wk9: BV - Paed exam communication and management

Question 1

When is measuring vision of a child not typically possible? (2)

Answer 1

if child is very young (under 3) or unable to respond due to cognitive difficulties

Question 2

What methods can we use to measure vision in children? (3)

Answer 2

Lea symbols
Pattie Pics
HOTV

All using a randomised chart where possible

Question 3

How can we maintain the child’s attention when measuring vision subjectively?

Answer 3

Make it a “matching game” to ensure child understands the concept

Question 4

If you are unsure of child’s cognitive abilities when measuring vision subjectively, what can you do to make the child more likely to cooperate?

Answer 4

Start with a single symptom that is big so child feels that what you are asking is EASY and they can have a go

Question 5

Should measuring a child’s vision subjectively start monocularly or binocularly?

Answer 5

binocularly first to gain child’s confidence (also minimal disruption for child)

Question 6

What is HOVT?

Answer 6

Literally a V.A chart with only the letters H, O, V, and T in random orders

Question 7

What can you do if a child of 3-5 years confidence improves when measuring vision?

Answer 7

measure single symbol with isobars (crowding/contour interaction bars)

Question 8

At what age might you consider LogMar presentation for vision testing? And when?

Answer 8

5+ years and only if sure child is able to udnerstand

Question 9

At what age will we first expect 6/6 vision?

Answer 9

6 years old

Question 10

What are the distance V.A expected norms for the following ages?
3, 4, 5, 6, 7,

Answer 10

3: 6/12
4: 6/9
5: 6/7
6: 6/7
7: 6/6-

Question 11

What are the near V.A expected norms for the following ages?

3, 4, 5, 6, 7

Answer 11

3: 6/15
4: 6/12
5: 6/9
6: 6/7
7: 6/6-

Question 12

For the SCCO 4+ system for evaluating oculomotor fucntion: what represents a rating of 4 +? (3)

Answer 12

fixation ability: smooth and accurate
pursuit ability: smooth and accurate
saccadic ability: smooth and accurate

Question 13

For the SCCO 4+ system for evaluating oculomotor fucntion: what represents a rating of 3+ (3)

Answer 13

fixation ability: one fixation loss
pursuit ability: one fixation loss
saccadic ability: some slight undershooting

Question 14

For the SCCO 4+ system for evaluating oculomotor fucntion: what represents a rating of 2+? (3)

Answer 14

fixation ability: 2 fixation losses
pursuit ability: 2 fixation losses
saccadic ability: gross undershooting and overshooting or increased latency

Question 15

For the SCCO 4+ system for evaluating oculomotor fucntion: what represents a rating of 1+? (3)

Answer 15

fixation ability: more than 2 fixation losses
pursuit ability: more than 2 fixation losses or uncontrolled head movements
saccadic ability: inability to do task or any uncontrolled head movement

Question 16

What is the most valuable tool we have as optometrists when seeing children? Why?

Answer 16

Retinoscopy: it’s objective, relaible

Question 17

How may regular retinoscopy differ when used on a child? (1)

Answer 17

consider only putting working distance lens in eye you are doing ret on because otherwise child may not see target properly and therefore not comply/not look at target

Question 18

What is the most reliable form of retinoscopy in children?

Answer 18

Retinoscopy with cycloplegia

Question 19

What is the advantage of near/dynamic retinoscopy?

Answer 19

it gives you a real life indication of how the accommodative-vergence system behaves at near. This can sometimes be the only indicator of near function in children,because it is objective

Question 20

What is mohindra retinoscopy? (2)

Answer 20

Done at 50cm in dark, monocular with no wd lens

Adjust finding: -0.75 for infants, -1.25 after 2 years old

Question 21

In addition to ret, name 3 other objective refractive evaluation tools

Answer 21

1. Keratometry/corneal topography: do routinely on all newly presenting school-aged kids
2. Reduced VA from uncorrected Rx
3. Autorefraction: can be considered when need further information on refractive status, best with cycloplegia,

Question 22

What is the downside to autorefraction?

Answer 22

can often overestimate cyl/astig

Question 23

Why should you do keratometry/corneal topography on school aged children?

Answer 23

serves as a baseline should there by any change in the years following. Also picks up suspicious looking corneas early and can be most valuable when tracking or diagnosing a first time keratoconic

Question 24

State 5 clinical pearls for evaluating maximum plus with blur function

Answer 24

1. children have very active accommodation: therefore over minusing needs to be avoided
2. children are more dependent on their spatial (proximal) cues than adults, accuracy may be worse behind phoropter
3. do refraction in free space: trial frame
4. don’t waste time on conventional subjective refraction unless sure child is reliable
5. even in some older children subjective refraction is difficult

Question 25

Describe in 6 steps how you evaluate maximum plus with blur function in kids

Answer 25

1. Add about +1-+1.50 over ret binocularly (or monocularly if child vision assymmetrical)
2. Warn child it will be initially blurry
3. Use randomised chart and progressively make easier
4. Don’t ask if better or worse, get them to read the line
5. Keep going until plateau or maximum plus to 6/6
6. Can do monocularly as well when child with asymmetric vision

Question 26

When assessing binocular vision, what is it your goal to evaluate? (4)

Answer 26

Binocularity: is child binocular? do the 2 eyes work together?
Visual efficiency: How efficient is this visual system? How does it cope with age expected visual demands at far and near?

Question 27

How can you assess binocularity? (3)

Answer 27

Check suppression: worth 4 dot, distance and near, prism doubling
Check alignment: hirschberg, HH, cover test
Check sensory fusion: stereo tests, lang, fly, random dot

Question 28

How can you assess visual efficiency? (4)

Answer 28

Posture: phorias (distance and near), MEM, NPA
Facility: accommodative facility, vergence facility
Ranges: vergence and accommodative ranges
Near skills: AC/A, NPC< PRA, NRA

Question 29

How can we measure phoria when child is young? (5)

Answer 29

Prentice card:

• place vertical prism 6-8^BDR
• ask child if mum/dad looks funny or different
• if child picksup that mum has 2 heads, then you can have a go at measuring phoria
• take it slow with step by step instructions

Question 30

How can we measure binocular vision status in very young children from 3-6? (3)

Answer 30

NPC
MEM ret
Cover TEst

Question 31

What is the Bruckner Test? (5)

Answer 31

Dim room
1 metre test distance
No pupil dilation
Shine ophthalmoscope onto bridge of nose to illuminate both pupils at same time
Compare brightness and whiteness of fundus (red) reflexes through pupils

Question 32

What does an unequal reflex in bruckner test mean?

Answer 32

could indicate refraction differences between eyes

Question 33

What does the bruckner test show if strabismus is present?

Answer 33

deviated eye looks whiter and brighter

Question 34

What does the bruckner test show if media opacities are present?

Answer 34

can see this via absence of red reflex or obstruction to red reflex