Two very good responses so far to the case in Part 1, both very reasonable approaches in light of the information I presented. Dr. Dominick Maino wrote:
I’d give him the dry with the cyl and up to a +2.00 add. Once he adjusts to the specs…I’d increase the +. May also recommend VT depending upon how the vision system responds to the specs.
Dr. Charles Boulet wrote: “What the child needs is an adequate Rx for full-time wear, and perhaps we can discuss what the Rx ought to be. Since this sort of Rx also wreaks havoc on accommodation and vergence, I would advise general VT to ensure these are normalized.”
A little more background about Brayden. He is a very intelligent child, but also “all over the place” in the vernacular. He was inquisitive about everything going on during the examination, almost to a fault. (Can curiosity ever be “unhealthy”?) Although terribly apprehensive about the drops I put in his eyes, he was endlessly fascinated by the blur.
When repeating auto-refraction under cycloplegia, encouraging Brayden to keep his eye as steady as he could on the beautiful hot air balloon at the end of the road, I told him what a great job he was doing and that I could see exactly where his eye was looking. He ran around to my side and was disappointed that he couldn’t see his eye on the screen. I pulled out my “eye phone” and told him that if he held his head and eye steady on the balloon, I could take a picture of what his eye looked like, and that pleased him considerably.
What I didn’t share in Part 1, in the report from the OT, is that Brayden’s diet centers heavily on fast food items. We know that nutritional factors can play a significant role in development, and I will mention in a tactful way to his parents.
So I’m in full agreement with Drs. Maino & Boulet that we need to Rx something for Brayden, but what? There is a strong school of thought as Dr. Maino notes that we can Rx the manifest finding and make up the difference in latent hyperopia on cycloplegia in the add value. Might there be reservations in prescribing a multifocal Rx to a child who is easily distracted?
Brayden’s parents will be returning for a conference next week, and I will lay out both Rx options. The good news here is that I really don’t think one is right and one is wrong – there is wiggle room. I’m leaning toward full time wear of the single vision Rx, but I have a week to change my mind. I also believe vision therapy is indicated, and that we can help Brayden improve his visual focus and binocular control which will in term aid his overall control of attention. One could make an argument for incorporating prism in his Rx, as seems to be quite in vogue these days, yoked or otherwise, but the “KISS” principle seems reasonable in nudging the obvious accommodative/vergence issue with plus lenses and to respect that the WR cylinder isn’t going to disappear and might be additive to the mild bilaterally amblyogenic hyperopia. So I won’t incorporate prism at this point, but I still have the week to change my mind. But if the conference were done “chairside”, and I had to Rx on the spot, it would be single vision manifest, no add, and no prism — get the Rx first, and then begin VT, with the proviso that indications for an add and/or prism will be revisited during each progress evaluation.