Pediatric Vision Care PDF

Introduction to Pediatrics age 5 6 Pediatric Vision Care First eye exam recommended at 6-12 months - 6 Months: Several developmental milestones and visual abilities should be developed - Then, age 3. Then age 5-6 (AOA guideline...

Introduction to Pediatrics age 5 6 Pediatric Vision Care First eye exam recommended at 6-12 months - 6 Months: Several developmental milestones and visual abilities should be developed - Then, age 3. Then age 5-6 (AOA guidelines), but it should be EVERY YEAR - InfantSEE is a program that provides free eye exams for kids from age 6-12 months Likelihood of having had an eye exam - 10 inches away 2-3 Months: 50% of infants have adult-like convergence ability 4 Months: 90% of infants show full convergence - InfantSEE exam expected to have full convergence or Vergence Frequency of reliable convergent and divergent movements increase between 1-3 months. 3 months: 70% capable of accurate convergence and divergence movements. 4-6 months: consistent fusional vergence movements. convergence divergence - Intermittent eye turn is not a concern until after 4-6 months. Reassure parents that you aren’t concerned and follow up after a few months. Accommodation 4months adult likeaccommodation Infants less than 3 months old tend to over accommodate - pseudomyopia - Target Proximity - Large depth of field - Poorly developed sympathetic innervation to ciliary muscle for relaxing accommodation. Emmetropic Infants: appropriate responses after 2 months. Hyperopic Newborns will have poor distance and near visual resolution. - Need appropriate accommodation to place clear image on retina à learning appropriate accommodation topreventamblyopia - Need clear retinal image for normal cortical development. Response accuracy improves with age - variability decreases with age. Less accurate response for higher demand. Refractive error causes a variety of accommodative responses. Visual Development - Binocularity Stereopsis Hierarchy of Binocular Function 1. Simultaneous Perception: one image perceived from each eye 2. Flat Fusion a. Motor Fusion: bifoveal fixation b. Sensory Fusion: combination of two retinal images into the perception of one collective image 3. Stereopsis: highest level of binocular function. Ability to discriminate minute disparity in retinal images. 3D Acquired Ability: not present in newborns. Sudden onset between 3-4 months. Continues to develop through the first 2 years of life. O Almost 100% of infants with normal binocularity have stereo by 7 months. (Should have stereo by infantSEE exam) - No high uncorrected refractive error - No strabismus - No visual deprivation Color Vision - Some rudimentary color vision at birth - 2-3 Months: discriminate among chromatic stimuli across most of the visible spectrum - 4 Months: same photopic spectral sensitivity as adult. All 3 cone types exist, takes several years to develop adult level color vision. Motor Development and Primitive Reflexes Primitive Reflexes: assist infant to adapt to new environment and survival Postural Reflexes: safety and assist in positioning body appropriately (large limbs and head) Gross Motor Control: bilateral integration, large limb movements (scribbling), head/trunk movement for vision - Understanding letter reversal, sense of left and right sidedness, movement is spatial and temporal orientated Fine Motor Control: handwriting and oculomotor control Primitive Reflexes Measures and predicts newborn motor development. Most emerge in utero, fully developed at birth, suppressed/integrated months later. - Inhibition often correlates with acquisition of new skill Autonomic, stereotyped movements, directed from the brainstem and executed without cortical involvement. Persistent reflexes in children or adults may indicate possible cerebral palsy, traumatic lesion, or stroke. - Indicates level of neurological function. o Kids: delayed development o Adults: reverting to more primitive function after neurological incident We can TEST for these in patients we suspect have retained them and may be affecting their vision and behavior. Spinal Galant is often included in testing due to its effects on attention. Reflexes that are related to visual development: I 1. Moro 2 4months 2. Tonic Labyrinthine (TLR) 2 4months 3. Head Righting Reflex persiststhroughout Lif 4. Asymmetrical Tonic Neck Reflex (ATNR) months 5. Symmetrical Tonic Neck Reflex (STNR) 11months 9 Spinal Galant 3 9months Why is this important? Reflexes are subconscious and automated. Can’t be suppressed. Overrides conscious decisions regarding movement. - Reflexes persist past appropriate time Poor EOMcontrol accommodative insufficiency - Inability to control large muscles appropriately 4 - Large muscle control in the foundation for fine motor control - Poor fine motor development convergence insufficiency o Poor control of oculomotor muscles and poor handwriting Oculomotor dysfunction binocular dysfunction: binocular and accommodative dysfunction - Accommodative and convergence insufficiency 2 4months Moro Reflex gygroReflex Startle Reflex (panic alarm). Triggers: suddenenvironmental stimuli try - Unexpected occurrence of any kind - Sudden movement - change in head position (vestibular) open arms legs to grasp - Loud noise - Change of lights - Pain, temperature change, or being handled too roughly tispoor balance Visualperceptionproblem Action: arms and legs open to reach for mother, then close to grasp mother - connected arm/leg opening and closing at the same time. Newborn cortex is not fully developed, reflex is early protective mechanism - releases adrenaline. Integrated at 2-4 months. Long term effect if not integrated appropriately: - Child is constantly “on alert” and in a heightened state of awareness - Difficulty separating top and bottom halves of body - Motion sickness, poor balance and coordination - Physical timidity - Visual perceptual problems (cannot ignore irrelevant info) - Behavior/attention problems stim.in YeamoitIIIiIi Tonic Labirynthine Reflex (TLR) Toft Stimulus: Head movement in front of/behind spinal column *vestibular* forword flexion bagging helps muscletone balance - Forward = flexion of the limbs into fetal position Gravity proprioception - Backward = extension of arms and legs to straighten body Unintegrated poor balance visapperception Thought to assist in initially dealing with gravity after birth. weakmusclespoorposture uncomfortablespati - Induces tonic muscle tone throughout body to “straighten out” after being in fetal position. - Assists in training muscle tone, balance, and proprioception Integrated at 2-4 months. Floppy kids Symptoms of unintegrated TLR: - Vestibular difficulties: poor balance, car sickness - Visual-perceptual difficulties: Spatial skills and judging distances and time - Uncomfortable in spatial world: usually doesn’t enjoy sports - Weak muscle tone and poor posture Asymmetrical Tonic Neck Reflex (ATNR) response separateddown themidline O Infant lies on back, head turning to one side causes extension of the arm and leg on same side. Flexion will occur on opposite side. Important as one of first “look and reach” tasks. Assists in birthing process. Integrated by 6 months. crawling is 6 9months Long term effects if unintegrated: - Difficulty crawling (6-9 months): important for bilateral integration and directionality and may have difficulty with reversals of letters at school age. - Poor balance - Difficulty determining a dominant hand/leg - conscious effort - Crossing the midline (ocular effects) - important for vision and coordination - Poor handwriting switch hands when writing Symmetrical Tonic Neck Reflex (STNR) Stimulation: extension/flexion of the head - Flexion: arms bend, legs extend (leaning forward onto hands/arms) - Extension: legs bend, arms extend (sitting back on heels) Purpose: defy gravity to stand. Integrated by 9-11 months. Long term effects: should beable to lyr lyryz - Difficulty crawling and separating arm/leg movements difficultywalking - Poor eye-hand coordination, flexibility of binocular vision. - Slow copying from the board - “W” leg position when sitting Spinal Galant Examiner stimulates one side of body’s trunk while on hands/knees (table top position). Causes hip rotation on same side as stimulus. Integrated by age 3-9 months. Twitchy but Long term effects: - Fidgeting = poor attention - Bedwetting - Poor concentration - Hip rotation to one side when walking  Palmer Grasp 3 6 months should graspthings on their own Finger or small object placed in infant’s palm causes involuntary (grasp) of thumb and fingers around object. Integrated at 2-3 months. Long term effects: not visual - Poor fine muscle coordination - Poor speech and articulation - Lack of “pincer grip” which will affect pencil grip when writing (and tongue) - Child makes movements with mouth when trying to write or draw Rooting and Sucking Reflex Gentle stimulation of cheek. Mouth opens and baby turns head toward object. Tries to place stimulus in mouth. Integrated at 3-4 months. Long Term Effect: - Hypersensitivity around lips and mouth - Swallowing and chewing certain foods difficult - Speech and articulation problems Plantar/Babinksi Sign curling adults Stroke outer part of sole of foot. extensions less than 1 yr - Plantar Reflex expected in adults - plantar flexion of toes and downward pointing of foot. shouldbe gone by thetimethey'rewalking - Babinski Reflex expected in babies up to 12-18 months - extension of toes (fan outward) underdeveloped myelination of corticospinal tract. Abnormal in adults (indicates damage in CNS) Postural Responses Postural Mediated from level of the midbrain, and their appearance signifies the active involvement of higher brain structures over brainstem activity, and a sign of increased maturity of the CNS. Transition from primitive reflex reaction to postural control is not an automatic one. - Both reflexes operate together for a short period of time - If primitive reflexes do not integrate appropriately they can interfere with proper development of postural responses Superman Landau Reflex counteracts tonic labreflex starts splayingout instead of flexinginward Onset ~2 months, integrated between 3-3.5 years. Essential for independent sitting and walking. Not a true primitive or postural reflex - more of a transitional reflex. Stimulus: infant suspended in prone position (superman) by support at the stomach - Increased extensor tone of entire body - Arms, legs, and head push upward Transient Reflex not Primitive Is thought to assist with inhibiting flexion response (head forward) of the TLR reflex to make way for higher postural control. Similar symptoms of unintegrated TLR. Head Righting I 6months sitting and holdingheadUP Onset ~2-4 months, persists throughout life. Ensure head maintains a midline position despite movement of other body parts. Poor balance controlled eye movements and visual perception. Parachute Response should beable to while crawling 9 12months Onset by 9 months, persists throughout life. Infant moved abruptly headfirst in a downward direction - extension of arms and legs symmetrically. Early Childhood Intervention - Occupational Therapy (OT): skills related to performance of daily activities and taking care of daily needs - behavioral - Physical Therapy (PT): rehabilitation, muscle relationships, injury, develop strength and coordination - physical function - Speech Therapy - Physician Denver Developmental Screener Test (DDST) Administered for toddlers or preschoolers when developmental delays or learning problems are suspected. Assists in detecting developmental level, visual perceptual dysfunction, children at risk for learning related vision problems. - Main categories: gross motor, language, fine motor (adaptive), personal (social) - Abnormal test results: ≥ 2 delays - Suspect: 1 delay and/or 2 cautions Developmental Level visualperception dysfunction Infant Exam Learning related vision problems Purpose of Infant Exam Gross motor finemotor language personal Early Intervention - Vision is not fully developed yet = critical time - Corrective actions for abnormalities is typically more effective with earlier detection Ensure there are no GROSS irregularities/abnormalities - Pathology: o Life threatening: tumors, vascular abnormalities, etc o Vision threatening: media opacities, ROP, glaucoma - Refractive Error outside of norms: o Amblyogenic factors