Pediatric Visual Screening Assessment

Nut-Free Zone

• A sign indicating a nut-free zone is shown.
• Images of various foods, including candy bars and nuts, are included.
• Products like facial creams and lotions are also shown.

Lecture Recording Information

• The lecture is being recorded as part of Plymouth University's Content Capture Project.
• The recording will be available via the Panopto block on the module DLE pages.
• Students can ask questions during the lecture.
• Comments and questions may appear on the recording.
• Students can ask the lecturer to pause the recording if they do not want their question to be recorded.

Paediatrics Lecture 04 (Intended Learning Outcomes)

• Students should consider GOC regulations.
• Paediatric sight testing is important for child development.
• Awareness of challenges in testing paediatric patients and adapting routines is necessary.
• Knowledge of available vision/visual acuity tests for children and their relation to age is required.
• Recognition of significant refractive errors in children and when prescription is needed is important.
• Understanding differences in facial anatomy and development, including Down's syndrome, is necessary.
• Ability to select appropriate frames and make lens choices is important.

GOC Regulations

• Unregistered persons are not allowed to sell prescription spectacles to children under 16 or patients with vision impairments, unless the sale is supervised by a registered practitioner.
• The sale/supply of spectacles may be delegated, but the delegating person remains responsible.
• The supervising person must be present during key stages of spectacles sale for restricted-group patients.
• Supervisors ensure those undergoing the sale of spectacle follow the correct procedures specified.
• Supervisors must be identified, so each is responsible for supervision of a sale and supply of spectacles.

Regulated Ophthalmic Dispensing

• GOC registrants have a duty of care to ensure that dispensing to children is carried out in person or, if the dispensing is carried out by someone else, the optometrist or dispensing optician ensures a supervised individual has the appropriate knowledge to perform the task.
• A professional should maintain a high level of vigilance during the dispensing process to ensure the process is carried out safely.

Summary

• Sale of spectacles to under-16s, with sight impairment, is forbidden unless supervised by a registered practitioner.
• Supervision is necessary if delegation is made to other persons.
• Delegates should be competent.
• Dispensing and collection must be supervised by an optometrist or dispensing optician.

Child Protection Issues

• All children should be accompanied by a parent or guardian in the consulting room.
• Important to note who accompanied the child.
• Maintaining suitable test room environment.
• Child protection team should be informed for a neglect/abuse concerns.

Provision in UK

• Vision screening is available to Reception year (4 and 5 years old) in schools.
• Routine eye tests are available for any age.
• Refusal to take patients due to their age alone is forbidden.

Other Important Points (BUT)

• Limited distance-reading tests might miss ocular pathology.
• Screening does not cover ocular health.
• Parents might incorrectly assume that if a child passes a visual screening, an eye care is not needed.
• Visual screening is not performed by an optometrist but an orthoptist.
• Too many referrals might be unnecessary and waste healthcare resources.

Importance of Paediatric Eye Examinations

• Visual disorders are leading causes of childhood disability.
• Common childhood visual disorders include amblyopia and strabismus.
• Uncorrected refractive error is a significant issue.
• Visual disorders impact a child's personal and educational development.

Visual Development

• Infant and early childhood are crucial times for visual development, including eyeball growth, vision improvement and skill maturity.

Paediatric Eye Testing (Necessary Skills)

• Enthusiasm, skill, speed, accuracy and adaptability are needed in paediatric eye tests.

The Routine: What is expected of you?

• Students should follow College of Optometrists (C1) guidelines for examining younger children.
• Obtaining information about vision/visual acuity, oculomotor balance, refractive error, and the health of the eyes is crucial.
• Rapport with the child is important, showing respect and explaining the test procedures clearly.

Checklist

• The checklist shows what needs to be done during an eye examination for children.

By the end of the test...

• Eye straightness, any refractive errors, evidence of amblyogenic factors and the wellbeing of ocular media, optic nerves and macula are important to know.
• Re-booking the test if everything is not achieved in the first visit is also good practice.

Starting Point

• Engage children directly and introduce oneself.
• Ask simple questions.
• Parents holding the child, if nervousness, is acceptable.
• Make general observations about eye/head position and visual attention.

History & Symptoms

• Collect accurate and relevant history from the child and parent.
• Pay attention to whether there are other concerns.
• Use child-friendly language when questioning the child.
• Get details on birth history, developmental issues, visual behavior, and school progress.
• . Collect details on general health, medications and their family history (myopia, strabismus or high prescription).

Caution

• Some eye conditions do not display symptoms.
• Symptoms of an issue, such as difficulty concentrating, frequent eye rubbing, or headaches, can be indicators of an underlying problem.

Assessment of vision

• It's important to assess monocular vision, not only binocular.
• Simple tests such as eye patches can be helpful.
• Acuity tests, depending on age, are important aspects, such as preferential looking and vanishing optotypes.

Approx VA by age

• Visual acuity improves quickly in the first 12 months, and then develops further to maturity levels by 5 to 6 years of age.
• The visual acuity for each month has been provided in the summary.

Preferential looking - Keeler/Teller cards

• This is a fast and sensitive way to test young children's vision.
• It relies on children looking at patterns with the best visual interest.
• Testing distance is 55cm or 84cm

Vanishing Optotypes - Cardiff acuity cards

• Used for children aged 12-36 months.
• A target is made with white or gray bands.
• Visual acuity is the best view recognized by the child.

Picture/Letter matching tests

• Can be used for various age groups to assess their vision and ability to match patterns.

Crowding phenomenon

• A task that requires a more sensitive test.
• Amblyopic patients tend to fare worse in crowded tests.

Next step...

• Cover tests depend on the child's age and should be visually appealing.
• Suitable targets for young children include, but are not limited to, toys, puppets, picture cards, and pen torches.
• Alternatives include the Hirschberg test, and 20D base out test.

Stereopsis

• Evidence of good stereopsis shows bi-foveal fixation and good binocular vision.
• This test is a useful, additional test or alternative if other methods are not suitable.
• It's often a fun, interactive way to perform.
• Difficult to detect clinically until 12 months of age with steady improvement by 6 years.

Colour vision

• Similar to stereopsis, colour vision testing can be interactive and fun.
• Appropriate targets depending on age should be selected.
• If an issue is found, both the child and parent should be informed so they can be addressed to aid the betterment of the child's eyesight.

Retinoscopy and Refraction

• Most children initially have hyperopia, which decreases with age to reach emmetropisation.
• Normal refractive errors for each age category are listed for a better understanding.

Static Retinoscopy

• Relies on good fixation.
• Use caregiver support during testing for better results and to encourage the child.
• Use a dark room and a 50cm working distance.

Indications for cycloplegia

• Unexplained poor vision acuity, lack of stereopsis are some reasons for cycloplegia.
• Anisometropia (more than 1.5D difference in the eye's refractive power) is also an indicator.
• A family history of high hyperopia or strabismus, together with poor cooperation and a dry ret (refraction) are some considerations.

Inserting cyclopentolate

• Follow standard eye drop procedures.
• Ensure safety measures are taken.
• Position the patient to allow easy instillation.

Recall

• Recall duration for an earlier test depends on the presence or absence if an anomaly.
• Specific age thresholds for follow-up are given.

Cyclo: How to Explain

• Explain the process of cycloplegia clearly and appropriately to the patients and their parents.

Paediatric Prescribing

• Assessing and deciding when to prescribe for children depends on factors like age, binocular status, visions, anisometropia, and symptoms.

General Prescribing Guidelines

• Extreme refractive errors, strabismus and amblyopia, or anisometropia (1.00D+) should be reasons to prescribe.
• Younger children (under 2) should often only be monitored initially.
• Signifiant Rx in older children, with no signs of decreasing, should also be a reason to prescribe.

Significant refractive errors in age 2+

• High hyperopia, myopia, and astigmatism are considered significant in children above 2 years old.

When/What to refer

• Refer patients to other providers when the optometrist's skills or expertise are not enough to manage the child's case appropriately
• Large angles, or manifest tropia may need surgical intervention.
• Refer patients who have anisometropic amblyopia but also observe the improvement in visual acuity for the first six months.
• Significant astigmatism should be referred to appropriate specialists.
• The referring optometrist should consider how long the child needs to be seen, and if it is necessary to carry out cylco and prescribe the child while waiting.

Lens choice

• Lens material options for children include CR39, Polycarbonate, Trivex, and High Index Plastic.
• Various aspects, such as high impact-resistance, surface durability, and suitability for UV protection, are important to consider when selecting lenses for children.

Frame Selection

• Frames should be anatomically correct and comfortable.
• Visual axes must be considered.
• Frame fit and comfort should not inhibit the child's facial development.

Children's frame design

• Frames must hold lenses correctly and safely.
• Frames need suitable stability, rigidity, and strength.
• Frames must be well fitted and comfortable.
• The natural field of view should be considered for the frames design and position.

Children's frames Vs Adults frames

• Children's frames should accommodate a child's lower crest height compared to adult frames.

Results from Studies

• Facial growth is not steady, and facial structures differ from adults.
• The nose structure changes substantially during development and does not attain the complete adult state during a child's growing process.
• Only two dimensions remain unchanged.

General facial development

• Features like head width and facial structure, such as nose and front curvature, changes between the ages of 13 and 13+.

Down syndrome: Visual stats

• Children with Down syndrome might have a high prevalence (up to 60%) of requiring correction for refractive errors and other related conditions like strabismus and cataracts.
• Accommodative problems are highly prevalent in children with Down syndrome (76%).
• Facial features such as a broad nasal bridge may cause glasses to slip.

Down syndrome: ocular complications

• Complications such as congenital nystagmus, strabismus, cataract, blepharitis and reduced visual acuity, as well as keratoconus, might arise.

Baby Frames

• Various types of frames for babies and toddlers are available.
• Features include, but are not limited to, Grilamid frames, flexible and lightweight plastic material, or rubber on samples.

Metal Frames

• Different metal frame styles are available for children.
• Features might include adjustable styles, or adjustable elements for personalization or modification, for a customized fit of the frame.

Side Styles

• Different types of side styles are available for children, depending on age.
• Examples include, but are not limited to, loop-end, drop-end or curl styles for young infants or toddlers, while larger children may have more complex side styles.

Length to Bend

• The length of the temple area from the dowel point to the middle of the temple bend is measured on a child's head with appropriate equipment.

The Fitting Triangle

• This is a diagram for understanding how to fit a frame to a child's head
• The diagram features points for fitting children's frames to a child's head with reference to the bridge, the sides of the head, and the temples.

PD measurement

• Binocular PD (pupillary distance) is measured from the nasal side to the temporal side of the limbus.
• Monocular PD measurement should always be accompanied by +/- 3.00DS.
• Binocular PD is measured from the inner to outer canthus.

Crest height

• Measuring the distance from lower eyelid to the nasal crest on the face using ruler or appropriate measuring equipment.

Bridge Projection

• Measuring the distance from the face of the eye using a device to measure from the face of the eye to the eye lashes, when the frame is positioned or protruding..

Frontal angle

• Measuring the angle of the frame from the horizontal plane using angled measurement equipment placed on the child's nasal bridge area to the horizontal plane.

Splay Angle

• Measuring the angle of the frame from the vertical plane using angled measurement equipment placed on the child's nose to the vertical plane.

Facial measurement and frame measurement

• Table illustrating the different measurements of the facial structure to aid in the fitting of frames to children.

Head width and Temple width

• Head width is the distance between ear points calculated using callipers.
• Temple width measurement is done 25mm from the front.

Pantoscopic angle/tilt

• The angle of the frame sides, where viewed in relation to primary eye position, aids in measuring the pantoscopic angle.

Video Clips

• Links are provided for instructional videos for testing visual acuity in children, such as 4-year-olds, 8-year-olds and a 6-month-old.

Recommended Reading

• A list of relevant articles and texts for further research, with links, on pediatric ophthalmic and dispensing topics.

This quiz evaluates key concepts in pediatric visual screening, focusing on important characteristics of practitioners, common misconceptions, and the significance of early assessments. It includes essential testing methods and the impacts of false-positive referrals in visual screening outcomes.