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Binocular vision, visual impairment and paediatrics > Examining children > Flashcards

Examining children Flashcards

1
Q

What are the key stages in a paediatric eye test:

A
  • History
  • Visual function (Vision & Visual Acuities and if needed contrast sensitivity)
  • Refraction - retinoscopy under cycloplegia and subjective refraction
  • Binocular vision status – cover test, ocular motility
  • Colour Vision (if appropriate)
  • Anterior segment and Fundus examination
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2
Q

Examining infants and children:

A

Observe child in the waiting area….
- Do you notice a squint for example
- Is the child wearing glasses
- Are they looking through/over their glasses

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3
Q

History taking in paediatrics dos and donts:

A
  • Your observation should continue into the examining room
  • Tailor history according to child’ age
  • Introduce yourself to parent and child
  • Talk to the child (if appropriate) not the parents, this may mean that you have to come to the child’s eye level!
  • Use the child’s name frequently
  • Always praise the child, don’t criticise
  • Good to have a selection of toys and ensure the practice is child friendly
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4
Q

What to include in history for paediatrics

A
  • Establish why the child has come for an eye test?
  • If they (parents/carers) are worried what is it they are specifically worried about
  • When did the worries begin, frequency, duration, triggering factors, are they getting worse?
  • Past ocular history
  • Family history is important
  • Birth history is also important
  • Also establish normal milestones
  • Medical history, Medications, Allergies
  • Tailor your questions to children where appropriate
  • Use child friendly language where appropriate
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5
Q

Reasons for coming in for eye test child:

A
  • Routine eye exam
  • Or are there worries about the child’s vision
    • E.G. family history of squint
    • Baby not making eye contact
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6
Q

Examples of past ocular history child eye test:

A
  • Patching
  • Squint
  • Amblyopia
  • Hospital visits
  • Surgery
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7
Q

Examples of family history child eye test:

A
  • Patching
  • Squint
  • Amblyopia
  • Hospital visits
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8
Q

Examples of birth history child eye test:

A
  • Pre-term
  • Full term
  • Birth weight
  • Type of delivery
  • Maternal illness during pregnancy
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9
Q

Examples of key developmental milestones for infant to 1 year old:

A
  • Able to drink from a cup
  • Able to sit alone, without support
  • Babbles
  • Displays social smile
  • Gets first tooth
  • Plays peek-a-boo
  • Pulls self to standing position
  • Rolls over by self
  • Says mama and dada, using terms appropriately
  • Understands “NO” and will stop activity in response
  • Walks while holding on to furniture or other support
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10
Q

Important milestones newborn to 3 year olds:

A
  • Understand several short words- 1 year
  • Imitate sounds- 1 year
  • Speak 20 words or more- 1.5 years
  • Use short sentences- 2 years
  • Know name and gender- 3 years
  • Understand abstract words- 5 years
  • Touch object with forefinger- 10 months
  • Begin to knows colours- 3 years
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11
Q

Visual development - what acuity can children see:

A
  • Birth: VA of 6/120, focus at 25cm, responds to stimuli
  • 2 months: stable eye contact
  • 3 months: focus at 20-40cm; fixes/follows/looks for objects
  • 5 months: eyes straight, watch and copy hand movements
  • 9 months: recognise faces
  • 3 years visual acuity 6/12
  • 4 years visual acuity 6/9
  • 5 years visual acuity 6/6
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12
Q

Types of visual acuity testing:

A
  • Electrophysiological testing = objective method of measuring VA
  • Behavioural testing = subjective method of measuring VA
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13
Q

Is visual acuity testing in children binocular or monocular and when do you start observing VA:

A
  • Monocularly
  • Observe behaviour when child occluded
  • Usually from 3 months
  • Child will object to ‘good’ eye being covered
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14
Q

Types of electrophysiological testing:

A
  • Flash VEP stimulus- from birth
  • Pattern VEP stimulus
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15
Q

When would you use electrophysiological testing:

A
  • In hospitals
  • When you cant get a reading of what child can see
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16
Q

What does flash VEP involve:

A

Sitting child in front of screen or bowl and show them flashing light

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17
Q

What does pattern VEP involve:

A

Show them pattern – checkerboard which keeps flashing or moving

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18
Q

What does electrophysiological testing involve:

A
  • Looking at signals that go to brain from these patterns
  • So when child is looking at flashing light or checkerboard pattern, there are visual signals going to the occipital cortex
  • And the flash VEP can look at those signals
  • So there are electrodes placed over occipital cortex on head
  • And can see latency of responses and whether responses are delayed
  • Child doesn’t have good VA if delayed
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19
Q

Testing visual acuity in children - preferential looking:

A
  • Fantz et al, 1962
  • ‘Infants would prefer to look at a pattern than a blank stimulus’
  • Iso-illuminant stimuli i.e pattern has same luminance as grey blob
  • Behavioural test
  • Principle based on resolution tests = ability to detect and resolve a target ( use black and white target )
  • Ability to discriminate different spatial frequencies (or other metrics)
  • 1 black and 1 white line = 1 cycle
  • Measure how many cycles you get per cm and convert how many cycles you get per degree – depends on distance your sitting from test
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20
Q

Which px’s is preferential looking not good for:

A
  • Less sensitive to amblyopic defects especially in strabismus
  • Because it’s a resolution test and resolution tests are easier to do
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21
Q

What is spatial frequency:

A

Black and white target measured in cycles/degree

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22
Q

What does narrower stripes mean:

A

Higher spatial frequency = harder to see

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23
Q

What age do you do preferential looking VA:

A

0 - 24 months

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24
Q

Examples of preferential looking tests:

A
  • Teller Acuity Cards
  • Keeler acuity cards (City Sight)
  • Lea Grating paddles
  • Cardiff acuity cards (Vanishing optotypes) (City Sight)
  • Peekaboo App
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25
Q

Keeler acuity cards:

A
  • Working Distance: 38cm
  • Usually 15 cards with black-&-white stripes on right or left side, 1 blank card
  • 4mm hole in centre
  • Range 0.32 to 38 cycles per degree
  • Usually start with low spatial frequency/poor VA i.e broader black and white stripes and move in 1 or half octave steps up (if correct response or down if incorrect response) i.e 1 card or skip a card
  • Correctly identifies the same stimulus twice means the child can resolve that card
  • Clinically significant interocular difference: Greater than/equal 2 cards (McDonald et al, 1986)
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26
Q

Summary of keeler acuity cards method:

A
  • Look through hole
  • Present card to px
  • Trying to see if px is looking at stripes or not
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27
Q

Working distance for keeler acuity cards:

A

38cm

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28
Q

Cardiff acuity cards:

A
  • Vanishing optotypes
  • Also used in special needs patients – stroke, dementia
  • Pictures (duck, house, fish, car, train, boat dog) at top or bottom
  • No crowding – if present letter, theres nothing surrounding that letter but if line of letters or letter in box = crowding
  • If someone has amblyopic defect, if show them non crowded target, they may still be able to read 6/9 but if crowded, 6/36
  • May overestimate VA if have a test that measures non crowded VA
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29
Q

Method of cardiff acuity cards:

A
  • 50cm or 1m depending on age
  • 3 cards for each of the 11 acuity levels
  • Present cards at eye level and watch eye movements
  • Start with card with widest target (lowest acuity level)
  • Observe eye movements
  • Masked to tester
  • 2 out of 3 responses correct – go to next lower acuity
  • Clinically significant interocular difference: Greater than 2 cards (Adoh and Woodhouse, 1994)
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30
Q

Which VA range to use in cardiff acuity cards:

A
  • 1.0- 0.1 LogMAR using at 1m (older children)
  • 1.3-0.5 LogMAR using at 50cm (younger children)
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31
Q

Working distance for cardiff acuity cards:

A

50cm or 1m depending on age

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32
Q

Peekaboo App:

A
  • 2 forced choice or 4 forced choice, Livingstone et al; 2019
  • Free Ipad App , currently (August 2022) unavailable
  • Touching the pattern results in a yippee sound and a cartoon appearing, positive feedback, four or two choices
  • Results comparable to Keeler
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33
Q

Working distance for peekaboo app:

A

25 - 50 cm

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34
Q

What VA is measure for peekaboo app:

A

VA measured 0.2-1.3 LogMAR

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35
Q

How to test VA for older children 2 years and above:

A
  • Recognition acuity: Ability to detect, resolve and recognise a target
  • More sensitive to amblyopic defects especially in strabismus especially crowded targets
  • 2 years: usually use picture matching
  • 3 years: can use picture and or letter matching
  • Greater than 3 years can consider naming pictures or letters
  • Matching cards can be supplied at home for practice before clinic visit
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36
Q

Kay pictures:

A
  • Pictures of common objects known to a child (E.g. duck, house, apple)
  • Single pictures or crowding in LogMAR format (3m)
  • Single pictures in Snellen format (3 or 6 metres)
  • Each line equivalent to 0.1 LogMAR acuity
  • Tests also available as an app for iPad
  • Clinically significant interocular difference (Crowded) :Greater than 3 pictures (less than 4 years); Greater 1 than picture (above 4 years)
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37
Q

What VA is used for kay pictures:

A
  • 1.0 – 0.1 LogMAR
  • 3/3 (6/6) – 3/30 (6/60)
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38
Q

Lea symbols:

A
  • Same principles as LogMAR test
  • Single and Crowded version of letters
  • Test distance 3m
  • Test symbols: Simple shapes familiar to small children which blur equally: Square, House, Circle and Apple
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39
Q

Working distance for lea symbols:

A

3m

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40
Q

What VA is used for lea symbols:

A

0.10-2.0 LogMAR

41
Q

Letter matching tests - types of tests:

A
  • Sheridan-Gardiner test
  • Cambridge Crowded acuity test
  • Tumbling E or Landolt’s C could be used
42
Q

Sheridan-Gardiner test:

A
  • Single letters 6m, can be performed at closer distances
  • Uses flip chart
  • No crowding
  • Linear letters with crowding available
  • 6/60-6/4
43
Q

Cambridge Crowded acuity test

A
  • Uses Sheridan-Gardiner letters 3m or 6m
  • Identify the letter in centre which is surrounded by four others
  • Crowding
44
Q

Keeler LogMAR Crowded test:

A
  • Flip-chart
  • 6/38 (0.80) to 6/3 (-0.30)
  • 3m
  • LogMAR principles
  • Screening and uncrowded sets also available
  • Similar to Sonsken Silver (uses Sherdian Gardener letters) but more crowding as letters closer together
  • Clinically significant interocular difference: 0.1 LogMAR; Sonsken Silver is 0.125 LogMAR
45
Q

What distance is keeler logMAR crowded test done at:

A

3m

46
Q

What VA’s are used for keeler logMAR crowded test:

A

6/38 (0.80) to 6/3 (-0.30)

47
Q

Other methods of testing VA on children:

A
  • Bradford Visual Function Box
  • Hundreds and thousands/Visually directed reaching
48
Q

Bradford Visual Function Box test:

A
  • Variety of targets of different sizes: beads, bauble, balls, toys and books
  • Useful when none of the other VA tests work
  • Observation response to the target e.g. eye movement, head movement,
49
Q

Hundreds and thousands/Visually directed reaching test:

A
  • Usually over 6 months
  • Small cake decorations (100s & 1000s) held in the palm of the hand
  • Nine months: may prod the decorations
  • One year: may attempt to pick up. VA roughly 6/60 @25 cm
  • Rarely used
50
Q

What tests to use on birth to 2 years for VA:

A
  • Keeler Acuity Cards
  • Peekaboo App
  • Cardiff Cards
51
Q

What tests to use on 2 - 4 years for VA:

A
  • Picture naming/matching
  • Lea symbols
  • Kay pictures
52
Q

What tests to use on 3 - 5 years for VA:

A
  • Letter naming/matching
    • Sheridan-Gardiner
    • Sonksen-Silver
    • Cambridge Crowding Cards
    • Keeler LogMAR acuity cards
    • Landolt C/Tumbling E
  • Can also use picture naming and matching so Kay pictures and Lea symbols
  • Remember crowded cards better
  • Above 5 years regular charts
53
Q

How to measure near vision for 2 years onwards:

A
  • Kay Picture Near Test
  • Lea Symbols Near vision
  • Reduced Snellen (Landolt’s C/ Tumbling E)
54
Q

What is the kay picture near test:

A
  • Age: 2 years onwards
  • Working distance: 33cm
  • Crowded & Uncrowded
  • See what child can read
55
Q

What is the lea symbols near vision test:

A
  • Age: 2 years onwards
  • Working distance: 40cm
  • 6/120 – 6/3
56
Q

What age is reduced Snellen (Landolt’s C/ Tumbling E) used for:

A

2 years onwards

57
Q

What are the two tests to measure contrast sensitivity on children:

A
  • Cardiff Contrast Sensitivity Test
  • Hiding Heidi
58
Q

Cardiff Contrast Sensitivity Test:

A
  • Same vanishing optotypes as the Cardiff Acuity
  • Three cards at each contrast level from 46% to 1% in twelve steps.
  • Testing distance usually 50cm
  • Use PLT or matching/naming depending on age
  • 12 months onwards but probably use from younger
  • Get px to point where symbol is or is symbol is up or down
59
Q

What distance is cardiff contrast sensitivity done at:

A

50cm

60
Q

Hiding Heidi test:

A
  • Five contrast levels: 25%, 10%, 5%, 2.5%, and 1.25%
  • Two cards: White and one with ‘Heidi’ – ask px to point to where Heidi is
  • Use PLT or matching/naming depending on age
  • 0 months onwards
  • Variable working distance infant/examiner dependent
61
Q

Tests on children to test binocular function:

A
  • Cover test
  • Hirschberg test
  • Extra Ocular Motility
  • Motor fusion
  • Sensory Fusion
  • Near point of convergence
  • Stereopsis
  • Accommodation
62
Q

Cover test on children:

A
  • Very useful test- Gold standard .
  • Accommodation needs to be simulated so use an interesting target, e.g. a toy with some detail, sticker etc = can ask questions about the target to stimulate interest
  • Can use palm/thumb to occlude child’s eye rather than occluder
63
Q

What is it common and normal to have on cover test for children:

A

EXOP at near

64
Q

Hirschberg Test on children:

A
  • Useful if cover test is difficult
  • Can flash light on and off to encourage fixation
  • Temporal reflex = esotropia.
  • Nasal reflex=exotropia.
  • Higher reflex suggests hypotropia
65
Q

EOM test on children:

A
  • Needs interesting target, could use flashing lights, auditory stimulus may be useful.
  • In very small children may need to move child rather than target as may not understand
66
Q

Motor fusion 20D BO test:

A
  • BO prism is held before either eye in turn with child fixating suitable target.
  • Eye behind prism should adduct rapidly to restore fusion and abduct again on removal
  • Speed of the fusion movement helps establish binocularity
  • Start with 20Δ BO then reduce to 15Δ BO to 10Δ BO if slow to overcome
67
Q

Abnormal responses of 20D BO test:

A
  • No movement
    • Either no fusion or lack of attention
  • Slow to overcome the prism/slow recovery
    • Possibly poor fusion
  • Prism fusion range (full) can be attempted in school going children
68
Q

What test do you use for sensory fusion in children:

A
  • Worth 4 dot test / Worth’s lights
  • Bagolini lenses /glasses
69
Q

Worth 4 dot test / Worth’s lights:

A
  • Four lights, usually round but can be different shapes
    • 2 green
    • 1 red
    • 1 white
  • View through red and green goggles
  • Red filter before RE / green filter before LE
70
Q

Why test sensory fusion in children:

A
  • Normal Retinal Correspondence.
  • Diplopia (Exotropia and Esotropia)
  • Suppression
  • ARC
71
Q

Bagolini lenses:

A
  • Spot light seen by both eyes
  • Striations oriented in different directions for each eye
  • Striated lenses positioned at 45 & 135 degrees
  • Streaks of light seen separately by either eye
72
Q

Near Point of Convergence in children:

A
  • Gross convergence ability
  • Use an interesting target such as a toy or a sticker
  • Move target towards child until one eye turns out/eyes converge till nose
73
Q

Normal values for near point of convergence in children:

A
  • Dependant on age
  • Children/ younger adults <6cms
  • Break 5cms recovery 7cms
74
Q

What age can you measure near point convergence:

A

Should be able to do from about 6 months

75
Q

Measuring stereopsis on children:

A
  • Based on age & test
  • For example 40” of arc for adults > 9 years old 60” for adults with TNO
76
Q

Examples of stereopsis test to use on children:

A
  • Lang’s two pencil test
  • Lang stereo-test- good for young children
  • Frisby test
  • TNO
  • Titmus test
  • Randot test
77
Q

Lang strereotest:

A
  • Random dot
  • No glasses required
  • Lang 1 (cat, car, star)
    • At 40 cm: 1200” to 550”
  • Lang 2 (elephant, car, star, moon)
    • At 40 cm: 600” – 200”
  • Good screening test
78
Q

What distance is lang stereotest done:

A

40cm

79
Q

Frisby stereo test:

A
  • No glasses
  • 4 squares of shapes per sheet
  • 3 thicknesses of sheet: 6mm, 3mm and 1mm
  • Disparity 875” to 20”
  • Viewing distance: 30 cm – 80cm
  • One square contains a central circle
  • Observe behaviour or ask question about circles
  • Turn around sheet ask again
  • Responses seen in infants as young as 6 months
80
Q

What distance is frisby stereotest done:

A

30 cm – 80cm

81
Q

Langs 2 pen test:

A
  • Patient and examiner each hold a pen vertically
  • Patient brings points of pens into contact
  • Cover one of patients eyes
    • Repeat test
82
Q

In langs 2 pen test what does it mean if accuracy poorer when using only one eye:

A

Indicates presence of stereopsis under binocularly conditions

83
Q

In langs 2 pen test what does it mean if theres an equal monocular and binocular response:

A

Absence of stereopsis

84
Q

Why is langs 2 pen test useful clinical tool:

A
  • Qualitative test
  • Tests low grade BSV
  • GROSS (Coarse) stereopsis
85
Q

What stereopsis tests to do in older children:

A
  • TNO
  • Titmus test
  • Randot test
86
Q

Ways of measuring accommodation in children:

A
  • Accommodative amplitude or range
    • Near point
    • Minus lenses
  • Accommodative facility
    • Flipper lenses
  • Accommodative lag or lead
87
Q

Measuring accommodation in children using dynamic retinoscopy:

A
  • Objective technique
  • Lag (under accommodation is normal approx. +0.75DS)
  • Lead (overaccommodation tends to be abnormal)
  • Spec Rx should be worn
88
Q

What are the two methods of dynamic ret:

A
  • MEM method (neutralise with lenses)
  • Or move backwards/forwards until neutral reflex obtained and then work out depending on target distance/ accommodative demand
89
Q

Who is dynamic ret useful for:

A

Very useful in children with special needs who often have poor accommodative facility/reduced accommodation and need bifocals

90
Q

Normal value for dynamic ret:

A

0.75D

91
Q

Why is cycloplegic refraction gold standard:

A

Accommodation controlled, large pupil

92
Q

Which cyclopentolate drops to use in children:

A
  • > 12months – use Cyclopentolate 1%
  • 6 - 12months with Light irides – use Cyclopentolate 0.5%
  • 6 – 12months with dark irides – use Cyclopentolate 1%
  • 3- 6 Months – use Cyclopentolate 0.5%
  • Do not use Cyclopentolate in children with a history of epilepsy
93
Q

How many drops of cyclopentolate to use:

A
  • If there is no sign of mydriasis in 10 mins a second drop can be instilled
  • If needed Proxymetacaine 0.5% can be used before instilling cyclopentolate to improve tolerance and the cycloplegic effect.
94
Q

Advantages and disadvantages of cycloplegic refraction:

A

Advantages
* Relaxation of accommodation: better estimation of refractive error
* Accurate fixation not needed
* Large pupil: view of fundus

Disadvantages
* Temporary blurred vision and photophobia

95
Q

When to do a cycloplegic refraction:

A
  • Pre school children especially first sight test
  • When prescribing glasses
  • Unexplained poor VA
  • Reduced stereopsis
  • Presence/suspicion of squint e.g. Esophoria, Esotropia
  • Underactive accommodation or accommodation appear to fluctuate
  • Family history of high hypermetropia or squint.
96
Q

Near Mohindra Retinoscopy:

A
  • Non cycloplegic
  • Occlude one eye
  • Room should be completely dark
  • Use a 50cm working distance
  • Ret as normal, neutralise all meridians
  • Original study suggests correction factor of +1.25DS
  • Saunders and Westall (1992) suggest +1.00DS over 24 months and +0.75DS if younger
  • Repeat on other eye.
  • Observe pupil, quality of reflex and co-operation, may need Cyclo
97
Q

Colour Vision testing in children:

A
  • Not possible in infants
  • Colour Vision Testing Made Easy: Gold standard for identifying RG colour vision defects
  • Pseudoisochromatic principles
  • Generally 3 years and above
  • One demonstration plate and 9 test plates: circle, star, and/or square
  • Good validity when compared to Ishihara
98
Q

Anterior segment eye exam in children:

A

-Red reflex; pupil reflex
- Burton lamp
- Portable slit lamp if available
- 20D lens with magnification
- Regular slit lamp- child in parent’s lap: older child
- IOP (if needed)
* Tonopen
* Digital palpation

99
Q

Fundus exam in children - which drops to use:

A
  • Dilated is better
  • For infants younger than age 1: 0.5% tropicamide and one drop of 2.5% phenylephrine. If cycloplegic refraction also then 0.5% cyclopentolate
  • Above 1 year; 1.0% tropicamide or 1.0% cyclopentolate
  • Indirect ophthalmoscope

Binocular vision, visual impairment and paediatrics (6 decks)

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