I



I. Typical Behaviors & Exam Modifications:

Why examine kids under 5: early intervention & prevention (vision problems assoc w/ devel delays)

-VA screening isn’t effective (only 30% of 3 y/o with vision problems fail; 40% of 4 y/o; 50% of 5 y/o)

First exam:

-AOA says no later than 6 months

-9 months (most emmetropization is complete)

-3 months if FHx, premature, condition, developmental delay, parental concern

Age groups for exams: Developmental age groups:

-Birth to 2-3 -Infant: 0-1

-2-3 to 5 -Toddler: 1-3

-5+ -Preschooler: 3-5

Typical behaviors & exam relevance:

0-6 months

-Near testing only

-Not mobile

-Responds to voices

- easiest age to examine

← 6-12 months

-Near testing only

-Mobility starts

-Separation anxiety & fear of strangers

-Knows name and orients

← 13-23 months

-Short attention span

-No tolerance for limitations = tantrums

-Negativism starts

-¼ of language is understandable

-Use labeled praise

II. Assessment of Development

Milestones/delays:

-Changes in skill development during predictable time periods (sequential & predictable)

-Cognitive, social/emotional, speech/language, fine motor, and gross motor

-Delay = milestones not attained in the expected time period

- A delay in all areas is called a global delay

Intervention: Early intervention = better long term outcome

-Free intervention services available to all children birth through school age (IDEA)

-1 delay

o Untestable = >1 refusal completely to the left of where age line intersects the blue area

- Denver II scale: 25% left edge; 50% mark; 75% left edge of blue; 90% right edge of blue

- Denver II test is known for under referring in the language section... you may want to bump a patient into suspect

even if the test states they are normal (with one caution)

III. History

- Additional history: informant and their relationship to the pt, developmental, pregnancy, and birth

-Only do developmental/birth/pregnancy if preschool or with developmental/learning/visual problem

-Only do immunizations for preschool

POH: LEE, previous dx, previous tx (Rx, occlusion, surgery, other tx)

PMH: health status, asthma, allergies, meds, LPE, immunizations, ear infections (increased risk of language delays)

-Immunizations given at birth, 2 mo, 4 mo, 6 mo, 12 mo, 15 mo, 18 or 24 mo, and 4 years

-12 months = MMR, varicella, & HepA – only ones given at one year; all others are given earlier

Pregnancy & birth:

-APGAR – heart rate, respiratory rate, muscle tone, reflex irritability, color normal=2; weak=1; no response=0

-7 no attention needed

-1 minute is not predictive of future neurologic status; the longer the score is depressed the greater the risk of future anomalies

-Birth weight

-Normal >2500 grams (5.5 lbs)

-Low 1500-2500 grams (3.3-5.5 lbs)

-Very low 6 months |Stereopsis |

| |Prism fusion test |

|2 years |Cover test at distance |

|3 years |Threshold stereopsis |

|Any age |Cover test at near |

| |Bruckner |

VII. Preliminary Tests

Versions

-Under 6 months do not follow well

-Versions are full and comitant at birth

Pursuits

-Smooth pursuits are not mature at birth – develop through 1st year of life

-Horizontal develop before vertical

-Pursuits are smooth to large and very low velocity targets

-Often saccadic in young infants

Visual fields

-Very small fields at birth

-Rapid increase in field extent in the 1st 3 months

-Adult-like static fields at 6-9 months; kinetic at 1 year

-Assess confrontation fields in all patients

-At-risk: premature (IV/PV hemorrhage, PVL), hypoxia, seizures, in-utero/early stroke, multi-challenged

-Targets cannot make noise

Pupils

-Pupil size increases with age

-Iris muscles change a lot during the first 6 months

-Sphincter develops early during the 1st trimester – any full-term infant will have fully developed sphincter

-Dilator begins to develop at 6 months gestation – well developed by 2 months of age

-Normal direct & consensual if full-term

-Adult-like reactions by 2 months (but sluggish)

PD

-Important to measure if correcting RE (may have to guesstimate or use a chart)

Color vision

-Red-green response by 2 months

-Blue-yellow at 4 months

-No commercially available test for kids under 3 years

-Color Vision Made Easy Test screens for protans and deutans

-Ishihara for kids over 4 (trace numbers)

Ocular health

-Hand held slit lamp for kids under 3 with a CC

• Corneal diameter

-Normal = 10-11mm

-Micro 11.5mm

• Corneal clarity

-Rule out congenital glaucoma in kids with cloudy corneas

• Iris pigmentation

-Final eye color develops from 6-9 months (more pigment added through 12 months)

-Congenital Horner’s: lighter eye is affected eye

• Posterior seg

-Routine assessment beginning at 6 years

• IOP

-Tonopen for younger kids, NCT for older kids

VIII. Assessing Refractive Error

Hints

-Dry ret even if you’re going to do a wet ret

-If you think you see plus, it’s there

-Most preschoolers are slightly hyperopic, so start with a +2.50 lens to increase efficiency

Loose lens ret

-Fog the eye not being refracted (1.00-2.00 diopters over what you think their RE is)

-Assume eyes have equal RE

-Adjust the level of the fog as the RE in the other eye increases

Cycloplegic ret

-Uses: inconsistent distance fixation, ET, anisometropic, amblyopic, latent hyperopia

-AOA requires cycloplegic ret on every peds patient’s first visit

-Cyclopentolate is drug of choice – accommodation will be normal by the next day

-Atropine used for ET occasionally (instilled 3 days prior at bedtime)

-Tropicamide used for normal VA, normal dry ret, no amblyopia, low hyperopes, myopes

-Refract at 30 minutes (maybe 10 minutes if blue eyes)

-Still need to fog the fellow eye

Drops

-Light irides: 2gtts 0.5% cyclo 5 minutes apart (infants 6 months with previous adverse reaction)

-Use 1.0% cyclo in infants >6months (if no adverse reaction)

-Side effects of cyclo: sedation, nausea, flushed face, hallucinations

-Dark irides: 1gtt tropicamide with 1gtt cyclo (0.5% or 1.0% depending on age)

Mohindra/near ret

-Done when you can’t get distance fixation

-Substitute for dry ret

-Dark room with 50cm working distance

-Measures the resting state/dark focus and is static

-Net lens is gross -1.25

-Tends to under-plus hyperopes

Autorefractor

-Hand-helds have good testability on 2 year-olds and up

-Underplus on dry measurements

Photorefraction

-Screening tool

-Flash near the edge of the lens entrance pupil; horizontal and vertical meridians

-Uniform red reflex = emmetropia

-Myopia if crescent on same side of pupil as light source

-3 factors that affect results: distance of examiner, pupil size, distance of light source

-Less sensitive with farther distances and smaller pupil

Corneal measures

-Keratometry

Development of accommodation

-Not assessed routinely in preschoolers

-Start to see changes at 1-3 months (before, locked in at 20-25cm)

-Inaccurate response to change in target distance (adult-like by 4 months)

-No response to blur until 9 months

-Response may not be great because VA isn’t great

Assessment of accommodation

-Anti-seizure meds, ADHD, TBI, CNS anomalies, CP, Down, Fragile X, borderline hyperopia

• Pull-away

-3 years and up

• Dynamic ret amplitude

-Gradually move in to assess if they’re still accommodating

-Amplitude = distance where you see an increase in motion (larger lag)

-Not as accurate as pull-away

• MEM

-Distance is the Harmon distance

-+0.50-+0.75 is normal (>+1.00 is a large lag)

IX. Emmetropization

Prescribing is guided by:

1. VA (limited usefulness under 3 years)

2. Signs & symptoms

3. BV (strab, amblyopia)

Typical RE

-Newborns: +2.00 to +2.75

-12 months: - more similar to leptokurtic than normal distribution

-6 years: +0.75 – typical leptokurtic curve

-Range and variability decreases with age

-Most emmetropization occurs in first 9-12 months

Hyperopia

-Not all RE reduces

-Final magnitude is influenced by initial magnitude

-The more hyperopia early in life, the more rapid decrease, but they still end up more hyperopic

-If the RE isn’t changing much, it’s better to see the child more often

-More than +5.00 may be outside the range of effective emmetropization

|Magnitude |Emmetropization |

|+3.00 to +5.00 (3 months) |Variable emmetropization by 9 months |

|>+5.00 (3 months) |Little to no reduction in hyperopia |

|>+3.00 (9 months) |Greater odds of retaining >+2.00 at 3 years |

Myopia

-There is more myopia at birth than during preschool

-60% of infants are myopes at birth

-Emmetropization process is spread out more over time than for hyperopes

-Change at a very steady rate until 3 years

-Probably don’t prescribe initially, but monitor closely

-Most myopes become low hyperopes during preschool years

Astigmatism

-8% prevalence of astigmatism in adults (4-6% for older kids)

-20-65% prevalence of astigmatism >1.00D in the 1st year of life

-ATR or WTR

-Correlates with corneal toricity

-Adult-like astigmatism by 18-36 months

-Longer time course than hyperopia

-The more astigmatism you start with, the faster you lose it

-Higher astigmatism as infants, higher astigmatism at 3 years

Anisometropia

-14% of newborns have anisometropia (school-age kids 3.5-6%)

-Prevalence reduces by the first year of life (stable at 1-4%)

-Presence of aniso at 1 year doesn’t predict RE at 4 years

-More than 50% of anisos are transient and not retained between 1 and 4 years

-Lower magnitudes of aniso have a greater chance of losing it

-90% of infants with 3D or more aniso retain it at 10 years

-Constant unilateral strabs will not emmetropize in the deviating eye

Emmetropization and prescribing (mostly completed by 9 months)

-Most studies show that emmetropization isn’t affected by full or partial Rx

-Theory: minus lens increases growth rate (signals that eye is too short)

-As little as 1 hour without lenses prevents much/all adaptation

X. BV and Development Risk Factors

Hyperopia

-+5.00 is the threshold for isometropic bilateral refractive amblyopia

-Moderate hyperopia can be a risk for accommodative ET

-Moderate hyperopia at 9-12 months: 20-50% develop amblyopia by 3-4 years; 25% develop ET at 3 years

-Strabismus is reduced from 13X to 4X with an Rx

-Amblyopia is reduced from 6X to 1.6X with an Rx

-Partial Rx reduces strabismus by 70% and amblyopia by 75%

-Do no automatically Rx at 9-12 months

-Rx if strabismic, minimal/no change in RE, >+5.00 at under 1 year, >+3.50 at 3 years, s/s, reduced VA

-3 year-olds with moderate hyperopia have difficulty in matching, perceptual tasks, language development, etc.

Astigmatism

->2.00 diopters of astigmatism is the threshold for isometropic (meridional) amblyopia

-Isometropic amblyopia onsets by age 3

-Deeper amblyopia in MA and CMA

-Oblique astigmatism at 1 year is very amblyogenic ( all become amblyopia at 4 years

Anisometropia

-Aniso >1.00 diopter is associated with amblyopia and strabismus

-30% develop aniso if it’s persistent from 1-4 years

XI. Kids and Contacts

Indications

-High RE (bilateral high RE, accommodative refractive ET, aniso, aphakia); amblyopia (occlusion therapy); nystagmus; cosmetic/prosthetic/photophobia; bandage

Advantages: better peripheral vision, more normal appearance, reduced weight, reduced mag/mini, aniseikonia, prism, accommodative demand for hyperopes, photophobia (tinted), better chance for BV, better compliance

Disadvantages: ocular insult (abrasions 0-13%, SPK ................
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