I recently got a question about when a doctor might not prescribe glasses for a child, even if the child was nearsighted or farsighted. I did some research and found consensus guidelines for prescribing glasses published by the American Academy of Ophthalmology (Pediatric Eye Evaluations: Screening and Comprehensive Ophthalmic Evaluation, 2007, link to full text).
Before jumping to the guidelines, it’s worth emphasizing that these are general guidelines only, based on professional experience and not scientifically researched data. Let me repeat that: there are no good studies showing when a child should be prescribed glasses – this is in part due to the fact that prescribing glasses is complicated. Each doctor needs to take into account everything about the individual patient and there are many things that would lead a doctor to prescribe glasses at much lower refractive errors. These include strabismus or history of strabismus, developmental delays, other medical issues, visual acuity, acceptance of glasses, among other factors.
Prescribing Glasses to Children with Anisometropia
Children who have a significant difference in refractive error between their eyes (called “anisometropia”) are more likely to be prescribed glasses. This is because anisometropia is a significant factor is causing amblyopia. If one eye sees much better than the other, the brain is more likely to favor the vision from the “good” eye, leading to amblyopia.
| Condition and refractive error for prescribing glasses to children with anisometropia (eyes have different refractive errors): |
Age | ||
|---|---|---|---|
| Condition | 1 year and younger | 1 to 2 years | 2 to 3 years |
| nearsighted (myopia) | -2.5 or worse | -2.5 or worse | -2 or worse |
| farsighted (hyperopia) | +2.5 or worse | +2 or worse | +1.5 or worse |
| astigmatism | 2.5 or worse | 2 or worse | 2 or worse |
~~~
Prescribing Glasses to Children with Isometropia
For children whose eyes have similar refractive errors (so both eyes are seeing similarly), also called “isometropia”, doctors are less likely to prescribe glasses at lower refractive errors. In this case, there is a difference in prescribing guidelines for farsighted children depending on whether or not the child has strabismus or misaligned eyes. Again, this is due to the increased risk of developing amblyopia if strabismus is present.
| Condition and refractive error for prescribing glasses to children with isometropia (eyes have similar refractive errors): | Age | ||
|---|---|---|---|
| Condition | 1 year and younger | 1 to 2 years | 2 to 3 years |
| nearsighted (myopia) | -5 or worse | -4 or worse | -3 or worse |
| farsighted (hyperopia) with strabismus | +3 or worse | +2 or worse | +1.5 or worse |
| farsighted (hyperopia) with no strabismus | +6 or worse | +5 or worse | +4.5 or worse |
| astigmatism | 3 or worse | 2.5 or worse | 2 or worse |
It is again worth noting that these are only guidelines, and in fact, other studies have shown that many doctors prefer to prescribe glasses at lower refractive errors (Spectacle prescribing recommendations of AAPOS members).
The guidelines do fit closely with our own experience. When we first took Zoe in to the ophthalmologist, she was not crossing her eyes often, or severely. In fact, in some of the pictures we took with us, while it looked like her eyes were crossed, when you looked at the reflection of the flash in her pupils, they were actually aligned. Her refractive error at that time was probably around +4.5 or +5, high enough that the ophthalmologist told us to keep a close eye out for her eyes crossing and told us to come back in 6 months for a follow-up. Four months later, her eyes started crossing significantly, and her ophthalmologist had us back in and got her into glasses.
If you ever have a question as to why your doctor is or is not prescribing glasses for your child, please ask your doctor for an explanation. If you still are unsure, or if that explanation does not make sense, a second opinion may well be in order.
For Little Eyes 
Very interesting data! Thanks for summarizing and sharing.
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Please take these guidelines with a huge grain of salt. These were by the American Academy of Ophthalmology…ophthalmology may do many things well, refractions tend NOT to be one of them. They also tend to be re-active in nature and not preventative. Remember all children are different. All children have different visual needs. Also with the latest research on critical periods and neuroplasticity, in many cases it may be better to get a pair of glasses on the child sooner rather than later.
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Thanks Dr. Maino. I absolutely agree that these need to be taken with a grain (or tablespoon) of salt, especially, as they note in the guidelines themselves, they’re based on individual practice, rather than scientific studies. I did try to emphasize that at the very beginning of this post, but I’ve updated it a bit more to make that more clear.
As an aside, I did try to find similar guidelines from the American Optometric Society but was unsuccessful. I did find a study that looked at when hospital optometrists prescribed glasses to children in Britain, and the thresholds were slightly less conservative, but not very different (and a little hard to compare, since that study didn’t differentiate between correction for hyperopia with strabismus and with no strabismus, it also didn’t break out anisometropic myopia). There is also the study I linked to that showed that in practice many ophthalmologists prescribe less conservatively than the guidelines. I did briefly try to pull together a comparison of all the different studies of when glasses are prescribed, but again, the age ranges, and conditions looked at were not consistent, and I couldn’t come up with a good way of showing all that information in an easy to understand way.
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Ann….you are a most remarkable blogger! You do your research….and do it well. I have absolutely no complaints about your posts….and as you know you are listed on my blog as one of those that I pay attention to. I just wanted to make sure that your readers know that these are guidelines and may not apply to any individual’s specific needs. Thanks for making that clear in your post. Thanks for all you do to get the word out!
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Hi Ann,
I am also an optometrist and fellow of COVD (College of Optometrists in Vision Development).
If you go the AOA website and look at the Clinical Practice Guidelines,
http://www.aoa.org/x4813.xml
you will find some guidelines about prescribing for children. Its just not in one place in a handy dandy chart. Probably because putting it in a chart tends to oversimplify a complicated decision. I think its wonderful that you are discussing these concepts on your blog and getting the word out about how important it is to consider the role of vision in the life of our children!
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Thanks Rochelle and Dominick! Rochelle, I think it’s a good point that putting the information in a chart can make it seem far too simple for what really is a complicated decision.
Thank you both for all you do, too.
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It is so pity to see children earing eyeglasses at a very young age. However, these guidelines of yours are magnificent! You’ve done a good research. Thank you for posting this one.
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Thanks Bryan. While I was very upset when Zoe first got her glasses, I don’t see it as a pity that children are wearing glasses. While it means that they have vision problems that need correcting, it also means that their vision is at least in some way correctable, that it is they being treated, that they are seeing better now!
I should also mention that these are not my guidelines. They come from the American Academy of Ophthalmology.
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Very thoughtful post. This is is very helpful. There were always side effects in every thing, there are dark and light sides. It depends on you on how to balance it. Thanks for sharing this one. So thoughtful of you.
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Sir,
My 22 month baby has number. -1.25/100 & -0.25-0.5 what does this mean?
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Hi Monika, the -1.25 is probably the refractive error, though I’ve never see that written with the /100. In any case, -1.25 is mild nearsightedness or myopia, which means that your baby sees better close up than far away. The other two numbers I believe describe the astigmatism, which is a very mild astigmatism. If you’re interested, there’s more information on reading a glasses prescription here: http://littlefoureyes.com/2010/01/25/understanding-your-childs-glasses-prescription/
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its very good gor all the optometrist who working in field of paediatrics group
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Hi
We found out about three weeks ago our six month old needs glasses for farsightedness and astigmatism. She was born with very visible congenital cataracts so that is why we have had to take her into the eye doctor so young. She falls just slightly under the numbers for prescribing glasses that you posted but the doctor says she needs them. This doctor works for the children’s hospital in Wisconsin and is a pediatric ophthalmologist and has done a lot of work with kids with cataracts. I was confident in what she said about Addie needing glasses but now I’m a little confused. I guess that’s what I get for researching too much :S Should I get a second opinion? Her prescription is: right eye: sphere +3.25 cylindrical +2.05 axis 105, left eye: sphere +2.75 cylindrical +2.0 axis 075
Thanks!
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Vanessa, I think that if you’re confident in your eye doctor, then I would follow what she says. The numbers here are guidelines and they are affected by a lot of things that are particular to each child’s case. In my opinion, a doctor who has examined a child, especially that has experiences working with kids and vision, should have a higher weight than a blog you find on the Internet. That said, if you’re unsure, then I would go ahead and seek a second opinion.
Best of luck to you and your daughter!
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The amount of refractive error you note is considered significant in most instances and most docs would probably recommend glasses most of the time. There may be other reasons for not prescribing at this time.
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Question, how do I know my child’s RX is correct? He’s 4 years old OD-3.75 OS -4.00 he just got his first pair of glasses based off theses numbers. My questions is how do I know this is correct? Is there any signs that this RX may be to strong?
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That’s a fantastic question. First, a couple of ways the prescription can be wrong:
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My daughter is just shy of 2 years old and the pediatric opthamologist wants to put her in glasses, if she’ll wear them. She has a -1.50 in both eyes. After reading your chart I am a little puzzled. She does have other developmental delays and maybe that’s why? We purchased a pair today and just getting her to try them on was a huge obstacle. Thoughts on whether she really needs them yet?? My pediatrician said to trust the specialist. I just am wondering if waiting an extra few months or year til she understands more is better. The opthamologist seemed like she’ll eventually need them, so why not do it now if she lets you?
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Hi, I would really like a bit of advice. My son has a micro squint, and I think some amblyopia. He was checked at 3 with no problems, then a turn became obvious at 5y 9 months. The eye do. Started with glasses which a accommodated the squint and made the eye straight, my son has BV with glasses.
No patching was required as my son was a 6/9 in the turning eye.
His sph was 3.50 at the start, his cyl:-075 axis 90.
Left eye.
Stayed the same until two years ago, now
Sph:4.00 cyl:50 axis 85.
His right eye has no astigmatism and has gone from a 1.25 to a 1.50 in four years.
What explanation can there be for the prescription increasing, and the optician said he may need more.
My son is not 10. I’m am worried as I can’t find any info why this would happen.
Could you help?
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Hi Deb,
I think that as kids grow, their eye shape changes along with them. Generally, kids become less farsighted with time, but it’s pretty common for them to become more farsighted first, and then have the farsightedness decrease. That’s what happened with Zoe. What does your son’s eye doctor say?
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My daughter is farsighted +2.5 in the two eyes and has astigmatism +1 in each eye. She is now 8 years old and the doctor prescribed her glasses
I am worried about her as this is the first time she is checked by adoctor for her eyes and l am also is farsighted
I would like to know if the farsightedness will decrease as she grow or may be still as she now is 8
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