The College of Optometrists

I had a child today who was seen 1 year ago by my predecessor and put into bifocals (she is 13) with very small dist Rx and 1.50 add. She had complained of slight difficulties in changing focus from near to distance at that time. On my examination she has a slight esophoria (but straight on fixation disparity) and normal accommodation for her age. I am wondering if giving her bifocals is just giving her a crutch that she will end up always needing just because she has got used to not using much accommodation. I am thinking to take her out of them and see what happens, or to reduce the add with a view to removing them in 1 year... Opinions would be good!

If no lag, accommodation good and well compensated eso then I can see no reason other than placebo why she should now need them. Personally I would ask the px to wean off them.....with extra help by the parent 'losing' them with increasing frequency.

I agree with Patrick. There is really no need for this child to have bificals now. Decision whether to just stop gls altogether or try reducing add gradually is trickier. Clinically it would seem she'd cope fine without, but psychologically may be better to wean off gradually, depending on what the pt and her parents are like.

On a related topic, if you had seen the pt a year ago what would you have done? I would rather try +/- flippers before giving a 13 y/o an add. (not having a go at sl by the way, I understand you're just reporting what your predecessor did).

Lisa

I agree that a year ago, exercises would have been my first choice, but could not have been appropriate at the time for some reason. I have come accross a few children over the last year who wear bifocals - for some reasons Americans seem to settle in my part of britain! They seem to do it a lot over there, but I have seen only one case where I would have agreed with dispensing them.

But it is a difficult situation to be in making the decision to stop BF wear. I would wean off too - in effect exercising and building up accomodation, would prob give orthoptic exercises too.

I have been wearing VFs since I was 18 and have very lazy accomodation now, but at least im prepared for presbyopia!!

I wonder what the Health Board reaction would be when processing a claim for kids Bifocals?

In 20 years of practice, I have never needed to prescribe bif's for any child. Kids do tend to throw up odd symptoms unrelated to objective findings.

Mostly they disappear if you tell the child that their eyes are really good, and that most good eyes do occasionally "play up". Recheck in 6 months usually shows that the symptoms gradually resolved.

I did have one 8 or 9 year old girl who, over a 2 year period, exhibited a consistent, gradually decreasing Visual Acuity, from 6/6 to about 6/24. Rx about +0.50 R & L consistently, fundoscopy & everything else I could think of was normal.

I referred her in the end, and the Ophthalmologist agreed that acuity was poorer than it should be, but no pathology. They brought her back again with the same result:- no answer.

It's still ongoing, it wasn't that long ago. Strange.....!

Never Rxed bifs!??? How do you control near esot/ decompensated esop? in children in the short term?

It is nice to be in agreement - but we all agree. I did hear of the PPC causing a rumpus over bifocals for kids down in my area. I thought we were to give what is evidence based and ont symptom based. As you say P - talking the px eyes 'up' - can cure all kinds of eye strains. Trouble with exercises is compliance.

Curious case of yr 8 y o girl with increasing blur, of no known cause. I had a young lady like that once. Here vision was never better than 6/24 - appart ffrom odd spells. In the end - I refered - but the GP (was is a friend) said that the whole family were like that - with phantom broken limbs and limps and mystery head aches - so he felt the whole referal would be a waste. In the end, the girl fell pregnant and joined the army of one parent mums up the estate. (perhaps her vision got better ): palfio

With the history of this case as descibed above IMHO the psychological handling of parent[s] and child is the most important factor. Weaning off with confidence boosting phrases eg "eyes are much stronger now" and no charge 5 minute appointments say every two weeks for two months with eg "read the bottom line" one visit and a quickie ret or ophthalmoscopy for psychological boost the next to re-inforce the "message" should have the child and parent satisfied in 3 months.

depends who the child is - the parent or the kid, I suppose

Thanks for all the posts, I'm speaking to the mum on friday - we are first trying a week out of Rx to determine what happens, hopefully we can remove immediately. I think I will try reducing Rx if we have a problem, or if anything shows up for orthoptic treatment, treat accordingly (further to Lisa's question, I would have gone down this road first before prescribing bifs)

Thanks again, it's always good to get other's input in this lonely job!

Interesting to hear comments from all & sundry re Bifocals etc. I have hardly ever given a kid bifocals, maybe 5x in 30 years. I have however come across many cases of reduced VA, binocularly for all sorts of reasons, we used to refer to "hysterical amblyopia" but I guess this is non PC now. Usually if you precribe a few early nights, a bit of helping with the washing up & keeping their room tidy PLUS a LOT of TV, particularly interpersed with watching teletext over increasing distances, using a small font - the next check up in say 3/12 invariably gives some VA improvement. Far less costly & much more acceptable than bifocals