Paediatrics - Optometric Examination Flashcards
When should children be managed solely by optom in community?
- Normal VA
- Normal fundus examination (and clear media)
- 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
When would children be managed solely by HES?
- 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
When would children be co-managed with orthoptist & optom?
- 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
What are your responsibilities when co-managing with orthoptist?
- 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
What are your responsibilities when testing children under GOS?
- 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
What should be included in an eye examination in children?
- Relevant history and symptoms
- Vision
- Binocular status
- Pupil reflexes
- Ocular motility
- Refraction
- VA
- Ocular examination
- Visual fields
- Other tests you feel are appropriate
What would ensure you ask in a paediatric H&S?
- 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
How would you measure vision in a child?
- 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.
Describe Kays Pictures vision test?
- 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
Describe Crowded logMAR vision test?
- 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
How would you asses the BV status in a child & why?
- 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
What is the management of common BV disorders in children?
- 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
Describe pupil reflexes and ocular motility in children?
- 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
Describe refraction in a child?
- 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
What do you need to do prior to cycloplegic refraction in a child?
- 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