8.1.5 Manages children at risk of developing an anomaly of binocular vision.

Question 1

Risks

Answer 1

• Family history
• Developmental - birth issues
• Conditions

Question 2

Family history

Answer 2

• FH - if parents have tropia, very likely child will have it
  
  • Ask “Any family history of squints/lazy eye?”
  • Ask about hereditary health conditions like diabetes

Question 3

Developmental - birth problems

Answer 3

• What is premature??
• Say (when talking to parent), “This might sound a little strange but were there any problems during the birth of (px name) such as prematurity, emergency c section, forceps delivery or anything else? I am only asking as these are risk factors for developing eye related problems like squints and would require more investigation”
• “Any accidental or non-accidental head trauma, systemic illness, epilepsy, medication?”
• Pre-natal & delivery:
  
  • Unplanned/emergency caesarian section or breech delivery (distress to the foetus can lead to developmental problems e.g. cerebral palsy),
    Forceps delivery (can lead to damage to the lateral recti or their nerve supply),
    Significantly pre-term (developmental problems, retinopathy of prematurity),
    Low birth weight (developmental abnormalities), Normal birth weight between 6-9 pounds, Low is < 5.5 pounds
    Oxygen or hospitalisation (more than 3 days) after birth
• Neo-natal & Infancy:
  
  • Hyper/hypo activity, epilepsy, accidental or non-accidental head trauma, significant systemic illness, medication

Question 4

Conditions

Answer 4

Downs Syndrome, Cerebral palsy, Autism (difficult in visual processing)

Question 5

Appropriate Examination

Answer 5

• Stereopsis
  
  • Reduced early on puts child at risk
• VAs
  
  • If assymetrical or they don’t like one eye compared to the other to be covered then indicates start of amblyopia
• Squint
  
  • If early onset, then automatically at risk of amblyopia
• 20 base out
  
  • Looks for any suppression
• CT
  
  • Looking for a squint generally speaking
  • Sometimes an esophoria or exophoria can start decompensating early on depending on extent of fusional reserves and cause a tropia. If within critical period then suppression can build to prevent diplopia
• Pull up amplitude test
  
  • Accommodative insufficiency will affect Down syndrome patients!
  • It can also affect normal children so it must be measured to allow the correct Rx to be given for close up tasks, otherwise their education will be affected
  • Dynamic - a lag greater than 1 D suggests a degree of hypermetropia that the child cannot manage. An unequal lag between the two eyes suggests a degree of anisometropia that is poorly compensated for
• Motility
• Shadow test - to check AC angle
• Ret - Cyclo normally
• Ophthalmoscopy
  
  • Pathology puts px at risk of amblyopia e.g. a congenital cataract