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 Before the Exam: Establish Rapport With Parents: - Sensitive and skillful handling of their child - Tell the parent how to assist you - Helps to inform that your tests will likely appear like play - Informed consent for drops With Baby: - Infant should be held by adult or in carrier - Gentle touches and soft vocalization - Lights, small toys, facial expressions - Change target often to maintain interest Limitations to Consider: Not your typical exam, Objective vs Subjective measurements, Recording observations with your exam results, Endurance - work quickly, PATIENCE. DO NOT UNDERSTAND THE POWER OF OBSERVATION. Test Sequence Be flexible! Binocular testing first. Be ready to distract the baby immediately after hand, occlude, or patch is introduced. Consider starting with tests you deem most important first. - Resistance to occlusion (red flag if asymmetrical) Case History - Visual, medical, and developmental history - Chief Complaint: 4HPIs recommended or parent concerns - Different ages have different complaints/worries: Infants based on family description and observation Key Points: - Parent/pediatrician concerns? - Milestones/developmental delays - Premature? O2? (special testing)? - Pregnancy/birth/delivery - Family Hx - strabismus, tumor complications? - Medications - Medical conditions/history - Injuries/surgeries - Allergies Key Ocular Hx Questions - Eye turn? - White pupil? - Watering/redness? - Poor visual awareness? - Eye rubbing, closing an eye APGAR: How well child adapted to birthing process and new environment. Measure at 1 and 5 minutes after birth. 1 minute score measures how well baby tolerated birthing process. 5  score of less than 7 a medical intervention minutes score assesses how well baby is adapting to environment. Score of 0, 1, or 2 for each category (max score of 10) A = Activity (muscle tone) A Activity I min birthingprocess P = Pulse P Pulse 5min a environmental adaptation G = Grimace (reflex irritability) G Grimace A = Appearance (skin color) R = Respiration A Appearance R Respiration Visual Acuity Binocular Monocular 6 Month 20/50 - 20/200 20/80 - 20/300 12 Month 20/50 - 20/200 20/80 - 20/300 Avg 201100 30 Month 20/20 - 20/50 20/20 - 20/50 Avg 20150 36 Month 20/15 - 20/40 20/15 - 20/40 Expected Acuity: - VEP: 20/20 between 6 and 9 months of age one - Preferential Looking: Avg 20/100 at 6 months, Avg 20/50 at year Fix/Follow LastResort for VA Procedure: Performed monocularly. Move target and observe if baby follows with eye. Target: Penlight, light up toy. Attempt with smaller targets as able. Do NOT use toys that make sound. ONLY recommended when baby is unable to participate in more accurate testing. Performed unable to get VA. Benefits: Fast and easy Drawbacks: Only means the infant has GROSS acuity. No quantitative information. Resistance to Occlusion Procedure: Cover one eye and observe behavior. Key is looking for asymmetry in response. - Ex: Cover baby’s right eye and no change in behavior. Cover baby’s left eye and he begins to cry and push hand aside. eye that is uncovered o Likely asymmetry in the right eye Not a true measure of visual acuity. Induced Tropia Test (Vertical Prism Test) I Used with patients that have no evident strabismus - relies on suppression. Not a true measure of visual acuity. Provides information about presence or absence of fixation preference and equal input form the two eyes.  Procedure: Fixate interesting near target. Occlude one eye (if able). Introduce 10-15pd vertical prism over other (un-occluded) eye. Should observe eye shift toward apex of prism = fixating. Uncover occluded eye and observe response. Possible Responses: 1. Alternates fixation = diplopia (looking at each target, equal awareness of both eyes) Normal 2. No movement = patient may prefer fixation with initially un-occluded eye 3. Single movement to fixate with eye that has just been uncovered = patient may prefer fixation with the initially occluded eye. focusing with eyeyoprism could be suppressing Perform with other eye occluded initially and compare symmetry of response. w prism eye must check othereye Forced Choice Preferential Looking Resolution or Detection Begin with larger grating à smaller grating. One choice has stripes, other choices has gray field of equal size and luminance. Child will instinctively move eyes or head toward pattern if they can detect it. If child can’t detect stripes, no apparent head or body movement will be detected = no resolution/threshold or loss of attention. Teller Cards: Cycles/cm recorded in cycles/degree for Snellen Equivalent. Resolution Lea Paddles: Cycles/cm recorded in cycles/degree for Snellen Equivalent. Resolution Cycles/cm to Snellen Equivalent (accommodates for different test distance) Cycles/degree = test distance/55cm * cycles/cm cycles degree testify t Snellen Denominator = 20 * [30/(cycles/degree)] SD 20 30 cycles degre t 20/20 ~ 16 cycles/cm ~ 30 cycles/degree at 55 cm 20 20 16cycles om 30 Face Dot (FDT or Richman): Variable test distance. Approximate Snellen equivalent. Detection cycles dog Optokinetic Nystagmus: Response are not impacted by significant uncorrected refractive error. - Not an accurate measured of VA - Partly facilitated by motion processing - Persistent asymmetry of OKN can indicate strabismus, amblyopia, unilateral cataract. Visual Evoked Potential (VEP): Capacity for adult levels of acuity develops in early infancy. VEP shows higher levels of visual potential in infants than other measures. 6 9 months Pupils, EOMs, CVF, NPC Similar to adult testing. However, 0 EOMs: Contrary to fix/follow, a target with sound CAN be used for attention. Consider purpose of test… we to know that eyes are ABLE to move into all cardinal positions.  CVF: Central target (bell, light). Bring SILENT target from periphery until child notices it. NPC: Often use a puppet or toy. May use light-up toy to observe corneal light reflex simultaneously. Objective CT Alignment Induced Tropia Test (Vertical Prism Test): information regarding suppression or VA (not a measure of alignment) Cover Test Hirschberg: evaluating corneal light reflexes - binocular. Transilluminator at 50cm. Looking for symmetrical reflexes.Does notmeasurephonas - Normal = slightly nasal reflexes (+0.5mm) because of angle kappa (monocular) - 1 mm displacement = 22 PD deviation (may have strabismus) - Nasal reflex = eyes sit in exo position; fovea shifted temporally Normal Findings: (+) 0.50 mm. Eyes are in a slightly exo position. Corneal reflex appears slightly O nasal. - Recording: Hirshberg: “symmetrical” “ortho” “+0.5 mm OD/OS” Temporal displacement of corneal reflex: Light reflex is temporal - more minus. Indicates inward turning eyes. Recorded with (-) Nasal displacement of corneal reflex: Light reflex is nasal - more plus. Indicates outward turning of eyes. Recorded with (+) Krimsky: Used to neutralize deviation found with Hirschberg. Rough estimate of deviation (CT inocular is more accurate) 1. Prism in front of the deviating eye - adjust prism until corneal reflexes look symmetrical. - Not performed 2. Prism in front of non-deviating eye - adjust prism until reflex of the deviating eye matches the previous position of the non-deviating eye. untildeviating eye matches non deviating Brucker: DO is set with +1.00 50 cm to 1 m from patient. Observe both eyes simultaneously and compare brightness of fundus reflexes. symmetrical reflexes Normal result: Equal brightness. If difference noted, the brighter eye is likely: strabismic, more anisometropic, may have pathology (white pupil) - Bruckner: “OD = OS” or “OD brighter than OS” Accommodation (unlikely): MEM finding sometimes helpful Color (unlikely): no great test for this Stereopsis comes 3 4 months monthsfullydeveloped Smile Stereo Pass Test: (requires polarized glasses) forced choice preferential looking. Random dot pattern with face on one side. VA of at least 20/80 and no constant strabismus is required. Randot E: (requires polarized glasses) forced choice preferential looking. Control plate with 3D image (letter is actually physically raised - only 3 cards) - Randot Test Plates: blank v.E Lang: no polarized secs necessary. Recognition - must know shape, could be challenging. would not perform forinfants Retinoscopy Often challenging to determine refractive error. Must be able to rely on your objective measurements. Mohindra Non-cycloplegic technique. Monocular test performed in a dark room (completely dark if possible). No other stimulus possible, fixates on retinoscopy light. Infant/child fixates dim retinoscope at 50 cm - dim light viewed monocularly is a poor stimulus for accommodation - tonic accommodation left over. Correction factor is subtracted from neutralizing lens - estimation method, looking for agreement with cycloplegic values. Correction factor is not the same as your working distance. - Between -0.75 and -1.25 (-1.25 recommended) - -1.25 is typically subtracted from gross findings Good screening for higher refractive errors. If the RE is high, do cycloplegic exam (usually recommend this anyway for DFE). If prescribing is appropriate, best to check cycloplegic retinoscopy to determine final Rx. Infants have a LOT of accommodation and typically have POOR control over accommodation. Variability in dry retinoscopy is to be expected. Static Retinoscopy Child fixates a distance target. - Often use a video or parent making faces across room. - Difficult for an infant - Usually more successful with a toddler but may attempt Cycloplegic Retinoscopy Cyclopentolate is the drop of choice for routine cycloplegia. - 0.5% for infants under 1 year or younger 1 or 0.5 Tropicamide - 1% if older than 1 year Complete: Patient should fixate the retinoscope light. On-axis measurements (rare to get complete cycloplegia) Incomplete: fixate distance target Cycloplegia in Infants More difficult to obtain satisfactory cycloplegia in infants than in older children. - Avoiding excessive medication - Greater accommodative power - Reduced action of cycloplegic agent at receptor site - Difficulties administering drops Reduced reliability, high degrees of astigmatism and hyperopia expected, high prevalence of anisometropia reported in infants. Why Not Atropine? Crosses BBB causesside effects onlyreveals 0.50more than cyclo Used more commonly in the past. Most potent cycloplegic and mydriatic agent. - Higher incidence of systemic side effects - Rash, thirst, fever, urinary retention, tachycardia, somnolence, excitement, hallucinations - “Blind as a bat, red as a beat, hot as a hare, mad as a hatter” Cyclo reveals 0.50 less hyperopia than atropine Atropine: onset of action 1-3 hours Cyclo: only 45 minutes You will not always prescribe what you find. It is NORMAL for infants to have small to moderate amounts of refractive error and/or astigmatism. Refraction - No Vergences - Unlikely Near Ret - consider MEM Ocular Health Anterior segment can be evaluated with: - Penlight/Bluminator, 20D lens and transilluminator - magnification, Slit lamp for an older child IOP can be measured with: Finger touch (usually for infants), Tono-pen, Icare tonometer now  Shadow 501 Angle Evaluation - Shadow test, 0 = closed angle, 4 = wide open amorally sameplaneas iris Posterior Segment can be evaluated with: - BIO, DO, PanOptic (Monocular Indirect Ophthalmoscopy - wider FOV thatnDO) TMag t For no stereosince monocula Sometimes Easiest When: the infant is drowsy or being fed and with the help of an assistant to direct the infant’s gaze - look for gross abnormalities. Exam Under Anesthesia (EUA): May need to be performed under sedation if unable to get views and problem is suspected. Must refer to ophthalmology. Dilation Drops O 0 Tropicamide (either 0.5% or 1%) or Cyclopentolate (0.5% for < 1 yr). In isolation provides moderate/variable dilation. - Phenylephrine is NOT recommended for children under 3 years of age or kids with cardiovascular abnormalities Avoid overdosing the infant. Let excess medication flow laterally and wipe with tissue. Use one drop at a time, repeat after 5 minutes if necessary. - Spray Atomizer: great value over a wider area. Potential for side effects is increased. After The Exam Discuss management with parent: - Important for them to understand diagnoses and recommendations - Open-ended questions should be used - Have parent repeat back in own words - Eye models/diagrams/written material mustincludein RX If recommending glasses, discuss FRAME STYLE - Miraflex and MEASURE PD Select appropriate follow-up schedule and may need to communicate with professionals: - Note back to referring doctor - Physical Therapy/Occupational Therapy: requires parental consent, record release paperwork Toddler and Preschool Exam General Guidelines Appropriate appointment time - pick a time when the child is usually awake. Work quickly! - May start exam by doing a “cool” or more “fun” activity - stereo, ect. - Engage the child/establish rapport - be familiar with cartoon/popular characters and have pictures, puppets, and toys on hand - Allow child to remain with parent or sit on parent’s lap during testing - May need to be flexible with position of patient Limitations to Consider - Ability to follow directions - Be prepared to see variability - Attention to task between kids of the same age! - Endurance - work quickly and be - Age ≠ Maturity Level flexible with order of tasks Examination Suggestions Communication - Allow time child to get comfortable - Speak slowly, quiet voice, simple - Assume eye level or lower position words - Avoid quick movements - Avoid multiple direction/choices - Talk directly to child, not just parent Exam Considerations - Duration - Avoid words like “test” (game/activity) and use praise - May have parents bring familiar toys Parents in the Exam Room? Pros: Assistance, Encouragement to apprehensive child, Evolving case history Cons: Interference Usually prefer for parent to be in exam room with child. Test Sequence Case History Typically based on parent/family input. Similar to infant - likely more developmental info. - Chief complaint with 4 HPIs - Birth complications, prematurity, - Visual and medical history, pre/post-natal complications medications, family history, allergies - Developmental history - milestones - Any specialized testing? Common Complaints - Failed school screening - Vision symptoms (less common) - Family history of eye problems - Achievement Issues - Observations by teachers, parents, relatives Signs of Uncorrected Refractive Error - Difficulties with depth perception - Double vision and hand-eye coordination “clumsy” - Closes or covers one eye - Confuses similar things/objects - - Lack of interest in the outdoors or poor discrimination of details sports close working distance to - Rubs eyes, blink excessively, squints books, TV, etc. OR avoids near tasks Visual Acuity By age 3, most children can perform subjective acuity testing. Recognition acuities preferred rather than preferential looking. Consider using a forced choice or matching task. Detection Acuity Cardiff Cards: 50 or 100 cm; Acuity Range: 20/12.5 - 20/320 Detection Recognition Acuity Lighthouse: easy to guess, dissimilar pictures Recognition Allen Figures (D&N): somewhat outdated pictures Recognition Lea Symbols (D&N): 4 alternative forced choice naming or matching Recognition HOTV (D&N): 4 alternative forced choice naming or matching Recognition Resolution Acuity Tumbling E or Landolt C: May be difficult for children with directionality issues Resolution Broken Wheel: 20/20 to 20/200 at 10ft, Landolt C target, highly correlated to Snellen. Must get 4/4 presentations correct for credit for each level. Resolution Electric Charts: Great system for a pediatric office. Snellen, Allen figures, Tumbling E, version of broken wheel, HOTV, numbers, crowding bars. Hand controller so examiner sees what is on screen when facing child. Single line and single letter, Randomized characters, Videos - Record how acuity was taken. Pupils, EOMs, CVF, NPC, CT (alignment) done the same as anyone else Amplitude of Accommodation Maximum diptric value produced by accommodative system. - Average = 18.5 - 1/3(age) - Minimum = 15 - ¼(age) Pull Away - Most likely for Toddler: move the target away from the spectacle plane until the patient can recognize the target. Centimeters à Diopters Push Up: patient reports when the target becomes blurred. Results often inflated. Color Ishihara, Color Vision Made Easy (CVME): includes 4 plate screening test, HRR numbers shapes shapes Fusion Wort 4 Dot (~4 yrs) 3 Figure Flashlight (~2 yrs): Red girl, green elephant, white ball. Uses Lea Shapes - green house, white circle, red square. Stereopsis Lang: No stereo specs required Random Dot 3: Lea Shapes Randot: Local and global Forced Choice Preferential Looking PASS Test: preschool assessment of with a smile, non-stereo target is used to determine understanding. VA of at least 20/80 and no constant strabismus is required. Randot E: Control plate with 3D image. Randot test plates blank vs E. Keystone Basic Binocular Refractive Error Measurement Static Retinoscopy (usually attempt): Movies help maintain fixation. Ret bars and lose lenses vs. phoropter. Damp Retinoscopy: 1% Tropicamide Cyclo Retinoscopy: 1% Cyclopentolate (only necessary if fluctuating accommodation) Mohindra: Make sure room is as dark as possible. Monocular ret, dim ret, have them look directly at the light. Subjective Refraction: Unlikely, but can attempt NRA, PRA, FCC Evidence-based clinical practice guidelines - comprehensive pediatric eye and vision examination. - Cycloplegic retinoscopy is the preferred procedure for the first evaluation of preschoolers. (Tropicamide is good enough) Auto Refractor: not controlling for accommodation, the Welsh Allen ER is portable, can use after instilling tropicamide. Vergences o Step Vergences: Prism bar, No blur reported, OBJECTIVE. Break may be sooner than reported, must watch for break/fusion maintenance. Use fixation target or stereo target when stereo looks flat or check suppression L and R. Smooth Vergences: Behind phoropter, Subjective Dynamic Retinoscopy Monocular Estimation Method (MEM): Accommodative lag/lead. - Working Distance: habitual (usually 40 cm) - Target: age appropriate reading material/pictures - you will notice a greater lag with easy reading material (use picture targets) - Patient reads out loud, examiner dips lenses close to face and QUICKLY scopes - 0.25 seconds before patient makes adjustment in accommodative status. - Expected findings between +0.50 and +0.75 Anterior Segment Evaluation Techniques: - Penlight - Slit lamp for an older child - 20D lens and transilluminator (preferred) - Burton Lamp Bluefilter IOP Can be measured with: - Finger touch (infants) - iCare tonometer (fixate on letter or - Tono-pen (scary for kids)requiresanesthetic movie) - NCT and i cornealcontact Posterior Segment (Ocular Health) Depending on age and cooperation of child, techniques may be a blend of infant/toddler exam and adult exam. BIO (large field of view and periphery), direct o-scope, Pan Optic (MIO), 78/90 D. After the Exam Discuss management with parent - Important to understand the diagnosis and recommendations - Open-ended questions - Repeat words back in own words - Models/Diagrams/Written Material  O Discuss any spectacle Rx given and frame/lens recommendations - likely Miraflex frames and Polycarbonate lenses (impact resistance) Select appropriate follow-up schedule May need to communicate with school or other professionals - requires parental consent, record release paperwork. - Consider an award or prize for the patient. - Praise the child and the parent. Strabismus Fun Facts - 2.5-4.6% of population - Peak onset age 3 (most prior to age 6) - Risk Factors: o Down Syndrome 50% o Low birth weight o Cerebral Palsy 44% o Hydrocephalus o Craniofacial Dysostosis 90% o Family History o Premature Strabismus History Onset: time and sudden or gradual Frequency: constant or intermittent (at distance or near, ask parent for photos of kids) Change in size or frequency Hx of neurological, systemic, Unilateral or alternating developmental disorders Diplopia or other symptoms Family Hx Strabismus Head tilt/turn Previous Treatment? previous records Signs/Symptoms Abnormal motility of one or both Headaches eyes Abnormal head posture Double vision Blurred vision Decreased vision and stereo Cosmetic - low self esteem Ocular discomfort (fatigue) Strabismus Definitive Tests: Cover Test 9 Fields, W4D, DFE i Consider: Visuoscopy? Anomalous correspondence? Classifications (Distance and Near), Magnitude (Prism Diopters), Direction (Exotropia, Exotropia, Hypertropia, Cyclotorsion), Comitance, Frequency (Constant, Intermittent %), Laterality (Alternating %OD vs OS, Unilateral) iisandormar.im inti q Ieso.mamreamuonaant.inm Laterality AlternationI ODOf unilateral Comitance Samemagnitude in all fields of gaze Comitant: Magnitude = in all directions of gaze (within 5∆) - Decompensating Phoria - Congenital Strabismus - Less worrisome, especially for adults. Less likely a neurological issue. Noncomitant: Magnitude varies in different gazes - Usually a muscle or nerve problem (acquired) - Deviation is largest in the direction of action of the affected muscle/nerve - The deviation varies with the eye used for fixation - Document in 9 fields - More of a concern, muscle or nerve problem, possible stroke Esotropia Most present before school age - often constant. Subclassified magnitude at distance and near: - Basic Type: within 10pd at distance and near - Convergence Excess: near > distance by 10pd - Divergence Insufficiency: distance > near by 10pd 1. Pseudoesotropia: False appearance of esotropia. CT normal and Hirschberg normal. Cause: Flat, broad nasal bridge, prominent epicanthal folds, narrow interpupillary distance, more common in Asians due to anatomy. Treatment: Education and monitor, no treatment because not a true strabismus and consider - eyes usually straighten by 2-3 months. 2. Infantile Esotropia: (usually not present at birth) 8.1% of Esotropia. Infants with confirmed onset earlier than 6 months. Girls = Boys. Risk Factors: Prematurity, Cerebral Palsy, Hydrocephalus, Other neurologic disorder Signs and Symptoms: Amblyopia in 40-72% - Cross Fixation: OD views left field and OS view right field (not true deficit) - EOMs: may show abduction deficit. difficulty movingeyeoutward o Monocular Ductions: medial rectus can become tight if unilateral (abduction problem) - Normal Refractive Error - 40 to 60 pd range, distance = near Associated Findings: both eyesmove up during CT - Dissociated Vertical Deviations (DVD): Slow upward movement of one/both eyes when covered. May show hyper deviation of each eye when covered… no hypo deviation. - Inferior Oblique Overaction (78%) eye with turn moves up in adduction towardsnose 0 displaces upward obliques isolated I  - Nystagmus (30%) - Poor N à T OKN Responses Treatment: - Spectacles (+) lenses help - Prism? Prism adaption - doesn’t - Patchingso - Bi-nasal occlusion foil - always lead to positive Tx outcome Surgery? Treatment of choice for - VT (fixate and follow) ophthalmology, early intervention 3. Acquired Esotropia Accommodative Esotropia Refractive Accommodative Convergence associated with accommodative reflex. 50% of all childhood esotropia are either fully or partially accommodative. Onset 2-3 years (accommodation isn’t used, noticed while doing near work). Signs and Symptoms: - Often constant ET at near - Hyperopia (2.00D to 6.00D), anisometropia increases the risk - Deviation near > distance, 10-35pd - Normal to High AC/A (patient doses well with (+) at near) Nonrefractive Accommodative Esotropia: 5% of accommodative esotropia patients. - Minimal refractive error helps nothingto do with RE - ET at near - strictly due to near accommodation - High AC/A just accommodation Treatment: Spectacles, Near add - PLUS LENSES improve alignment, Vision Therapy - Do NOT provide access to near without bifocal - Top of bifocal should bisect the pupil (always include on Rx where the bifocal seg is located) No Surgery Non-accommodative Esotropia: Onset 6 months - 6 years. ~10% of all esotropia. Intermittent or Constant Esotropia. Signs and Symptoms: - Refraction - most hyperopic, 5% myopic - 20-70 pd range - Normal AC/A (plus lenses don’t change alignment) Treatment: Prism, VT (always recommended patients to do VT even if recommending Sx), Surgery (aligning eyes surgically, eyes cannot understand how eyes work together) Glasses Don't Help Acute Esotropia Characteristics: Sudden onset in school aged or older. Previous normal binocular vision. - Diplopia - Immediate Evaluation needed Treatment: Determine cause - imaging (MRI, CAT scan of orbit)Treat cause - Consider prism to re-establish binocular vision (temporary) - Vision therapy (prism or black patch to resolve underlying cause first) - Surgery (better outcome long-term) if causetreated butstillpresent eyeturn Fresnel Prism: temporary stick-on - Advantages: easy to change, varying amounts (trial frame), light weight, cost - Disadvantages: air bubbles, reduction in VA Causes: - Neoplasm - MS - Head Trauma - Meningitis - Intracranial Aneurysm - Myasthenia Gravis - HTN - Sinus Disease - DM - Chiari 1 Malformation - Atherosclerosis - Chemotherapy - Hydrocephalus - Ophthalmoplegic Migraine 4. Secondary Esotropia Sensory Esotropia: Visual deprivation, suppression, or trauma in one eye that limits sensory fusion. - Refractive amblyopia - suppression - Optic atrophy - Unilateral cataract (30%) - Macular disease - Corneal opacity Treatment: - Clear visual axis if possible - VT - Optical correction - Surgery? (mostly cosmesis - if vision - Prism can’t improve) Consecutive Esotropia: Surgical correction of exotropia. Surgical side effects: - Amblyopia - Variable vertical and horizontal - Loss of normal binocular vision misalignment (cyclo deviation) - Diplopia Anomalouscorrespondence Treatment: - Optical correction - VT - Prism - Surgery more than on Sx to correct strabismus  Prism over op no movement on op suppression 5. Microesotropia: Less than 10pd typically less than 3 years old. Signs and Symptoms: - Constant and Unilateral = amblyopia - Diagnosed by 4 Base Out Test - Visual acuity ~20/50 range My- Eccentric Fixation not usingfoveatofocus R- Anomalous Correspondence o Normal: Both eyes shift in direction of apex, no foveal suppression, other eye fixates no refixation forealsuppression o Foveal suppression: other eye does not refixate, no movement, foveal suppression in eye with prism. No info in foveal response in contralateral eye. no surgery Treatment: Optical correction, prism (unlikely, angle is so small), vision therapy Prism Consider Bi-Nasal Occlusion (BNO) for Esotropia: occlude the nasal field of the eyes. Purpose: to prevent cross-fixation, stimulus for divergence, peripheral awareness/processing. From the lens’ nasal edge to the: - Consider different positions - depends on response o Nasal pupillary border o Nasal limbus - Tilt tape nasally inferiorly to allow convergence - May tape asymmetrically I l Exotropia XT is usually intermittent - affecting 1% of population - Basic Type: within 10pd at distance and near - Convergence Insufficiency: near > distance by 10pd - Divergence Excess: distance > near by 10pd 1. Infantile Exotropia: First 6 months of life. Can be caught by Infantsee exam but surgery is recommended. Less common than infantile esotropia - very rare. Signs and Symptoms: - 30-80pd at distance and near - Constant, typically alternating Can be associated with: neurological, craniofacial, and structural abnormalities. 2. Acquired Exotropia Intermittent Exotropia: Onset 6 months - 4 years. Characteristics: - Convergence Insufficiency - near - Divergence Excess: occur when daydreaming, sick, tired, or distracted. Problem with automaticity of fusion. Often have difficulty with attention. mostvisible - Normal refractive error  - tinty Discomfort during or following prolonged visual acuity - Diplopia Treatment: - Optical correction - Surgery? NO! (maladaptation, turns - VT (responds well, especially CI) into constant strabismus) - Prism (intermittent so angle not OF always the same) Acute Exotropia: Suddenly develops in an older patient who previously had normal binocular vision. Ocular emergency until proven otherwise. Characteristics: - Onset in school aged or older - Diplopia - Previous normal binocular vision - Immediate Evaluation needed Causes: - Neoplasm - Meningitis - Head Trauma - Myasthenia Gravis - Intracranial Aneurysm - Sinus Disease - HTN - Chiari 1 Malformations - DM - Chemotherapy - Atherosclerosis - Ophthalmoplegic Migraine - Hydrocephalus (Particularly concerning in adults) 3. Secondary Exotropia Sensory Exotropia: Unilateral decrease in vision that disrupts fusion. - Refractive amblyopia - suppression - Optic atrophy - Unilateral cataract - Macular disease - Corneal opacity Treatment: - Clear visual axis if possible - VT - Optical correction - Surgery? (cosmetics in cases where - Prism vision can’t be corrected) Consecutive Exotropia: Surgical overcorrection of an esotropia. Prevalence as high as 20% for esotropia patients treated with surgery. - Typically variable BV testing after surgery - Muscles DO NOT know what their new position is in Treatment: - Optical correction - Prism  - VT - Surgery? 4. Microexotropia Characteristics: - Constant XT - Eccentric Fixation - Less than 10pd - Anomlaous Correspondence - Much less frequent than micrET Treatment: - Optical correction - Vision Therapy - Prism O Surgery Vertical Strabismus: Cyclovertical Strabismus Involve: Oblique or vertical recti muscles. Vertically acting muscles also have cyclorotary actions in most fields of gaze. Innervational or mechanical abnormalities. Often noncomitent. Trochlear 4CNN th Nerve Palsy is most common Eye appears up - Congenital (more common) Sup Oblique not as a concern until decompensating o Long Hx of head tilt intortorts o No torsional diplopia o Larger vertical vergences ranges adapted entire life o Treatment: VT/prism/surgery - Acquired o Acute onset: neurological or head trauma (emergent patient) o Torsional diplopia o Treatment: neuroimaging, blood work, BP APark’s 3 Step to identify which muscle is the problem. Strabismus Syndromes: Duane Congenital defect of innervation to the lateral rectus. Anomalous innervation of the later rectus. Typically unilateral, but can be bilateral. Females > Males. Left eye > Right eye. - CN6 may have normal, reduced, or no innervation - CN3 paradoxically innervates lateral rectus Characteristics: - Limited abduction and/or adduction - Retraction of the globe on adduction - Narrowing of the palpebral fissure of adduction Hubner Classificiation: Type I: Limited abDuction. (Most common) LR has nearly no CN 6 stimulation = poor abduction. LR has some paradoxical CN3 stimulation (but more heavily stimulates MR) = adduction intact Type II: Limited aDDuction. LR has sub-normal (but moderate) CN6 stimulation = abduction intact. LR has paradoxical CN3 stimulation (equal stimulation of MR and LR = no adduction) Type III: Limited abDuction and aDDuction. LR has no CN6 stimulation = no abduction. LR has H paradoxical CN3 stimulation (equal stimulation of MR and LR) = no adductions Should assess children with Duane’s for hearing loss, skeletal or spinal abnormalities and features of Goldenhar’s Syndrome (incomplete bone development in the face, chromosomal, unilateral) Strabismus Syndromes: Brown Syndrome Restricted movement of the SO tendon through the trochlea. Limitation of elevation in adducted position, appears as an inferior oblique palsy. Usually congenital, but can be acquired. Right eye > Left eye. Difficult in superior fields and contralateral gaze. adducted Diagnosis: Forced Duction Test - attempted manual elevation of the effected eye - Done under anesthesia or in operating room - POSITIVE forced duction test: affected eye does NOT move. Restriction O Treatment: Observation or Surgery Moebius Infantile Esotropia th th Combined 6 and 7 nerve palsies causing lateral gaze paresis and facial paralysis (congenital). Unilateral or bilateral. Inability to use facial muscles. Facial palsy usually observed in first few weeks due to lack of sucking and feeding issues. Mask like faces - unable to grin and wrinkle forehead, etc. Various skeletal muscle defects are common - clubbed feet, missing fingers or toes. Ocular Characteristics: CNJmuscles Still work - Inability to abduct the eye(s) - Vertical and convergence - Congenital esotropia is common movements are intact - Inability to blink/close the eyes Treatment: - Optical Correction - Prism - Bifocals - ET o Less than 20pd total o High AC/A o Ground in vs Fresnel o Deviation N>D - Vision Therapy - Over minus - IXT - Surgery? o Eso > 15pd o Exo > 20pd - Treat the AMBLYOPIA After the Exam - Close follow ups - Education - might still see eye turn without Rx or tired - More Information: Optometric Clinical Practice Guideline, Care of the Patient with Strabismus Esotropia and Exotropia