Week 13 - Paediatric patients Flashcards
When should children be managed soley by an Optometrist in community:
- Normal VA
- Normal Fundus examination
- Normal binocular status
• Fully accommodative esotropia
• Anisometropia with Normal VA (under age 8)
• Anisometropia, strabismus and amblyopia following discharge from HES
• Anisometropia with amblyopia in children over age 8
• Cosmetically acceptable strabismus with amblyopia over age 8
• Minor eye conditions within your area of competence and confidence
When might children be managed solely in HES
• Amblyopia and are under age 8
• Strabismic and need surgery or botox I
• Congenital ocular anomalies
- Ocular disease requiring treatment/monitoring beyond the scope of optometric practice - e.g. vernal keratoconjunctivitis, rare congenitial conditions
- Which require surgery e.g. congenital cataract
- Which require amblyopia therapy e.g. optic disc hypoplasia, congenital cataract, albinism
• If they have additional support needs - may attend HES / a specialist service (e.g. in Glasgow in one of the Child Development Centres, or GCU additional needs clinic)
When they may be co-managed with an orthoptist in the hospital and an optometrist in practice.
• In some areas all children being seen at HES are co-managed with community optometrists
• If VA at visual screening is borderline. 0.1 to 0.2 LogMar
• If patient is receiving amblyopia treatment and there is not optometric capacity available at the hospital
Responsibilities when co-managing with an orthoptist
- Cycloplegic refraction - with the appropriate cycloplegic agent
- Ocular examination - using an appropriate technique
- Other tests you deem appropriate
• If patient is discharged from HES they ARE NOT under the care of HES anymore and duty of care lies with you - You need a full GOS test and are your clinical responsibility
Responsibilities when testing children under GOS: Supplementary eye exam
• 2.0 Cycloplegic Refraction
- For when you have carried out a GOS exam and deem a cycloplegic refraction to be clinically appropriate
• 2.1 Paediatric Review within 12 months
- Used for children who require follow up following a primary exam
~ Amblyopia
~ Binocular Vision Anomaly
~ Reduced Stereopsis
- Including appropriate follow up tests
Responsibilities when testing children under GOS: Enhanced supplementary eye exam
• 4.1 - Paediatric Review (with dilation/cycloplegia that does not follow a primary eye examination)
- This code is to be used to review a child within 12 months of a primary eye examination, as judged clinically necessary, and dilation/ cycloplegia is required.
• 4.6 - Enhanced supplementary Sight test for patient under age 16 referred from the hospital eye service
- Referred for a cycloplegic refraction and internal and external examination
Full paed assessment:
• Relevant History and symptoms
• Vision
• Binocular status
• Pupil Reflexes
• Ocular Motility
• Refraction
• VA
• Ocular examination
• Visual Fields
• Other tests you feel are appropriate
Differences needed for a paediatric H and S
• How are they managing at school at home? Any tasks they struggle with? e.g. smartboard at school, reading at home?
• Ask about birth history
• History of strabismus/amblyopia/refractive error
• Medical History
- Down’s syndrome, Marfan’s syndrome
- Did they reach developmental milestones at correct age e.g. crawling, smiling, walking and talking
• Family ocular/medical history
• Allergies?
Measuring Vision:
• Age 1 - 3years Cardiff Cards
• 2 - 4 years Kay’s Picture test Crowded LogMar
• 3-4 - 8-10years Keeler Crowded LogMar letter test or Sonksen Crowded LogMar test
• Thomson test chart has crowded LogMar chart and a crowded Kays picture chart - make up your own identification chart and laminate it!
Kays Pictures
Normative values for children under 4 years of age are:
• Uniocular acuities of 0.100 LogMAR (6/7.5 Snellen) or better with an intraocular difference of no more than 0.050 LogMAR (two pictures).
Normative values for children aged 4+ years are:
• Uniocular acuities of 0.050 LogMAR ( 6/6-2 Snellen) or better, with an intraocular difference of no more than 0.025 LogMAR (one picture).
• If either eye is 0.200 or less then referral should be considered
• An intraocular difference of 0.100 may be indicative of mild amblyopia,
• An intracular difference of 0.200 should warrant referral
Tests for children Binocular vision status:
• Appropriate test very much dependent on patient age and cooperation Ideally
- Cover test with and without Rx - try using your hand instead of the occluder for young children
- Ocular motility - may have to ask mum to hold their head and you shine a light peripherally and check if corneal reflexes are symmetrical
- Stereopsis - chose an appropriate test and know what normal and abnormal values are for that test - beware of TNO
• Other tests which may be useful if cooperation is poor or attention is limited
- Check corneal reflexes - 1mm deviation of corneal reflex = 10^ deviation
- Objection to occlusion
- 20 A base out test
Management of Common Binocular Vision Disorders
• If under age 8 and you detect a strabismus which is not fully accommodative and has not been seen at ophthalmology before refer
• If patient over age 8 or has been discharged from HES you may manage in the community
• Refer if amblyopia suspected and within visual plasticity period
- e.g. a decrease of 0.2 LogMar compared to age matched normal, or an interocular difference of 0.2
- e.g. over age 4-5 refer if VA worse than 0.2 LogMar either eye
• Nystagmus which has not previously been investigated refer to ophthalmology to ensure no pathological cause
Refraction on child:
• Cycloplegic or non-cycloplegic refraction
• Mohindra’s technique
• Cycloplegia required
- First visit to your practice
- All children under age 8
- Under age 8 with significant refractive error
- Suspicion of latent hyperopia at any age
- Reduced VA
- All children with evidence of strabismus - even if VA appears normal
• Cycloplegia may not be required
- Children age 6-8 who have had a cycloplegic refraction in the past and are cooperative i.e. can answer questions during subjective refraction well
- Older children
- Myopia over age 8
Prior to cycloplegic refraction
• Give patient information leaflet to parents
• Discuss effects of the drops and how long the effects will last and potential side effects
• Obtain parental consent (often this is now written consent) prior to administering the drops
Drug used for refraction of paed + contraindications
• Cycloplegia
- Cyclopentalate 0.5% for under age 1
- Cyclopentalate 1% for age 1-8
- 0.5% can be used in older children age 12/13…. If light irises
- If poor VA, patient has very dark irides and insufficent cycloplegia with 1% then refer to HES for atropine refraction
- No published evidence that 2x1% cyclopentalate leads to more effective cycloplegia than 1%
• Contraindications
- Children with Down’s syndrome - high proportion of heart defects
- Children with congenital heart problems
Helpful tips on cycloplegic refraction in children:
• Bracket!!!!!
• Speed is of the essence
• Don’t worry about distance fixation too much - they should have little residual accommodation if cycloplegia has worked well
• Make sure you are on axis
• Make it into a game - have mum holding a toy near your head to keep their fixation
• Be as accurate as possible - but sometimes you have to prescribe your best estimate based on bracketing
When to prescribe for paed:
• VA reduced
• Significant Refractive error
• Strabismus and significant refractive error present
• Amblyopia and significant refractive error
• If you find significant refractive error and you need to refer for strabismus and or amblyopia prescribe full plus Rx prior to referral to improve the visual outcome
Normal levels of hyperopia in infants?
- 3 months = +2.16 ÷ 1.30 D (mean + sd)
- 1 year = +1.46 ‡ 1.01D (mean + sd)
• Be very cautious about prescribing spectacles below age 1 as emmetropisation is taking place - Balance up the need for a clear image to aid normal visual development with the possibility of disrupting emmetropisation
- The kinds of prescriptions which should be prescribed for are:
: highly hyperopic infants e.g. +8.00 to +10.00,
: infants with infantile esotropia and a hyperopic Rx
: highly myopic infants -5.00 plus (under correct by 2D as emmetropisation can occu myopes)
What is Significant Refractive error based on age?
• Age 2-5
- Prescribe for hyperopia ≥ +3.50DS if assymptomatic
- Prescribe for myopia >-2.00D (reduce by 0.50-1.00D until school age)
- Prescribe for astigmatism ≥ 1.50DC
• Age 5 plus
- Hyperopia > +1.50DS
- Myopia > -0.50DS prescribe full correction if improves VA
- Prescribe for astigmatism ≥ 0.75DC
• Anisometropia
- ≥1.00D if aged 1-8 and anisometropia is presistent after 4-6 months
Ocular examination:
• Use the best techniques available.
• Ideally slit lamp assessment of anterior chamber on older children - especially if you suspect a problem, kids can stand or kneel!
• Ophthalmoscopy assessment of anterior segment in younger children… if possible
• Posterior segment
- Headmounted binocular indirect with a 20 or 30D Volk lens gives the best stereoscopic view on young children
- Can also use direct opthalmoscope with 20D lens
- Direct ophthalmoscopy, if no 20 or 30D and too small for conventional slit lamp bio
- Slit lamp bio for older kids
Ocular exam: 20D vs 30D
- 20D smaller field and more magnified image than 30D
- 20D great for children with better concentration but still not able to sit at a slit lamp
- 30D great for babies and children with poor concentration
