ANISOMETROPIA in CHILDREN

and ITS PROBLEM

Sagung Gede Indrawati, MD

Refraction and Contact Lenses Division

Ophthalmology Department
Faculty of Medicine
Universitas Gadjah Mada - Dr. Sardjito General Hospital
 ANISOMETROPIA

 The condition where the refractive

error differs between the two eyes

 The difference in spherical equivalent

refraction (SER) of 1.00 D or more
(≥ 1.00 D)
 usually used as the definition unless
otherwise noted
 Why Anisometropia become an
important issue ?

 The prevalence  age dependent

 Young children : 1.6 – 4.3 %

Significant association between

anisometropia & amblyopia

24-37%
Amblyopia due to anisometropia
Other study 50%
CAUSES of ANISOMETROPIA
 Inborn defect on the eye
 Uneven growth in both eyes
 Miscalculation of IOL power during the
cataract surgery
 Aphakic condition due to cataract
extraction
 TYPES of ANISOMETROPIA
 Antimetropia
– The refractive errors of the eyes are of
opposite signs and difference amount
(OD + 3.00 D / OS - 4.00 D)

 Isoanisometropia
– A condition of equal refractive error with
differing of dioptric power :
• Anisomyopia (OS – 2.00 D / OD – 5.50 D)
• Anisohypermetropia (OD + 3.75 / OS + 1.25 D)
Other classification :
 Simple anisometropic eye :
– simple myopic
– simple hypermetropic
 Compound anisometropic eye
 Mixed anisometropic eye

Due to board definition of anisometropia

The majority of refractive errors we face daily
will fit this description
 Symptom of Anisometropia
Severe asthenopia symptomps :
 Anisokonia
 Headache
 Eye strain
 Light-sensitivity
 Complexity in reading
 Nausea
 Double vision / diplopia
 Faintness
 Sheer tiredness
 Impaired depth perception / stereopsis
 Loss of binocular function
 Cosmetically unappealing eye wear
 The practitioners should address an
anisometropia if patients presents the
symptomatic effects of :

– Diplopia during acentric gaze

– Loss of deep perception or stereopsis
– Blurred vision due to anisokonia
– Complaint of eye fatique / extreme
headache without other causes
DEGREES of SEVERITY

 Mild ≤ 2.00 D
 Moderate > 2.00 – < 6.00 D
 Severe ≥ 6.00 D
 When should the amount of
anisometropia indicate the need
for special attention ???
Degree of Diopter Imbalance

1.00 D or less of imbalance No correction needed

> 1.00 D but < 5.00 D of imbalance Correction

> 5.00 D Correction may be futile

THE FACTS
 GROWTH and DEVELOPMENT
of THE EYE
The dramatic anatomical and physiologic
development  1st year of life
 GROWTH and DEVELOPMENT
of THE EYE
 The Axial length  rapid growth period 6 m.o
of life ( ± 4 mm )

 Corneal growth  changes markedly

52.00 D at birth
46.00 D at 6 m.o
42.00 – 44.00 D by age 12 y.o

 Average corneal horizontal diameter

- 9.5 – 10.5 mm in born  12.00 mm in adult
- Mostly occurs in the 1st year of life
 GROWTH and DEVELOPMENT
of THE EYE

 The lens power  decreases dramatically

over 1st several years

Important consideration !!
IOL implantation in infancy / an early
childhood after cataract surgery ????

Departure from the normal may indicate

pathology  failure Emmetropization
 BLURED RETINAL IMAGE
 An emmetropic eye focused on distant object
would be subject to hyperopic blur for nearby
objects

 An animal model suggests that hyperopic blur

promotes eye growth
This would be expected promote the
myopia

Under correction ???

 TREATMENT ?????

Spectacles ??? Refractive surgery ???

Contact lens ???

SPECTACLES

 Need high compliance

 Disadvantages :
– spherical aberration
– induce prismatic effect s with eye
movements
– minification of the eye and of the image if
high minus
– prevention of fusion leading to
suppression
REFRACTIVE SURGERY
 Corneal refractive surgery
 irreversible result
– Permanent reduction of VA
“vision loss in doctor lingo”
worse vision after surgery even when
corrected with glasses
– Glare
– Reduction of night vision
– Dry eye
– Need further surgery “enhancement”
– Complications  flap related problems, corneal
scarring, variable refractive outcome, regression
 REFRACTIVE SURGERY
 IOL Exchange  capsular bag shrinkage
increases risk of capsular damage, zonules
damage and vitreous loss

 Supplementary AC Lens  risk of corneal

endothelial loss, pupil abnormality

 Piggy-back Posterior IOLs  risk of

interface opacities

Refractive surgery on children still as an

investigational procedure
WHY CONTACT LENSES ?
 Contact Lenses
Contact lenses reduce many of
disadvantages above

 A negative power lens  produces small image

 Depends on :
– the distance : nodal point - correction plane
– the power of the negative lens

The longer the distance between nodal point and

correction plane the smaller the image
The high the power of the lens the smaller the image
 For high myopia CL improves the contrast
sensitivity
– first order aberration in spectacle due to many
material with difference refraction index
(air – glasses – air – cornea)
– high aberration decreases contrast sensitivity

So there are differences of the image size and

contrast sensitivity for person with glasses and
contact lenses (CL)

The image size on CL are similar to emmetropic eye

 Indications
 Visual
– Anisometropia
– High myopia
– Aphakia
– Irregular corneas, scarring,
keratoconus, graft
– Failure with refractive surgery
 Indications (cont’d)
 Occupational (stage performer, armed
forces, professional sport)
 Cosmetic
– enhancement (avoid spectacle, change eye
color)
– restorative (corneal cicatrix)
 Medical (therapeutic, bandage)
 Psychological (can not accept spectacle)
 Other (physical reasons: allergy to frame
material, nasal problem)
 Contraindications
Few of them absolute  carefully assessed
before fitting

 Visual (low refractive errors, visual acuity with

CL worsen)
 Occupational → legal constraints (commercial
pilot)
 Cosmetic → large-angle squint, facial
disfigurement
 Medical (active infection, allergies, diabetes,
smoking, misshapen lid)
 Environment (dust, fumes, dryness)
 Visual Consideration
1) Ocular refraction
Convert spectacle refraction to ocular
refraction
Ocular refraction ≈ the power of CL
Vertex distance (BVP) mainly for high power
> 4.00 D
Vertex distance 11.00 – 13.00 mm

F glasses = K
1 + (dK)
2) The correction of ammetropia
- For a rigid lens = a liquid lens on the anterior and
back surface of the CL
- Liquid lens power depends on the curvature of the
back surface of the CL and that of the anterior
surface

Steeper lens fitting (than ‘K’) → positive tears power

Alignment lens fitting → plano
Flatter lens fitting (than ‘K’) → negative tears power

For soft CL  minimal power due to it’s the same shape

with cornea
3) Corneal and residual astigmatism

The mm keratometry → Dioptric equivalent

Rule of thumb 0.05 mm = 0.25 D

e.q = ‘K’ reading 7.80 x 180

7.60 x 90
difference K = 0.20 mm → 1.00 D

Steeper cornea → D equivalent is greater

Flatter cornea → D equivalent is less
2 basic assumption =
1) Ocular astigmatism consist of :
- corneal astigmatism
- lenticular astigmatism
2) Most corneal astigmatism is transferred
through a soft contact lens to its anterior
surface

Initial examination on spectacle correction + K

reading is important
 Spherical cornea with spherical refraction

Rx = - 7.00 D
K = 7.85 mm x 180 (43.00 D)
7.85 mm x 90 (43.00 D)

Ideal case for CL fitting

Equally good vision with either rigid or soft CL
 Spherical cornea with astigmatism
refraction

Rx = - 5.00 / 2.75 x 90
K = 7.85 mm x 180 (43.00 D)
7.85 mm x 90 (43.00 D)

The astigmatism is almost entirely lenticular

The visual result is the same with either soft / rigid CL
For reason of comfort = soft CL is recommended
 Toric cornea with astigmatism refraction

Rx = - 2.00 / 1.75 x 180

K = 7.80 mm x 180 (43.25 D)
7.50 mm x 90 (45.00 D)

All the astigmatism is corneal

A spherical rigid lens is recommended
(neutralizes 90% of corneal astigmatism)
Or a Toric soft CL
4) Monocular patient

 Much more disturbed by lens mobility,

flare or unstable vision

 Similar to fitting in dominant eye

5) CL sensitivity and quality of vision

 CL do not always gives absolute stability of vision

 Variations depends on = lens + environmental
factors

The “quality of vision” → a subjective interpretation

Does not necessary correlates with Snellen acuity

Contras sensitivity reading can be difference while
visual acuity remains the same
 CONTACT LENSES for
CHILDREN ?
 Some considerations :
• Lens parameters
• Insertion and removal traumatic problem :
extended or continuous wear
• Hyperopic correction more readily than
high minus
• Custom-designed soft contact lens ( D 12.0
/ BC 6.80) : expensive for regular
replacement
THANK YOU