Clinic Prep: Paediatrics Revision Flashcards
When to prescribe for myopia: 0-1 yo 1-2 yo 2-3 yo 3-4 yo
0-1: >/= -5.00D.
1-2: >/= -4.00D
2-3: >/= -3.00D
3-4: >/= -2.50D
Give full correction
When to prescribe for hyperopia (no strabismus): 0-1 yo 1-2 yo 2-3 yo 3-4 yo
0-1: >/= +6.00
1-2: >/= +5.00
2-3: >/= +4.50
3-4: >/= +3.50
Give partial Rx reduced by up to 50%
When to prescribe for hyperopia (with EsoT): 0-1 yo 1-2 yo 2-3 yo 3-4 yo
0-1: >/= +2.00
1-2: >/= +2.00
2-3: >/= +1.50
3-4: >/= +1.50
Give full correction
When to prescribe for astigmatism: 0-1 yo 1-2 yo 2-3 yo 3-4 yo
0-1: >/= 3.00
1-2: >/= +2.50
2-3: >/= +2.00
3-4: >/= +1.50
Give full correction
When to prescribe for anisometropia: 0-1 yo 1-2 yo 2-3 yo 3-4 yo
0-1: >/= +2.50
1-2: >/= +2.00
2-3: >/= +1.50
3-4: >/= +1.50
Susan Leat’s recommendation for hyperopic patients 4-5yo.
Prescribe hyperopia >+2.50, give 1 diopter less than full.
Susan Leat’s recommendation for hyperopic patients 5+ yo/school age
Prescribe full correction for hyperopia >1.25 or 1.50
Susan Leat’s recommendation for myopia patients 5+yo
Full correction for any myopia
Susan Leat’s recommendation for astigmatism, 15 months - 2 years
> 2.50DC, full correction
Susan Leat’s recommendation for astigmatism, >2 years
> 1.75DC, full correction
Susan Leat’s recommendation for astigmatism, >4 years
> 1.25DC, full correction
Susan Leat’s recommendation for astigmatism, school children
> 0.50DC, full correction
Susan Leat’s recommendation for anisometropia, >4 years
> 1.00D anisometropia, full.
For symptomatic adult patients, at what magnitudes do optometrists generally prescribe for the following: Hyperopia Reading add (presbyopia) Astigmatism Horizontal and Vertical heterophoria
Hyperopia: +1.00 Near add: +0.75 Astig: +0.75 Horizontal prism: 1.5 Vertical prism: 1
In general, do optometrists correct asymptomatic patients with hyperopic anomalies or heterophorias?
No, they do not, if the patient is asymptomatic
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
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
By what age would ambylopia have fully developed? What magnitude of amblyopia should not be ignored?
By age 3
Greater than 1.00D should not be ignored
List 8 clinical tests you can perform on a patient under 3 years old
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
How can you measure vision in a patient under 2 years?
VEP (Visual Evoked Potentials) most reliable. Try a preferential viewing chart/grating or OKN drum (optokinetic nystagmus)
How can you measure vision in a patient between 2-3 years old?
Consider matching games, if child is able
How do you perform Mohindra Retinoscopy?
@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)
When might you perform Mohindra Retinoscopy?
As an alternative when you can’t cyloplege (e.g. due to timing, drop accessibility, safety)
List 5 additional tests you can perform on a patient between 3-6 years old
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)
How should you perform subjective refraction (on >6 or >8 depending on child)? (2)
Start binocularly (to build confidence) Do a blur function
How do you perform a blur function?
Using a trial frame
- Add +1 to +1.50 over ret finding binocularly (monoc if asymmetrical vision)
- Warn child of blur and will slowly make things clearer
- Random chart, child reads a few letters as best as they can
- Once they start making errors, reduce plus by 0.25 or 0.50
- Keep going until plateau or get maximum plus to 6/6
How do you decide whether to measure phoria in a young child? (4)
Make sure they understand the concept of double vision before attempting to measure phoria with Howell prentice card:
- Place in vertical prism over RE
- Ask child if mum/dad looks funny/different
- If child understands that mum has two heads, then you can have a go at measuring phoria
- Take it slow to ensure child understands what is being asked of them
What is the general checklist for a paediatric examination? (12)
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
List the minimum battery of tests for visual efficiency/BV (7)
CT (D+N) NPC/NPA HH Phorias Acc/Verg facility MEM ret Stereo
Provide the instructions for assessing: Posture Range Facility Amp
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”
At what age is 6/6 vision typically achieved?
5-6 years of age
How can we measure visual acuity in infants? What would be the equivalent of 6/6 vision?
Forced preferential looking, usually involving a large card with gratings
30 cycles/deg is 6/6
What is the mean Rx for a 12 month old? Will this change greatly over time?
+0.50DS. Typically minimal change until 8yo, followed by a small myopic shift.
At what age are the following systems fully developed:
Stereopsis
Acc/Converge
Eye movements (OKN, saccades, pursuits)
Stereo: 4mo?
Acc/Converge: 6mo.
Eye movements: 1 year
List 3 red flags for poor vision in child of 0-3 years of age
No eye contact (in children >6mo)
Large slow travelling nystagmus
Slow travelling eye movements
*travelling/roving - i.e. moving about/unfixed.
List the 6 most common reasons for presentation to a paediatric clinic in descending order
Hyperopia (45%) Accom-Vergence (30%) Strabismus (30%) Normal (20%) Special Needs (16%) Astigmatism (15%)
Normal values for:
NPC
NPA
CT/Phoria
NPC Break = 8cm Recovery = 10cm
NPA Avg 18-1/3age or Minimum 15-1/4age
CT/Phoria 3xp +/- 3 @ N, 1xp +/- 1 @ D
Normal values for:
Acc. facility
Verg. facility
MEM Ret
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
Normal values for:
Stereo
PRC/NRC
ACA
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
Provide an example clinical test structure for a BV/paediatric workup
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.
Define Sheard’s criterion
Reserve >/= 2 x phoria
Define Percival criterion
Phoria = 1/3rd reserve
Describe 3 characteristics of Accommodative Insufficiency
High Lag
Low NPA
Poor facility
Describe 3 characteristics of Accommodative Excess
Variable VA
No lag, or lead
Fails +ve facility
Describe 3 characteristics of Accommodative Spasm
Reduced VA
Lead
Fails +ve facility
Describe 2 characteristics of Ill-sustained Accommodation
High variable lag
Slow facility
Describe 1 characteristics of Accommodative infacility
Slow facility both + and -
Describe 3 characteristics of Convergence Insufficiency
N exo > D (beyond normal)
Reduced PRC/BO facility
Remote NPC
Describe 2 characteristics of Convergence Excess
N eso > D
Reduced NRC/BI facility @ N
Describe 3 characteristics of Divergence Insufficiency
D eso > N
Reduced NRC @ D
D blur/diplopia
Describe 3 characteristics of Divergence Excess
D exo > N
Reduced PRC @ D
Intermittent ExoT
How can you manage Convergence Insufficiency? (6)
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)
How can you manage Convergence Excess? (6)
Correct Rx Educate + Counsel Plus near add Vision therapy Prism (BO compensatory) Referral (if sudden etc)
How can you manage any accommodative problem? (3)
Plus add @ Near
Vision therapy
Cyclo (for accommodative spasm only)
How can you manage Divergence Excess? (4)
Vision therapy
Minus lens add for D (if too young/unwilling for VT)
BI prism (compensatory)
Sx
How can you manage Divergence Insufficiency? (4)
Check etiology (if recent onset/acquired refer for MRI)
Yoked prism?
Vision Therapy
Prism (BI compensatory)
How can you manage Basic Eso? (4)
Tx any hyperopia/near add
Yoked prism?
Vision therapy
Prism (BO compensatory)
How can you manage Basic Exo? (2)
Tx near as would CI
Tx distance as would DE
How can we manage Vertical Phoria? (2)
Vision therapy
Compensatory prism
When should you prescribe spectacles for EsoTropia? (3)
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
List the 5 principles of treatment for any EsoT
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
When might you consider surgery for EsoT? (2) What is considered a successful outcome of surgery?
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.
What is the success rate of a single EsoT surgery:
At one month
long term
one month: 80%
long term: 55%
they can get another surgery in the future if long term fails
How can a strabismus be described? (4)
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
List 5 methods to detect/assess a strabismus. Which is the most accurate objective tool and what does it tell you?
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)
What prism should you use to neutralise:
ExoT
EsoT
Hyper
ExoT: BI
EsoT: BO
Hyper: BD
What are the 4 stages of Vision therapy? How long might a typical vision therapy for convergence insufficiency last?
- Monocular - accommodation, fixating skills
- Biocular - anti suppression, simultaneous viewing
- Binocular - Acc/Verg binocularly
- Proficiency - combining skills and adding distractions
About 12 weeks
Provide examples for each of the 4 stages of vision therapy management
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
List a developmental milestone for a 0-6 month patient for each of the following: Physical Intellectual Emotional Social
Physical: suck and grasp reflex
Intellectual: vocalises/understand can cry for response
Emotional: attached to parents
Social: recognises parents/smiles when they arrive
List a developmental milestone for a 6-18 month patient for each of the following: Physical Intellectual Emotional Social
Physical: feeds self/sits/stands/2+blocks
Intellectual: 1-2 words
Emotiona;: Hugs parents
Social: games/peek-a-boo
What does PEDIC ATS 2B suggest as best practice for amblyopia occlusion?
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
When should you review amblyopia occlusion?
1 month after treatment stopped, then 3 months, 6 months and yearly. This is to check for revidicism.
List the 7 TVPS tests
Discrimination Memory Sppatial relations Form constancy Visual sequential memory Figure ground processing Closure
What is the Rosner Test and when is it useful
Rosner Test of Visual Analysis Skills (Rosner TVAS) is a screening developmental test for the learning disabled child. Useful from prep-grade 3.
What are the normal results for the Rosner TVAS for:
Grade 1
Grade 2
Grade 1: around plate 7
Grade 2: around plate 9-10
What are the 3 management options for oculomotor defects?
Correct refractive error
Near addition
Vision therapy
What are the components in integrative analysis of a paediatric examination? (4)
Patient symptoms
Patient needs and demands
Risk factors
Clinical findings and Characteristic Features
List a type of VIP test that assesses the following: Visual discrimination Visual Memory Fine Motor Sequencing
Visual discrimination: Split/divided form board
Visual memory: tachitoscope
Fine motor: Grooved Pegboard
Sequencing: AVIT
Does King devick (an eye movement test) take into account the child’s rapid automatic naming skills?
No it does NOT.
Can hyperopia over +1.50 contribute to VIP delay?
Yes it can, you should correct this when patient symptomatic/reading difficulties.
