Pediatrics. for the Primary Care Optometrist. Marianne E. Boltz, OD, FAAO. Penn State Eye Center

Transcription

1 Pediatrics for the Primary Care Optometrist Marianne E. Boltz, OD, FAAO Penn State Eye Center American Academy of Optometry Meeting San Antonio 2018

2 Disclosure Statement: Nothing to disclose

3 Learning Objectives Describe the most effective eye exam techniques for infants and the pre-school population Review recommendations when to prescribe glasses for young children Identify the most common causes and treatment of binocular dysfunctions, decreased visual acuity and ocular pathology in the pediatric population

4 Why should your practice see more kids? Kids have eye problems A report of children 6mo 6 yrs showed* 33% had hyperopia 22.5% had astigmatism 9.5% had myopia 5% had binocular vision disorders 21.1% had strabismus 7.9% had amblyopia 0.5% had retinal problems *J Am Optom Assoc 1996;67(4):

5 Why should your practice see more kids? Practice Management 1 01 = see more patients, make more $$ You develop a patient for life as well as the possibility of bringing in multiple generations of family members Kids Welcome Here, InfantSEE not just education, but to grow your practice!

6 Why should your practice see more kids? Most importantly: For the fun of it!! For the gratitude from parents For the homemade drawings, pictures and hugs that you get from the kids For the personal fulfillment knowing that you play an important role in the health and future success of these special patients!

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8 What prevents many OD s from seeing infants or preschool children? Lack of familiarity/comfort with basic exam techniques Same could be said of doing any skill like scleral indentation! (if not performing often) Practice makes perfect.. Not equipped with the tools of the trade Being prepared is the key like surgeon laying out his tray of tools

9 Basic tools of the trade (shopping list) Fixation targets = so, so important! Distance = ipad/dvd/tv across room or M&S Technologies computer system Near = finger puppets, toys, small stickers & letters on popsicle sticks Distance and Near acuity tests Loose prisms (not bar) Pre-school color vision test Infant/pediatric trial frame

10 Infant and Pre-school Exam Basics History Visual acuity Ocular motility/alignment Anterior segment exam Pupil exam Refraction Posterior segment exam/dfe

11 History Mother s Pregnancy hx Length (prematurity < 28 weeks, risk of ROP) Drug/alcohol use Delivery Birth weight (< 1500 g, risk of ROP) Complications (long labor, O2 used?) Apgar Score (10 is perfect) Developmental hx: milestones on time? Motor delay, speech delay, cognitive delay Behavioral hx Autism spectrum, ADD/ADHD Academic hx Reading issues? IEP?

12 Ocular History Amblyopia or Strabismus Age of onset Previous treatment: glasses, patch, orthoptics Family history Eye surgery (muscle or cataract) Double vision Itching, rubbing - allergies? Chronic tearing nasolacrimal duct obstruction? Eyelid crusting - blepharitis? Behaviors Tilt/Turn head Sit close to TV, hold book too close

13 Visual Acuity - Infants Light detection = WTL Object detection tests Fix and Follow Finger puppet or toy Record: F&F 2 toy at 12 distance Lea (Heidi) face stimulus paddles 3 different sizes (2, 4, 8 ) Note target, size and test distance Occlusion Hold hand over each eye = avoid patch Note resistance to occlusion? Also tests ocular motility

14 Visual Acuity - Infants Preferential Looking Teller = time and $$ Lea Gratings Detects recognition of lines of decreasing width Present gray and striped paddles simultaneously Held at 57 cm (~2 feet) Record in cycles per cm (cpcm) Largest =.25 cpcm, smallest = 8.0 cpcm

15 Visual Acuity - Toddlers Ages 18 mo 3 years Object detection Fix and follow Preferential looking Lea gratings Cardiff Cards Recognition tests Broken Wheel test Preferential looking

16 Visual Acuity Preschoolers Occlusion: Try Opticlude adhesive or pirate-type or clip-on patch (instead of occluder) LEA Symbols Standard for ~Age 3-6 (or delayed) Test distance 10 feet Record 10/10, 10/20 Matching card for nonverbal Near vision cards available

17 Binocular Vision Assessment - Infants Bruckner Red Reflex Baby fixates ophthalmoscope at 1M distance Focus large beam to illuminate both eyes simultaneously Judge relative whiteness/brightness of pupils Note: problem eye has brighter reflex! Record: EQUAL or R/L whiter/brighter

18 Binocular Vision Hirschberg Test Determine if strabismus present, identify direction, estimate frequency and magnitude Baby fixates penlight at 50cm Examine relative placement of corneal reflexes to center of the pupil Binocular alignment = symmetrical displacement 1 mm displacement = ~22 pd

19 Hirschberg Test A. Normal B. Left ET C. Left XT D. Left HT

20 Krimsky Prism Test Estimate the magnitude of strabismus Observe Hirschberg reflex Place correcting prism over FIXATING eye until the reflex of the deviating eye is symmetric (BI or exo, BO for eso) Amount of prism = magnitude of strabismus

21 Vertical Prism Test (10 pd) Determine eye preference to rule out strabismus or amblyopia Target is small finger puppet or single letter Present BD prism, one eye at a time Watch for eyes shifting UP Example: If both eyes shift up when prism is placed in front of the RE, but NOT the LE, then the LE may be strabismic or amblyopic! Binocular Vision - Infants Cover testing Target is penlight or toy for infants Use your HAND or THUMB as a cover for infants Target for pre-school small picture or letter Near Point of Convergence Present at age 6 months Target is finger puppet or single letter

22 Binocular Vision Assessment - Preschoolers Cover testing More reliable distance, near and can try multiple positions of gaze At near, make sure to use an accommodative target ~20/40 letter or very small sticker on popsicle stick Modified Thorington Test Easy way to measure near phorias Allows for direct observation of the eyes in a natural environment & easy directions for kids

23 Slant Modified Thorington Card with transilluminator adaptor Use with Maddox Rod putting red line vertically (to measure horizontal phoria) & horizontally (to measure vertical phoria)

24 Color Vision Preschool Color Vision Testing Made Easy Pseudoisochromatic Quick test identify boat, dog, balloon, car Full test identify or match circle, square, star Preschool and School Age H.R.R. Pseudoisochromatic Plates Diagnostic plates can help you differentiate between mild, medium or strong Red/Green and medium or strong Blue/Yellow defects Eliminates potential for memorizing and malingering Series of 6 screening and 14 diagnostic plates

25 There s an App for that! H.R.R. Calculator Richmond Products $19.99

26 Anterior Segment Exam Burton lamp Hand-held slit lamp Penlight/transilluminator with or without 20 D lens

27 Trade Secret #1 The Eye Doctor Motorcycle

28 Refraction = Retinoscopy Lens bars Loose lenses Less distracting for infants Mohindra (near retinoscopy) method Monocular technique, dark room Baby fixates retinoscope at 50cm Make animal sounds, sing, call name Results adjusted by D Neutralizing lens +3.25sph, result is +2.00sph

29 Cycloplegic refraction Why? Paralyze accommodation Allows for more accurate refraction Does not matter if child looks at you What to use? Cyclopentolate 1.0% Longer duration - 8 to 12 hours 2 drops (each one 5 min. apart) : wait 30 minutes May also use in combination with 2.5% phenylephrine for improved fundus exam (greater pupil diameter) Educate parents on low risk side effects Flushing, tachycardia, hyperactivity

30 Cycloplegic refraction When not to use? Do NOT use for baby s with Down Syndrome and heart abnormalities or history of heart sx When to use? Hyperopia, Esotropia, Amblyopia Uncooperative patient or poor fixation (BABIES) and most pre-schoolers )

31 Speaking of drops Be prepared for various forms of protest! Can make spray formula OR just place drops on eyelash margin Some tricks of the trade Wrap baby in blanket papoose Elicit parents, techs help holding arms & legs Secure baby s head and place on parent s knees

32 Dilated Fundus Exam Position child same as when instilling drops With BIO, use 20 D (more mag) or 28 D (larger field of view) Remember, everything is smaller Don t expect to get all or perfect peripheral views» But with many children you may get better success using a catchy fixation targets

33 Trade Secret #2 Ultimate fixation targets Great for ocular motility testing and getting peripheral fundus views!

34 If all else fails Don t get too frustrated! Can have child return on another day for a second try Refer to pediatric ophthalmologist for an exam under sedation/anesthesia (EUA)

35 What are we really looking for?? Does this child need glasses? Does this child have strabismus? Does this child have amblyopia? Does this child have ocular disease?

36 Refractive Errors Infants and pre-schoolers We prescribe to prevent amblyopia and to allow for normal vision development Not so concerned with low astigmatism, hyperopia or myopia

37 Potentially Amblyogenic Refractive Errors Warranting Correction in Infants and Young Children Isometropic D Anisometropic D Astigmatism >2.5 Hyperopia >4.5 Myopia >6.0 Astigmatism >1.5 Hyperopia >1.5 Myopia >3.0

38 Trade Secret #3 Miraflex frames Truly nonbreakable frame..very light weight and comfortable!

39 Defining Strabismus Review of nomenclature Comitancy = same magnitude in all positions of gaze Noncomitant deviations: poorer prognosis, usually caused by paralysis or restriction neuro work-up? Frequency: constant -XT or intermittant- X(T) Laterality: unilateral (one eye turning ONLY) or alternating (either eye turns)

40 Defining Strabismus Magnitude: measure in prism diopters Remember: measure ET with Base OUT, XT with Base IN Direction: ESO (ET), EXO (XT), HYPER (HT) Distance/Near relationship Age of onset Congenital/Infantile (before 6 mo) Acquired (past 6 mo)

41 Most common types of Esotropia Accommodative Esotropia Convergence Excess (High AC/A) Esotropia Infantile Esotropia Pseudo-esotropia

42 Accommodative Esotropia Presents between 1½ to 3 years of age Caused by the overconvergence associated with increased accommodation Uncorrected hyperopia causes accommodation! Associated with significant hyperopia Above typically +4-6 D Prescribing full refractive correction improves (partially accommodative) or totally corrects the ET cosmetic and functional cure!

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44 Convergence Excess (High AC/A) Esotropia A sub-type of accommodative ET ET is corrected at distance with their hyperopic glasses, but a residual ET occurs at near Less often occur with emmetropia or myopia Treatment = bifocals! Prefer flat-top = younger age, better for muscle alignment No bifocal contacts when older

45 Infantile Esotropia Large angle esotropia that is constant and presents during the first few months of life (before 6 mo) Usually an isolated problem, but can be associated with Down s Syndrome, Albinism or Cerebral Palsy Must rule out Sixth Nerve Palsy (r/o muscle restriction via motility testing) Treatment = strabismus surgery referral to Pediatric Ophthalmologist ASAP!

46 Pseudo-esotropia Even pediatricians are fooled by this Eyes are straight but appear to be crossed due to Wide nasal bridge Epicanthal folds of skin

47 Most common types of Exotropia Intermittent Exotropia Variable frequency at all distances or commonly more at distance (less at near due to accommodative convergence) Typical sign: closes eye in bright light Manifests when tired or daydreaming Convergence Insufficiency-type XT just measured at near (or greater at near)

48 Most common types of Exotropia Treatment for X(T) or CI-type Over-minus glasses for pre-school children with intermittent XT Usually -2.00sph or similar adjustment to Rx VISION THERAPY In-office program recommended Better compliance and results Supplement with Home Computer Orthoptics program by HTS, Inc.

49 Most common types of Exotropia Constant, Basic Exotropia Magnitude is same in all positions of gaze Rarely congenital Must rule out sensory XT caused by severely decreased acuity typically pathologic or neurologic Treatment Large magnitude (>25pd) = should consider strabismus surgery Followed by post-op VT? Small magnitude = Prism to improve fusion/stereopsis

50 Most common cause of vertical strabismus Congenital CN IV Palsy (superior oblique) May present with head tilt (compensatory) LHT worse in right gaze and left tilt RHT worse in left gaze and right tilt Make sure to evaluate all children with torticollis Is child turning head to prevent diplopia or due to tightening of sternocleido-mastoid?

51 Amblyopia A diagnosis of exclusion must rule out ocular or neuro pathology AND fall into one of 3 categories: Refractive, Strabismic, Deprivational Refractive should always involve full correction of ametropia first Treatment initiated even if child is 1 st diagnosed after Age 8! Reality of treatment = despite excellence compliance, may not get to 20/20..

52 Causes of Amblyopia Strabismus Constant, unilateral - most common cause Refractive - Anisometropia Unequal refractive error 2 or more lines of vision difference Hyperopia or astigmatism > +1.5 D Myopia > -3 D

53 Causes of Amblyopia Refractive - Isometropic Bilateral reduction of acuity Equal, uncorrected refractive error Hyperopia > +4.5 D, Myopia > -6D Astigmatism >2.5 D Deprivational Most damaging & difficult to treat Congenital / early acquired cataracts (>3mm) Congenital ptosis

54 Amblyopia Treatment Full Spectacle Correction Occlusion therapy PATCHING! PEDIG study guidelines Part-time occlusion 2 hours/day to begin May work up to 4-6 hrs if necessary Simultaneous nearpoint activities Coloring, drawing, activity books, Legos, Game Boy Try to keep it as fun as possible

55 Amblyopia Treatment Types of Patches With Glasses Patch Works brand Fit onto glasses No Glasses (or for younger children) Ortopad or Opticlude adhesive Make sure parents check for possible peaking!

56 Trade secret #4 Homemade foam patches Very comfortable and difficult to peak

57 Amblyopia Treatment Optical Penalization Goal is to make better-seeing at least one line of vision worse than amblyopic eye Over or Under-correction of spectacle lens Blurs image rather than total occlusion Current Rx for better seeing eye is +5.00, make it a (or no lens) Rx is +1.00, make it a Bangerter Foils/Filters Thin, flexible static vinyl of varying opacities; provides specific level of blur 0.0 (Most dense) (Least Dense) Prescribe least amount to change fixation preference

58 Bangerter Occlusion Foil/Filter Occlusion Foils stick to eyeglass lenses and can be trimmed with scissors to match the frame shape. Visual acuity approximated by each foil: LP = Light Perception Only (flesh color) >.1 = Acuity of Less Than 20/ = Acuity of 20/ = Acuity of 20/ = Acuity of 20/ = Acuity of 20/ = Acuity of 20/ = Acuity of 20/ = Acuity of 20/20

59 Amblyopia Treatment Pharmacologic Penalization Atropine 1.0% (educate on side effects) Dose: One drop before bedtime OR weekend use (blue iris or school-age) PEDIG studies show good success may take longer compared to patching To make sure effective: pupil should be unreactive must note fixation preference of amblyopic eye

60 Amblyopia Treatment When do you stop treatment (patching, atropine, foil)?? When you have tried all patching or penalization options When you can prove that vision has not improved over 3 consecutive follow-up visits Follow-ups are usually recommended every 6-8 weeks

61 Amblyopia Treatment Even though improved acuity, accommodative and binocular vision skills are often sub-par in amblyopes Don t forget vision therapy Home therapy = computer orthoptics Amblyopia inet (home) program by HTS, Inc. = $ In-office therapy = Referral to local VT colleague

62 Common Causes of Ocular Pathology Nasolacrimal duct obstruction Optic nerve hypoplasia Most common congenital disc anomaly Leukocoria Optic atrophy Retinopathy of Prematurity Cortical vision impairment

63 Nasolacrimal duct obstruction Most common cause of infant tearing Discharge, crusting NO red eye Uni or bilateral 90% resolve by Age 1 Tx: warm compress, digital duct massage If persists: probing done NOT before Age 1

64 Optic Nerve Hypoplasia Typically unilateral Double ring sign Vision range from 20/30 to NLP Often associated with other CNS malformations Work-up: MRI (to rule out septooptic dysplasia), bloodwork to screen for endocrine problems (hypothyroidism)

65 Leukocoria Differential diagnosis: Retinoblastoma Coats Disease/ RD

66 Leukocoria Differential diagnosis: Congenital Cataract Uni or bilateral Immediate extraction if significant = avoid amblyopia Fit with aphakic CL s post-op Monitor if small or not central (often ant. polar)

67 Optic Atrophy Often profound acuity loss (<20/200) Visual field defects (hemianopias) associated with stroke Hydrocephalus = #1 bilateral cause Increased by multiple failed shunts Tumor or intracranial hemorrhage also common etiologies

68 Retinopathy of Prematurity All premature children need to be screened for this have an increased risk of strabismus and high refractive error and should be seen for yearly exams! Retinopathy: Risk of development <1500 g birth weight or <32 weeks gestational age

69 Stages 1 through 5 Retinopathy of Prematurity Laser sx necessary at Stage 3 (neo at elevated demarcation ridge) Plus Disease - tortuous /dilated vessels Dragged/ectopic fovea causes major vision loss

70 Cortical Vision Impairment (CVI) Bilateral profound acuity loss Now most prevalent form of congenital visual impairment primary dx in 35-50% cases Cerebral insult to optic radiations of visual cortex Hydrocephalus and hypoxia most common causes Diagnose by: visual behavior (lack of visual attention, roving eye movements, extreme variability in visual responses) flash VEP

71 In conclusion remember these 5 simple rules for success 1. Have the right tools 2. Do the right tests 3. Work quickly 4. If in doubt: recommend followup or refer to colleagues 5. Have fun!

72 Questions? Tweet about this session: #academy16 Remember to complete your session evaluations online!