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 ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- how do i sell stocks i own
- i ask or i asked
- synonyms for i believe or i think
- i choose or i chose
- i think i found the one
- i bet or i ll bet
- humss cw mpig i 11 humss cw mpig i 12 humss cw mpig i 13
- i took a deep breath and listened to the old brag of my heart i am i am i am
- i feel like the things i should say are the things i can t say
- i have loved words and i have hated them and i hope i have made them right
- i looked and looked at her and i knew as clearly as i know th
- i e 577 02 9006 yah shua 577 02 9006 holy spirit i i e yah shu