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Eye and Vision Care

4-year-Old Prescription too Strong?

10/02/2009

Question:

My son has been seen by an ophthalmologist through our HMO, Kaiser, since he was 6 months old. From an early age it was clear that he had some farsightedness, but not enough to warrant glasses. At his most recent visit the doctor made a prescription for + 5 lenses. For a few reasons we decided to get a second opinion (one being that my son had bumped his head during the examination and was a little dazed and upset). We have separate eye insurance and decided to go to the University of Berkeley Eye Center, which is a covered provider. The doctor there did a full examination, but did not dilate my son`s eyes. She prescribed a +10.

Now i am concerned because the prescriptions are so different. We actually went ahead and ordered the glasses through the Berkeley Eye Center, but since then I have been paying even more attention to what he says he can see. I know he has issues with his vision, but when we read a book, do matching games, look at photos or look for letters it seems like he can tell me pretty accurately what he sees. When i raised this with the UCB Dr. she said that we should go ahead and order the glasses she prescribed, and then have him checked in 2-3 weeks.

My questions are: 1. how could two qualified doctors come up with such different prescritptions? who do we trust? 2. when starting with new glasses is it better to start with a milder prescription and then make adjustments? 3. should we go ahead and do a trial run with the stronger glasses, is there any risk in doing this? If yes, how long is appropriate? 4. what is the best way to talk with our Dr. at Kaiser about the second opinion? (it feels a bit awkward) 5.MOST IMPORTANTLY, how do we ensure that we get an accurate prescription for our son? 6. Are there any other questions that i should be asking?

Answer:

Question 1: How could two qualified doctors come up with different prescriptions?

Hyperopia can occasionally be somewhat tricky in terms of accurately determining the correct prescription. A reason this can be somewhat difficult is because children can accommodate (change their focusing position) so much. However, I would argue that the difference of +10 versus +5 would easily be determined.

Both doctors may have found the same prescription and prescribed different powers. This is not uncommon. Some doctors do not believe in giving a patient (full plus) while others are much more comfortable with giving a prescription much closer to full plus (+10 in this case).

The most important issue for a child with as much farsightedness (hyperopia) as your son is to make sure his eyes do not turn in towards his nose. The doctor should prescribe enough plus to keep the eyes aligned. You did not reflect this in your question, but I am wondering if your son's eyes ever turned in towards his nose.

In terms of answering your question in dealing with your Kaiser doctor:

Was the first doctor someone who specializes in or sees a lot of pediatric patients? If not, I would probably trust the doctor at Berkeley a little more, as they most likely deal with pediatric patients much more regularly. Even though they did not dilate your son's eyes, if they saw +10 D of hyperopia and it aligned his eyes, then they probably just went with that prescription. Typically what we do here at Ohio State when we see a prescription like that is prescribe it and then have the child return a few weeks later to make sure his eyes are aligned, his visual acuity is ok, and his focusing abilities are normal (so that is not out of the question for the Berkeley doc to have him return).

I would simply ask the doctor:
1. if there are any signs of your son's eyes turning in
2. if his visual acuity is good in each eye and if not, will it continue to improve (ask if he has any amblyogenic risk factors - reduced visual acuity due to an eye turn or a high or unbalanced prescription)
3. Just ask them why their prescription was so different than the +5.00 which was prescribed prior to that visit. (People ask us these things all the time and it really does not offend us at all.)  They should be able to give you a good answer.

Good luck and I hope this helps.



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Response by:

Aaron  Zimmerman, OD, MS Aaron Zimmerman, OD, MS
Clinical Associate Professor of Optometry
College of Optometry
The Ohio State University