In this survey-based study, sixty optometrists in reputed hospitals of ophthalmology/ optometry clinics in Riyadh were given the survey of Lyons SA [1]. To use this survey for this research, permission from Lyons SA was obtained through email. The survey included questions related to prescribing philosophies for the prescription of amount of hyperopia and anisometropia in asymptomatic children. The questions were included for three age groups; 6 months, 2 years, and 4 years. These surveys were given to the responsible authorities of eight hospitals for the distribution to their optometrists.

The names of the hospitals participated in this study were King Abdul Aziz University hospital; ophthalmology department, King Khaled Eye Specialised Hospital, The eye center (Tabbara), The Eye Consultants Ophthalmic Center, Binrushd ophthalmic center, Eye world center, Magrabi Eye Hospital; Al Hayat National hospital branch, and King Fahad Rd branch. The study was completed in four months from January to April 2017. Ethical approval (Ethics Number: CAMS 068-37/38) was obtained from the Research ethics committee at King Saud University.

The practitioners were given a scenario of a parent bringing her child for a routine exam and that they have no visual complaints, and medical and family history is unremarkable. They were asked to assume that the results have been consistent at two different occasions and the refractive error is measured by cycloplegic refraction [see Annexure 1].

The percentage of optometrists that chose each of the choices was calculated for each question separately using Microsoft Excel 2016 software program.

Out of sixty surveys distributed to different hospitals, only 26 (43.3%) optometrists responded. Some of the optometrists did not answer every question which resulted in different totals for some questions. The optometrists were asked about the number of patients younger than two years of age, they examine in a month. Even though only 16 answered this question, it can give an idea on the practitioner’s experience with children. Mostly Riyadh optometrists reported that they examined 20 or fewer patients under two years of age. The data is given in [Table/Fig-1].

Practitioners were asked about which level of bilateral asymptomatic hyperopia they would consider prescribing for different age groups; six months, two years, and four-year-old children. For all the age groups majority of the Riyadh optometrists reported that they prescribe for more than 3D of hyperopia [Table/Fig-2].

The survey also questioned the practitioners about their philosophy for prescribing the full or less than the full prescription of asymptomatic bilateral hyperopia in six-month-old infants. Optometrists were asked whether they prescribe the full or less than the full amount of the cylinder and sphere components for the prescription [Table/Fig-3]. Approximately, 54% of the Riyadh optometrists reported that they would prescribe less than the full cycloplegic amount of hyperopia and less than the full amount of astigmatism.

The survey queried about a particular rule of thumb for prescribing the less than the full amount of sphere or cylinder portions in a six-month-old infant’s prescription. The practitioners were asked if they would prescribe certain amounts of fractions or another unspecified rule of thumb to cut the prescription. These questions were conditioned questions meaning that if the practitioner does not cut any amount from the prescription, they will not answer these questions. Due to these conditioned questions the total number of optometrists (n) is different in [Table/Fig-4]. The majority of Riyadh optometrists (28%) agreed on not using a fractional rule to cut the hyperopic portion of an infant’s prescription; they rather preferred cutting a certain amount of hyperopic power. On the other hand, they preferred cutting a fractional amount from the astigmatic portion of the prescription and the majority of Riyadh practitioners (47.8%) would cut half of the cylinder portion.

Lastly, the optometrists were asked about the amount of asymptomatic bilateral hyperopic anisometropia they would prescribe for in different age groups [Table/Fig-5]. For all the stated age groups majority of the optometrists agreed on prescribing for more than 3D of hyperopic anisometropia.

The prescribing philosophies of Riyadh optometrists were gathered for asymptomatic bilateral hyperopia in three age groups (six months, two years and four-year-old children) and it was found that the majority of Riyadh optometrists would prescribe for 3D hyperopia or more. Regarding the philosophies in whether to prescribe the full or less then the full amount of the cycloplegic refraction (sphere and cylinder) in six-month-old infants the Riyadh optometrists reported that they prescribe less than the full amount of both hyperopia and astigmatism. However, when comparing to previous studies by Lyons SA in US and Reiter C in Germany, which included ophthalmologists, there was an obvious difference between ophthalmologists and optometrists in the prescribing philosophy for the astigmatic portion of the correction [1,14]. The ophthalmologists in both studies agreed to prescribe less than the full amount of hyperopia and the full amount of astigmatism.

In a guideline suggested by Leat SJ, it was advised to give partial astigmatic correction for children under 3 or 4 years of age by which time emmetropisation has been completed [9]. This guideline agrees with the optometrist. Lastly, there was a difference in the prescribing philosophy of bilateral hyperopic anisometropia in two and four-year-old children between the Riyadh optometrists and US optometrists/ophthalmologists from a previous study done by Lyons SA [1] and German ophthalmologists from a previous study done by Reiter C et al., which used the same survey as this study [14]. The Riyadh optometrists reported that they would prescribe for hyperopic anisometropia more than 3D on the other hand, the practitioners from previous studies reported that they would prescribe for hyperopic anisometropia more than 1D in those age groups. In an article written by Donahue SP, it was reported that hyperopic anisometropia more than 1.5D should be corrected in preschool children to prevent anisometropic amblyopia [8].

This study faced some limitation, the biggest being the sample size. There were a lot of difficulties faced during the data collection such as rejection of some hospitals to distribute the survey in their facility.

A general understanding of the prescribing philosophies of optometrists in Riyadh was established for the amount of hyperopia and anisometropia in asymptomatic children. Further studies need to be done to examine the consequences of these philosophies and compare them to philosophies of the practitioners in other countries to establish a more unified guideline in prescribing for those children.