peadiatric eye assessment
TRANSCRIPT
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PePeadiatric eye adiatric eye assessmentassessment
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Visual DevelopmentInfancy and early childhood is an important time in visual development
The eyes grow and emmetropise
Vision improves
Stereopsis matures
Accommodation develops
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Visual problems
Visual disorders are the leading cause of childhood disability
Aside from congenital pathology common disorders include amblyopia, strabismus and refractive error
Early detection means prevention and better treatment
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Visual milestonesVery soon after birth - can fix and follow a light source, face or large, colourful toy
1 month- Fixation is central, steady and maintained, can follow a slow target, and converge, preference of looking at face
3 months- Binocular vision and eye coordination, eyes follow a moving light or face, responsive smile
6 months - Reaches out accurately for toys
9 months- look for hidden toys
2 years - picture matching
3 years - letter matching of single letters
5 years - snellen chart by matching or naming
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What are the challenges?
How to examine the children???
Be sensitive!!!You are a stranger to him, He feels safe only if the parents are comfortable with you.
Initially ignore the baby and act normal
Start by communicating with the parents
Slowly and be natural
While talking to the parents, introduce some toys at the same time
If he accepted the toy, you almost gained his trust.
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Eye exam and Vision screening
Birth to 3 years
Ocular History
Vision assessment
External examination
Ocular motility/ alignment- corneal light reflex, alternate cover test, stereo acuity
Pupil examination
Red reflex
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Ocular HistoryFor babies aged 0-3 years, history from parents are very important;
Asked questions like:
Does your child hold objects close to his or her face?
Does your child’s eyes appear straight or crossed?
Relevant family history regarding eye disorders
Birth history- full term, normal delivery?
Visual behaviour of child- clumsy, visually inattentive, close viewing distance
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Visual Assessment
Mainly we want to see if baby can fix and follow
To determine whether each eye can fixate on an object, maintain fixation and follow the object into various gaze positions
The assessment should be performed binocularly and then monocularly.
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External Examination
Consists of penlight evaluation of the lids, conjunctiva, sclera, cornea, and iris.
Persistent discharge or tearing may be attributed to ocular infection, allergy or glaucoma but the most common cause is lacrimal duct obstruction
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Ocular motilityAlternate cover test
occlude one eye
move occluder to other eye
watch for shift of recently occluded eye
Corneal light reflex= Hirschberg’s test
reflexes symmetric= normal
reflex nasally= exotropia
reflex temporally= esotropia
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Red ReflexReferral
dark spots in reflex
blunted/ dull reflex
lack of red reflex
white reflex
asymmetry color/ brightness/ size
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Age 3 years and older
all previous and…
Age-appropriate visual acuity
attempt at ophthalmoscopy
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Visual AcuityRecommended test
Snellen letters
Snellen numbers
Tumbling E
HOTV
Allen Figures or LEA
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Preferential looking test of vision
Keeler/Teller cards for infants
Cardiff acuity cards for toddlers
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Picture test of vision
Kay pictures
LEA symbols
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Fundus examination
Important to examine the fundus to ensure no pathology
Abnormal findings could explain poorer than expected vision
Direct ophthalmoscopy can be difficult with young children due to the proximity required. They also have a tendency to keep looking at the ophthalmoscope light
Indirect methods can be more successful
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Routine ReferralFailed visual screening
Amblyopia or amblyopia risk factor
Strabismus, horizontal nystagmus, torticollis
Eyelid abnormality
Nasolacrimal duct obstruction
refer at age 10-12months or sooner if problematic recurrent/resistant secondary infections
95% resolve by 12 months with conservative management: lacrimal massage and topical antibiotics
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Urgent referralPreseptal cellulitis not responding to treatment
CN palsy/ acute onset strabismus
unusual nystagmus
red eye
severe conjunctivitis not responding to topical antibiotics
HSV keratitis
concern for acute uveitis
congenital glaucoma
Dacrocystocele
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emergent referralophthalmia neonatorum
ocular trauma
concern for penetrating trauma
severe blunt trauma
leukocoria
Orbital cellulitis
sudden loss of vision
papilledema
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THANK YOU…