Spectacles May Improve Reading Speed in Children with Hyperopia @ 怡碩視光眼科診所(台北視光中心)

大綱：這一篇報告是在研究小孩的遠視和閱讀能力之間的關連性，作者邀請了荷蘭當地100多位的9-10歲的國小學生做一些問卷和測試。問卷調查的內容包括了，過去的病史、遮蓋測試、斜視測試、散瞳後驗光檢查。做完第一階段的檢測後進行分組和淘汰，最後留下有遠視和近視的學生，再讓他們做閱讀測試(一分鐘的測試、Klepel測試)。最後得到的試驗結果，如果有遠視的小孩經過矯正是可以使它閱讀能力變好(看近的能力)。

心得：因為小孩的眼睛尚未發育完全，因此有遠視，而遠視會造成眼睛看近的事物成像不清楚，所以當小孩在學習書本的字時可能因為看不清楚字體使學習效果受到影響。然而這樣的小孩可能會被父母或學校認定他們是因為腦部發育遲緩造成學習遲緩，但其實只是因為他無法看清楚字體，只要透過矯正讓他視力能達到1.0，閱讀能力便能受到改善。但是幫兒童做矯正是需要考慮跟評估，亞洲的小孩多半會朝近視發展，而小孩漸漸長大眼球會長大，遠視就會慢慢消失。小孩的屈光度數變化較大，如果1-2年就要調整眼鏡的度數，可能父母親不太願意接受，配一副眼鏡也是個不小的開銷。而小孩也比較不受控制，不見得會乖乖的配戴眼鏡，如果都不戴它，就沒有達到矯正的功能。結論不管是否幫孩童配眼鏡，建議孩童定期回來做檢查，然後選擇最適合孩童的矯正方式幫他做矯正。

當我們要給予0-6歲的兒童度數處方時，必須考量到以下幾點：

1. 兒童的屈光不正是否符合其年齡的範圍？(Is the refractive error within the normal range for the child’s age?)
2. 該名兒童的屈光不正是否正視化？(Will this particular child’s refractive error emmetropise?)
3. 兒童的屈光不正是否會影響其正常的視覺發展或功能性視覺？(Will this level of refractive error disrupt normal visual development or functional vision?)
4. 讓兒童戴眼鏡是否能提升其視覺功能或功能性視覺？(Will prescribing spectacles improve visual function or functional vision?)
5. 讓兒童戴眼鏡是否會影響其正常的正視化過程？(Will prescribing glasses interfere with the normal process of emmetropisation?)

如何給予孩童處方，可參照下列表格：

遠視
何時給予處方	給予何種處方	考參文獻
一歲以上在任何子午線的度數≧3.50D	矯正部分遠視根據Atkinson的試驗方案，用正散光的格式，在此年齡層應：球面：給予兒童其子午線上最少的遠視度數再少1.00D的處方散光：若散光超過2.50 D，矯正一半的散光度數	Atkinson J, Braddick O, Nardini M, Anker S.Infant hyperopia:Detection,distribution,changes and correlates—Outcomes from theCambridge infantscreening programs. OptomVision Sci 2007; 84: 84–96. Ingram RM, Walker C, Wilson JM, Arnold PE,Dally S. Prediction of amblyopia and squint bymeans of refraction at age 1 year. Br J Ophthalmol1986; 70: 12–15.
四歲以上＞2.50D	依然只矯正部分的遠視矯正不足 1.00~1.50D，即此年紀的平均遠視度數，這種矯正不足並非由於正視化(在這個年齡幾乎完成)，而是孩童不需完全矯正遠視就有良好的視覺功能。	Abrahamsson M, Fabian G, Andersson AK,Sjöstrand J. A longitudinal study of apopulationbased sample of astigmatic children. I.Refractionand amblyopia. Acta Ophthalmol (Copenh) 1990;68: 428–434. Shankar S, Evans MA, Bobier WR. Hyperopia andemergent literacy of young children: Pilot study.Optom Vis Sci 2007; 84: 1031–1038. Rosner J, Rosner J. Some observations of therelationshipbetween the visual perceptual skillsdevelopment of young hyperopes and age of firstlens correction. Clin Exp Optom 1986; 69: 166–168.
學齡≧1.50D無症狀	由於正視化實際上已經結束，在這個年紀的遠視可全矯或幾乎全矯	Mutti DO. To emmetropize or not toemmetropize? The question for hyperopic development.Optom Vis Sci 2007; 84: 97–102. French AN, Rose KA, Burlutsky G, Mitchell P.Does correction of hyperopia affect the pattern of children’s activities, and does this differ fromthat of emmetropic children? Invest Ophthalmol Vis Sci 2009; 50: E-Abstract 3961. Rosner J, Rosner J. Therelationship betweenmoderate hyperopia and academicachievement:How much plus is enough? J Am Optom Assoc 1997; 68: 648–650. Williams WR, Latif AHA,Hannington L, WatkinsDR. Hyperopia and educational attainment in aprimary school cohort. Arch Dis Child 2005; 90: 150–153.
散光
何時給予處方	給予何種處方	考參文獻
15個月以上散光>2.50D	3、4歲正視化已大部分完成，在此之前只矯正部分散光，即矯正不足1.00D或只給予一半的散光度數	Gwiazda J, Bauer J, Thorn F, Held R. Meridionalamblyopia doesresult from astigmatism in early childhood. Clin Vis Sci 1986; 1: 145–152. Atkinson J, Braddick O, Nardini M, Anker S.Infant hyperopia:Detection, distribution,changes and correlates—Outcomes from theCambridge infant screening programs. OptomVision Sci 2007; 84: 84–96.
2歲以上≧2.00D	3、4歲之前只矯正部分散光，3、4歲後散光度數全矯	Atkinson J, Braddick O, Robier B, Anker S,Ehrlich D, King J,Watson P et al. Two infantvision screening programmes: Prediction andprevention of strabismus andamblyopia fromphoto- and videorefractive screening. Eye 1996;10: 189–198.
4歲以上≧1.50D	散光度數全矯，若兒童之前的高度散光矯正不足，一開始可先矯正部分散光讓孩童適應後再全矯	Roch-Levecq AC, Brody BL, Thomas RG, BrownSI. Ametropia, preschoolers’cognitive abilities,and effects of spectacle correction. Arch Ophthalmol2008; 126:252–258. Marsh-Tootle W. Infants, toddlers and children.In: BenjaminWJ, ed. Borish’s Clinical Refraction. Philadelphia: WB Saunders, 1998. p 1060–1118.
1歲起矯正≧1.00D的斜軸性散光	2歲前矯正約3/4的散光，2歲後就全矯	Abrahamsson M, Fabian G, Andersson AK,Sjöstrand J. A longitudinal study of a populationbased sample of astigmatic children. I. Refractionand amblyopia. Acta Ophthalmol (Copenh) 1990;68: 428–434. Mayer DL, Hansen RM, Moore BD, Kim S, FultonAB. Cycloplegic refractions in healthy childrenaged 1 through 48months. Arch Ophthalmol 2001;119: 1625.
散光在學齡≧0.75D而無症狀	散光度數全矯，若兒童之前的高度散光矯正不足，一開始可先矯正部分散光讓孩童適應後再全矯	Congdon NG, Patel N, Esteso P, Chikwembani F,Webber F, Msithini RB, Ratcliffe A. The associationbetween refractive cutoffs for spectacle provision and visual improvement among schoolagedchildren in South Africa. Br J Ophthalmol2008; 92: 13–18.
雙眼屈光不等
何時給予處方	給予何種處方	考參文獻
伴隨弱視的雙眼屈光不等	完全矯正雙眼屈光不等及散光，但依年齡矯正遠視或近視度數
1歲以上兩眼相差≧3.00D	若兒童有弱視則完全矯正其雙眼屈光不等；若孩童無弱視，則可減少矯正雙眼屈光不正的度數(例如：給予兩眼實際相差度數再少1.00D的處方，並依年齡矯正球面及散光度數	Abrahamsson M, Sjöstrand J. Natural history ofinfantile anisometropia. Br J Ophthalmol 1996; 80:860–863.
1歲後兩眼相差≧1.00D但<3.00D	持續監測4~6個月，若情況仍不變，則完全矯正雙眼屈光不等及散光，但依年齡矯正遠視或近視度數	Ingram RM, Traynar MJ, Walker C. Screening forrefractive errors at age 1 year. Br J Ophthalmol 1979; 63: 243–250. Abrahamsson M, Fabian G, Sjöstrand J. A longitudinalstudy of a population based sample ofastigmatic children. II. The changeability ofanisometropia.Acta Ophthalmol (Copenh) 1990; 68:435–440. Almeder LM, Peck LB, Howland HC. Prevalenceof anisometropia in volunteer laboratory andschool screeningpopulations. InvestOphthalmolVis Sci 1990; 31: 2448–2455.
3歲半後遠視球面雙眼屈光不等≧1.00D、近視球面雙眼屈光不等≧2.00D、散光雙眼屈光不等≧1.50D	完全矯正雙眼屈光不等及散光，但依年齡矯正遠視或近視度數，如有弱視則需先監測	Abrahamsson M, Fabian G, Sjöstrand J. A longitudinalstudy of a population based sample ofastigmatic children. II. The changeability ofanisometropia.Acta Ophthalmol (Copenh) 1990; 68:435–440. Weakley DR. The association between nonstrabismicanisometropia, amblyopia and subnormalbinocularity. Ophthalmology 2001; 108:163–171. Dobson V, Miller JM,Clifford-Donaldson CE,Harvey EM. Associations between anisometropia,amblyopia, and reduced stereoacuity in aschoolagedpopulation with a high prevalence of astigmatism. Invest Ophthalmol Vis Sci 2008; 49: 4427–4436.
近視
何時給予處方	給予何種處方	考參文獻
第一年近視<-5.00D	由於正視化會造成近視，矯正不足約2.00D	American Academy ofOphthalmology PediatricOphthalmology/Strabismus Panel. PreferredPractice Pattern Guidelines. Amblyopia. SanFrancisco, CA: AmericanAcademy of Ophthalmology;2007. Available from: http://www.aao.org/ppp. Accessed on August 27, 2010. Ciner EB. Management of refractive error ininfants, toddlers and preschool children. ProblOptom 1990; 2: 394–419. American Optometric Association. OptometricClinical Practice Guideline; Care of the patientwith myopia. Available from http://www.aoa.org/documents/CPG-16.pdf. Accessed onOctober 9, 2010.
第一年或兒童會走路時的近視<-2.00D	因為有時正視化仍在進行，直到學齡，矯正不足0.50 D或1.00D	American Academy of Ophthalmology PediatricOphthalmology/Strabismus Panel. PreferredPractice Pattern Guidelines. Amblyopia. SanFrancisco, CA: American Academy of Ophthalmology;2007. Available from: http://www.aao.org/ppp. Accessed on August 27, 2010. Miller JM, Harvey EM. Spectacleprescribing recommendationsof AAPOS members. J Pediatr OphthalmolStrab 1998; 35: 51–52. American Optometric Association. OptometricClinical Practice Guideline; Care of the patientwith myopia. Available from: http://www.aoa.org/documents/CPG-16.pdf. Accessed onOctober 9, 2010. Farbrother JE. Spectacle prescribing in childhood:A survey of hospital optometrists. Br J Ophthalmol2008; 92: 392–395. Marsh-Tootle W. Infants, toddlers and children.In: BenjaminWJ, ed. Borish’s Clinical Refraction.Philadelphia: WB Saunders, 1998. p 1060–1118. Goss DA. Myopia. In: Brookman KE, ed. Refractive Management of Ametropia. Boston:Butterworth-Heinemann, 1996. p 13–44.
4歲到學齡前	若≦1.00D的度數能使視力更好，就可在此年齡全矯	Congdon NG, Patel N, Esteso P, Chikwembani F,Webber F, Msithini RB, Ratcliffe A. The associationbetween refractive cutoffs for spectacle provision and visual improvement among schoolaged children in South Africa. Br J Ophthalmol 2008; 92: 13–18. Miller JM, Harvey EM. Spectacleprescribing recommendationsof AAPOS members. J Pediatr OphthalmolStrab 1998; 35: 51–52. Marsh-Tootle W. Infants, toddlers and children.In: BenjaminWJ, ed. Borish’s Clinical Refraction.Philadelphia: WB Saunders, 1998. p 1060–1118. Goss DA. Myopia. In: Brookman KE, ed. Refractive Management of Ametropia. Boston:Butterworth-Heinemann, 1996. p 13–44. Viner C. Refractive examination. In: Harvey W,Gilmartin B, eds. Paediatric Optometry. Oxford:Elsevier Butterworth-Heinemann, 2004. p 21–26. American Optometric Association. OptometricClinical Practice Guideline; Care of the patientwith myopia. Available from: http://www.aoa.org/documents/CPG-16.pdf. Accessed onOctober 9, 2010. Leat SJ, Shute RH, Westall CA. Assessing Children’s Vision: A Handbook. Oxford: Butterworth-Heinemann, 1999. Marsh-Tootle W. Infants, toddlers and children.In: BenjaminWJ, ed. Borish’s Clinical Refraction.Philadelphia: WB Saunders, 1998. p 1060–1118. Werner DL, Press LJ. Clinical Pearls in RefractiveCare. Boston:Butterworth-Heinemann Medical,2002. Goss DA. Myopia. In: Brookman KE, ed. Refractive Management of Ametropia. Boston:Butterworth-Heinemann, 1996. p 13–44. Milder B, Rubin ML. The Fine Art of PrescribingGlasses without Making a Spectacle of Yourself,3rd ed. Gainsville, Florida: Triad PublishingCompany, 2004.
學齡的近視	全矯，看近有內斜位及較大的調節遲滯(>0.43D)或慣用距離較近，可考慮配戴加入+2.00D的漸進多焦點鏡片	Gwiazda J, Hyman L, Hussein M, Everett D,Norton TT, Kurtz D, Leske MC et al. A randomizedclinical trial of progressive addition lensesversus single vision lenses on the progression ofmyopia in children. Invest Ophthalmol Vis Sci 2003;44: 1492–1500. Gwiazda JE, Hyman L, Norton TT, Hussein M,Marsh-Tootle W, Manny R, Wang Y et al. Accommodationand related risk factors associated withmyopia progression and their interaction withtreatment in COMET children. Invest OphthalmolVis Sci 2004; 45: 2143–2151.

兒童在正視化過程的第一年會失去1/2的等價球面度數[3]，於9-21個月失去1/3的等價球面度數，而約2/3的散光是在9-21個月時消失[4]。當兒童一歲時的雙眼屈光不等≧3.00D時，就有很高的風險會發展為弱視[5]。對於年紀較大且散光≧1.00D的兒童(初次治療時間介於4.75~13.5歲)，他們的視覺功能會受到影響，包含光柵敏銳度、字母敏銳度、游標敏銳度、對比敏銳度及立體視覺[6]。

過去曾有兩份研究探討其結論是遠視(尤其是≧1.00D的遠視)和不良的閱讀技巧相關[7, 8]。特別對於那些有輕微遠視而無法聚焦兒童來說，矯正其遠視能幫助他們閱讀[9]。這個結果和本篇研究的結果一致，雖然仍需要更多的研究證實。若您給予兒童較多的遠視矯正度數，每次約4~6周的回診監控是非常迫切需要的，在這段監控期間，視光師應詢問父母親其孩子是否有任何斜視的徵象，並仔細檢查兒童斜視及斜位的變化，此外還要測量兒童的視力及再次驗光。

本篇由中台科技大學實習生Jacobs於閱讀van等人的論文後所發表之心得，指導老師為吳怡璁博士。

參考文獻：

1. van Rijn, L.J., et al., Spectacles may improve reading speed in children with hyperopia. Optom Vis Sci, 2014. 91(4): p. 397-403.

2. Leat, S.J., To prescribe or not to prescribe? Guidelines for spectacle prescribing in infants and children. Clin Exp Optom, 2011. 94(6): p. 514-527.

3. Pennie, F.C., et al., A longitudinal study of the biometric and refractive changes in full-term infants during the first year of life. Vision Res, 2001. 41(21): p. 2799-810.

4. Ehrlich, D.L., et al., Infant emmetropization: longitudinal changes in refraction components from nine to twenty months of age. Optom Vis Sci, 1997. 74(10): p. 822-43.

5. Abrahamsson, M. and J. Sjostrand, Natural history of infantile anisometropia. Br J Ophthalmol, 1996. 80(10): p. 860-3.

6. Harvey, E.M., et al., Changes in visual function following optical treatment of astigmatism-related amblyopia. Vision Res, 2008. 48(6): p. 773-87.

7. Simons, H.D. and P.A. Gassler, Vision anomalies and reading skill: a meta-analysis of the literature. Am J Optom Physiol Opt, 1988. 65(11): p. 893-904.

8. Grisham, J.D. and H.D. Simons, Refractive error and the reading process: a literature analysis. J Am Optom Assoc, 1986. 57(1): p. 44-55.

9. Arnold, R.W., Pseudo-false positive eye/vision photoscreening due to accommodative insufficiency. A serendipitous benefit for poor readers? Binocul Vis Strabismus Q, 2004. 19(2): p.

75-80.