Paediatrics - Optometric Examination Flashcards

1
Q

When should children be managed solely by optom in community?

A
  1. Normal VA
  2. Normal fundus examination (and clear media)
  3. Normal binocular status
    * Fully accomm esotropia – give full cyclo Rx and VA is equal then can keep in community
    * Anisometropia with normal VA (<age8)
    * Anisometropia, strabismus and amblyopia following discharge from HES – could be nearer the end of their plasticity period or they’ve met their full quota for patching
    * Anisometropia with amblyopia in children >age8
    * Cosmetically acceptable strabismus with amblyopia >age 8 – e.g. v small esotropia
    * Minor eye conditions within your area of competence and confidence
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1
Q

When would children be managed solely by HES?

A
  • If they have amblyopia and are under age 8
  • If they have strabismus and need surgery or botox
  • If they have congenital ocular anomalies
    o Ocular disease requiring tx/monitoring beyond scope of optometric practice – e.g. vernal keratoconjunctivitis, rare congenital conditions e.g. Stargardt’s
    o Which require surgery e.g. congenital cataract
    o 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 ASN clinic)  in some settings it may be expected that child with ASN is seen in community e.g. rural areas
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2
Q

When would children be co-managed with orthoptist & optom?

A
  • In some areas all children being seen at HES are co-managed with community optoms
  • If VA at visual screening is borderline – 0.1 to 0.2 logMAR
  • If px is receiving amblyopia tx (& deemed not at risk) & there is not optometric capacity available at the hospital
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3
Q

What are your responsibilities when co-managing with orthoptist?

A
  • You are responsible for carrying out the procedures required and stated on the proforma. The procedures required usually include:
    o Cycloplegic refraction – with the appropriate cycloplegic agent
    o Ocular examination – using an appropriate technique
    o Other tests you deem appropriate – e.g. male child then check colour vision
  • If patient is discharged from HES they ARE NOT under the care of HES anymore and duty of care lies with you
    o You need a full GOS test and are your clinical responsibility
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4
Q

What are your responsibilities when testing children under GOS?

A
  • Supplementary Eye Exam:
    o 2.0 Cycloplegic Refraction
     For when you have carried out a GOS exam and deem a cycloplegic refraction to be clinically appropriate
     Can claim 2.0 on top of a primary
    o 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
  • Enhanced Supplementary Eye Exam:
    o 4.1 Paediatric Review (with dilation/cycloplegic 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
     E.g. if think px may cooperate better 2nd time round
    o 4.6 Enhanced supplementary Sight test for patient under age 16 referred from the hospital eye service
     Referred for a cycloplegic refraction & internal and external examination
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5
Q

What should be included in an eye examination in children?

A
  • Relevant history and symptoms
  • Vision
  • Binocular status
  • Pupil reflexes
  • Ocular motility
  • Refraction
  • VA
  • Ocular examination
  • Visual fields
  • Other tests you feel are appropriate
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6
Q

What would ensure you ask in a paediatric H&S?

A
  • Make sure to involve the child in the conversation
  • 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 – preterm babies, complications at birth
  • History of strabismus/amblyopia/refractive error
    o 1st degree relatives most important
  • Medical history:
    o Be more general than you would with an adult
    o Look out for systemic conditions which increase risk of strabismus/refractive error/amblyopia/ocular associations
     Down’s syndrome, Marfan’s syndrome (skeletal changes (elongation of limbs & digits), displacement of lens of eye, tendency to develop aneurysms especially of aorta) – associated increased risk of strabismus/amblyopia/refractive error
    o Did they reach developmental milestones at correct age e.g. crawling, smiling, walking & talking
     If no delays then would expect vision to be normal
     If there were delays then likely vision will be delayed too
  • Family ocular/medical history:
    o Less concerned about a grandparents cataracts or mum having HBP and more concerned about hereditary conditions occurring in childhood e.g. type 1 diabetes, atopy
  • Allergies – not all allergies may not be discovered yet
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7
Q

How would you measure vision in a child?

A
  • Your test will depend on the patients age and ability (and what you have available) – can start based on age then refine once know their ability
  • Rough guide:
    o Age 1-3yrs Cardiff Cards
    o 2-4 yrs Kay’s Picture test Crowded logMAR
    o 3-4 – 8-10yrs Keeler Crowded logMAR letter test or Sonsken Crowded logMAR test
    o Thomson test chart has crowded logMAR chart and a crowded Kays picture chart – make up your own identification chart & laminate it
  • If don’t have a crowded letter test then Single Kay’s pictures or Sheridan Gardiner will do but v poor at picking up mild/moderate amblyopia – so be aware

e.g. 12-18mth old – normal VA with Cardiff Cards 6/12—6/48 binocularly and 6/15-6/48 monocularly.
Key thing with Cardiff Cards is to look for intraocular differences – if larger difference intraocularly then that should ring alarm bells for amblyopia.

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8
Q

Describe Kays Pictures vision test?

A
  • Normative values for children under 4 years of age are:
    o 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 and five years are:
    o 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).
  • Generally in Scotland 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 intraocular difference of 0.200 should warrant referral
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9
Q

Describe Crowded logMAR vision test?

A
  • From 5th to 95th percentile (where 90% of children with no known ocular pathology or amblyopia would fall in terms of VA)
    o E.g. 3 year old – lowest 5th percentile (poorest VA you would expect in that age) is 0.37
     The 95th percentile (best VA) typically recorded in that age group is -0.05
     If child sits somewhere within that barrier then can say probably their VA is normal at that age
    o As child gets older it starts to level out
    o Key when trying to determine the cut off for normal VA or not
  • 0.200 chosen for the cutoff to refer to HES – 0.200 in either eye
    o Lowest percentile at 4yrs sits at 0.200
     So would expect in children that age with no ocular pathology, no amblyopia, no refractive error – would have VA of better than 0.200 at that age
     Need referred with lower than 0.200 to determine if there is something else going on
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10
Q

How would you asses the BV status in a child & why?

A
  • If don’t accurately assess BV status or miss something then can lead to long-term amblyopia
  • Appropriate test very much dependent on patient age and cooperation
  • Ideally:
    o Cover test with and without Rx – try using your hand instead of the occluder for young children
    o Ocular motility – may have to ask mum to hold their head and you shine a light peripherally and check if corneal reflexes are symmetrical
    o 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
    o Check corneal reflexes - 1mm deviation of corneal reflex = 10∆ deviation
    o Objection to occlusion – can determine if there is dense amblyopia/pathology/high refractive error present
    o 20 ∆ base out test:
     A: eye’s well aligned with good fusional convergence to a near target
     B: exophoria is induced by introducing base out prism, patient initially fixates with left eye causing a version movement in the right eye thus placing the fovea of the left eye on the image
     C: due to herings law of equal innervation the right eye then and the image is on the right fovea
     D: the patient once again fuses
     If this does not happen it indicates amblyopia, and or strabismus or microstrabismus, they should look at your pentorch
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11
Q

What is the management of common BV disorders in children?

A
  • If under age 8 and you detect a strabismus which is not fully accommodative and has not been seen at ophthalmology before refer to ophthalmology
  • 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:
    o e.g. a decrease of 0.2 LogMar compared to age matched normal, or an interocular difference of 0.2
    o 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
    o Oscillopsia indicates recent onset nystagmus
    o Oscillopsia consider urgent referral, absence of oscillopsia routine referral
    o Oscillopsia: illusion of unstable vision, made up of perception of to-and-fro movement of environment
  • Refer if dense amblyopia or cosmetically unacceptable even if over age 8
  • If older children and no oscillopsia then the referral so
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12
Q

Describe pupil reflexes and ocular motility in children?

A
  • Same as adults, kids tend to be fine for this as interested in the light, don’t worry if they fixate on your pen torch
  • Do both pupils react equally? Any abnormalities?
  • Ocular Motility – pay attention to corneal reflexes as patient may not be able to tell you if they get diplopia
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13
Q

Describe refraction in a child?

A
  • Cycloplegic or non-cycloplegic refraction
  • Mohindra’s technique
  • Cycloplegia required
    o First visit to your practice
    o All children under age 8
    o Under age 8 with significant refractive error – on annual basis
    o Suspicion of latent hyperopia at any age – not only for paediatric pxs – e.g. university students that are doing more studying
    o Reduced VA
    o All children with evidence of strabismus – even if VA appears normal
  • Cycloplegia may not be required
    o 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
    o Older children
    o Myopia over age 8 – won’t be able to hide myopia in same way hyperope can
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14
Q

What do you need to do prior to cycloplegic refraction in a child?

A
  • Give px info leaflet to parents
  • Discuss effects of the drops and how long the effects will last and potential side effects
    o Takes around 30minutes to work
    o Effects can last up to 36hrs in blue eyed children – and often 24hrs in most children
  • Obtain parental consent (often this is now written consent) prior to administering the drops
  • If doing cyclo on older child or adult – MUST ensure they are not going to be doing any hazardous activities later in the day e.g. cycling or operating heavy machinery
  • If child going back to school that day – ensure teacher knows that their near vision will be out of use for the rest of the day
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15
Q

Which type of cycloplegia is required in children and what are the contraindications?

A
  • Cycloplegia:
    o Cyclopentolate 0.5% for under age 1
    o Cyclopentolate 1% for age 1-8 – keen to do this in darker irises
    o 0.5% can be used in older children age 12/13 - & if light irises
    o If poor VA, patient has very dark irises and insufficient cycloplegia with 1% then refer to HES for atropine refraction – try 2 drops of 1% (separated by 15mins)
    o No published evidence that 2x1% cyclopentolate leads to more effective cycloplegia than 1%
  • Contraindications
    o Children with Down’s syndrome – high proportion of heart defects – can affect the heart rate – refer to HES for cyclo refraction where there are other medical professionals present were there to be any problems with heart rate
    o Children with congenital heart problems
16
Q

What are helpful tips on completing cycloplegic refraction in children?

A
  • Bracket! – start with big steps
  • Speed is of the essence – don’t refine 0.25DC if other eye hasn’t been done yet
  • Don’t worry about distance fixation too much – they should have little residual accomm if cycloplegia has worked well
  • Make sure you are on axis – otherwise will get excess cyl
  • 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
    o e.g. you may find +6.00 but child not v cooperative so prescribe that and bring them back when they cooperate more and find +1.00 cyl present too – better that they were +1.00DC under corrected than +6.00DS
  • If child’s rx is found at the hospital to be +6.75/+1.00 & you find roughly +6.00D - give it! It will help their visual development much better than nothing
17
Q

When should you prescribe in a child?

A
  • VA reduced
  • Significant refractive error
  • Strabismus and significant refractive error present
  • Amblyopia and significant refractive error
  • If find significant refractive error & you need to refer for strabismus and or amblyopia prescribe full plus Rx prior to referral to improve the visual outcome:
    o RX always given for 3 months prior to commencing patching now so if they are on the waiting list for 3 months and you have given an accurate rx they may start patching at first HES visit!
    o PEDIG study showed that 16-18 weeks of refractive correction alone even in strabismic amblyopia prior to commencing occlusion therapy led to the best visual outcomes in children aged 3-6
    o Correction of refractive error for 18 weeks can improve visual acuity in the amblyopic eye by two or more lines in at least two-thirds of children 3 to 7 years old who have untreated anisometropic amblyopia.
    o Correction of refractive error for 18 weeks can improve visual acuity in the amblyopic eye by two or more lines in at least two-thirds of children 3 to 7 years old who have untreated anisometropic amblyopia.
    o Helps the orthoptist and gets them treated at earliest possible stage
18
Q

What is a significant refractive error (children)?

A
  • Normal levels of hyperopia in infants
    o 3 months = +2.16 ± 1.30 D (mean ± sd) – +1.50-3.50DS (anywhere within that bracket don’t prescribe in 3mths old)
    o 1 year = +1.46 ± 1.01D (mean ± sd) – could have +2.50DS and be normal
  • Be very cautious about prescribing spectacles below age 1 as emmetropisation is taking place – if they are +10 then you would prescribe it but otherwise speak to orthoptist
    o Balance up the need for a clear image to aid normal visual development with the possibility of disrupting emmetropisation
    o 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 occur in myopes)
  • Age 2-5
    o Prescribe for hyperopia ≥ +3.50DS if asymptomatic
    o Prescribe for myopia >-2.00DS (reduce by 0.50-1.00D until school age) – to prevent growth of eye
    o Prescribe for astigmatism ≥ 1.50DC
  • Age 5 plus
    o Hyperopia > +1.50DS
    o Myopia > -0.50DS prescribe full correction if improves VA
    o Prescribe for astigmatism ≥ 0.75DC
  • Anisometropia
    o ≥1.00D if aged 1-8 and anisometropia is persistent after 4-6 months
19
Q

Describe the ocular examination in a child?

A
  • 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 – may instil NaFl and use blue light
  • Posterior segment
    o Head mounted binocular indirect with a 20 or 30D Volk lens gives the best stereoscopic view on young children
    o Can also use direct ophthalmoscope with 20D lens
    o Direct ophthalmoscopy, if no 20 or 30D and too small for conventional slit lamp bio
    o Slit lamp bio for older kids
  • 20D vs 30D & head-mounted indirect:
    o 20D smaller field and more magnified image than 30D
    o 20D great for children with better concentration but still not able to sit at a slit lamp – more cooperative child can ask them to move eye around to see more
    o 30D great for babies and children with poor concentration – wide FoV but lower mag
20
Q

Describe visual fields testing in children?

A

Part of the GOS contract
* Strategy dependent on px age
* Saccadic Vector Optokinetic Perimetry – ideal for children but not widely available – px fixates a target then other target appears and they need to look at that for next target to appear and maps VF that way
* Face outline for babies, toddlers, ideally monocular but may need to be binocular
* Confrontation for children age 4-8/10 – ask how many fingers seen each quadrant, monocular
* Standard automated perimetry for children age 8-10+, e.g. Humphrey C40

21
Q

What are other tests that should be considered when testing a child?

A
  • Colour vision – can affect future career choices – more common in boys than girls
  • Fundus photography
  • OCT – older child usually
  • Pentacam – useful in children you suspect keratoconus
  • Tonometry – not used often in children but may be used on teenager who is getting headaches
22
Q

What are some considerations to make when testing children?

A
  • Review for paediatric patients may need to be more frequent if monitoring VA due to the visual plasticity period – especially if giving glasses
  • All children under 16 need to have their glasses fitted by a qualified optometrist or dispensing optician – during pre-reg will need you supervisor to supervise these fits
  • Make sure your advice to the parents properly explains what they need to do and THE IMPORTANCE OF COMPLIANCE – px needs to understand the effect of non-compliance, can lead to permanent vision problem in an eye for e.g.