Clinic Prep: Paediatrics Revision Flashcards

1
Q
When to prescribe for myopia: 
0-1 yo
1-2 yo
2-3 yo
3-4 yo
A

0-1: >/= -5.00D.
1-2: >/= -4.00D
2-3: >/= -3.00D
3-4: >/= -2.50D

Give full correction

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2
Q
When to prescribe for hyperopia (no strabismus): 
0-1 yo
1-2 yo
2-3 yo
3-4 yo
A

0-1: >/= +6.00
1-2: >/= +5.00
2-3: >/= +4.50
3-4: >/= +3.50

Give partial Rx reduced by up to 50%

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3
Q
When to prescribe for hyperopia (with EsoT): 
0-1 yo
1-2 yo
2-3 yo
3-4 yo
A

0-1: >/= +2.00
1-2: >/= +2.00
2-3: >/= +1.50
3-4: >/= +1.50

Give full correction

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4
Q
When to prescribe for astigmatism:
0-1 yo
1-2 yo
2-3 yo
3-4 yo
A

0-1: >/= 3.00
1-2: >/= +2.50
2-3: >/= +2.00
3-4: >/= +1.50

Give full correction

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5
Q
When to prescribe for anisometropia:
0-1 yo
1-2 yo
2-3 yo
3-4 yo
A

0-1: >/= +2.50
1-2: >/= +2.00
2-3: >/= +1.50
3-4: >/= +1.50

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6
Q

Susan Leat’s recommendation for hyperopic patients 4-5yo.

A

Prescribe hyperopia >+2.50, give 1 diopter less than full.

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7
Q

Susan Leat’s recommendation for hyperopic patients 5+ yo/school age

A

Prescribe full correction for hyperopia >1.25 or 1.50

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8
Q

Susan Leat’s recommendation for myopia patients 5+yo

A

Full correction for any myopia

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9
Q

Susan Leat’s recommendation for astigmatism, 15 months - 2 years

A

> 2.50DC, full correction

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10
Q

Susan Leat’s recommendation for astigmatism, >2 years

A

> 1.75DC, full correction

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11
Q

Susan Leat’s recommendation for astigmatism, >4 years

A

> 1.25DC, full correction

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12
Q

Susan Leat’s recommendation for astigmatism, school children

A

> 0.50DC, full correction

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13
Q

Susan Leat’s recommendation for anisometropia, >4 years

A

> 1.00D anisometropia, full.

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14
Q
For symptomatic adult patients, at what magnitudes do optometrists generally prescribe for the following:
Hyperopia
Reading add (presbyopia)
Astigmatism
Horizontal and Vertical heterophoria
A
Hyperopia: +1.00
Near add: +0.75
Astig: +0.75
Horizontal prism: 1.5
Vertical prism: 1
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15
Q

In general, do optometrists correct asymptomatic patients with hyperopic anomalies or heterophorias?

A

No, they do not, if the patient is asymptomatic

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16
Q
List the evidence-based guidelines for amblyogenic factors to be detected by vision screening for the following: 
Hyperopia
Myopia
Astigmatism
Anisometropia
Strabismus
Ptosis
Media opacity
A
Hyperopia: >3.50 in any meridian
Myopia: >3.00 in any meridian
Astigmatism: >1.50 at 90 or 180; 1.0D in oblique
Anisometropia: >1.50 (sph or cyl)
Strabismus: any manifestation
Ptosis: = 1mm margin reflex distance
Media opacity: any opacity >1mm in size
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17
Q

By what age would ambylopia have fully developed? What magnitude of amblyopia should not be ignored?

A

By age 3

Greater than 1.00D should not be ignored

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18
Q

List 8 clinical tests you can perform on a patient under 3 years old

A
Objective cover test (incl HH)
Hirschberg test
Bruckner's
Ocular motility
Fixation + coordination during play
Retinoscopy (dry, wet, near - MEM, Mohindra)
Pupils
Direct ophthalmoscopy/Retinal photos
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19
Q

How can you measure vision in a patient under 2 years?

A

VEP (Visual Evoked Potentials) most reliable. Try a preferential viewing chart/grating or OKN drum (optokinetic nystagmus)

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20
Q

How can you measure vision in a patient between 2-3 years old?

A

Consider matching games, if child is able

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21
Q

How do you perform Mohindra Retinoscopy?

A

@50cm in a dark room. Adjust your finding depending on age by:

  • 0.75 for infants (i.e. subtract 0.75)
  • 1.25 for 2+yo (i.e. subtract 1.25)
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22
Q

When might you perform Mohindra Retinoscopy?

A

As an alternative when you can’t cyloplege (e.g. due to timing, drop accessibility, safety)

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23
Q

List 5 additional tests you can perform on a patient between 3-6 years old

A
As for <3yo, +:
Lea symbols
Colour Vision and Stereopsis
BV (W4dot, prism doubling, phorias by school age)
Accom/Convergence (by school age)
Slit lamp/tonometry (on indication)
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24
Q

How should you perform subjective refraction (on >6 or >8 depending on child)? (2)

A
Start binocularly (to build confidence)
Do a blur function
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25
Q

How do you perform a blur function?

A

Using a trial frame

  1. Add +1 to +1.50 over ret finding binocularly (monoc if asymmetrical vision)
  2. Warn child of blur and will slowly make things clearer
  3. Random chart, child reads a few letters as best as they can
  4. Once they start making errors, reduce plus by 0.25 or 0.50
  5. Keep going until plateau or get maximum plus to 6/6
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26
Q

How do you decide whether to measure phoria in a young child? (4)

A

Make sure they understand the concept of double vision before attempting to measure phoria with Howell prentice card:

  1. Place in vertical prism over RE
  2. Ask child if mum/dad looks funny/different
  3. If child understands that mum has two heads, then you can have a go at measuring phoria
  4. Take it slow to ensure child understands what is being asked of them
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27
Q

What is the general checklist for a paediatric examination? (12)

A

Vision: Binoc first, then monoc lea single presentation first
CT: Interesting targets
NPC: assess ability to converge + break
Excursions: check for head movement
Retinoscopy: dist/near/cyclo/ret lens rack
Stereo: randot lang fly
Colour Vision
Topography/Autorefraction: be patient with child (great objective test esp when VA down)
Refraction: objective, blur function, subjective if mature enough
Oc health: pupils, ophthalmoscopy, SL, photos, IOP
Binocularity: alignment, suppression
Visual efficiency: phoria, ac/a, verg/acc facility, reserves, MEM ret

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28
Q

List the minimum battery of tests for visual efficiency/BV (7)

A
CT (D+N)
NPC/NPA
HH
Phorias
Acc/Verg facility
MEM ret
Stereo
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29
Q
Provide the instructions for assessing:
Posture
Range
Facility
Amp
A

Posture: “measure how well you can focus at near”
Range: “see how close/far you can focus”
Facility: “measure how quickly you can change your focus”
Amp: “how well you can focus”

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30
Q

At what age is 6/6 vision typically achieved?

A

5-6 years of age

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31
Q

How can we measure visual acuity in infants? What would be the equivalent of 6/6 vision?

A

Forced preferential looking, usually involving a large card with gratings
30 cycles/deg is 6/6

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32
Q

What is the mean Rx for a 12 month old? Will this change greatly over time?

A

+0.50DS. Typically minimal change until 8yo, followed by a small myopic shift.

33
Q

At what age are the following systems fully developed:
Stereopsis
Acc/Converge
Eye movements (OKN, saccades, pursuits)

A

Stereo: 4mo?
Acc/Converge: 6mo.
Eye movements: 1 year

34
Q

List 3 red flags for poor vision in child of 0-3 years of age

A

No eye contact (in children >6mo)
Large slow travelling nystagmus
Slow travelling eye movements

*travelling/roving - i.e. moving about/unfixed.

35
Q

List the 6 most common reasons for presentation to a paediatric clinic in descending order

A
Hyperopia (45%)
Accom-Vergence (30%)
Strabismus (30%)
Normal (20%)
Special Needs (16%)
Astigmatism (15%)
36
Q

Normal values for:
NPC
NPA
CT/Phoria

A

NPC Break = 8cm Recovery = 10cm
NPA Avg 18-1/3age or Minimum 15-1/4age
CT/Phoria 3xp +/- 3 @ N, 1xp +/- 1 @ D

37
Q

Normal values for:
Acc. facility
Verg. facility
MEM Ret

A

Acc facility: 8cpm @ N z 2D flipper
Verg facility: 15cpm @ N z 3BI/12BO flipper (or 6cpm z 12BI/14BO)

MEM Ret: +0.50 +/- 0.25D

38
Q

Normal values for:
Stereo
PRC/NRC
ACA

A

Stereo: 60”, Global + local good, no suppression
PRC/NRC:
Near BI>/= 10/16/10 BO >/= 10/16/10
Dist. BI >/= -/6/4 BO >/= 10/16/10

ACA: 4 +/- 2pd/D

39
Q

Provide an example clinical test structure for a BV/paediatric workup

A

Dist VA –> Dist CT –> Near VA –> Near CT –> NPC/NPA –> HH –> Confrontation/RedCap –> MEM Ret –> Phorias/facility –> Stereo –> Colour Vision (if male) –> Pupils –> Refraction

Something like that. Can do Range and ACA on indication. ACA would be good to fit into phorias actually.

40
Q

Define Sheard’s criterion

A

Reserve >/= 2 x phoria

41
Q

Define Percival criterion

A

Phoria = 1/3rd reserve

42
Q

Describe 3 characteristics of Accommodative Insufficiency

A

High Lag
Low NPA
Poor facility

43
Q

Describe 3 characteristics of Accommodative Excess

A

Variable VA
No lag, or lead
Fails +ve facility

44
Q

Describe 3 characteristics of Accommodative Spasm

A

Reduced VA
Lead
Fails +ve facility

45
Q

Describe 2 characteristics of Ill-sustained Accommodation

A

High variable lag

Slow facility

46
Q

Describe 1 characteristics of Accommodative infacility

A

Slow facility both + and -

47
Q

Describe 3 characteristics of Convergence Insufficiency

A

N exo > D (beyond normal)
Reduced PRC/BO facility
Remote NPC

48
Q

Describe 2 characteristics of Convergence Excess

A

N eso > D

Reduced NRC/BI facility @ N

49
Q

Describe 3 characteristics of Divergence Insufficiency

A

D eso > N
Reduced NRC @ D
D blur/diplopia

50
Q

Describe 3 characteristics of Divergence Excess

A

D exo > N
Reduced PRC @ D
Intermittent ExoT

51
Q

How can you manage Convergence Insufficiency? (6)

A

Correct Rx
Educate + Counsel
Plus near add (if accommodative component)
Vision therapy
Prisms (BI compensatory)
Referral (medical opinion for sudden onset or if illness/trauma suspected)

52
Q

How can you manage Convergence Excess? (6)

A
Correct Rx
Educate + Counsel
Plus near add
Vision therapy
Prism (BO compensatory)
Referral (if sudden etc)
53
Q

How can you manage any accommodative problem? (3)

A

Plus add @ Near
Vision therapy
Cyclo (for accommodative spasm only)

54
Q

How can you manage Divergence Excess? (4)

A

Vision therapy
Minus lens add for D (if too young/unwilling for VT)
BI prism (compensatory)
Sx

55
Q

How can you manage Divergence Insufficiency? (4)

A

Check etiology (if recent onset/acquired refer for MRI)
Yoked prism?
Vision Therapy
Prism (BI compensatory)

56
Q

How can you manage Basic Eso? (4)

A

Tx any hyperopia/near add
Yoked prism?
Vision therapy
Prism (BO compensatory)

57
Q

How can you manage Basic Exo? (2)

A

Tx near as would CI

Tx distance as would DE

58
Q

How can we manage Vertical Phoria? (2)

A

Vision therapy

Compensatory prism

59
Q

When should you prescribe spectacles for EsoTropia? (3)

A

Hyperopia over +2
EsoT responding to plus lenses (+ve Raab +3 test)
Hyperopia less than +2 but there is a high ACA ratio/convergence excess

60
Q

List the 5 principles of treatment for any EsoT

A
Give full + [cycloplegia]
Rx for any amblyopia
\+ for amblyopic eye is for vision
\+ for fixating eye is for EsoT
Consider realignment for any residual EsoT after best amblyopia result and + has been rechecked
61
Q

When might you consider surgery for EsoT? (2) What is considered a successful outcome of surgery?

A

Cosmetic defect despite wearing full plus
Spectacles not working or not tried because unlikely to work (e.g. a +1.00D hyperope with a 50pd EsoT)

Success is defined as cosmetically acceptable (i.e. = 10pd)

NB: do surgery if >/=15pd after spectacles.

62
Q

What is the success rate of a single EsoT surgery:
At one month
long term

A

one month: 80%
long term: 55%

they can get another surgery in the future if long term fails

63
Q

How can a strabismus be described? (4)

A

Constancy: constant or intermittent
Direction: Eso, Exo, Hyper, Hypo
Laterality: which eye, or does it alternate
Commitancy: a commitant strabismus has essentially the same magnitude in all directions of gaze, where as an incommittant strabismus doesn’t

64
Q

List 5 methods to detect/assess a strabismus. Which is the most accurate objective tool and what does it tell you?

A

General inspection
Hirschberg test (light @ 50cm. Good for larger strab)
Krimskey: Hirschberg + prism (accurate to 10pd)
Cover test (unilateral or neutralising with prism) for detection

Alternating Cover test is the most accurate objective tool, however it does NOT dx laterality or distinguish phoria and tropia. But it DOES tell you the SIZE of the strabismus (accuracy up to 4pd)

65
Q

What prism should you use to neutralise:
ExoT
EsoT
Hyper

A

ExoT: BI
EsoT: BO
Hyper: BD

66
Q

What are the 4 stages of Vision therapy? How long might a typical vision therapy for convergence insufficiency last?

A
  1. Monocular - accommodation, fixating skills
  2. Biocular - anti suppression, simultaneous viewing
  3. Binocular - Acc/Verg binocularly
  4. Proficiency - combining skills and adding distractions

About 12 weeks

67
Q

Provide examples for each of the 4 stages of vision therapy management

A

Stage 1: loose lens rock, mental minus, flippers
Stage 2: loose prisms, R/G bars, prism doubling, binocular mental minus
Stage 3: loose prisms + flippers, aperture rule, brock string, HTS, tranyglyphs
Stage 4: add cognitive task

68
Q
List a developmental milestone for a 0-6 month patient for each of the following:
Physical
Intellectual
Emotional
Social
A

Physical: suck and grasp reflex
Intellectual: vocalises/understand can cry for response
Emotional: attached to parents
Social: recognises parents/smiles when they arrive

69
Q
List a developmental milestone for a 6-18 month patient for each of the following:
Physical
Intellectual
Emotional
Social
A

Physical: feeds self/sits/stands/2+blocks
Intellectual: 1-2 words
Emotiona;: Hugs parents
Social: games/peek-a-boo

70
Q

What does PEDIC ATS 2B suggest as best practice for amblyopia occlusion?

A

Part time (2 hour) occlusion for first few months until acuity 6/12, followed by full time occlusion afterwards

*Tell kids 3 hours/day because kids will do less than you ask

71
Q

When should you review amblyopia occlusion?

A

1 month after treatment stopped, then 3 months, 6 months and yearly. This is to check for revidicism.

72
Q

List the 7 TVPS tests

A
Discrimination
Memory
Sppatial relations
Form constancy
Visual sequential memory
Figure ground processing
Closure
73
Q

What is the Rosner Test and when is it useful

A

Rosner Test of Visual Analysis Skills (Rosner TVAS) is a screening developmental test for the learning disabled child. Useful from prep-grade 3.

74
Q

What are the normal results for the Rosner TVAS for:
Grade 1
Grade 2

A

Grade 1: around plate 7

Grade 2: around plate 9-10

75
Q

What are the 3 management options for oculomotor defects?

A

Correct refractive error
Near addition
Vision therapy

76
Q

What are the components in integrative analysis of a paediatric examination? (4)

A

Patient symptoms
Patient needs and demands
Risk factors
Clinical findings and Characteristic Features

77
Q
List a type of VIP test that assesses the following:
Visual discrimination
Visual Memory
Fine Motor
Sequencing
A

Visual discrimination: Split/divided form board
Visual memory: tachitoscope
Fine motor: Grooved Pegboard
Sequencing: AVIT

78
Q

Does King devick (an eye movement test) take into account the child’s rapid automatic naming skills?

A

No it does NOT.

79
Q

Can hyperopia over +1.50 contribute to VIP delay?

A

Yes it can, you should correct this when patient symptomatic/reading difficulties.