10/6/14 Eye Exams for Kids: Do’s & Don’ts Disclosures Commercial: none Salary Support: NIH/NEI Susan Co=er, OD, MS Southern CA College of Optometry Marshall B Ketchum University Fullerton, CA US Preventive Services Task Force Which Kids Need Eye Exams? • Children 3-‐5 yrs be screened at least 1x to detect amblyopia & amblyogenic risk factors United States PrevenVve Services Task Force. Pediatrics 2011;127:340-‐6. American Optometric AssociaVon Eye ExaminaVon RecommendaVons • By 6 months or as recommended • 3 years or as recommended Direct Referral Guidelines* • Children at high risk for vision disorders • Readily recognized eye abnormalities • Annually or as recommended ≥ 6yrs *NaVonal Expert Panel (NEP) to NaVonal Center for Children’s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraVon, US Dept of Health & Human Services. In press: Optometry & Vision Science 1 10/6/14 Strabismus Nystagmus Ptosis Leukocoria Pupil Irregularity Direct Referral Guidelines • Neurodevelopmental disorders – Hearing impairment – Cerebral palsy – Down syndrome – Cognitive impairment – Autism spectrum disorders – Speech delay – Etc. *NaVonal Expert Panel (NEP) to NaVonal Center for Children’s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraVon, US Dept of Health & Human Services. In press: Optometry & Vision Science 2 10/6/14 Direct Referral Guidelines • Systemic diseases (e.g., JIA, diabetes) • Medications known to cause eye disorders • Family history of first-degree relative with strabismus or amblyopia • Prematurity (<32 weeks gestation) • Parent thinks child may have a vision-related problem *NaVonal Expert Panel (NEP) to NaVonal Center for Children’s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraVon, US Dept of Health & Human Services. In press: Optometry & Vision Science Amblyopia What Are We Looking For? ≤ 6 years • Amblyopia or risk factor • Strabismus • Significant RefracVve Error • Color Vision Defect • Eye Health Disorder Constant Strabismus • Reduced visual acuity in one or both eyes • Not from ocular pathology & not correctable with opVcal correcVon • Most common cause of vision loss in children Intermi=ent Strabismus Head Tilt or Turn? 3 10/6/14 Pseudoesotropia Esotropia? Pseudoesotropia • Follow up: later diagnosed w/ esotropia • 19% Anwar et al. • 10% Silbert et al. • Serial examinaVons & parent educaVon recommended Anwar et al. Strabismus 2012; 20(3), 124–126; Silbert et al. AAPOS 2012;16(2):118-9. RefracVve Error RefracVve Error Eye Disease RouVne Eye ExaminaVon Eye Exams for Young Children Minimum Data Base n Eye Alignment n Visual Acuity n RefracVon n Ocular Health n Color (Preschoolers) 4 10/6/14 RouVne Eye ExaminaVon Eye Alignment Visual Acuity Minimum Data Base n Eye A lignment RefracVon n Visual Acuity Ocular Health n RefracVon n Ocular H ealth Color & Stereo n Color (Preschoolers) (not infants) Color Vision TesVng Made Easy Minimum Data Base Eye Alignment Co=er, Lee, French. Optometry & Vision Science 1999;76(9):631-‐6. Versions: Extraocular Muscles • Rule out strabismus • Measure stereopsis • Test muscle funcVon Stereopsis TesVng Versions for EOMs Versions 5 10/6/14 Randot Preschool Stereotest Lang Stereotest Use an AccommodaVve target Pass Stereotest Cover TesVng Hirschberg Test 6 10/6/14 Hirschberg (Corneal Reflex) TesVng Brückner Test Brückner Test Brückner Test DetecVon of Strabismus & Anisometropia Brückner Test • Ability of Brückner to detect strabismus & anisometropia in populaVon-‐based cohort of infants / young children • 8601 children (6 to 72 months) • Brückner prior to eye examinaVon by eye doctor • Data analysis – Constant strabismus at near – Anisometropia Huang K, Co=er SA, MEPEDS et al. Optom Vis Sci 2011; 89:E-‐abstract 120023 SensiVvity and Specificity Strabismus Strabismus 23 (+) Brückner (-‐) Brückner ≥ 1D ≥ 2D ≥ 3D (+) Brückner 84 33 9 (-‐) Brückner 540 42 9 SensiVvity (Specificity) 13.5% (98.0%) 44.0% (97.5%) 50.0% (97.3%) No Strabismus 208 true posiVves false posiVves 25 8259 false negaVves Anisometropia by Magnitude true negaVves SensiVvity = 47.9% Specificity = 97.5% 7 10/6/14 Visual Acuity TesVng Brückner Test • Ability to… – IDENTIFY: leaves many children undiagnosed – PREDICT: <50% with (+) Brückner will have strabismus or anisometropia • Not sufficiently sensiVve as screening test for strabismus & anisometropia in children 6 to 72 months of age • Normal for age? • RE & LE equal? Huang K, Co=er SA., MEPEDS et al. Optom Vis Sci 2011; 89:E-‐abstract 120023 Visual Acuity TesVng Visual Acuity TesVng Monocular Visual Acuity Not recommended Monocular Visual Acuity Problem Charts 8 10/6/14 Preschool Visual Acuity TesVng HOTV or LEA Symbols • High contrast, single surrounded optotypes • 2-‐alternaVve forced choice or matching (use lap card) • Avoid necessity of verbal or direcVonal response • Shorter test distance (5 feet for screening) • Environment quiet and free of distracVon LEA Symbols VIP Vision Screening LEA 5 feet BEST PRACTICE: NaVonal Expert Panel (NEP) to NaVonal Center for Children’s Vision & Eye Health,, funded by Maternal & Child Health Bureau of Health Resources & Services AdministraVon, US Dept HHS. VA Screening: Pass/Fail Criteria • Must identify correctly 3 of 3 or 3 of 4 of: – 20/50 (5/12.5) level for 36 - 47 months – 20/40 (5/10) level for 48 to <72 months Untestable Preschool Children • Inattentive or uncooperative • Will not allow one eye to be covered • Do not appear to understand screening task ……Twice as likely to have a vision problem than those who successfully pass screening VIP Group. InvesVgaVve Ophthalmology & Visual Science 2007; 48: 83-‐7. 9 10/6/14 Visual Acuity: Toddlers Infants: Teller Acuity Cards Cardiff Cards Visual Acuity: Infants Infant Visual Acuity Teller Acuity Cards • Teller Acuity Cards • Children <1 year of age Teller Acuity Cards A Public Health Program for America’s Youngest Pa>ents 10 10/6/14 Eye Drops for DilaVon/Cycloplegia Determine RefracVve Error Determine RefracVve Error Determine RefracVve Error RefracVon Eye Health EvaluaVon 11 10/6/14 Biomicroscopy Anterior Segment ExaminaVon of External Ocular Structures Intraocular Pressure ReVnal ExaminaVon • iCare Tonometer • Others 12 10/6/14 ReVnal ExaminaVon ReVnal ExaminaVon School-‐age Children Not COTTEr slide – see what erin says Toy Auer Eye Drops • Eye Teaming • Eye Focusing – Ability – Accuracy – Flexibility • Eye Tracking “She is Blinking All of the Time!” Excessive Blinking Bilateral (89) > Unilateral (10) 6 months – 13 years 2:1 Boys Intermi=ent (79) vs, Constant (20) Characterized by – Excessive rate -‐ 46 – Excessive duraVon & force -‐ 16 – Both -‐ 37 • Child complained to parents (29) • • • • • * Coats et al. Ophthalmology 2001:108:1556-‐1561. 13 10/6/14 Bilateral Blinking in 89 Children Diagnosis # Pa>ents Habit Vc 21 Uncorrected refracVve error 14 ConjuncVviVs 14 surface Psychogenic • Foreign bodies -‐ ocular 10 Myopia 6 • Chronic Mean keraVVs -‐ oAsVgmaVsm cular IXT or exophoria 10 5 duraVon 9 wrosacea ks (1-‐52) • Acute microbial Worse kweraVVs ith s5 tress 25% Hyperopia 4 KeraVVs 85% resolved Dry eyes 5 at FU *Blinking only sCondiVon ign noted by parents known & CNS disease 4 under treatment before Lid abnormaliVes 3 blinking onset Toure=e syndrome 1 Unclassified 2 * Coats et al. Ophthalmology 2001:108:1556-‐1561. Excessive Blinking -‐ Rule Out • Anterior segment or eyelid disorder • Uncorrected refracVve error • Intermi=ent strabismus / high phoria • RouVne neurologic & neuroimaging not indicated for isolated excessive blinking* • Habit Vc -‐ management Bilateral Blinking in 89 Children Diagnosis Habit Vc Uncorrected refracVve error ConjuncVviVs Psychogenic IXT or exophoria KeraVVs Dry eyes CNS disease Lid abnormaliVes Toure=e syndrome Unclassified # Pa>ents 21 14 14 10 10 5 5 4 3 1 2 * Coats et al. Ophthalmology 2001:108:1556-‐1561. Current Amblyopia Treatment • Glasses correcVon • Patching 2-‐6 hours /day • Atropine drops in sound eye • Age?? * Coats et al. Ophthalmology 2001:108:1556-‐1561. Symptoms Associated with Eye Teaming or Focusing Problems What is Vision Therapy? • frequent loss of place • loss of concentraVon • double vision • blurred vision • headaches • reading slowly • eyestrain • Vred eyes • sleepiness • trouble remembering what was read • need to re-‐read same line of words 14 10/6/14 [email protected] 15
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