Paediatrics Lecture 04 PDF

Attendance code QZ-QO-FH Attendance code: Lecture 04: Paediatrics Ellie Livings OPT505  Attendance code: Intended Learning Outcomes Consider GOC regulations Comprehend the importance of paediatric sight testing with regar...

Attendance code QZ-QO-FH Attendance code: Lecture 04: Paediatrics Ellie Livings OPT505  Attendance code: Intended Learning Outcomes Consider GOC regulations Comprehend the importance of paediatric sight testing with regard to child development Show awareness of the challenges involved in testing paediatric patients and the need to adapt your routine Recall the tests available for assessing vision/visual acuity in children and be able to relate them to age Comprehend what is classed as a significant refractive error in a child and when a prescription may need to be issued Understand the differences between facial anatomy and development Understand facial variants – Down’s Syndrome Consider frame selection – bridge and sides and how to adjust frames Be able to make appropriate lens choices GOC Regulations A348 Unregistered persons must not sell prescription spectacles to children aged under 16 and patients who are registered as sight impaired or severely sight impaired, unless the sale is supervised by a registered practitioner. A354 You may delegate the sale and supply of spectacles but you remain responsible for the whole process. A355 You must be on the premises when you are supervising the sale of spectacles to someone in a restricted group (that is, patients under 16 or who are registered as visually impaired) at key stages of the sale.133 A356 If you are supervising someone undertaking the sale of spectacles to a patient you should ensure they have taken the steps listed in the section on Principles. A357 If you work in a team, it should be clear, on a daily basis, which professional is responsible for the supervision of sale and supply. The practice should ensure that supervisors are in a position to fulfil their supervisory role. https://www.college-optometrists.org/clinical-guidance/guidance/knowledge,-skills-and-performance Regulated Ophthalmic Dispensing GOC registrants have a duty of care to ensure that dispensing to children is carried out in person, or if the function is to be conducted by an individual who is a non-registrant, the optometrist or dispensing optician should ensure that the said individual has appropriate knowledge to undertake this task under supervision. Should the latter be applicable, the professional should maintain a level of vigilance and have means to intervene at any point during the dispensing process ABDO guidelines – Pathway for dispensing to Children  Attendance code QZ-QO-FH Summary Sale/supply of spectacles to px U16 and SI/SSI NOT allowed unless you ARE a registered practitioner OR you are supervised by a registered practitioner. Supervision You must be on the premises AND able to intervene if necessary. Delegated persons should be competent You are still responsible if you delegate Dispense and collection must be supervised/checked by an Optom/DO. Other important points... Child protection issues (and protecting yourself against unfounded allegations): Recommended that all children should be accompanied by a parent or guardian when in the consulting room with you (and note who it was) If not, door should be left open during the test Don’t position yourself between the child and the door Practice should have a chaperone policy Can ask for another staff member to be present, Be aware of duties to safeguard children: refer any concerns of child neglect or abuse to local child protection team (linked to Clinical Commissioning Group)  Attendance code QZ-QO-FH Provision in UK: Vision screening offered in school year Reception (4 &5 years old) Optician’s routine test from any age* A228 You must not refuse to see a patient based on their age alone. You should arrange a transfer of care or a referral if a specialist assessment is in the patient’s best interests. You should make a reasonable attempt to include all appropriate tests. In exceptional circumstances, you may not be able to complete all the indicated tests for a very young child. In these situations, you should base your management on the findings you do have and act in the child's best interests. Records should reflect what was attempted and why it was not possible to complete an examination, and details of a referral made if required. Attendance code QZ-QO-FH https://www.rcophth.ac.uk/wp- content/uploads/2023/05/Vision-Screening- Diagnostic-Pathway.pdf  Attendance code QZ-QO-FH BUT Limited testing: only tests distance-reading difficulty may go unnoticed Ocular Health: The screening does not provide any information about a child’s ocular health. A child could have 6/6 sight, but still have a serious ocular pathology. Parental misunderstanding: Parents may assume that if their child ‘passes’ the visual screening, they do not need any further eyecare. Registered practitioner Screening is not performed by a registered optometrist (but is orthoptist -led) High level of false-positive referrals unnecessary https://view-health-screening- worry and HES time recommendations.service.gov.uk/document/452/download Importance of paediatric eye examinations: Visual disorders are a leading cause of childhood disability Most common childhood disorders include: Amblyopia Strabismus Uncorrected refractive error Presence of a visual disorder impacts on a child’s personal and educational development Visual Development Infancy and early childhood is an important time in visual development The eyeball grows Vision improves Stereopsis matures Accommodation develops So why is it important to assess a child’s visual status at this early stage…? Paediatric eye testing – what you need: Enthusiasm Skill Speed Accuracy Adaptability The Routine: What is expected of you? See College of Optometrists guideline C1: examining the younger child Need to obtain as much information as possible about: » Vision/visual acuity » Oculomotor balance » Refractive error » Health of the eyes You must communicate appropriately: » Establish rapport with the child » Respect the child’s fears and concerns » Communicate in a way appropriate to the child’s age, maturity and ability to understand » Explain the nature and purpose of the tests to the child and accompanying adult in a way that they can understand Checklist: Test (in aprox. Order) When? Note H&S Always Child centric Vision Always Appropriate test Cover test Always D+N NPC If possible Esp. if H&S/CT shows up issue Accommodation If possible As above (binoc OK) Motility Always Rule out congen. issues Pupils Always Stereopsis Always 20BO^ or better (age appropriate) Colour vision If possible Consider @later test? Retinoscopy & VA Always May need to cyclo Subjective? If possible Age/compliance Health always Even if only disc and mac. seen By the end of the test you should aim to know if: the eyes are straight there is any significant refractive error there is any evidence of amblyopia/amblyogenic factors the ocular media, optic nerve and macula are healthy If you don’t achieve everything you need to at the first visit don’t be afraid to re-book the child and try again Starting point… Engage the child, introduce yourself and talk directly to them. Ask an easy question Remember child can sit on parents lap if they are very little or are very nervous Look at px (and parents!) Make some general observations about eye/head position and visual attention History and Symptoms Very important to get accurate and relevant history from the child (if old enough) and parent any concerns from parent or elsewhere? If asking child use terms they can relate to e.g. books, tv, ‘far away’, board at school etc... Birth history Developmental issues? Visual behaviour clumsy, visually inattentive, unusual viewing distances? How are they progressing at school? Are writing/reading levels appropriate for age? General Health and medications Family history amblyopia, strabismus, high Rx, CV defects?  Caution Some eye conditions do not display any signs or symptoms. Children do not always complain. Signs which may show there is a problem with a child’s sight include: An eye appearing to drift inwards or outwards Difficulty concentrating Behavioural problems Headaches Sitting too close to the television Frequent eye rubbing Assessment of vision Very important to get a measure of vision Need to assess monocular as well as binocular vision Look for objection to occlusion Fun eye patches or occluding spectacles can be helpful! Age Method Acuity test 0-12 months Preferential looking Keeler/Teller cards 12-24 months Vanishing optotypes Cardiff acuity cards 2-6 years + Single picture matching Kay pictures (singles) Single letter matching Sheridan-Gardner (singles) Crowded picture matching Lea symbols (logMAR) Crowded Kay pictures Crowded letter matching LogMAR (Keeler) acuity cards Snellen acuity (naming) Snellen acuity (naming, point to letters) Approx VA by age... Visual acuity improves rapidly over the first 12 months of life and then matures gradually to adult levels by 5-6 years of age Age Normal level of Vision Birth 6/120-6/360 1 month 6/90-6/360 4 months 6/24-6/90 6 months 6/15-6/90 9 months 6/15-6/90 1 year 6/15-6/90 18 months 6/12-6/30 2 years 6/9-6/24 3-4 years 6/5-6/12 5-6 years + 6/5-6/6 Preferential looking – Keeler/Teller cards Quick and sensitive assessment of vision in children Based on assumption that child will prefer to look at an object with visual interest Uses sine wave gratings Test distance: 55cm or 84cm Visual acuity is estimated from the highest spatial frequency grating that the child is perceived to see Vanishing Optotypes – Cardiff acuity cards Ages 12 – 36 months Perform at either 1m (6/60 to 6/6) or 50cm (6/120 to 6/12) Target made up of white band boarded by two black bands, each half the width of the white band all on a neutral grey background White band decreases in width until merges with grey background (vanishes) Visual acuity taken as the finest image that is perceived to be observed correctly by child (top or bottom) Picture/Letter matching tests Sheridan Gardner Kay pictures (single/crowded) logMAR crowded test Lea Symbols Crowding phenomenon Crowding refers to presentation of letters or pictures together in a line, as opposed to singly (as in Sheridan-Gardner for example) More difficult test and a more sensitive measure of acuity Important when detecting amblyopia Amblyopic patients tend to have significantly worse crowded acuity than uncrowded acuity Next step… Cover test Target depends on age Should be visually interesting Very young children: toys, finger puppets Budgie stick – pictures Pen torch Alternatives: Hirschberg test 20D base out test 30∆/15̊ 40-50∆/20-25̊ 90∆/45̊ Stereopsis Good stereopsis is proof of bi-foveal fixation and good binocular vision Very useful as an additional test and if all else fails! Generally quite fun and interactive to perform Hard to detect clinically until 12 months of age Steadily improves to adult levels by 6 years of age Colour vision Similar to stereopsis that it is generally quite fun and interactive to perform Choose appropriate targets depending on age If it’s a first sight test and a defect is found remember to explain this to both the child and parent. Why would it be important to inform school? Retinoscopy and Refraction Most children start off hyperopic and this reduces with age = emmetropisation Normal level of refractive error by age: Age Average Rx 1-3 months +3.00DS 6 months +2.50DS 12 months +2.00DS 18 months +1.50DS 2 years +1.25DS 3 years +1.00DS 4-6 years +0.50DS  Retinoscopy Static retinoscopy (standard) Relies on good fixation Keep talking to child and changing fixation target, use parents as well Mohindra Dark room, retinoscope light acts as fixation target 50cm working distance Monocular (occlude other eye) Take 1.25D off the end refraction to account for working distance Cycloplegic refraction Check they are blurred back Indications for cycloplegia: have a low bar to cyclo Unexplained poor VA Poor stereopsis with no obvious cause Esophoria or manifest esotropia Anisometropia (>1.50D) Evidently over or under active accommodation Family history of high hyperopia or strabismus Poor cooperation/fixation on retinoscopy More plus found with dry ret than patient will accept subjectively Accommodative spasm Squint concerns from parent Ret result significantly larger than subjective result Inserting cycloplentolate Same as for all drop insertion you must: -Check it’s safe - Wash hands - Avoid dropper contact - Ask your patient to tilt their head backwards and look up https://www.youtube.com/watch?v=d3wtEWX7HxU - Instil through eyelids if necessary https://www.youtube.com/watch?v=MOOxpT9q2mo Recall Under 16 years, in the absence of any binocular vision anomaly, 1 year Under 7 years with binocular vision anomaly or corrected refractive error 6 months 7 years and over and under 16 with binocular vision anomaly or rapidly progressing myopia, 6 months If an NHS sight test is clinically necessary more frequently than these intervals, any GOS claim form has to be coded to explain the reason for the earlier test Cyclo: How to explain? Break! Paediatric prescribing Depends on: Age Binocular status Visions Anisometropia Symptoms Deciding what and when to prescribe is not an easy task... General prescribing guidelines... Regardless of age, prescribe if: Extreme refractive error Strabismus and/or amblyopia Anisometropia (1.00D or more) Children under age of 2: Generally monitor Rx only (emmetropisation) Children over age of 2: Prescribe any significant Rx that shows no sign of decreasing But what do we class as significant?  Significant refractive errors in age 2+: Hyperopia of +3.00D or greater May prescribe a modified Rx, reduced by 1.00D in each eye if BV normal Myopia of -0.75D or greater Astigmatism of 2.50D or greater Children with Down syndrome, cerebral palsy or other disabilities: Less likely to emmetropise so may prescribe earlier Likely to have poor accommodation (give full Rx) or bifocals  When/What to refer... Any case in which you do not feel you have the skills or expertise to manage the child appropriately Large angle, manifest tropias may require surgery or aggressive treatment for any accompanying amblyopia Anisometropic amblyopia can be monitored in practice but refer if do not observe any improvement in VA during first 6 months Significant astigmatism if px is keratoconic, x-linking may be indicated Consider how long it may be before your patient is seen by the HES: carry out cyclo if necessary and prescribe so child is corrected during interim period Attendance code QZ-QO-FH Lens choice for children Lens Material CR39 Polycarbonate Trivex High Index Plastic Impact Resistance Good High High Good Surface durability Good Very soft Good Good UV protection To 355nm To 385nm To 380nm To 380-396nm Used when? General dispense Safety concerns Less common in uK High RX * NEVER give a child glass lenses Frame selection Very important in children Should not be solely on aesthetics Ensure anatomically correct fit and place lenses correctly regarding visual axes Be comfortable, stable and not damage forming features Not inhibit the natural development of nasal structure Children’s frame design The prerequisites of a child’s frame are: to hold the lenses in the required position the frame must display stability, rigidity and strength the frame must be comfortable to wear and give acceptable cosmesis best use must be made of the natural field of view No different to those of an adult! Children’s frames Vs Adults frames = larger = lower = larger = smaller Results from studies Childrens faces do not grow at a steady rate Facial structures differ in proportion from those of adults The nose alters considerably during development Only two dimensions remain practically unchanged - The angle of crest and the apical radius General facial development Most childrens facial measurements will equal those of adults by the age of 13 The exceptions to this are the head width and the front to bend -both increase by approximately 10mm after 13 years Adult bridges have heights of 5-7mm and splay/frontal angles of 20- 25o Down syndrome: Visual stats 60% of children with Down syndrome will have a refractive error requiring correction Strabismus and cataract are more common wrt typical population. 76% of children with Down syndrome have accommodative problem Nasal bridge is typically broad and flat-glasses tend to slip. Different facial characteristics require careful frame selection  Down syndrome: ocular complications Congenital nystagmus Strabismus Cataract Blepharitis Reduced visual acuity Keratoconus https://erinsworldframes.com/ https://www.ezcontacts.com/blog/2019/09/26/asian-fit/ Paediatric bifocal fitting Seg top must be in a position where add must be used when reading This means at pupil centre not at standard bifocal fitting position as for adult. Largest flat-top should be supplied (D35) Frame should allow at least 10mm above dividing line* *ABDO Pathway for dispensing to children Paediatric bridge support 90% of a frame’s weight rests upon the bridge –no single fitting feature of a child’s frame is more important The main feature in a good bridge fit is the amount of the frame’s bridge surface that rests flush upon the nose –the larger the area of contact, the more support and less pressure To give correct centration, pad-arms should be soldered along the nasal rim at a height approximately the same height as the sides If the nose pads are incorrectly positioned, the frame will sit either too high or too low on the child’s face Plastic frame selection The bridge of the frame must be compared to the child’s bridge –they should have the same shape and be of equal width A regular bridge with a negative projection is the most suitable design for the underdeveloped nasal structure of an infant or toddler Mean children’s bridge measurements Age (years) 3 - 41/2 41/2 – 6 61/2 – 81/2 10 – 111/2 13 Trend c age Crest Height -0.8 -0.5 +0.5 +2.4 +4.5 Increases Projection +0.2 +1.0 1.4 +1.6 +3.0 Increases Frontal Angle 34 34 32 31 25 Reduces Splay Angle 35 34 32 29 26 reduces  Bridge measurements for children with Down syndrome Age 7-9 9-12 12-14 Trend Crest Height -3.0 -1.3 -1.4 Small throughout Projection -1.0 -2.4 -2.8 Low throughout Frontal Angle 26.25o 26.4o 26.3o Smaller than typical Splay Angle 33.8o 35o 33.8o Larger than typical Woodhouse 1994  Measurement Comparison Measurement Down syndrome v typical Children v adults Frontal angle smaller larger Splay angle wider wider PD smaller smaller Apical radius smaller smaller length to bend shorter shorter Temple width larger smaller Head width Larger in younger children smaller Smaller in older children Baby Frames Metal Frames Side Styles Very young children –loop-end sides Toddlers and older children –curl sides School age children –curl or drop-end sides  Length to Bend The distance between the dowel point and the middle of the temple bend (ear point) The Fitting Triangle PD measurement If child has strabismus, always Binocular PD (nasal occlude each to temporal limbus) eye in turn Monocular PD: always if +/- 3.00DS Binocular PD (inner to outer canthus) Crest height Bridge Projection Frontal angle Splay Angle https://www.opticianonline.net/cpd-archive/5048/ https://www.opticianonline.net/cpd-archive/5048/ Video clips... Lets see some of these skills in action... https://www.youtube.com/watch?v=fCCqy9xiCHk 4 year old ST https://www.youtube.com/watch?v=wwEsOWRoNH8 8 year old ST https://www.youtube.com/watch?v=ICo5wv7w2bw 6 month baby ST Recommended Reading https://www.opticianonline.net/cpd-archive/5048/ this article is really good Griffiths, A. (2003) Practical Dispensing, Chapter 11. ABDO Bartlam, E (2014) Dispensing to Children, Optometry Today vol 54:17 September, AOP Hughes, E (2012) Dispensing Spectacles for Children: Young Children's Vision Part 6, Optometry Today. AOP Keirl, A. (2010) Paediatric eyecare 1 & 2. Dispensing Optics (June/October), ABDO Woodhouse J M, Hodge S J and Earlam R A (1994) Facial characteristics in children with Down’s syndrome and spectacle fitting Ophthal. Physiol. Opt 14 pp25-31