optometry schools - typoscope - low vision clinic

192: I have just examined a ten-year-old boy complaining of occasional headaches and eye ache when reading. His schoolwork is not going well and his reading ability is that of an 8-year old. He has a refractive error of +0.50 DS in each eye. His accommodative amplitude is 18 dioptres in each eye and 20 with both eyes together. Without refractive correction, he has a very small esophoria and with refractive correction, he is orthophoric at near. His parents are keen for him to have glasses. What should I do?

This is a difficult clinical dilemma. One that I faced a lot in clinical practice as I had a reputation for helping children who were underachieving with education.

Let’s break it down into parts. Some clinicians would be of the opinion that +0.50 DS is a small amount of hyperopia and as the boy has lots of accommodative amplitude he can easily accommodate through this level of hyperopia. These clinicians would not supply glasses in a case like this.

However, other clinicians would say that without glasses the boy is having to over accommodate by +0.50 DS. This extra accommodation drives over convergence at near. The small esophoria without refractive correction is a sign of over convergence. The fusional vergence system will try to use divergent fusional reserves to counter this over convergence. This conflict between the tendency to over converge and the divergent fusional reserves is probably causing headaches and eye aches. This may not be the only cause of the educational underachievement but it could be part of it.

I have come across this clinical dilemma many times. My approach is to recommend glasses for all school tasks and any leisure reading. I inform the parents that the refractive correction is small and that some eye specialists would not advise glasses. I note my advice and the parents’ comments in the clinical records.

I ask the parents to let the teachers know of the use of glasses and to monitor the boy’s educational development and have a review with me in three months’ time to see how things are going. Unless things have gone badly during those three months I will advise another three months of use. If there has been a sustained positive effect on the headaches and eye aches and/or an improvement in learning then I will advise continuation with the glasses. Bear in mind that the improvement in learning should be more than expected over the six-month period for a 10-year old boy. This can be difficult to gauge.

As I mentioned this is a difficult clinical dilemma. Giving clear, honest advice and keeping good clinical records will benefit you and your patient.


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