# Optical Forums > Ophthalmic Optics >  Bifocals for kids

## Rhonda

I have an OD in my area who puts almost all kids into bifocals.  She told one parent that by putting the kid (-4.50 ou) into a bifocal (+1.00) that it would slow down her change in 
the distance RX. (My terminology seems to still be asleep - can't think of the correct terms!!)  Seems a little strange to me, but I thought I'd see what you guys think of this and if it is really some form of vision therapy.  By the way, I see more Dr. changes on refractions from this OD than any other for adult RXs.

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## Pete Hanlin

Today, bifocals are usually prescribed for children with accomodative insufficiencies.  

In your case, however, it sounds like the OD may be a bit "Old School" in thought... at some time in the past there was a theory concerning the use of add powers and the arrest of myopic progression.  I believe Borish's book on refraction covers it at some length (but I don't have access to a copy at the present).  To my knowledge, that theory is no longer adhered to by most refractionists...

Its too bad the doc doesn't do something more effective, like the application of RGP contact lenses, if she is concerned about myopic progression.

Pete

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## David Wilson

You're right Pete, the myopia control idea has been around for a while and I think that Prof Borish may have been one of those who published something on it (I know of another well known US author who devoted a chapter to the subject but his name slips my mind), but I don't think that it has gone away quite yet. I believe that there are studies currently underway on the use of progressives instead of bifocals for the control of myopia.

Regards
David

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## chip anderson

Ain't it amazing how some theories result in more profits to the one with the theory?  Have heard some possibly ligitamite theory that if one uses accomodation during growth period myopia may increase.  Have also heard that this was used mostly to increase profits on eyeglasses.

Have you ever noticed how many medicaid Rx's are +.50-.50 or less. (Appearently, no Rx, no exam fee.) and paying kids don't get Rx's this low.

Ever notice how when the practioner has a financial interest in dispensary, you will see Rx's for +.25 cylinder in a pair of welding goggles?  Or the doctor wanting UV on a pair of readers?  See a patient with a pair of plano's who say's ?"He told me to only wear them when I read?

Something stinks in Denmark.

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## Darryl Meister

Actually, quite a few persons have investigated techniques to slow the progression of myopia. I think that there might actually be several schools of thought for using bifocals to do this. I believe that one asserts that progressive myopia is called from prolonged accommodation and "ciliary spasm." Another is that prolonged accommodation causes "pressure stress" in the vitreous chamber. And yet a third is that prolonged near work might lead to a kind of "emmetropization" (the process of the visual system developing in such a way as to minimize refractive error) of the eye for a near working distance. Consequently, anything that reduces accommodative demand should reduce these potential mechanisms of myopia progression. Several studies have shown that myopia progression can be arrested in certain instances with bifocals. However, as with any speculation, there are those who think that this is all voodoo.

Best regards,
Darryl

[This message has been edited by Darryl Meister (edited 07-28-2000).]

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## pedseye

Rhonda,

I work for an ophthalmologist who did an extra year fellowship in pediatric ophthalmology.  If anyone knows about this, he does.  His therory is there are some O.D.'s and M.D.'s who believe this theory DOES slow down the progression of myopia.  He has not yet found that to be true, but is not quick to dismiss their theories.  It is like progressive lenses, opticians will always think THEIR brand of choice works best for the patients and they have very little non-adapts.  He personally only prescibles them when a high AC:A ratio is involved with an accomodative esotropia and the esotropia is not improving with a sv hyperopic crx alone.  It's all about what is working best for his/her patient's and I am sure they are only doing what they think is best for the child.  I do not agree however with the one's that are prescribing low hyperopic crx's for children who are naturally hyperopic. ie: +.50,.75 etc. or those Plo -0.25 rx's.  give me a break!

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## Optom

BIFOCALS FOR CONTROL OF JUVENILE
       STRESS MYOPIA.
This is still valid & effective means of control of juvenile stress myopia,a commonly practised method in many parts of the world,continental europe certainly.
There is considerable evidence gathered that shows the involvement of accommodation as causative factor in myopia arising in childern under 13 years of age.In a controlled study done by Prof.Francis Young,(WSA)atropine eye drops were put in one eye of myopic childern to paralyse the ciliary muscles and he used the other eye as a control.The atropinised eye regressed about 0.50D and stabilised for the year in which it remained atropinised whilst the other eye progressed further into myopia,which suggest that ciliary muscle spasm may be involved,so the result of this study provokes the hypothesis that prolonged use of accommodation is a causative factor of myopia in some young childern(also vitrous chamber stress).
I have on record many cases with bifocals used for control of juvenile myopia which demonstrated regression or reduction of myopia of about 0.75D average on a first call up visit of childern after 6 months later, in my Optometric Centre confirming above study that spasm of accommodation is involved in juvenile stress myopia.Note that with childern over 12 years of age there is no advantage prescribing bifocals because of myopia arising after this age is possibly correlation myopia.
Also,we should not forget role of heredity,race and geography in cause myopia.
I have tried prescribing progressives with poor results so I continue fitting bifocals with segment top 1 mm below pupil.In my own study I have gained good results!

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## Joann Raytar

Any fitting tips or advice when it comes to kids with special needs and bifocals?  The other night we filled a bifocal Rx for four year old little Jimmy.  We fit him in an oval frame without too much room to sneak around the bifocal and fit the seg vertically just below center.  Working with him in dispensing he kept saying he couldn't see.

When I got him to go slow and led him through how to use the top and the add he said he saw better with the glasses.  When he was left to his own devices he kept covering his eyes with his hands.  Watching him it appeared that he was not able to use the different areas properly, using the bottom for far away and the top for close up.  His eyes were everywhere.  His response was drop and sit with his knees curled up against his chest, elbows on his knees and hands covering his face.  OK, I am trying to say his reaction broke my heart.  Even though he had a very over active energy level, when he did calm down he was a little sweetheart.  I know the whole concept of glasses scared the dickens out of him at first.  He kept saying he didn't like it here and it was scarry; so he doesn't have alot of patience for any type of trial and error.

There is and there isn't alot of parental support for Jimmy.  Part 2 of the heartbreaker is Big Jim's illness.  Mom works two jobs because Jim can't work.  He is at home raising his two boys.  Big Jim is awaiting a liver transplant and is on a ton of medication; just getting Jimmy's glasses exhausted him.  He is currently feeling very guilty because his illness caused him to miss a couple of Jimmy's appointments with his doctor.  After seeing how thick the lenses were he just got upset with himself for missing the appointments.  I am not so sure he understands what the Doc is trying to do for Jimmy and I think he is blaming himself.

[This message has been edited by Jo (edited 02-27-2001).]

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## Joann Raytar

Sorry guys, I had to get that one off my chest.  What started out an annoying exchange with an insurance company ended up being a multiple tear jerker.

PS - To put my own mind at ease.  If Jimmy does not learn to adjust to the lenses at his age, what other treatments may help correct his lazy eye.

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## Optom

Jo
Tell me what type of bifocal was he fitted with,and where was seg set,i.e.at limbus or just below pupils?
Other options are patching good eye and stimulating amblyopic eye.If the child removes his eye patch every now and than,paralysis of ciliary muscles with atropine drops in good eye and under supervision may help.

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## Joann Raytar

Shabbir:

He was fit with a FT28 just below the pupils; sorry for saying below center earlier.

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## Carol D

I spent 4 years fitting and dispensing exclusively peds.My office was in the same building as a pediatric Ophthalmology group. None of them ever prescribed bifocals for myopia. However, about 75% of the kids were Rxd bifocals for strabismus. I fit over half of those with progressives. Kids love them because they don't get teased as much by other kids. Parents loved it because they already felt guilty about their kid wearing "old people" glasses. Docs liked it because they worked and gave parents an option. Of course, I liked it because not only helped the child but I made more money.
Varilux published a pretty good study on the use of progressives on kids in the 70s or 80s. I would love to see a more recent one if anyone knows of one.

Carol D

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## Optom

TIPS ON FITTING BIFOCALS TO CHILDERN
     FOR CONTROL OF ACCOMMODATION
Jo,
Try fitting E style or large round seg bifocal with segment tops just 1mm below pupil,reason for this high fitting is to ensure that the child does not use upper portion of the lens for close work,and in the event if his/her spectacles get loose.Also use specially designed spectacle frames for very small childern which have loop-end sides thru which a ribbon can be passed and tied at the back of the head to secure spectacles.With hyperactive small childern use frames fitted with bridle.For older childern frames with curl ends serves the purpose well.
If the child does not accept glasses, try experimenting with different positioning of segment tops, keeping in mind that he is required not to look from distance portion of segment for close work.

[This message has been edited by SHABBIR KAPASI (edited 02-28-2001).]

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## chip anderson

The pediatric ophthalmologists' that I do work for (3) when they prescribe a bifocal for a child (usually to correct a muscle problem), all say the bifocal should be an executive(if available in Rx or the widest thing that is if exec is not available) and it should split the pupil.

Chip

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## Jackie L

We get quite a few peds patients from an O and we usually talk the MD into a FT 35 or FT 40 instead of the bulky, heavy and unsightly executive.  Most parents freak out when they see the finished product with an Exec.  

By the time you have edged the blank into a small frame, the seg is usually enough.  We fit the seg at the center of the pupil and if the child is too small for a pupilometer to be accurate, we measure his/her pd by their inner tear duct on the right to the outer lower lid on the left.  (usually with a lolly pop or toy in their hands so they can't pull at the mm rule)  

Don't you just love the little ones?

Jackie O

------------------

Still a Maina for now

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## pedseye

Carol D,

Nice to hear your success with the progressives.  That is what I like to do too.
I am curious, what do the parents do when you tell them how much more a progressive will cost?  It's always nice to hear different spills from fellow opticians. I've heard some pretty good one's on this board and they've helped.  Also, where did your Varilux rep tell you to fit it and do you mark the oc's where they tell you too or do you modify it.

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## Joann Raytar

At LC kids lenses were one price whether SV, FT or Progressive, unless you get into special coatings.

Adults, however, go into sticker shock if they have never worn them before.

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## Darryl Meister

I agree, Executive-style lenses for children are overkill. For one thing, these lenses are often prescribed to reduce accommodative esotropia, which often occurs in highly hyperopic children (who need a high plus power). These lenses are excessively thick, heavy, and limited in material availability.

A FT-35 should provide more than enough width for a child (I can't imagine a child turning his/her gaze out that far to read anything -- it's almost a 40-degree eye rotation). Also, a FT will leave a little temporal vision for seeing the ground in the periphery more easily. It should be pretty easy to get a FT-35 in several materials, including polycarbonate.

As far as progressives for children... I would be tempted to use a short-corridor progressive, myself (and only if cosmetics are a serious issue). Most children wearing bifocals do so because of binocular vision disorders, not because of reduced accommodative amplitudes. This means that children can often see clearly anywhere through the distance, corridor, or near zone of the lens. However, if the child doesn't reach the full power of the near zone the benefits of the lens are not realized. This is exactly why bifocals are positioned so high with children. Progressive lenses, which already require more depression of the eyes while reading, must be positioned several millimeters above the pupil on children. You should also be aware of reduced distance and near utility.

On the other hand, certain "computer" lenses might show more promise for children. I believe there was actually a study conducted to evaluate such lenses for children, although I do not have the results handy. Blended bifocals, fit high, might also be an affordable option.

Best regards,
Darryl

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## Optom

progressives have failed in many studies for control of juvenile stress myopia for following reasons:
1)effect of pupil size-myopes generally have large pupils and have increased intolerence  to blur compared to patient with small pupil which have better chances to adapt to ppl's.
2)variation in progression corridor excites accommodation.So no effective control of accommodation is obtained.
3)slight change is frames pantascopic tilt with ppl's has detrimental effect on child vision which is possible due to daily play & tumble.
An E style bifocal made for control juvenile stress myopia will not neccessarily look thick and ugly like E style bifocal made for child with an accommodative esotropia.


[This message has been edited by SHABBIR KAPASI (edited 03-02-2001).]

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## chip anderson

If you can't measure a child pupil to pupil, don't go inner canthus to outter canthus.  Go inner iris limbus to outer iris limbus.  Reason:  The more the parts you measure are separated, the more the chance of anatomical error.

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## Jackie L

Chip, you are absolutely correct.  Although, while measuring a toddler (we have fit a child as young as 18 months old) it is extremely dificult for the child to fixate or gaze on demand.  

Thanks for the correct terminology.

Jackie O

------------------

Still a Maina for now

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## Darryl Meister

Hi Shabbir,

I wouldn't necessarily say the myope's "intolerance to blur" is greater because they have larger pupils (assuming that they do have larger pupils)... Larger pupils actually create more blur and reduce the depth of focus of the eye. A given amount of relative blur - that is, the blur spot size of an image point compared to the overall basic image size - should produce the same reduction in visual performance for hyperopes, myopes, and emmetropes. However, as the pupil size increases the size of the blur circle also increases proportionally.

With progressive lenses, there is another issue related to pupil size. Progressive lenses are changing in power continuously across the surface. Even along the progressive corridor, where the power is virtually spherical at any infinitesimal point, cylinder power error exists if you look at a larger, finite region around any given point. This cylinder error increases as the size of the pupil increases. The eye perceives no blur, however, as long as the average cylinder power across the pupil is within the depth of focus of the eye.

For instance, if the add power is +2.00 and the corridor length is 10 mm we can assume that the lens is changing roughly 0.10 D for every 1 mm. If the pupil of the eye is 4 mm, this means that there is a difference in power from the top of the pupil to the bottom of nearly half a diopter (of cylinder power). The eye essentially integrates the variation in power across the pupil to produce a resultant spherocylindrical error. The larger the pupil, the greater the error.

All this might be a moot point though... The pupils of the eyes constrict during near vision (as part of the "near synkinetic reflex" or "near triad"), which helps reduce blur and increase the depth of focus of the eye during near vision. So I would wonder just how much of a difference any small variations in the anatomical size of the pupil (between myopes and everyone else) would actually make in terms of near vision performance. Not to mention the fact that a child's pupil should be anatomically smaller than an adult's.

Also, although Executive-style lenses might not be as thick for myopic children, I still don't think that they should be the lens style of choice for children.

Best regards,
Darryl

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## chip anderson

Pupils also constrict in various lighting conditions and will constrict with sexual interest.   Don't know how this is relevant though.   Have had a lot of problems with bifocal contacts, especially the aspheric type on patients with large pupils.  Progressive spectacles are more or less and an aspheric hybrid, this could be why most pediatric ophthalmologist don't like them on kids with fusion problems.

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## Sara

Darryl,
Shabbir & uncle Chip are old fashioned opticians,they do not realise profit we make by selling progressives and good cosmesis it gives to child.
Forget E style, we are in world of progressives now.
Sara

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## Joann Raytar

Sara:

Please forgive me if I sound harsh.  In the case of children, our primary concern should be the early correction of visual defects, such as Jimmy's strabismus - before the child develops amblyopia, as well as accomodative disorders not just profit margins.  If another lens will do the job better, than that is what the child should be fit with.  Health should be put before profit and cosmetics.

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## chip anderson

Sara:  I have always concidered an optician's job to be to provide whatever services best serve the needs of the patient.  If this is not the most profitable option for me, or not the most cosmetic option for the patient, so be it.

I may die poor, naked and alone.  But I will feel that I was a good Optician, Ocularist, Contact Lens Technician (and I spell them all with capitals).   No one will ever accuse me of being a salesman (which I concider to be another term for liar).

Keep your money, maybe you can buy your way in.

Chip

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## Sara

Jo & Uncle Chip,
I appreciate your concern & will emulate your examples.Thanks for putting me on right track.
Sara

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## Sara

Uncle Chip
What does Ocularist mean? Its my first time to come across this word.
Sara

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## chip anderson

Sara:  Ocularist:  Expensive sounding word for an artificial eye maker.

Hope you are not too mad.

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## Joann Raytar

> Originally posted by chip anderson:
> _Ocularist:  Expensive sounding word for an artificial eye maker.
> 
> _


Chip:

Through your experiences, what are the top reasons, injury or disease, why you're services as an ocularist are needed?

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## chip anderson

While we see everything from gunshot wounds to strange diseases.  In the very, very young I would say retinitus blastoma, In medium age children scissors, in young men in the lower echelons of society (these two other guys was in a fight).   In the somewhat higher age/incomes diabetes.  Used to see an awful lot of "It started out as a cataract."  but I started getting bad feelings about some surgeons and stopped asking years ago.

Have only seen one in 42 years that started out as a contact lens infection (pt. also got treated with cortizone too long).


Chip

Sorry I forgot to mention bottle rockets, aways good for a few eyes each year.

[This message has been edited by chip anderson (edited 03-06-2001).]

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## Joann Raytar

Chip:

A couple of nights ago there was a news special on about a young child being fit for an artificial eye.  The detail to the prosthetic was amazing.  The eye looked very natural as far as color and anatomical detail.  What goes into making an artificial eye and about how long does it take you?

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## Carol D

Pedseye

I measured most of the kids at center pupil or very slightly above. At the time I was getting $250.00 for a pair of poly progressive lenses. Generally, the easiest way to sell them was to show the parents a pair of cute frames with a FT35 already mounted in them and then show them a pair made with progressive. I left the decision up to them. I never had a child non-adapt, but of course, I always told the parent that if the child could not adjust to them I would remake them in FT 35 at no additional charge. 
I think parents liked the way I dealt with the kids. If the child wanted to sit or lay on the floor then I would sit or lay on the floor too. I always got down to their level to take measurements and framestyle. It made parent and child more comfortable. Oh yeah, one other thing,the mirrors on my dispensing tables were plastic. They got moved and knocked around alot.

Carol D.

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## chip anderson

Jo:  I think I have the record on fitting young patient's the earliest I started was 23 hours.  Have done a couple at 98 years. As to making one (short version) I take a mould of the socket, make a plaster cast of this, then a wax model to attain socket/lid fill.  Make a mold of that with pupillary center pegged. Paint an Iris, mold white plastic around that, strip off some of the white plastic, apply veins (red nylon fibers) and match the color of the sclera.  Then I apply a layer of clear plastic, and smooth an polish.   Working time  4 to 12 hours with some notable exceptions each way.

Long version is too long for this forum.

Chip

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## Joann Raytar

Thanks for the reply Chip.  I never knew what went into making prosthetic eyes.  I guess that is where you get your knack for paying attention to details in other areas of optics.  After watching that news special, you guys to some terrific work.

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## Diane

In this Opticians view, I believe that if we need to fit a child with a bifocal, for the various reasons sited here, a good Optician will evaluate each and every child (patient).  Then and only then determine whether a lined bifocal would be best or if the child is beginning to get a little older, and would benefit from a PAL.  Sometimes we fail to remember that if a child is made fun of, then he/she will not wear the glasses, so what use are they then.  Identify the visual and emotional needs of the child and do what is best for each of them.  If a PAL is determined to be the option, then a style with a short corridor is best.  I believe that we hold these very important patient's lives in our hands, and we have a great responsibility to them.

Diane

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## chip anderson

If our "selection" results in failing to correct a childhood strabismus or amblyopia for "the poor child's psychology"  we fail.  
We are in the vision correction business not mental care.

Children are teased more for crossed or cocked eyes, than glasses and this can last forever.

Chip

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## Jocelyn

I am hoping that although this thread is old, someone will be able to reply to me in a short amount of time. I am not in your profession at all but am just a mother looking for answers. I took my 8 year old to the Optometrist for a check the other day and he has been diagnosed as being near-sighted. The Optometrist also did some tests on his focusing ability and said that he would benefit some wearing bi-focals as his right eye is a lot stronger than his left and it may help him to have both eyes working together for close-up work too. I will give you his prescription:-0.75 Right eye, -1.25 Left. She has also written that if he gets bi-focals, Add: +1.75R and +1.75L. She said something about research indicating that there is a lesser rate of decline in vision amongst those who wore bi-focals. They were not her exact words and I think she is echoing some of what I've seen on this thread. Not being up on all the terminology though, I haven't been able to see a definitive view which would help our situation. Any advice would be welcome.

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## drk

> I am hoping that although this thread is old, someone will be able to reply to me in a short amount of time. I am not in your profession at all but am just a mother looking for answers. I took my 8 year old to the Optometrist for a check the other day and he has been diagnosed as being near-sighted. The Optometrist also did some tests on his focusing ability and said that he would benefit some wearing bi-focals as his right eye is a lot stronger than his left and it may help him to have both eyes working together for close-up work too. I will give you his prescription:-0.75 Right eye, -1.25 Left. She has also written that if he gets bi-focals, Add: +1.75R and +1.75L. She said something about research indicating that there is a lesser rate of decline in vision amongst those who wore bi-focals. They were not her exact words and I think she is echoing some of what I've seen on this thread. Not being up on all the terminology though, I haven't been able to see a definitive view which would help our situation. Any advice would be welcome.


We here have a rule that we shouldn't second guess a "non-cyber" Dr.'s opinion.  

It is a fact, though, that the evidence for accommodation as a component of myopia progression is controversial, as the body of studies do not strongly indicate one way or another.

I note, though, that that is only a secondary reason for the bifocal prescription.  The primary reason seems to be for accommodative insufficiency, and this is a completely mainstream treatment for such a diagnosis.

Suffice it to say that there is no indication that your Dr. is doing anything risky or controversial.

I hope this helps.

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## Jocelyn

I'm sorry I didn't realise that you had that rule about not contradicting a non-cyber Dr - even though it makes sense. I guess I'm the one leaning toward getting the bi-focals whereas my husband thinks that the prescription for his distance correction should be enough and we'll wait and see. The Optometrist was not emphatic that my son should also have bi-focals but said they would probably help. I guess I'm wondering if we should err to that side rather than just getting the distance ones and waiting to see if his vision then gets worse and requires bi-focals later.

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## Alvaro Cordova

> Sorry guys, I had to get that one off my chest.  What started out an annoying exchange with an insurance company ended up being a multiple tear jerker.
> 
> PS - To put my own mind at ease.  If Jimmy does not learn to adjust to the lenses at his age, what other treatments may help correct his lazy eye.


There are various types of patches and drops (last resort before going to surgery (if muscle imbalance is the culprit for the eye turn)) that are used on the good eye.  

Sometimes when I write a post, I'm finding that my writing resembles Scheme, a programming langauge that has ungodly amounts of parenthesis.

;;; Hello World in Scheme

(define helloworld 
        (lambda ()
                (display "Hello World")
                (newline)))

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## eyeboy

> I am hoping that although this thread is old, someone will be able to reply to me in a short amount of time. I am not in your profession at all but am just a mother looking for answers. I took my 8 year old to the Optometrist for a check the other day and he has been diagnosed as being near-sighted. The Optometrist also did some tests on his focusing ability and said that he would benefit some wearing bi-focals as his right eye is a lot stronger than his left and it may help him to have both eyes working together for close-up work too. I will give you his prescription:-0.75 Right eye, -1.25 Left. She has also written that if he gets bi-focals, Add: +1.75R and +1.75L. She said something about research indicating that there is a lesser rate of decline in vision amongst those who wore bi-focals. They were not her exact words and I think she is echoing some of what I've seen on this thread. Not being up on all the terminology though, I haven't been able to see a definitive view which would help our situation. Any advice would be welcome.


Could you talk a little bit more about the original symptoms?

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## eyeboy

I should also add that I never prescribe bifocals for kids except in say near vision strabismus such as convergence excess. In my experience most near problems for kids can be sorted out with regular review and possibly exercises. In this case it doesn't appear clear as to why this child was prescribed bifocals, was it their first visit?, had they complained of near vision problems?

In an 8 year old I would be worried about messing with binocular control by giving bifocals. Intrestingly I have read that in myopes with esophoria for near myopia could be reduced by 20% using a +1.50 add, this is a small subgroup of myopes, (Pickwell's Binocular Vision, pg111). Even so personally I would still be careful unless I felt the myopia was 'galloping away' and they are esophoric for near.

Incidently I am am new to this site, and it is absolutely fantastic. I wish something like this was around when I was studying years ago!!!!

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## QDO1

As a lowly Dispensing Optician I only ask Ophthalmic Opticians, MD's or whoever else prescribes Bifocals to kids one thing... dont start a war with the other local professionals (via the parants). Bifocals for kids are quite emotive.

If you prescribe bifs. for kids dont tell the parants how useless other (non-prescribing) practitioners are

If you are not a bifocal for kids prescribing practitioner, dont slag off the prescribing ones (via the parants)

I have twice worked in a district with a bifocal prescribing practitioner, and been at the brunt end of this practice of dissagreement between professionals. Once betwenn two long term locums in the same practice! The rub is that the kid gets upset, parant very upset, and the proffesion looks stupid and inconsistant. The dispensers desk also sports a box of tissues

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## eyeboy

> As a lowly Dispensing Optician I only ask Ophthalmic Opticians, MD's or whoever else prescribes Bifocals to kids one thing... dont start a war with the other local professionals (via the parants). Bifocals for kids are quite emotive.
> 
> If you prescribe bifs. for kids dont tell the parants how useless other (non-prescribing) practitioners
> 
> If you are not a bifocal for kids prescribing practitioner, dont slag off the prescribing ones (via the parants)
> 
> I have twice worked in a district with a bifocal prescribing practitioner, and been at the brunt end of this practice of dissagreement between professionals. Once betwenn two long lterm ocums in the same practice! The rub is that the kid gets upset, parant very upset, and the proffesion looks stupid and inconsistant. The dispensers desk also sports a box of tissues


I'm not entireley sure if this was directed towards my reply, but I feel I should at least defend my last post. 
I actually did say I would dispense bifocals in certain cases and actually sited recent research which showed that Myopia could be controlled in a small sub group of Myopes.
I do not agree with your point of view about disagreeing with other practioners. The evidence for prescribing bifocals in all cases for reducing myopia in children is vague. If an optician has anecdotal evidence proving that they can reduce the myopia with bifocals is this ethical? They would have to show that it is statistically significant over a population of screened individuals. With any form of such research it would have to be put before an ethics comittee. This would be even more important, with the test population comprising of children and where there is a risk of causing a problem with the motor control for near. Personally with any new advances in optics I think professionals should fully review the research before applying the 'advance' to a patient.
I have met opticians who have not performed any further education in years, who still apply old fashioned methods and perform inadequate examinations to the detriment of the patient and our profession. Should I disagree with these practioners? Yes! Should I slag them off? No! The public has the right to a second opinion and in this case the parent was obviously concerned about the treatment carried out to subscribe to this thread. In fairness I was interested in the symptoms in more detail. From what she said though it did seem strange to put a child into bifocals. I also thought it sounded a bit like the childs first visit. As a dispensing optician would you have been comfortable prescribing bifocals in this instant?

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## chip anderson

This all goes back to the question of trust.  The question of whether the precriber can be trusted or not.  If the precriber has no financial interest in the filling of the Rx then one can assume the Rx is based on his genuine belief that his theories and exams are based in fact.   However since bifocals can also be prescribed to increase profits if the precriber has a financial interest in the filling of the Rx his motives come into question.   And no, the amount of education one has bears no resemblence to personal integrity.


Chip

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## QDO1

> I'm not entireley sure if this was directed towards my reply, but I feel I should at least defend my last post. 
> I actually did say I would dispense bifocals in certain cases and actually sited recent research which showed that Myopia could be controlled in a small sub group of Myopes.
> I do not agree with your point of view about disagreeing with other practioners. The evidence for prescribing bifocals in all cases for reducing myopia in children is vague. If an optician has anecdotal evidence proving that they can reduce the myopia with bifocals is this ethical? They would have to show that it is statistically significant over a population of screened individuals. With any form of such research it would have to be put before an ethics comittee. This would be even more important, with the test population comprising of children and where there is a risk of causing a problem with the motor control for near. Personally with any new advances in optics I think professionals should fully review the research before applying the 'advance' to a patient.
> I have met opticians who have not performed any further education in years, who still apply old fashioned methods and perform inadequate examinations to the detriment of the patient and our profession. Should I disagree with these practioners? Yes! Should I slag them off? No! The public has the right to a second opinion and in this case the parent was obviously concerned about the treatment carried out to subscribe to this thread. In fairness I was interested in the symptoms in more detail. From what she said though it did seem strange to put a child into bifocals. I also thought it sounded a bit like the childs first visit. As a dispensing optician would you have been comfortable prescribing bifocals in this instant?


No the post was not directed at you.

My post merely commented that pediatric optometry, and dispensing, can be very emotive, and as the dispenser, I am often the person somoothing out the issues raised by Optometrists, (and holding the box of tissues).  

I am 100% happy to dispense anything a OO or MD asks me to

Within a small town (or practice) there are a lot of different ideas about how to deal with chidrens vision, and often the parant ends up ping ponging between different practitioners with thier different methods of approach to childrens Optometry.  I feel practitioners have a responsibility to ensure that the child comes first and not thier ego.   If that means that the practitioner has to spend an extra hour explaining to the parants the philosophy of thier desision, then so be it.  If that means a second practitioner disagrees, then a smidgen of diplomacy (which is often not evident) would go a long way

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## chip anderson

One must remember that I think in the UK (and most of Europe) and Optician is what we call an Optometrist.. In the US, Optometrists are writers of prescription who usually dispense or have a dispensary. In the US Opticians dispense spectacles and can sell nothing without an Rx. 

In the US an optician may have some leeway as to what type of bifocal and a few other options on the spectacles may be used, but actual power, SV or bifocal is not an option of the Optician.

Also until about 1965 or so Ophthalmologists for the most part, practiced medicine, surgery and examinations. Most did not have ownership interest in the dispensary. This has changed since that period, and I fear will never change again unless spectacles should become for the most extent unprofitable.


Chip

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## QDO1

> One must remember that I think in the UK (and most of Europe) and Optician is what we call an Optometrist.. In the US, Optometrists are writers of prescription who usually dispense or have a dispensary. In the US Opticians dispense spectacles and can sell nothing without an Rx. 
> 
> In the US an optician may have some leeway as to what type of bifocal and a few other options on the spectacles may be used, but actual power, SV or bifocal is not an option of the Optician.
> 
> Also until about 1965 or so Ophthalmologists for the most part, practiced medicine, surgery and examinations. Most did not have ownership interest in the dispensary. This has changed since that period, and I fear will never change again unless spectacles should become for the most extent unprofitable.
> 
> 
> Chip


You are right. Despite changing all the names of the professionals, and deregulating a few years ago the basic structure of the optical profession in the UK is as follows

OMP = Eye surgeon = Allowed to refract
OO = Optometrist / Ophthalmic Optician = Allowed to refract + fit contact lenses +performs a complete Eye examination including ocular health, and will refer if any problems
DO = Optician = Dispensing Optician = Not allowed to refract or fit contact lenses
CLDO = Contact Lens Optician = Dispensing Optician who fits conttact lenses (only allowed to refract in terms of contact lenses)
(Q)DO = (Qualified) Dispensing Optician

Incidentally there is a new breed (anyone can call themselves a dispensing optician, so long as they do not use the word qualified :angry: )

Qualified Dispensing Opticians are an increasingly rare breed over here


This set up tends to mean the folowing:

OMP's work in hospitals, and tend not to bother refractingOO's work in practice, but mainly refract in a testing room all day and tend not to dispense, and refer patients with a medical problem to their GP who then refers to an OPM /OpthalmologistDO's tend to be the practice manager, and deal with all of the dispensingUnqualified dispensers tend to do most of the dispensing in the UK ans work mainly for multiplesIn terms of prescribing a bifocal for a child.. an Opthamlologist / OMP or OO would prescribe the bifocal, a dispenser would then Dispense, produce, fit and deal with the parant. Because often the DO is nowhere near the OMP/Opthalmologist, the OMP/Opthalmologist is generally never that aware of the issues they cause to the parant / child / practice. In terms of a OO prescribing a bifocal, well they have it comming at them from all angles - a higher opinion is available from OMP/Opthalmologist's, other opinions are offered by other OO's, and then the Dispensing Optician is Having a go at them about the amount of Kleenex they are using!

In my observation, the best system over here is where the child goes to the hospital, and all the dispensing is done in house, using the hospital's OMP/OO/DO team who work in unison

Back to the original question:




> I have an OD in my area who puts almost all kids into bifocals. She told one parent that by putting the kid (-4.50 ou) into a bifocal (+1.00) that it would slow down her change in 
> the distance RX. (My terminology seems to still be asleep - can't think of the correct terms!!) Seems a little strange to me, but I thought I'd see what you guys think of this and if it is really some form of vision therapy. By the way, I see more Dr. changes on refractions from this OD than any other for adult RXs.


Rhonda seems to have the same problem as me. That is that she is not the prescriber (of the bifocals), but is picking up the questions and queries from the patients parants. That is why I say that if you do prescribe bifocals for children, then a lot more time is needed in councelling the patient and parant. In that way, if there is a problem, the patient and parant will tend to go back to the original practitioner, and not the one over the road to the next practitione, who may have a different opinion about pediatric refraction and dispensing methodology

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## QDO1

> I have an OD in my area who puts almost all kids into bifocals


Does any one know the % of Kids with a relevant RX / need for dispensing bifs?

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## Lynne

> Jo: I think I have the record on fitting young patient's the earliest I started was 23 hours. Have done a couple at 98 years. As to making one (short version) I take a mould of the socket, make a plaster cast of this, then a wax model to attain socket/lid fill. Make a mold of that with pupillary center pegged. Paint an Iris, mold white plastic around that, strip off some of the white plastic, apply veins (red nylon fibers) and match the color of the sclera. Then I apply a layer of clear plastic, and smooth an polish. Working time 4 to 12 hours with some notable exceptions each way.
> 
> Long version is too long for this forum.
> 
> Chip


:) Wow, Chip, what a wonderful job!  That must be so very satisfying, to see the final piece in use, and what a difference it must make to the patient.  I know that Columbo, what is his real name?  has one, and its really hard to tell which eye it is!  :cheers:

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## chip anderson

Lynne:  

Actually I have always thought that Peter Faulk's and Sammy Davis, Jr.'s were horrible.  I wish I knew Mr. Faulk as I have always admired his work and would like to make him a better one.   

There are rumors that Sandy Duncan and David Bowie have prosthetic eyes, if so they are very good work.

Chip

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## Stopper

I do believe Sandy has one but I think Bowie just has two different eye colors. Probably from congenital Horners syndrome
Cheers

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## mhboptics

My office fits alot of kids with bi-focals, but, we also do alot of vision thearpy and as mentioned before, these kids have convergence problems.

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