M3 Flashcards
concerns dictate that a child patient, including older children, should be accompanied by a parent or guardian while they are in the consulting room with you
Child protection
should always be obtained
Parent’s/Guardian’s consent
TYPES OF VISION EXAM
- Screening
- Comprehensive
- Refraction
- Contact lens
Brief examination with limited elements of testing
Screening
assess risk factors and determine presence or absence of potential risk factors
Screening
recommend appropriate treatment pathway and timing
Screening
patient reports with medically related diagnosis
Comprehensive
examine all basic areas of vision including refractive, oculomotor and eye and systemic health
Comprehensive
brief examination devoted only to refractive status
Refraction
medical diagnosis unnecessary , often routine care
Refraction
examine only refractive status, new or re- evaluate
Refraction
⚬medical diagnosis unnecessary, often routine are for fitting, re-fitting or other assessment of contact lens status
⚬examinerefractiveandeyesystemichealthstatusas applied to contact lens wear, new or re-evaluate
Contact lens * Basic or complex evaluation and fitting
⚬medical diagnosis uncessarry, often routine care to check CL status
⚬examine refractive and eye and systemic health status as applied to contact lens wear, new or re-evaluatE
Contact lens * Check
Limited Testing - VA only
Vision Screening
Untrained personnel
Vision Screening
Inadequate testing equipment
Vision Screening
Complete and detailed test
Comprehensive
Optometrists/ Ophthalmologists
Comprehensive
Specialized equipment and procedures
Comprehensive
- evaluate the functional status of the eyes and visual system, taking into account each child’s level of development and special vision demand and needs
- assess ocular health and related systemic health conditions
- establish a diagnosis (or diagnoses)
- formulate a treatment and management plan
- counsel and educate parents/caregivers regarding their child’s visual, ocular and releated health care status, including recommendations for prevention, treatment, management, and future care
Objectives of a compre pedia test (AOA)
newborn - 2 y/o
Infants and Toddlers
3-5y/o
Preschool Children
6-18 y/o
School-age Children
- Patient History
- Visual Acuity
- Refraction
- Accommodation
- Binocular Vision
⚬ OcularMotility
⚬ Stereopis
⚬ ColorVision - Ocular Health Assessment
Examination Procedures
an initial and ongoing component of the examination
Patient History
objective is to obtain specific information about the px, and/or parent’s or caregiver’s perception of the child’s eye and vision status, important background information and related medical issues
Patient History
helps identify and assess problems
Patient History
provides an opportunity to become acquainted with the px, parents, caregivers establishing confidence and trust
Patient History
- Electronic health record or paper charting system
- Chair/stool to enable sitting at child’s height or enough space to squat at child’s level for initial conversation
- Toys to maintain child’s attention as appropriate
- Before beginning, the clinician should be positioned in a way that eye contact can be made and is able to begin observation of the child
- if child can contribute to case hx, clinician should stay at child’s eye level and avoid towering over the child when speaking —> helps establish rapport
- when initial questioning is focused on the caregiver, three strategies can be used depending on the disposition of the child at the time:
Case hx intake (Equipment)
- All questions are directed to the caregiver if the child is very young (usually 4 y/o and under)
Child is calm/cooperative and does not need the caregiver’s full attention
- An assistant can begin objective and noninvasive testing of the child with the parent near the child and answering question
Child is calm/cooperative and does not need the caregiver’s full attention
- The child can be held or positioned behind the caregiver during the hx. The exchange should be friendly and warm so that trust is built as the child observes the interaction.
Child is apprehensive / uncooperative
- An assistant can give toys to the child to decrease any apprehension.
- A mildly cooperative (not just apprehensive) may need some toys or other distractions to help focus attention
- Significantly uncooperative child may require a “time out” conversation with caregiver to discuss if some goals for the exam can be achieved or whether it would be best to find another time when child is lessy sleepy, less stressed etc.
Child is apprehensive / uncooperative
- Caregiver may not be able to answer lengthy set of questions because child need the caregiver’s attention.
Child is young/immature such that parent must hold the child
- clinician should conduct an abbreviated case hx to obtain most vital details and immediately begin the exam to maximize time
Child is young/immature such that parent must hold the child
Observation during Case Hx
⚬ eye turn
⚬ squinting
⚬ head tilt
⚬ type and quality of communication between caregiver and child
⚬ behavior of the child
⚬ general wellness of the child
- Name
- Age
- Gender
- Address
- Contact nos
- Occupation/Course/Grade Level
- Hobbies/Avocation
Demographic Data
- Open-ended question: “What brings you in today?”
- What are the associated factors affecting the chief complaint?
Chief complaint/Hx of Present Illness
- When was the last full eye exam for the child, or is this the first?
- Has the child ever worn glasses? How old are the current glasses? How often does the child wear the glasses?
- Has the child ever worn CLs? If yes, how does she/he care for the CLs? (e.g. disposal, hygiene, etc)
- Any observations of lazy eye or eye turns?
Visual and Ocular Hx
- Prenatal, perinatal and postnatal hx
- Date of most recent medical examination
- major medical illnesses (review of systems)
- Hx of surgeries or inpatient admissions
- Head or ocular trauma hx
- vision or ocular tx
General Health hx
- medication list (Rx and non-Rx drugs, eye drops or ointments)
- drug, food and environmental allergies
Medication
- Family medical hx usually screens for cardiovascular disease or other hereditary conditions affecting the visual system
- Family ocular hx:
⚬ EOR (onset early in life)
⚬ Strabismus
⚬ Amblyopia
⚬ Glaucoma
⚬ CV deficiency
⚬ Blindess
Family Medical and Ocular Hx
*Remember that each child develops at different rate.
*Developmental milestone charts give approximate ages at which skills occur but children may not necessarily follow these timelines to the exact age
Developmental Hx
- Does the infant recognizes the caregiver’s faces?
- Does she follow you or preferred toy with their eyes?
- Are they reaching for objects yet?
- Any observation of lazy eye or eye turn?
Infants and Toddlers ask specific questions like
*questions that focus on typical milestones (motor skills, hand-eye coordination, verbal and social skills)
* this allows the clinician to make connections to visual development and coordinate with other providers as appropriate
Preschoolers ask specific questions like
- school performance is primary point of discussion and learning difficulties
- questions regarding visual habits
Elementary-aged children ask specific questions like
- may be less responsive to questioning
- ask questions first about themselves and their preferences may help to establish a safe space
- may also be interested in CLs, and clinician will assess the readiness of the child and parent
Teenagers/ Adolescents ask specific questions like
- Are there any learning-related visual symptoms?
- How is the child doing in school?
- Is the child in the age-approrpiate grade? Has she/he ever repeated a grade level? If yes, why?
- Is the child in a special education setting (individualized education plan or adjusted learning plan)?
Educational Hx
- What does the child do in her/his spare time? Include time spent outdoors and near work
- How much total screen time in a 24-hr period (including cell phones, video games, computers, tablets, tv, etc?
- Environmental hx: ask about pets at home and type of housing (important with cc of itching, watering, eye rubbing, etc)
Time outdoors & screen time
- for proper referral and coordination
Names and contact information for the pxs other health care providers
