We have all had cases in which we look back and question our treatment approach. These are not second thoughts related to which antibiotic was prescribed or whether the patient should have been sent for an MRI; rather, we have all questioned our refractions—something done on a daily basis. As we practice in an academic setting, maintaining continuity of care can be a challenge. The case presented this month was seen over the course of several years by four different clinicians, and I wanted to exercise my right—as the last one to examine the patient—to play Monday morning quarterback! 

Second Thoughts

Regarding the data, many questions exist, but the global question is: Looking back at the individual exams—would you have prescribed? I will be honest—every time I look at the data, I change my mind. The question in this case becomes: Should glasses have been prescribed earlier? Let’s tease apart the exam data to point out some aspects of the case that are noteworthy.

	4 years old	5 years old	6 years old	8 years old
Visual Acuity (D)	20/25 20/40 20/40	20/40  20/40  20/30	20/25  20/25  20/20	20/25  20/25  20/20
Visual Acuity (N)	20100 20/60 20/60	20/30  20/30  20/30	20/25  20/25  20/20	20/30  20/30  20/30
Stereo	50 sec, + forms	100 sec, + forms	40 sec, + forms	40 sec, + forms
CT	6 XP, 10 XP	ortho, 4 XP	ortho, 4 XP	ortho, 1 XP
NPC	8/10 X 3	Hirschberg +	TTN X 3	TTN X 3
Retinoscopy	+4.00-1.00 X 180 +2.50	+3.50-2.00 X 150 +2.50-0.75 X 020 20/30 20/30 20/30	+4.00-1.50 X 160 +2.75-0.75 X 010 (Cyclo +.25 more OS) 20/25 20/25 20/20	+4.00-1.00 X 180 +3.00-1.00 X 180 BB +3.00-1.00 X 180 +3.00-1.00 X 180 20/15 OD, OS, OU @ D 20/25 OD, OS, OU @ N
Treatment	No Rx	No Rx	No Rx-6m	Rx, full time

Before we start, let us preface the discussion with a few facts. This child came in for routine exams and did not present with academic difficulties. If a complaint of an eye turn or poor school performance existed, prescribing most likely would have taken a different direction. The patient was a normal little girl on every level.

The Case

Looking at the first exam (see table), we see decent adequate acuities at distance, but poorer acuities at near, which were taken with Lea symbols. The stereopsis and the NPC are acceptable, but the cover test shows a high exo posture. The retinoscopy warrants attention, since the anisometropia is at a level some might consider amblyogenic. Based on the visual acuity at distance, the retinoscopy finding did not seem to be an issue. Since acuities for a four-year-old can be variable and difficult to attain, I fall back on the stereopsis to help guide the decision making process. In this case, stereopsis was within expected values, so I would have watched closely and rechecked the patient in three months.

The exam at age five presents interesting findings to consider. While the acuities at a distance equalized at around 20/40, near acuities showed improvement. The stereopsis dropped from 50 to 100 seconds of arc, but the cover test normalized. The retinoscopy data show a small decrease in the anisometropia but an increase in the astigmatism in the right eye. To be honest, this is a tough call to make. The increase in astigmatism in one eye could signal that correction is needed; however, a case could also have been made for close observation only, since the uncorrected acuity was good—20/40.

At age six, we found the uncorrected acuities to be quite good. The stereopsis, cover test and NPC were all essentially normal. The retinoscopy showed a similar level of anisometropia (1D at 5-year-old exam vs. 1.25D at 6-year-old exam) and the right eye’s astigmatism dropped by 0.50D; but with this in place, the acuity did not change. Since the child was asymptomatic and had excellent acuities, the clinician decided to see the girl back in six months and did not prescribe. 

Monday Morning Quarterback

My first encounter with this patient came at the final exam at age eight. The testing was fairly normal with near acuities slightly lower than distance. We performed a subjective refraction for the first time; the binocular balance was +3.00-1.00 X 180 in both eyes, and both the distance and near acuities improved in the exam room. Given the improvement and knowing that near work would be more challenging—smaller text/longer working time—I decided it was prudent to prescribe. 

Lessons Learned

In such cases, the literature provides minimal guidance, but two recent studies show a possible link between uncorrected refractive error and learning. The research shows that the presence of astigmatism is negatively associated with academic readiness on the domains of the Work Sampling System as well as on the domains of the Ages and Stages Questionnaire.¹ The VIP-HIP Study Group compared the early literacy of four- and five–year-old uncorrected hyperopes (n=244) with emmetropes (n=248).² In comparing scores using three diagnostic metrics, hyperopes scored significantly worse. The impact was even greater if the binocular visual acuity was less than or equal to 20/40, or if the near stereo acuities were less than or equal to 240 seconds of arc.

The question, of course, is whether or not correcting astigmatism or hyperopia, as suggested by the studies, will impact the scores on the specific tests. More inductively, the impact of refractive correction on a child’s social, emotional and academic development remains unanswered by the research. Until this is answered by large-scale, longitudinal studies—which can take many years—we are left with our exams and intuition. 

1. Orlansky G, Wilmer J, Taub MB, Rutner D, Ciner E, Gryczynski J. Astigmatism and early academic readiness in preschool children.Optom Vis Sci. 2015 Mar;92(3):279-85.  2. VIP-HIP Study Group; Writing Committee:, Kulp MT, Ciner E, Maguire M, Moore B et al.  Uncorrected Hyperopia and Preschool Early Literacy: Results of the Vision in Preschoolers-Hyperopia in Preschoolers (VIP-HIP) Study. Ophthalmology. 2016 Apr;123(4):681-9.