The WORST-CASE SCENARIO Survival Handbook

Transcription

1 The WORST-CASE SCENARIO Survival Handbook I certify: I have no proprietary interest in the tested product I have no equity interest or significant payments by the sponsor of a covered study Lecture content and format is free from commercial bias Lecture content was independently prepared by myself By Raymond Chu, OD MS Fix Follow Maintain Monocular Fixate on an object Follow the object into various gaze positions Maintain fixation Binocul Vis Strabismus Q. 2001;16(2): The use of the FFM is so insensitive, and so unspecific, that it s virtually useless. Fixation Preference Screening test for strab & amb Sensitive to > 3 line difference Dissociate: 10 BU Sensitivity (specificity): aniso 20% (94%) strab 69% (79%) Cotter et al. Ophthalmology 2009 Teller Acuity Cards (TAC) Keeler Acuity Cards Designed for 6 months to 3 yrs Median time: min Repeatable ± 0.5 octave 1 octave IOD is significant 30 cpd 20/20 Snellen equiv. Precision-Vision Full set: $3929 ½ set: $2131 Richmond Products: Set of 18 cards $1,800.00

2 LEA Grating Test Same principle as TAC Designed for 12 months to 2 yrs Good-Lite: $250 Cardiff Acuity Test Vanishing optotype Avg admin: 3-5 min. Designed for 6 months to 3year olds 3 cards per acuity level Threshold: 2/3 correct or 3/4 Can be used in cases of suspected malingering Richmond Products: $1800 LEA Matching / ID Well standardized for 2+ year old children VIP study: Superior to HOTV test in 3 y.o. Crowding sensitivity for amblyopia IOD >1 line may be significant LEA Matching / ID Well standardized for 2+ year old children VIP study: Superior to HOTV test in 3 y.o. Crowding sensitivity for amblyopia IOD >1 line may be significant Picture Chart Visual acuity for preschoolers Patti Pics Wright figures Isolated single optotype High-contrast optotype Without directional component A matching response Presented at 3m

3 HOTV Letters do not blur out equally 3-5 yr olds VIP study: 4 y.o. HOTV or LEA 10 ft. ATS study: ± 1 line Dry Retinoscopy Need to control accom and on-axis Phoropter vs lens bars Refracting glasses Don t forget to subtract WD Richmond Products: $ Trial Frames Mohindra/ Near Retinoscopy Richmond Products Set of 5: $100 $27 each 50 cm working distance Dark room illumination Ret beam: minimal intensity Occlude non-tested eye Correcting factor D Borghi and Rouse (1985): Cycloplegia revealed to D more plus than near retinoscopy Cycloplegic Agents Infant (<1 yr): 2 drops, 0.5% cyclopentolate spaced 5 min apart Child ( 1 yr): 2 drops, 1.0% cyclopentolate spaced 5 min apart Wet Retinoscopy For Strab: occlude nontested eye Increase in aberrant reflection Gulden Ophthalmic: $22.00 / dozen

4 Autorefraction EOM Non-cyclo = not reliable Diagnostic only when cyclopleged Doll s Head Reflex (oculocephalic reflex) Brückner WD: 1 meter Room illumination: Dark Brighter reflex = suspected eye Hirschberg Corneal reflex displacement Nasal = (+) Temporal = (-) (+) (-) Kappa Test Cover Test 4 mm 12 mm 1 mm displacement = 22 D Ensure fixation and accommodation on target

5 Pediatric Flashlight Stereopsis RDS E Testability 86% for 3 yo, 89% for 4 yo, 93% for 5 yo Richmond Products: $158 Lang II Preschool Assessment of Stereopsis with a Smile (PASS) No polaroid glasses needed Bernell Good- Lite: $ Stereopsis Among children aged 3 yrs 0 months through 3 years 6 months Stereopsis Preschool Randot Test Randot Stereo Test Good-Lite: $189 Latham and Phillips Ophthalmics: $365 Stereo Fly Good-Lite: $189 Randot Preschool Stereoacuity Test Binocular & Accommodative testing J AAPOS 2008;12:23-26 Subjective Phorometry Risley prism vergence ranges Accom Amps & Facility NRA / PRA Objective NPC Cover Test Prism bar vergence ranges MEM

6 Confrontation VF Color Vision X-link recessive: 1:12 boys and 1:200 girls have color deficiency Bernell: 6-7 months, ~93% of an adult Richmond products: $279 Cotter et al (1999): 100% sensitivity and 90.5% specificity in screening of kindergartners (5-7 yrs) IOP Standard of care in school age children IOP Veatch Ophthalmic: $3990 Icare $3750 Tonopen vs GAT Baseline Characteristic N (%) Average Tonopen IOP (OD, mmhg) (12) 11 to (66) 16 to (31) >21 22 (5) Mean (range) 15.4 (6 to 25) Average GAT IOP (OD, mmhg) (14) 11 to (66) 16 to (19) >21 2 (0.4) Mean (range) 14.2 (8 to 23) Dilating Agents Phenylephrine 2.5% Don t use in <3 yo or hx of cardiovascular problems No effect on accom Tropicamide 1% Safest dilating agent

7 Anterior Segment Evaluation Bluminator / 20 + transilluminator 7x image EIDOLON Hand Held Slit Lamps 5x magnification Eidolon: $595 $ Eidolon Set of 10: $675 $75/each Poterior Segment Evaluation MIO: 5x, ~45 o BIO: ~2.5x, ~35 o DO: ~15X, ~ o Optos ~ 200 o view without dilation The younger the child, the more difficult the setup Examination of the infant/toddler Examination of the preschooler 1. Hx 2. Teller / LEA grating / Cardiff/ Fixation preference 3. EOM, NPC 4. Hirschberg & Kappa & Brückner 5. MEM 6. Ant seg eval, pupils 7. Cyclo ret (0.5% for <1 yr) 8. Post seg eval 1. Hx 2. LEA (3 or 4) or HOTV (4) VA s 3. EOM, NPC, Cover Test, Stereo 4. Dry ret 5. MEM 6. Ant seg, pupils 7. Color vision OU 8. Cyclo ret 9. Post seg