy of Optometry Binocular Vision, Perception, and Pediatric Optometry Section; the College of Vision Development; the pediatric and binocular vision faculty members of the colleges of optometry; and the American Association for Pediatric Ophthalmology and Strabismus. Surveys were mailed to 314 participants: 212 optometrists and 102 ophthalmologists. RESULTS: A total of 161 (75%) of the optometrists and 59 (57%) of the ophthalmologists responded. About one-third of optometrists surveyed prescribe optical correction for symptom-free 6-month-old infants with +3.00 D to +4.00 D hyperopia, but fewer than 5% of ophthalmologists prescribe at this level. Most eye care practitioners prescribe optical correction for symptom-free 2-year-old children with +5.00 D of hyperopia, and this criterion for hyperopia decreases with age. Most ophthalmologists (71.4%) prescribe the full amount of astigmatism and less than the full amount of cycloplegic spherical component, and most optometrists (71.6%) prescribe less than the full amount of both components. When prescribing less than the full amount of astigmatism, eye care practitioners do not tend to prescribe a specific proportion of the cycloplegic refractive error. CONCLUSION: Pediatric eye care providers show a lack of consensus on prescribing philosophies for hyperopic children. > Dear "L", > [quoted text clipped - 102 lines] > > > > DrG Dear "L", All of that is very nice -- but Pat seems to not be "impressed", and it seems his kids were to be put into a strong plus with no knowledge on his part of these issues. So he had to get the real truth of this situation from an ophthamologist -- who and no problem SUGGESTING that the plus was not necessary. I do not recall Pat stating that he was given a choice in this matter. If he had, he would have made his mind up with no need to post on sci.med.vision. Best, Otis > Read and enjoy: > [quoted text clipped - 189 lines] > > > > > > DrG > I do not recall Pat stating that he was > given a choice in this matter. If he had, > he would have made his mind up with no > need to post on sci.med.vision. I see that facts and the scientific method do not impress you. But, we've know that for quite awhile now, haven't we? Pat exercised choice on three occasions as far as I can tell. DrG True, she (OD) really didn't seem to lead me to believe that there was any choice in the matter. She was happy to march us straight into the lobby to look for frames, yet both boys can discern a "flea on a flea" with their naked eyes. > Dear "L", > [quoted text clipped - 220 lines] >>>> DrG >>>> No, not shopping for the advice I *wanted* to hear. Rather, only putting 5 year-olds (now 6 year-olds) into glasses only if really necessary. Apparently, it's not. > >> Otis> and yes, you do receive training -- but fail to discuss [quoted text clipped - 29 lines] > > DrG > No, not shopping for the advice I *wanted* to hear. > > Rather, only putting 5 year-olds (now 6 year-olds) into glasses only if > really necessary. Volumes have been written about the "necessity" of wearing corrective lenses. Perhaps "advisable" is a better word in many cases. Moderate uncorrected hyperopia is the only refractive condition that is highly associated with reading/learning deficits in children, and would be alert to early signs of fatigue and shortened attention span for close work. DrG >Otis> and yes, you do receive training -- but fail to discuss >the seecond opinion when a child has a refractive STATE of >+1.5 diopters, and the second-opinion is that the >child should not be wearing the "plus" at that time. We've been down this road before. I ALWAYS DISCUSS the options of wearing glasses with parents. Often, +1.50 is optional, often not at all necessary. Sometimes it is crucial. Do you know anything about AC/A ratios? Some kids that are +1.50 are esotropic because of it. Did you know that? Did you know some of these kids can develop amblyopia if they are NOT corrected early, and that sometimes a simple plus lens can easily fix an esotropia? If things were as simplistic as you think, I would have only needed a few hours of physiological optics, binocular vision, and vision analysis training, instead of years. For your level of knowledge and understanding of this subject, you got just the right amount of training. Not content to be the "expert" on myopia, Otis is engaging in "mission creep" into hyperopia. Does his genius know no bounds? DrG > >Otis> and yes, you do receive training -- but fail to discuss > >the seecond opinion when a child has a refractive STATE of [quoted text clipped - 13 lines] > training, instead of years. For your level of knowledge and > understanding of this subject, you got just the right amount of training. > Otis> And, it is obvoius, you would also "omit" telling > Pat about the highly qualified judgment of an > Ophthamologist, who recommends that > a child with good visual acuity NOT wear > a plus lens for a refractive STATE of +1.75 diopters. Prescribing for hyperopia in children without amblyopia or accommodative esotropia is highly variable. Since +1.75 diopters of hyperopia in a 5 year old is far outside of the norm, there should definitely be a "discussion" about prescribing. Hyperopia of less than one diopter is another matter. Since the only thing that matters to you is performance on a static Snellen chart, the rest of this discussion is totally moot. However, the reality is that in this highly competitive world, a child who lacks good reading skills is at a distinct disadvantage. Myopes typically do not have this problem nearly as often as hyperopes. > Otis> That is WHY there is a second-opinion -- and > why it must exist and be understood by Pat. > If I had a choce between a highly qualified MEDICAL > opinion, and your OD opinion -- I would suggest > that hte ophthamologist is more qualified than > your are. And I would suggest that your opinions are absolutely worthless, and most here would agree. Just stick to what you know best: over the counter reading glasses to prevent myopia in pilots. DrG Pretty active thread, of course. Any time you get o.d.s against o.m.d.s or vice versa it gets interesting. > Our twins finally got a 2nd opinion from the opthamologist after being > told by an optometrist that they needed glasses. [quoted text clipped - 8 lines] > able to function well visually. He mentioned something about young > children having lots of "reserve". Are you sure they were - not +? -=myopia, +=hyperopia. > 3) He is currently doing about 20 second opinions each week (he had > done 4 by noon today when he called me back) and reversing virtually > all the recommendations received from optometrists for prescriptions > given to young children. As a result, there must be thousands of > young children out there wearing glasses unnecessarily. That's possible, but not necessarily true. It is also possible that he's undoing a lot of good. > For us, that makes twice in 3 years that the OD has overruled the > optometrist. We're going to follow his recommendation. Fine. There is room for differences of opinion about what is "necessary" and what isn't. You pays your money and takes your chances. Hopefully the kids won't suffer. An 8 y.o. with 3 D. would be prescribed by every o.m.d. I know, and most of them will go lower than that in both age and diopters. So I think your o.m.d. may be showboating and loves to hammer on o.d.s. w.stacy, o.d. > Fine. There is room for differences of opinion about what is > "necessary" and what isn't. You pays your money and takes your > chances. Hopefully the kids won't suffer. An 8 y.o. with 3 D. would > be prescribed by every o.m.d. I know, and most of them will go lower > than that in both age and diopters. So I think your o.m.d. may be > showboating and loves to hammer on o.d.s. Gee, you think? I only encounter this with pediatric OMD's, by the way. Otherwise, I get along just fine with other MD subspecialists who actually go out of their way to make me look like a hero in front of my patient. Can somebody shed some light on this syndrome? DrG |
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