Paediatrics - Optometric Examination

Question 1

When should children be managed solely by optom in community?

Answer 1

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

Question 1

When would children be managed solely by HES?

Answer 1

• 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

Question 2

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

Answer 2

• 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

Question 3

What are your responsibilities when co-managing with orthoptist?

Answer 3

• 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

Question 4

What are your responsibilities when testing children under GOS?

Answer 4

• 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

Question 5

What should be included in an eye examination in children?

Answer 5

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

Question 6

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

Answer 6

• 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

Question 7

How would you measure vision in a child?

Answer 7

• 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.

Question 8

Describe Kays Pictures vision test?

Answer 8

• 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

Question 9

Describe Crowded logMAR vision test?

Answer 9

• 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

Question 10

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

Answer 10

• 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

Question 11

What is the management of common BV disorders in children?

Answer 11

• 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

Question 12

Describe pupil reflexes and ocular motility in children?

Answer 12

• 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

Question 13

Describe refraction in a child?

Answer 13

• 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

Question 14

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

Answer 14

• 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

Question 15

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

Answer 15

• 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

Question 16

What are helpful tips on completing cycloplegic refraction in children?

Answer 16

• 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

Question 17

When should you prescribe in a child?

Answer 17

• 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

Question 18

What is a significant refractive error (children)?

Answer 18

• 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

Question 19

Describe the ocular examination in a child?

Answer 19

• 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

Question 20

Describe visual fields testing in children?

Answer 20

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

Question 21

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

Answer 21

• 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

Question 22

What are some considerations to make when testing children?

Answer 22

• 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.