An 18-month-old male came to clinic for his health maintenance visit.
He had a history of congenital strabismus that had been corrected with surgery. The father noted that the eyes were much better aligned and that the amount of eye drifting that he was seeing had markedly decreased.
However the father said that the toddler didn’t like to wear his glasses and that he wasn’t insisting on compliance as much as he had before.
“I think he is better and he probably doesn’t need to wear them as much,” the father stated.
The family history was positive for several children and adults with various vision problems.

The pertinent physical exam showed a healthy appearing male without spectacles with normal vital signs and growth parameters in the 25-75%.
The eyes were generally aligned but at the extreme lateral positions did appear not to be aligned as consistently.

The diagnosis of strabismus was made.
The pediatrician spoke with the father about the non-compliance with the spectacle use noting that although the patient had had improvement with surgery, the spectacle use was very important for vision now and in the future.
The pediatrician said, “the surgery gets the eyes back into position, but the glasses keep them in position and help the eyes and brain learn how to see. It’s really really important that he use the glasses as the eye doctor told you to wear them,” the pediatrician stated.
She went on, “I know you said that he keeps taking them off, but if you keep putting them back on then he will know that it is important and should also just get used to them. I know you have an appointment this month for followup and the eye doctor should have other ideas about how to help you keep his glasses on.”

Discussion
Uncorrected refractive errors (URE) are a major cause of visual impairment and blindness globally. It is estimated that more than 12.8 million children ages 5-15 years have URE.
URE can cause astigmatism, anisometropia, amblyogenic hyperopia and myopia. It can also be a factor in injuries, behavioral problems and academic and social impairments.
Spectacles (or eyeglasses or eye wear) are a low-cost, non-invasive, simple to use treatment for URE. Spectacle use has many benefits but depend on end-user use.

Learning Point
Non-compliance with spectacle use is estimated to be 40.1% overall with a range of 9.8-78.6% in a meta-analysis.
Non-compliance is associated with older children, living in a rural area and in some studies females more than males.
Compliance remains low even if the spectacles are provided at no-cost. Custom-made or ready-made spectacles do not change compliance overall.
Compliance is improved if there is a higher RE (i.e. patient has worse vision therefore child experiences improvement using the spectacles).

Reasons for non-compliance includes:

• Breakage/loss/forgetfulness – 23.3%
  • Broken or lost spectacles
  • Forgetfulness
• Personal factors – 25.8%
  • Parental and children perceptions
  • Peer pressure
  • Patient self-esteem
  • Injury concerns
  • Dislike of the spectacles, unattractiveness/poor appearance
• Vision problems/headache – 5.5%
  • Uncomfortable spectacles
  • Unclear vision
• Cost

Non-vision specialists should be aware that patients with low RE may not be prescribed spectacles as they may not assist in improved vision and have a lower rate of compliance even if prescribed.
Non-vision specialists can also discuss with patients and families their compliance and encourage adherence.

Ways to improve compliance spectacle use includes:

• Affordable or free spectacles can be obtained through vision insurance, governmental and charitable organizations. There are also inexpensive spectacles that can be purchased at some retail stores or on the Internet.
• Loss and breakage – This is common and in one study where 2 pairs of spectacles were provided free to children, (1 for daily use prescribed initially and one held at school as a backup for breakage or loss), both pairs were dispensed to all children over a 1 year time period because of loss or breakage of the first pair.
  Lightweight, unbreakable and attractive frames help to mitigate many reasons for non-compliance.
• Uncomfortable spectacles, unclear vision and headaches can be fixed by proper adjustment. Remember that adjustment may need to be performed again because of normal wearing conditions.
• Forgetfulness can be improved with adult encouragement including parents and school personnel. Also having access to a second pair of spectacles at school or home also improves compliance.
• Social barriers – parents should be educated about the importance of spectacle use for current and long-term vision outcomes, so they can encourage compliance. Children can be taught ways to mitigate teasing and bullying over their appearance.
  Acknowledging that there may be societal factors (i.e. child is seen as have a disability or is less desirable as a potential marriage partner) which may discourage use but individual use is important for the overall lifetime health of the patient.

Questions for Further Discussion
1. What are some of your own recommendations for increasing compliance with spectacle use?
2. How good is photoscreening for vision? A review can be found here
3. At what refractive error on visual screening should a child be referred to a vision professional?
4. What are indications for eye patching?

Related Cases

Disease: Eye Wear | Vision Impairment and Blindness

Symptom/Presentation: Blurred Vision

Specialty: Ophthalmology

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Eye Wear and Vision Impairment and Blindness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Maconachie GDE, Farooq S, Bush G, Kempton J, Proudlock FA, Gottlob I. Association Between Adherence to Glasses Wearing During Amblyopia Treatment and Improvement in Visual Acuity. JAMA Ophthalmol. 2016;134(12):1347-1353. doi:10.1001/jamaophthalmol.2016.3793

Morjaria P, McCormick I, Gilbert C. Compliance and Predictors of Spectacle Wear in Schoolchildren and Reasons for Non-Wear: A Review of the Literature. Ophthalmic Epidemiol. 2019;26(6):367-377. doi:10.1080/09286586.2019.1628282

Dhirar N, Dudeja S, Duggal M, et al. Compliance to spectacle use in children with refractive errors- a systematic review and meta-analysis. BMC Ophthalmol. 2020;20(1):71. doi:10.1186/s12886-020-01345-9

Hark LA, Thau A, Nutaitis A, et al. Impact of eyeglasses on academic performance in primary school children. Can J Ophthalmol. 2020;55(1):52-57. doi:10.1016/j.jcjo.2019.07.011

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa