Eye Exams for Infants & Young Children The Do s & Don ts. Children 3-5 yrs be screened at least 1x to detect amblyopia & amblyogenic risk factors

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1 Eye Exams for Infants & Young Children The Do s & Don ts Disclosures Photos removed for handout File too large even as PDF Susan Co@er, OD, MS Southern CA College of Optometry Marshall B Ketchum University Fullerton, CA Commercial: none Salary Support: NIH/NEI Course ObjecRves For infants, toddler, preschool eye exams RaRonale for eye exam / risk factors ExaminaRon strategy Age- appropriate evaluaron methods Clinical Rps Which Kids Need Eye Exams? US Preventive Services Task Force Children 3-5 yrs be screened at least 1x to detect amblyopia & amblyogenic risk factors American Optometric AssociaRon Eye ExaminaRon RecommendaRons For asymptomarc children 6 months 3 years 6 yrs - annually or as recommended United States PrevenRve Services Task Force. Pediatrics 2011;127: Pediatric Eye & Vision Examination: AOA Optometric Clinical Practice Guideline 1

2 Direct Referral Guidelines* Children at high risk for vision disorders Readily recognized eye abnormalities *NaRonal Expert Panel (NEP) to NaRonal Center for Children s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraRon, US Dept of Health & Human Services. In press: Optometry & Vision Science Direct Referral Guidelines Neurodevelopmental disorders Hearing impairment Cerebral palsy Down syndrome Cognitive impairment Autism spectrum disorders Speech delay Etc. *NaRonal Expert Panel (NEP) to NaRonal Center for Children s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraRon, US Dept of Health & Human Services. In press: Optometry & Vision Science 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 *NaRonal Expert Panel (NEP) to NaRonal Center for Children s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraRon, US Dept of Health & Human Services. In press: Optometry & Vision Science What Are We Looking For? Children 6 years Amblyopia or risk factor Strabismus Significant RefracRve Error Color Vision Defect Eye Health Disorder Amblyogenic RefracRve Error? Anisometropia Hyperopia >1.00 D Myopia >3.00 D AsRgmaRsm >1.50 D Isoametropia Hyperopia >5.00 D Myopia >8.00 D AsRgmaRsm >2.50 D AOA Clinical Practice Guideline on Amblyopia *Consensus opinion & does not address if age dependent Risk of Bilateral Decreased VA Associated with Hyperopia MEPEDS/BPEDS: 5704 AA, Hispanic, White Children months Bilateral SE Hyperopia Odds Ratio* 95% CI <0.0 D to <+1.0 D (reference) to <+2.0 D to <+3.0 D to <+4.0 D D Adjusted for age, asrgmarsm, gestaronal age. *Significant Odds RaRo s in bold. Level of hyperopia defined by least hyperopic eye. Tarczy- Hornoch et al. MEPEDS/BPEDS Ophthalmology

3 Risk Factors for Strabismus Risk Factor (MEPEDS/BPEDS: n= 9970) ET XT Maternal Smoking GestaRonal age <33 wks Family Hx of Strabismus Anisometropia AsRgmaRsm SE Hyperopia et al. Ophthalmology 2011;118(11): Risk of Esotropia Associated with Bilateral Hyperopia MEPEDS/BPEDS: 9970 AA, Hispanic, White Children 6-72 months Bilateral SE Hyperopia Odds Ratio* 95% CI 0.0 to <+1.00 D reference <0.00 (myopia) to <+2.00 D to <+3.00 D to <+4.00 D to <+5.00 D D Based on mulrvariate stepwise logisrc regression model; adjusted for age, anisometropia, maternal smoking, gestaronal age. *Significant Odds RaRo s (OR) in bold. * Level of hyperopia defined by less hyperopic eye Co@er et al. Ophthalmology 2011;118(11): Scheduling ConsideraRons Appointment Rme Ask parent to bring bo@le/snacks/favorite toys Caretaker for siblings May need addironal help Recording, holding fixaron targets WaiRng Room ConsideraRons ExaminaRon Equipment Establishing Rapport FixaRon targets / toys accessible Talk or play with child prior to examinaron 3

4 The Working PosiRon Special Needs Kids: ConsideraRons SensiRviRes TacRle Light Sound Likes & Dislikes PosiRve Reinforcement Case History Reason for visit Symptoms Eye history Treatment history Medical history (parent & family) Pre and peri- natal history MedicaRons / allergies to meds Developmental history Academic history Therapies or IntervenRons? Eye Alignment Visual Acuity RefracRon Ocular Health Color & Stereo (preschoolers) Ocular Alignment ObservaRon Random dot stereopsis Cover tesrng Hirschberg/Krimsky Brückner EOM s Minimum Data Base 4

5 Head Tilt or Turn? Chin Tip? Stereopsis Tests Random Dot vs. Lateral Disparity Titmus Fly lateral disparity only Randot Test Preschool Randot RDE PASS test Lang Stereotest Random Dot LEA RDS: No monocular cues; typically must be bifoveal Cover TesRng Use an AccommodaRve* Target *Small and detailed Hirschberg Test Krimsky Test 5

6 Brückner Test Pseudoesotropia Ability to IDENTIFY: leaves many children undiagnosed PREDICT: <50% with (+) Brückner will have strabismus or anisometropia Not sufficiently sensirve as screening test for strabismus & anisometropia in children 6 to 72 months of age 10-19% later diagnosed with esotropia Serial examinarons & parent educaron recommended Huang K, Co@er SA., MEPEDS et al. Optom Vis Sci 2011; 89:E- abstract Anwar et al. Strabismus 2012; 20(3):124-26;Silbert et al. AAPOS 2012;16(2): Versions: Extraocular Muscles Color Vision TesRng Made Easy Co@er, Lee, French. Optometry & Vision Science 1999;76(9): Waggoner HRR Test Visual Acuity TesRng Normal for age? RE & LE equal? 6

7 Preschool VA Test Desirable CharacterisRcs High contrast, single, surrounded optotypes LogMAR progression Reduced (3 meter) test distance 2- alternarve forced choice or matching Avoid necessity of verbal or direcronal response Demonstrate & Use Matching Card HOTV or LEA Symbols LEA Symbols LEA Near VA Screening with HOTV & Lea Testability & Agreement (3-5 yrs) Testability = 99% for both IdenRcal results for 67% When different, 3 yrs be@er VA on LEA VIP. Optom Vis Sci 2004;81:

8 Vision Screening: Untestable Preschool Children or uncooperarve Will not allow one eye to be covered Not appear to understand screening task Problem Charts Are twice as likely to have a vision problem than those who pass a screening VIP Group. InvesRgaRve Ophthalmology & Visual Science 2007; 48: Visual Acuity: Toddlers Cardiff Acuity Norms Cardiff Cards Age (months) Monocular Visual Acuity 12 to <18 20/160 20/50 18 to <24 20/100 20/25 24 to <30 20/63-20/25 30 to 36 20/40-20/20 Adoh & Woodhouse (1994). The Cardiff Acuity Test Used for Measuring Visual Acuity Development in Toddlers. Vision Research 34(4): Infant Visual Acuity Lea GraRng Paddles Teller Acuity Cards Children <1 year of age 8

9 Pax Stripes Square Wave GraRng Paddles FixaRon Preference TesRng Apparent manifest strabismus No manifest strabismus or 10 : Induced Tropia Test (12 BD) Grade A B Holds Well C Holds Momentarily D Does Not Hold Methods: FixaRon Preference Fixation Preference Criteria Observation made by doctor 1. Spontaneous alternation 2. When switching prism to fellow eye causes FP to reverse Fixation held with non-preferred eye for: 3 seconds, OR during a smooth pursuit, OR through a blink before refixation to preferred eye Fixation held with non-preferred eye for 1-<3 seconds Immediate (<1 sec) refixation with preferred eye when occluder removed from preferred eye SensiRvity/Specificity of FP TesRng For detecrng Any amblyopia = 31% Anisometropic amblyopia = 20% Strabismic amblyopia = 80% False posirves Many strabismic children Of strabismic kids with grade C/D, only 32% had amblyopia CoBer et al MEPEDS. Ophthalmology 2009; 116: Other Indirect Measures: Vision Defining Normal Visual Acuity Frequency DistribuRon - logmar VA by Age Fix and follow Resistance to occlusion 20/20 20/25 20/32 20/16 20/40 20/50 20/63 20/70 Pan et al., MEPEDS; Optometry and Vision Science 2009;86(6):

10 Mean logmar Visual Acuity and Thresholds for Lowest 5 th PercenRle Cycloplegic RefracRon Topical anestherc 2 drops cyclopentolate Tropicamide (0.5%) or phenylephrine (2.5%) - DFE 30 minutes refracron Nearest Snellen- equivalent line tested by ATS HOTV protocol. Alternate threshold is next be@er VA level. Pan et al., MEPEDS; Optom Vis Sci 2009;86(6): Determine RefracRve Error Determine RefracRve Error AutorefracRon? Eye Health EvaluaRon ExaminaRon of External Ocular Structures 20D Lens & BIO 20D Lens and transilluminator Bluminator Hand- held slit lamp 10

11 Intraocular Pressure ReRnal ExaminaRon icare Tonometer Other TesRng Reward Time NPC AccommodaRve amplitude MEM BI & BO vergences Pursuits Saccades 11