1. Optometric examination of children Flashcards
(156 cards)
1
Q
What are the key stages in a paediatric eye test:
A
*History ( to child, parent or parent only depending on age of px )
*Visual function (Vision & Visual Acuities and if needed contrast sensitivity depending on age of child)
*Refraction - objective refraction i.e retinoscopy under cycloplegia and subjective refraction but depends on the age of the child
*Binocular vision status – cover test, ocular motility
*Colour Vision (if appropriate)
*Anterior segment and Fundus examination
2
Q
What comes under binocular vision status children tests for children:
A
*Ocular motility
*Cover test
3
Q
Examining infants and children:
A
Observe child in the waiting area….
*Do you notice a squint for example
*Is the child wearing glasses - myopic or hyperopic
*Are they looking through/over their glasses
*Are they wearing an eye patch
4
Q
What could child with high hyperopic rx have:
A
ESOT
5
Q
What could child wearing patch indicate:
A
That they’re amblyopic
6
Q
History taking in paediatrics dos and donts:
A
*Your observation should continue into the examining room
*Tailor history according to child’ age
*Introduce yourself to parent and child
*Talk to the child (if appropriate) not the parents, this may mean that you have to come to the child’s eye level!
*Use the child’s name frequently
*Always praise the child, don’t criticise
*Good to have a selection of toys and ensure the practice is child friendly
- Might have to call child in another day to complete tests because child lost attention and didnt complete all tests
7
Q
What to include in history for paediatrics
A
*Establish why the child has come for an eye test?
*If they (parents/carers) are worried what is it they are specifically worried about
*When did the worries begin, frequency, duration, triggering factors, are they getting worse?
*Past ocular history
*Family history
*Birth history
*Normal milestones
*Medical history
*Medications
*Allergies
8
Q
Examples of reasons for child coming in to eye test:
A
*Routine if FH of squint and want childs eye tested not noticed anything abnormal
*Problem e.g. failed vision screening at school
*Or parent noticed child cant see well DV
*Baby not making eye contact or copying facial expressions
*Child close to TV
9
Q
Example of squint as worry:
A
*Did they notice it from birth
*Do eyes squint all the time or occasionally
*Cause of squint
*Association – any time it gets worse
10
Q
What could child have if parent says they have esotropia i.e eye squinting inwards:
A
Pseudostrabismus
11
Q
What does it mean if close family member has squint or high refractive error:
A
Child could have it too high chance
12
Q
What could child have if parent says they have EXOT
A
Exotropia
13
Q
Examples of past ocular history child eye test:
A
*Patching
*Squint
*Amblyopia
*Hospital visits
*Surgery
14
Q
Examples of family history child eye test:
A
*Patching
*Squint
*Amblyopia
*Hospital visits
15
Q
Examples of birth history child eye test:
A
*Pre-term
*Full term
*Birth weight
*Type of delivery
*Maternal illness during pregnancy
16
Q
What is full term baby associated with:
A
Refractive errors and other eye conditions
17
Q
What can happen in forceps delivery:
A
Corneal tear
18
Q
Examples of key developmental milestones for infant to 1 year old:
A
*Able to drink from a cup
*Able to sit alone, without support
*Babbles
*Displays social smile
*Gets first tooth
*Plays peek-a-boo
*Pulls self to standing position
*Walk at right time
*Rolls over by self
*Says mama and dada, using terms appropriately
*Understands “NO” and will stop activity in response
*Walks while holding on to furniture or other support
19
Q
Important milestones newborn to 3 year olds:
A
*Understand several short words- 1 year
*Imitate sounds- 1 year
*Speak 20 words or more- 1.5 years
*Use short sentences- 2 years
*Know name and gender- 3 years
*Understand abstract words- 5 years
*Touch object with forefinger- 10 months
*Begin to knows colours- 3 years
20
Q
Visual development - what acuity can children see:
A
*Birth: VA of 6/120, focus at 25cm, responds to stimuli
*2 months: stable eye contact
*3 months: focus at 20-40cm; fixes/follows/looks for objects
*5 months: eyes straight, watch and copy hand movements
*9 months: recognise faces
*3 years visual acuity 6/12
*4 years visual acuity 6/9
*5 years visual acuity 6/6
21
Q
Types of visual acuity testing:
A
*Electrophysiological testing = objective method of measuring VA
*Behavioural testing = subjective method of measuring VA i.e depends on response of child
22
Q
What is electrophysiological testing
A
Objective method of measuring VA
23
Q
What is behavioural testing
A
Subjective method of measuring VA
24
Q
Is visual acuity testing in children binocular or monocular
A
*Monocularly
*Cause will have different VA in each eye and if you measure VA binocularly, you cant pick that up
25
How else can you test VA in child:
*Observe behaviour when child occluded
*So occlude one of childs eye and see if child is happy with that
*Usually from 3 months
*Child will object to ‘good’ eye being covered
*If child objecting it means you are covering their only eye with good vision
26
What age can you start testing child VA
From 3 months
27
What condition can you only do monocular testing:
Amblyopia
28
Types of electrophysiological testing:
*Flash VEP stimulus- from birth
*Pattern VEP stimulus
29
When would you use electrophysiological testing:
*In hospitals
*When you cant get a reading of what child can see
30
What does flash VEP involve:
Sitting child in front of screen or bowl and show them flashing light
31
What does pattern VEP involve:
Show them pattern – checkerboard which keeps flashing or moving
32
What does electrophysiological testing involve:
*Looking at signals that go to brain from these patterns
*So when child is looking at flashing light or checkerboard pattern, there are visual signals going to the occipital cortex
*And the flash VEP can look at those signals
*So there are electrodes placed over occipital cortex on head
*And can see latency of responses and whether responses are delayed
*Child doesn’t have good VA if delayed
33
What does it mean if responses of electrophysiological testing are delayed:
Child doesn’t have good VA if delayed
34
Why wouldnt you generally use electrophysiological testing
Because need instrument and dont have that in clinics
35
What method of measuring va is used in clinics
Preferential looking test
36
What sort of test is preferential looking:
*Behavioural test
*Resolution test
37
What does preferential looking test measure:
*Ability to detect and resolve a target ( use black and white target )
*Infants would prefer to look at a pattern than a blank stimulus’
*Ability to discriminate different spatial frequencies (or other metrics)
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What kind of target does preferential looking test use:
Black and white target
39
How does preferential looking test work:
*‘Infants would prefer to look at a pattern than a blank stimulus’
*Ability to discriminate different spatial frequencies (or other metrics)
*Ability to detect and resolve a target ( use black and white target )
*Behavioural and resolution test
*1 black and 1 white line = 1 cycle
*How many black and white lines in 1cm
*Usually black and white target
*Measure how many cycles you get per cm and convert how many cycles you get per degree – depends on distance your sitting from test
*Need to make sure pattern is Iso-illuminant stimuli i.e pattern has same luminance as grey blob
40
What is important in preferential looking test:
Need to make sure pattern is Iso-illuminant stimuli i.e pattern has same luminance as grey blob
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What is 1 cycle:
1 black and 1 white line
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What is meant by iso illuminant stimuli:
Pattern has same luminance as grey blob
43
Which px's is preferential looking not good for:
*Less sensitive to amblyopic defects especially in strabismus
*Because it’s a resolution test and resolution tests are easier to do
44
What is spatial frequency and what is it measured in:
Black and white line measured in cycles/degree
45
What does narrower stripes mean:
Higher spatial frequency = harder to see
46
What does wider stripes mean:
Lower spatial frequency = easier to see
47
How do you obtain result for preferential looking test:
Measure how many cycles you get per cm and convert how many cycles you get per degree – depends on distance your sitting from test
48
What age do you do preferential looking VA:
0 - 24 months
49
Examples of preferential looking tests:
*Teller Acuity Cards
*Keeler acuity cards (City Sight)
*Lea Grating paddles
*Cardiff acuity cards (Vanishing optotypes) (City Sight)
*Peekaboo App
50
Keeler acuity cards:
*Working Distance: 38cm
*Usually 15 cards with black-&-white stripes on right or left side, 1 blank card
*4mm hole in centre
*Range 0.32 to 38 cycles per degree
*Usually start with low spatial frequency/poor VA i.e broader black and white stripes and move in 1 or half octave steps up (if correct response or down if incorrect response) i.e 1 card or jump a card
*If child doing well and responses are quick then can skip cards
*Correctly identifies the same stimulus twice means the child can resolve that card
*Clinically significant interocular difference: Greater than/equal 2 cards
51
Range of VA for keeler acuity cards:
0.32 to 38 cycles per degree
52
How do you know child can resolve card in keeler acuity:
Correctly identifies the same stimulus twice means the child can resolve that card
53
Summary of keeler acuity cards method:
*Look through hole
*Present card to px
*Trying to see if px is looking at stripes or not
54
Working distance for keeler acuity cards:
38cm
55
Example of keeler acuity cards method:
-If started with 6/60 card and child doing well then can go to 6/24 or 6/18 card
-If child not doing so well or responses not so clear, might want to go from 6/60 to 6/36
56
What should VA be in each eye:
Similar e.g. if 6/6 in one eye then want 6/6 in other eye OR can have slight difference
57
What difference in VA is not good in keeler acuity cards:
Clinically significant interocular difference: Greater than/equal 2 cards
58
Cardiff acuity cards:
*Vanishing optotypes
*Also used in special needs patients – stroke, dementia
*Pictures (duck, house, fish, car, train, boat dog) at top or bottom
*No crowding – if present letter, theres nothing surrounding that letter but if line of letters or letter in box = crowding
*If someone has amblyopic defect, if show them non crowded target, they may still be able to read 6/9 but if crowded, 6/36
*May overestimate VA if have a test that measures non crowded VA
59
What sort of test are cardiff acuity cards
- Vanishing optotypes
- Pictures (duck, house, fish, car, train, boat dog) at top or bottom
60
What type of pxs are Cardiff acuity cards used in:
Special needs pxs e.g. stroke, dementia
61
How are Cardiff acuity cards different for someone who is ablyopic:
If someone has amblyopic defect, if show them non crowded target, they may still be able to read 6/9 but if crowded, 6/36
62
What is bad about test with non crowded VA:
May overestimate VA if have a test that measures non crowded VA
63
Crowding vs non crowding:
No crowding – if present letter, theres nothing surrounding that letter but if line of letters or letter in box = crowding
64
Method of cardiff acuity cards:
*50cm or 1m depending on age
*3 cards for each of the 11 acuity levels
*Present cards at eye level and watch eye movements
*Start with card with widest target (lowest acuity level)
*Observe eye movements
*Masked to tester
*2 out of 3 responses correct – go to next lower acuity
*Clinically significant interocular difference: Greater than 2 cards
65
Which VA range to use in cardiff acuity cards:
*1.0- 0.1 LogMAR using at 1m (older children)
*1.3-0.5 LogMAR using at 50cm (younger children)
66
Working distance for cardiff acuity cards:
50cm or 1m depending on age
67
What difference in VA is not good in cardiff acuity cards:
Clinically significant interocular difference: Greater than 2 cards
68
Normal values for cardiff acuity cards:
69
Peekaboo App:
*2 forced choice or 4 forced choice
*Free Ipad App
*Touching the right grating pattern results in a yippee sound and a cartoon appearing, positive feedback, four or two choices
*Results comparable to Keeler
*Get px to touch screen
*Working distance 25 – 50cm
*VA measured 0.2-1.3 LogMAR
*
70
What sort of test is peekaboo app:
Preferential looking test
71
Working distance for peekaboo app:
*25 - 50 cm
*Can change it
72
What VA is measure for peekaboo app:
VA measured 0.2-1.3 LogMAR
73
What age can you do peekaboo app:
10 months
74
What age if preferential looking tests for:
Up to age of 2
75
How to test VA for older children 2 years and above:
*Recognition acuity tests: Ability to detect, resolve and recognise a target
*2 years: usually use picture matching
*3 years: can use picture and or letter matching
*Greater than 3 years can consider naming pictures or letters
*Matching cards can be supplied at home for practice before clinic visit
76
What tests are used for children >2:
Recognition acuity tests
77
Advantage of Recognition acuity tests:
More sensitive to amblyopic defects especially in strabismus and especially if you use crowded targets
78
What is definition of recognition acuity:
Ability to detect, resolve and recognise a target
79
Kay pictures:
*Pictures of common objects known to a child (E.g. duck, house, apple)
*Single pictures or crowding pictures in LogMAR format (3m)
*Single pictures in Snellen format (3 or 6 metres)
*Each line equivalent to 0.1 LogMAR acuity
*Tests also available as an app for iPad
*Clinically significant interocular difference (Crowded) :Greater than 3 pictures (less than 4 years); Greater 1 than picture (above 4 years)
80
What VA is used for kay pictures:
*1.0 – 0.1 LogMAR ( 3m )
*3/3 (6/6) – 3/30 (6/60) (3 or 6m )
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What test distance is kay pictures done:
*Single pictures or crowding in LogMAR format (3m)
*Single pictures in Snellen format (3 or 6 metres)
82
What is each line of VA in kay picyures:
0.1 LogMAR
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What difference in VA is not good in kay pictures:
- Clinically significant interocular difference (Crowded) :
- Greater than 3 pictures (less than 4 years)
- Greater 1 than picture (above 4 years)
84
Lea symbols:
*Same principles as LogMAR test
*Single and Crowded version of letters
*Test distance 3m
*Test symbols: Simple shapes familiar to small children which blur equally: Square, House, Circle and Apple
*If shapes are blurred, child cant distinguish between them cause they all look the same
85
Working distance for lea symbols:
3m
86
What VA is used for lea symbols:
0.10-2.0 LogMAR
87
Letter matching tests - types of tests:
*Sheridan-Gardiner test
*Cambridge Crowded acuity test
*Tumbling E or Landolt’s C could be used - ask child to put finger out where E is pointing
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Sheridan-Gardiner test:
*Single letters 6m, can be performed at closer distances
*Uses flip chart
*No crowding
*Linear letters with crowding available
*6/60-6/4
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Cambridge Crowded acuity test
*Uses Sheridan-Gardiner letters 3m or 6m
*Identify the letter in centre which is surrounded by four others
*Crowding
90
Keeler LogMAR Crowded test
*Flip-chart
*6/38 (0.80) to 6/3 (-0.30)
*3m
*LogMAR principles
*Screening and uncrowded sets also available
*Similar to Sonsken Silver (uses Sherdian Gardener letters) but more crowding as letters closer together
*Clinically significant interocular difference: 0.1 LogMAR; Sonsken Silver is 0.125 LogMAR
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What distance is keeler logMAR crowded test done at:
3m
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What VA's are used for keeler logMAR crowded test:
6/38 (0.80) to 6/3 (-0.30)
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What difference in VA is not good in keeler logMAR crowded test:
Clinically significant interocular difference: 0.1 LogMAR
94
Other methods of testing VA on children:
*Bradford Visual Function Box
*Hundreds and thousands/Visually directed reaching
95
Bradford Visual Function Box test:
*Variety of targets of different sizes: beads, bauble, balls, toys and books
*Useful when none of the other VA tests work
*Observation response to the target e.g. eye movement, head movement
*How child reacts to the target
*Make judgment about their VA
96
Hundreds and thousands/Visually directed reaching test:
*Usually over 6 months
*Small cake decorations (100s & 1000s) held in the palm of the hand
*Nine months: may prod the decorations i.e lift them up, eat them up
*One year: may attempt to pick up.
*VA roughly 6/60 @25 cm
*Rarely used
97
What tests to use on birth to 2 years for VA:
* Keeler Acuity Cards
* Peekaboo App
* Cardiff Cards
= preferential looking
98
What tests to use on 2 - 4 years for VA:
*Picture naming/matching
*Lea symbols
*Kay pictures
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What tests to use on 3 - 5 years for VA:
Letter naming/matching
*Sheridan-Gardiner
*Sonksen-Silver
*Cambridge Crowding Cards
*Keeler LogMAR acuity cards
*Landolt C/Tumbling E
*Can also use picture naming and matching so Kay pictures and Lea symbols
*Remember crowded cards better
*Above 5 years regular charts
100
When to use regular charts
>5 years
101
How to measure near vision for 2 years onwards:
*Kay Picture Near Test
*Lea Symbols Near vision
*Reduced Snellen (Landolt’s C/ Tumbling E)
102
What age to measure near vision in child:
2 years and above
103
What is the kay picture near test:
*Age: 2 years onwards
*Working distance: 33cm
*Using k pictures
*Crowded & Uncrowded
*See what child can read
104
What is the lea symbols near vision test:
*Age: 2 years onwards
*Working distance: 40cm
*6/120 – 6/3
105
What age is reduced Snellen (Landolt’s C/ Tumbling E) used for:
2 years onwards
106
What are the two tests to measure contrast sensitivity on children:
*Cardiff Contrast Sensitivity Test
*Hiding Heidi
107
Cardiff Contrast Sensitivity Test:
*Same vanishing optotypes as the Cardiff Acuity
*Three cards at each contrast level from 46% to 1% in twelve steps.
*Testing distance usually 50cm
*Use preferential looking test or matching/naming depending on age
*12 months onwards but probably use from younger
*Get px to point where symbol is or is symbol is up or down if older child
*If younger child, see where they look i.e preferential looking
108
What distance is cardiff contrast sensitivity done at:
50cm
109
What age to use Cardiff Contrast Sensitivity Test:
12 months onwards
110
Hiding Heidi test:
*Five contrast levels: 25%, 10%, 5%, 2.5%, and 1.25%
*Two cards: White and one with ‘Heidi’ – ask px to point to where Heidi is
*Use preferential looking test if 0 months or matching/naming if old
*0 months onwards
*Variable working distance infant/examiner dependent
111
What age to use Hiding Heidi:
0 months onwards
112
Tests on children to test binocular function:
*Cover test
*Hirschberg test
*Extra Ocular Motility
*Motor fusion
*Sensory Fusion
*Near point of convergence
*Stereopsis
*Accommodation
113
What determines which test to use on child:
*Age
*The circumstances
*What want to obtain from eye test
114
Cover test on children:
*Very useful test- Gold standard
*Accommodation needs to be simulated so use an interesting target, e.g. a toy with some detail, sticker etc = can ask questions about the target to stimulate interest
*Can use palm/thumb to occlude child’s eye rather than occluder
115
What is a gold standard binocular function test:
Cover test
116
How can you activate accommodation in cover test:
Use an interesting target, e.g. a toy with some detail, sticker etc = can ask questions about the target
117
What is it common and normal to have on cover test for children:
EXOP at near with rapid recovery
118
Reason for doing cover test or Hirschberg test:
If child has squint or not
119
Hirschberg Test on children:
*Useful if cover test is difficult
*Can flash light on and off to encourage fixation
*Use pen torch and look at corneal reflexes in childs eye at 50cm
*Temporal reflex = esotropia.
*Nasal reflex=exotropia.
*Reflex higher in one eye suggests hypotropia
120
Working distance for Hirschberg Test:
50cm
121
Use of Hirschberg test:
Determine if child has manifest deviation
122
What does temporal and nasal reflex suggest result:
*Temporal reflex = esotropia
*Nasal reflex=exotropia
123
What does it mean if reflex higher in one eye than other and is asymmetrical:
Hypotropia or hyperopia depending on which eye youre looking at
124
EOM test on children:
*Needs interesting target, could use flashing lights, auditory stimulus may be useful.
*In very small children may need to move childs head rather than target as may not understand
125
Motor fusion 20D BO test:
*BO prism is held before either eye in turn LE and RE, both eyes
*Child fixating suitable target.
*Looking for fusional movements
*Eye behind prism should adduct rapidly to restore fusion and abduct again on removal
*Speed of the fusion movement helps establish binocularity
*Start with 20Δ BO then reduce to 15Δ BO to 10Δ BO if slow to overcome
126
Abnormal responses of 20D BO test:
*No movement
*Either no fusion or lack of attention
*Slow to overcome the prism/slow/poor recovery
*Possibly poor fusion
*Prism fusion range (full) can be attempted in school going children
*Normal movements
*Nothing to worry about
127
What to check in 20D BO test:
*What the recovery is and if theyre slow to overcome
*Speed of the fusion movement helps establish binocularity
*Looking for fusional movements
128
What helps establish binocularity in 20D BO test:
Speed of the fusion movement
129
What test can you do on child if they go to school:
Full prism fusion range
130
What age is 20D BO test good for:
Children not at school, young children
131
What should happen to eye in 20D BO test:
*Eye behind prism should adduct rapidly to restore fusion
*And abduct again on removal
132
What to do if no response with 20D BO prism:
Reduce to 15Δ BO to 10Δ BO if slow to overcome
133
What can you measure in older child:
Sensory fusion
134
What test do you use for sensory fusion in children:
*Worth 4 dot test / Worth’s lights
*Bagolini lenses /glasses
135
Worth 4 dot test / Worth’s lights:
*Four lights, usually round but can be different shapes
*2 green
*1 red
*1 white
*View through red and green goggles
*Red filter before RE / green filter before LE
136
What does it mean if px only seeing green light:
RE suppression
137
Why test sensory fusion in children:
*Normal Retinal Correspondence.
*Diplopia (Exotropia and Esotropia)
*Suppression
*ARC
138
Bagolini lenses:
*Put bagolini lenses in front of pxs eyes
*Spot light seen by both eyes
*Striations oriented in different directions for each eye
*Striated lenses positioned at 45 & 135 degrees
*Streaks of light seen separately by either eye
*Show them torchlight
*Torchlight forms streaks
139
What does bagolini lenses test for:
If px has..
*Normal Retinal Correspondence.
*Diplopia (Exotropia and Esotropia)
*Suppression
*ARC
140
Near Point of Convergence in children:
*Gross convergence ability
*Use an interesting accommodative target such as a toy or a sticker
*Move target towards child until one eye turns out/eyes converge till nose
141
What do you see in Near Point of Convergence test:
When one eye diverges or do they continue diverging towards nose
142
What sort of test is Near Point of Convergence in children
*Gross convergence ability
*Objective when on young child
143
Normal values for near point of convergence in children:
*Dependant on age
*Children/ younger adults <6cms
*Older = 10cm
*Break 5cms recovery 7cms
144
Normal value for near point of convergence in adults:
10cm
145
What age can you measure near point convergence:
Should be able to do from about 6 months
146
Measuring stereopsis on children – normal value:
*Based on age & test
*For example 40" of arc for adults > 9 years old
*60" for adults with TNO
147
Examples of stereopsis test to use on children:
*Lang’s two pencil test
*Lang stereo-test- good for young children
*Frisby test
*TNO
*Titmus test
*Randot test
148
Which stereopsis test is good for young children:
Lang stereo-test
149
Lang strereotest:
*Random dot test
*No glasses required
*Lang 1 (cat, car, star)
*At 40 cm: 1200” to 550”
*Lang 2 (elephant, car, star, moon)
*At 40 cm: 600” – 200”
*Good screening test
150
What distance is lang stereotest done:
40cm
151
What sort of test is Lang strereotest:
Good screening test
152
Frisby stereo test:
*No glasses
*4 squares of shapes per sheet
*3 thicknesses of sheet: 6mm, 3mm and 1mm
*Disparity 875” to 20”
* Viewing distance: 30 cm – 80cm
*One square contains a central circle
*Observe behaviour or ask question about circles
*Turn around sheet ask again
*Responses seen in infants as young as 6 months
153
Frisby stereo test screening test:
*2 squares of shapes per sheet instead of 2
*2 sheets
154
What distance is frisby stereotest done:
30 cm – 80cm
155
Frisby stereotest young child:
*Will be preferential looking test
*Responses seen in infants as young as 6 months
*Need to see where child is looking
156
Normal values for frisby test
