Infants Vision.pdf

Infant’s Vision Bebé Héctor Héctor Santiago, OD, PhD, FAAO Ìnter American University of Puerto Rico School of Optometry Infant’s Exam • Early detection reduces vision loss • We can make the difference through early diagnosis and intervention Recommended schedule Age Asymptomatic At risk Ne...

Infant’s Vision Bebé Héctor Héctor Santiago, OD, PhD, FAAO Ìnter American University of Puerto Rico School of Optometry Infant’s Exam • Early detection reduces vision loss • We can make the difference through early diagnosis and intervention Recommended schedule Age Asymptomatic At risk Newborn to 6 months a 6 meses At 6 months At 6 m or as recommended 2 to 5 years 3 yo 3 yo or as recommended 6 a 18 years Before first grade and every 2 years Annually or as recommended AOA Pediatric Eye and Vision Examination Practice Guideline, 2000 Visual acuity Preferential Looking (Forced choice) http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page9.html Spatial Acuity Visual Acuity »1 cycle/ degree (20/600 newborn) »3 cycles/ degree (20/200) at 3 m »6 cycles/degree (20/100) at 6 m »12 cycles/degree (20/50) at 12 m »30 cycles/degree (20/20) at 35 yo http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html Saccadic eye Movements • Newborn: Horizontal hypometric – Increased latency, less speed • Normal by 1 yo Accommodation • Less than 2 months: Fixed accommodation, 30 cm • More than 2 months: Good accommodation (worst for hyperopes and myopes) Vergence • 3 months: 70% have accurate convergence and divergence • Primastic fusional vergence: Well developed by 6 months Pursuits • Presence for newborns if: – Big stimuli ( > 12 degrees) – Slow speed • Present at 6-8 weeks Optokinetic Nystagmus (OKN) • • • • Present at birth Poor nasal to Temporal Better temporal to nasal • Symmetric by 3-6 m http://www.opt.indiana.edu/ce/infant/graphics/okn.jpg Contrast sensitivity http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html Contrast Sensitivity Testing Low Spatial Frequency Low contrast High contrast High Spatial Frequency http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html Face Perception of mother: 2 days Face Perception Normal vs scrambled: 2 months http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page38.html Object Perception in Babies Color vision • Cones : L (Red-Orange) , M (YellowGreen), S (Blue) • 1 week: Discriminate L and M • Newborn to 1 month: Difficulties with S (blue) • By 2 months: S are functional • By 4 months: Normal trichromatic vision MYOPIA focused correctly. Nearsightedness is a very common vision condition that affects nearly 30 percent of the U.S. population. Some evidence supports the theory HYPEROPIA focused correctly. Common signs of farsightedness include difficulty in concentrating and maintaining a clear focus on near objects, eye strain, fatigue and/or headaches after close work, aching or burning eyes, irritability or ASTIGMATISM distances. People with severe astigmatism will usually have blurred or distorted vision, while those with mild astigmatism may experience headaches, eye strain, fatigue or blurred vision at certain distances. Disorders Pediatric Population Desorden 6 m to 5 y -11 m 6 y to 18 yo Hyperopia 33% 23% Astigmatism 22.5% 22.5% Myopia 9.4% 20.2% Binocular disorders (Non strabismic) 5% 16.3% Visual Disorders Type 6 m to 5 y - 11 m 6 y to 18 yo Strabismus 21.1% 10.0% Amblyopia 7.9% 7.8% Accommodative Disorders 1% 6% Retinal disorders 0.5% 2% Equipment l l l l l Trial case Prisms Lens bars Transilluminator Ophthalmoscope Toys l l l Brilliant colors With and without sound With movement Toys l Transilluminator Angle Kappa (monocular) Hirschberg Test (binocular) Measuring Angle Kappa and Hirshberg l l l l Catch attention Use source of light Occlude one eye: Angle Kappa Both eyes open: Hirschberg angle Cover test Extraocular motility l Auditory-visual stimulus Extraocular motility Pursuits l Visual, non-auditive stimulus Convergence 10 pd Base-Up Test l l l l Requires binocular attention BU prism eye sees image displaced down, the second eye sees a normal image If both images are clear, eyes switch from one to the other If one image is blurry, both eyes will look to the clear image 10 pd BU Test Confrontation (Visual Field) l Use noisy stimulus to catch central attention l Use interesting peripheral stimulus (eg puppet) l Wait patiently for a response! Confrontation Bruckner Test Bruckner Test l Symmetry, brightness, clarity between eyes l Subjective measure of visual acuity, deviation, refractive error Bruckner’s Test https://youtu.be/jBjMleVwxpE Pupillary reflexes External Eye Exam l l Transilluminator 20 D lens or magnifier Mohindra’s Refraction l l l l l Monocular 50 cm distance Introduce lenses to neutralize Decrease by 1.25 D Use lens bar Mohindra’s refraction Pearls l l l Normal infants: hyperopic (Mean about 2.00 D) Emmmetropization between 2-5 years-old 5-6 yo leptokurtic distribution, peak at low hyperopia Anisometropia l Anisometropic kids at risk of amblyopia – Astigmatism > 1.50D - Hyperopic anisometropia > 1 D - Myopic anisometropia > 3 D Prescription l Anisometropia Correct if > 1D with acuity reduction – Hyperopic anisometropia particularly harmful – Prescription guides l Myopia: – < 1 D generally ignore, only correct symptomatic and > 4 yo – 1 to 3 D: correct if > 3 yo – 3 to 5 D: correct > 1 yo Prescription guide l Hyperopia In general, correct if > 2.50D – School children, correct hyperopias > 1D – Internal eye exam l Monocular ophthalmoscope l DFE l Fixation, pursuits and lack of aversion to occlusion well signs of equal visual acuity Common causes of leukocoria l l l l l l l l Congenital cataracts Persistent primary hyperplastic vitreous Retrolental fibroplasia Tumors: retinoblastoma Coat’s disease Corioretinal Coloboma Old retinal detachment Intraocular inflammation: Toxoplasmosis Congenital Cataracts Persistent hyperplastic primary vitreous Mittendorf’s Dot can cause leukocoria. Doesn’t change through time Choroidal coloboma Congenital fissure of the choroid, RPE not present, retinal receptors present. Risk of retinal dettachment, strabismus Retinoblastoma Can have a unique origin or multiple origins in the same eye Calcium deposits in retinoblastoma show as radio opacities Retrolental fibroplasia Temporal retinal traction Paton et al - Introduction to ophthalmoscopy Coat’s disease Progressive abnormality of the vessels accompanied by a great number of hard exudates and often hemorraghes. It can be treated by photocoagulation (left). Congenital Toxoplasmosis Scarring due to toxo in the posterior pole. Note pigmentation and atrophy of the pigmentary epithelium. Toxocara canis Traction on retinal vessels Spalton –Atlas de Oftalmologia Clinica, 1984 Macular Granuloma with nematode Larvae passes into blood stream, choroid and retina Severe inflammatory rx… Cataracts and atrophy of optic nerve Infant’s Vision lEarly detection is key lLet’s work together to save vision – and may be life!