Paediatric Optometry Flashcards
know the average Rxs for each age group from baby - 6 years old
ok - check ss
Give some tips for good communication in child eye tests
-direct your communication towards the child by adapting to age, maturity and ability to understand
-include accompanying adult in the conversation
-explain what youre going to do before you do it
-keep encouraging the patient throughout even if they’re getting it wrong
-pay close attention to non verbal communication
what tests should you do on children?
-monocular va
-cover test
-ret
-stereopsis
-ophthalmoscopy/ volk
-assess objective accommodation
-assess near vision
-assess ocular muscle balance
what tests can you do to check VA in children and babies?
-teller cards
-keeler cards (same as teller but gratings are presented inside circles)
-cardiff cards
-kay singles
-crowded kay pictures
-lea kay singles (used in canada and america alot)
-sonksen LogMAR test = Keeler LogMAR test
for teller cards:
what age are they for?
what do they measure?
what type of test are they?
how do they work?
-birth to ~12 months
-measures resolution acuity
-preferential looking
-made up of gratings that become increasingly fine and get presented to the px 4 times and the VA is recorded as the last grating the patient saw
-does not work after 12 months old as the child will become more drawn to the practitioner behind them
for cardiff cards
what age are they for?
what do they measure?
what type of test are they?
how do they work?
-around 12 months to around 2.5 years
-resolution acuity
-preferential looking
-made of vanishing optotypes and you have to watch the px eye movements to judge where they are looking. the practitioner does not know where the picture is and the VA is the last card the px saw 2 out of 3 times
-may get boring as the child gets older as they are grey so not as visually stimulating
for kay singles
what age are they for?
what do they measure?
what type of test are they?
how do they work?
~2years to ~4years
-recognition acuity
-picture matching/ naming
-px either uses matching card to match the pictures or names them
for crowded kay pictures
what age are they for?
what do they measure?
what type of test are they?
how do they work?
-~2 years to ~4 years
-recognition acuity
-picture matching/ naming
-patient uses either matching cards to match the pictures or names them
(better than kay singles because children with amblyopia may seem to have better visual acuity if you use single pictures so it’s better to use multiple pictures to diagnose potential amblyopia and multiple pictures are also more like real life images they would see day-day)
for lea crowded singles
what age are they for?
what do they measure?
what type of test are they?
how do they work?
-~2 years to ~4 years
-recognition acuity
-picture matching/ naming
-patient uses either matching cards to match the pictures or names them
popular in Canada and USA - also come in single format but multiple images to match is better than singles to help diagnose amblyopia
for Sonksen LogMAR test
what age are they for?
what do they measure?
what type of test are they?
how do they work?
-~+3 years
-recognition acuity
-letter matching/ naming
-patient either uses matching card to match the letters or they name them
how is Keeler LogMAR crowded test different to Sonksen LogMAR tes?
in keeler the test comes with two booklets where one has letters that are crowded and the other has letters that are uncrowded. otherwise they’re the same
when doing cover test on a child, what could be a positive sign that the two eyes are clear?
a patient not rejecting an eye being covered
why are autorefractors not good on childeren?
-children can be very wriggly and autorefractors need a few seconds to work
-the child can accommodate at the target especially if they have not had cycloplegic drops so can give an unusual reading
what is the average Rx for children who are:
-three months old
-six months
-nine months
-one year
-18 months
-2 years
-3 years
-4 years
-5 years
-6 years
+3.00
+2.50
+2.25
+2.00
+1.50
+1.25
+1.00
+0.50
+0.50
+0.50
when should you recall a child?
-6 moths if they seem to have no problems
-if they have a turn then best to do 3 moths
-minimum recall in scotland and wales is 12 months, in england is 6 months
as long as your recall is sensible and you can back it up with necessary evidence and reasoning then that’s fine
how would you tell a parent you want the child to wear glasses full time?
- explain their vision is a little worse than what we would like
- start off slow with glasses wear and encourage wearing glasses while their hands are busy like eating or playing on ipad
- if parents/ anyone else in the house wears glasses encourage them to wear them around the child
- if they are at school ask the school to help
how should you end an eye test with a child/
end on a positive - Reassure parents after an eye test if the child turns out to need glasses talking about the plastic period and that there’s plenty of time to fix the child’s vision - helps them not to feel guilty
how can you measure a child’s near va?
-if they can read then use letter chart
-if not then you can use near picture charts
how can you measure a child’s accommodation?
with dynamic ret - most likely will not understand AoA
how can you test stereopsis in childeren?
using frensel prisms with lang I and lang II charts
-dont always work as they need to look at it for a few secs before the picture appears and some children will not look long enough
how can you test moto fusion in children up to age 5?
use 20 dioptre base out prism in front of one eye and in a normal response:
Eye behind the prism rapidly adducts to restore fusion
On prism removal, the eye quickly abducts again
what is a manifest deviation?
a deviation that’s detectable when both eyes are open
what is the incidence of heterotropia?
present in 2-4% of the population
what are the characteristics of tropias?
-Constant or intermittent
-Present only at either distance or near
-Changes with refractive error or does not change - so you need to make sure to state whether what you’re seeing is with or without glasses
-Can develop in childhood or later in life and consequences are different as in childhood, patient is at risk of developing suppression or arc or amblyopia or eccentric fixation whereas in adults they will develop diplopia and in only in some rarer cases where they develop suppression
What are the caused for a young child developing heterotropia?
Refractive (typically hyperopia)
Neurogenic
Myogenic (muscular)
Trauma
Associated with disease (systemic /
ocular)
Idiopathic
Congenita
what are the causes for heterotropia development in older children/ adults?
-Decompensation of existing -heterophoria
-Trauma
-Associated with systemic / ocular disease
-Neurogenic
give three signs of heteroptropia
-visible deviation
-asymmetric corneal reflections
-abnormal head posture (in incommitant)
what might you do to test for heterotropia?
-cover test
-hirschberg
-motility
how can you manage heterotropia in young childeren?
-Prescribe them glasses
-If the eyes still have not straightened up then refer to HES orthoptics as they may be a candidate for something like surgery and need careful monitoring to reduce risk of amblyopia development
how can you refract young children and why is it different to adults?
-cycloplegic refraction
-mohindra retinoscopy
to control accommodation as younger people have very high accommodation levels so static ret would be too variable
who else other than children can benefit from cycloplegic refraction?
any patient where you suspect accommodative problems:
-latent hyperopia
-unusual esophoria
what doses of cyclopentolate should you use on different childeren?
-1%: 3 months - 11 years
-0.5%: 11-17 years
what is the gold standard technique for cycloplegic refraction?
- Dry ret
- Quick subjective refraction
- Discuss whether it’s appropriate to do this patient - contraindications and consent
- Instil drops and you’ll need to wait 30 mins
- Check pupils are dilated
- Carry out cyclo (wet) ret
- If patient is capable to do subjective then consider doing it
- Compare results between dry and wet refraction
what is mohindra ret?
Mohindra ret can be an alternative to cycloplegic ret as it’s a drug free alternative but is done in the dark - means there’s nothing for the patient to look at so only leaves the patients tonic accommodation hence most accommodation is relaxed and you can do a more accurate ret. ideally done monocularly (can ask the parent to occlude one of the eyes)
what distance should you sit for mohindra ret?
50cm
How do you manage heterotropia in older children/ young adults where it’s existing
-prescribe Rx as needed
-routinely monitor
How do you manage heterotropia in older children/ young adults where it’s new onset?
you need to consider cause
-is it decompensation of an existing heterophoria?
-is it a pathological cause? (THIS NEEDS URGENT REFERRAL)
what is a latent deviation?
only present when both eyes are dissociated
what are examples of visual system stresses that cause decompensating heterophoria?
- Excessive close work, suddenly increased
close work, poor illumination - Accommodative issues
- Poor fusional reserves
- Refractive error
- Visual loss
what are non ocular causes of decompensating heterophoria?
- Poor general health
- Stress / fatigue
- Medication
what does a HA and eyestrain mean in decompensating heterophoria?
- Vergence mechanism struggling to control
the underlying phoria - Generally frontal or temporal.
- Generally dull, persistent and non-pulsatile.
what are the common symptoms of decompensating heterophoria?
- Includes eye-strain (asthenopia), headaches
and double vision. - Non-specific.
why may some patients with decompensating heterophoria have diplopia?
- When phoria actually breaks down to tropia
(unless suppressing) - May do so on an intermittent to semi-
permanent basis. - Must differentiate between blurred and
double vision and between physiological and
pathological diplopia
when in the day are patients more likely to experience decompensating heterophoria?
-ok in morning but gets worse end of day
-increases with eye usage
give 3 non clinical signs of decompensating heterophoria
- Screwing up eyes, closing or covering one eye, avoidance
of specific tasks (usually near). - Clumsiness / lack of coordination.
- Facial asymmetry.
what tests could you do to assess a decompensating heterophoria?
-accommodation
-convergence
-fusional reserves
-fixation disparity
-binocular vs monocular VAs
-refractive error
-foveal suppression
-stereopsis
which of the two types of heterophorias would you need to manage?
decompensating heterophorias as the fusional vergence is insufficient to obtain or maintain BSV so is often symptomatic
how can you manage decompensating heterophorias?
-eye exercises
-spherical manipulation
-prism
-daily habits
(rarely need referral but this may be a management option too)
what is the primary, secondary and tertiary positions of gaze?
-primary is where the eyes are straight ahead
-secondary is where the eyes are straight up/down/right/left
-tertiary is where the eyes are up & right / up & left / down & right / down & left (diagonal)
what is a comitant deviation?
where the deviation is manifest during testing and is the same in all directions of gaze
what is an incomitant deviation?
where deviation is manifest during the test but varies in different positions of gaze
theres usually ocular or orbital pain on an eccentric gaze
what can tell you an incomitant deviation is congenital?
it is asymptomatic
name 3 causes of incommitant deviations
-duane’s retraction syndrome
-brown’s syndrome
-blow out fracture
-thyroid eye disease
how does duane’s causer incomitant deviation?
when the 6th cranial nerve (abducens) which normally controls lateral rectus either does not develop or does not work properly causing the affected eye to not be able to move past the midline so it retracts in the globe causing a pseudoptosis
how does browns syndrome cause incomitant deviation?
as it causes a mechanical problem with the tendon of the superior oblique muscle so restricts it’s movement
how can a blow out fracture cause incomitant deviation?
causes a collapsing of the orbital floor and so tethering of the inferior rectus causing restrictions in both up and down gaze
how can TED cause incomitant deviation?
-causes fibrosis of the diseased muscle which reduces constriction and relaxation
-causes an increase in orbital tissue which proposes the eye resulting in abnormal eye movements and lid retraction
what is accommodative insufficiency?
where aoa is below normal range for age
what are the symptoms of accommodative insufficiency?
reduced NVA and asthenopia
what can cause accommodative insufficiency and accommodative fatigue?
-uncorrected refractive error
-health
-increased accommodative demand
how do you manage accommodative insufficiency?
-update/ prescribe Rx
-orthoptic exercises
what is accommodative fatigue symptoms?
where NVA is ok for short periods but reduces with duration of near work
what is accommodative infacility? How can you measure it?
delay in accommodative response, with the +2, -2 flippers and looking at the number of cycles in 1 min.
what are the symptoms of accommodative infacility?
patients report e.g. blurred vision when looking up from near tasks which slowly gets clearer
what can cause accommodative infacility?
-uncorrected refractive error and health problems
how can you manage accommodative infacility?
update RX
fix any health problems
improve convergence/ fusional reserves
how can you manage convergence insuffieciency?
-orthoptic exercises
-manipulation of Rx if pre presbyope
-prism
-in extreme cases surgery
what are signs and symptoms of convergence insufficiency
-reduced NPC
-blur/diplopia/asthenopia at near
-exophoria at near
what is accommodative spasm?
bilateral over accommodation which causes miosis and increased eso deviation at near
what are the symptoms of accommodative spasm?
- Blurred distance
vision (pseudo
myopia) - Headaches, pain
what can cause accommodative spasm?
-uncorrected hyperopia
-trying to control distance exotropia with accommodation
-fatigue
how can you manage accommodative spasm?
-medical treatment (cycloplegics to prevent accom)
-reduce amount of near work
-prescribe + lenses
when doing mohindra ret what do you have to take into account?
that the patient has not fully relaxed their accommodation but instead has stabilised
what should the beam brightness be in mohindra ret?
dim
what are the rules to find the correct refractive error in mohindra ret depending on your patient?
-for infants under 2 subtract 1.25 less than your working distance
-for children over 2 subtract 1.00 less than your working distance
-for young adults subtract 0.75 less than your working distance
who benefits from cycloplegic refraction?
-young children especially below 7
-a suspected latent hyperope
-someone with suspected accommodation problems e.g. may be suggested by aoa
-someone with unexplained poor vision
-children with special needs
what are the three drawbacks of cycloplegic drops?
-initial stinging
-blurred vision
-photophobia
how many drops of cycloplegics should you use and why
only 1 as adverse reactions (to 1%) in children are very common including, drowziness, hyperactivity or behavioural changes
what is the most common error in cycloplegic refraction?
neutralising the ret reflex seen for the whole pupil when really the periphery of the reflex should be ignored and you should focus on the centre of the pupil
what is emmetropisation?
an active developmental process where the brain uses visual input to modify corneal curvature and axial length to fine tune the genetics that formed the eyes shape to allow for sharp vision
at what age does emmetropisation peak?
peaks around age 5-6 but is usually in the low hyperopic range rather than no refractive error
what is the ideal refractive error for a child in pre-school age?
around +1.00
what is the pre myopia stage in childeren?
when the refractive state is ≤ 0.75 D and > -0.50 D so suggests there is risk of myopia development
when does myopia in childeren tend to progress most?
once it starts, usually most progression is in school years and the younger the age the faster the rate of progression
in myopia development, what gender is onset earlier?
girls (possibly as girls go through puberty earlier)
what causes myopia progression?
primarily elongation of vitreous chamber depth
what conditions can make children more likely to be hyperopic?
strabismus/ amblyopia because this can sometimes cause the eye to fail to emmetropise.
what is most likely the case of strabismus?
anisometropia
what kind of countries is myopia more common in?
-high income countries especially south and south east asia and is less common in low income countries
what lifestyle factors seem to increase development of myopia?
-Spending more time indoors
-Education
If education could be done outdoors, then this may provide a solution.
These do have a slight genetic factor
(shown by randomised controlled trials)
