Paediatric Ophthalmology Assessment. Justin Mora 2017

Transcription

1 Paediatric Ophthalmology Assessment Justin Mora 2017

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4 History Visual developmental milestones Aware of people in the room, reaching for objects, following toys, alignment should be central and stable by 3 months General health medical problems and any regular medications Birth and perinatal history Problems in pregnancy, any prematurity, problems at birth particularly asphyxia, APGAR scores, any time in special or intensive care units Family History Early onset vision problems, cataract, glaucoma, strabismus etc

5 History Visual developmental milestones Aware of people in the room, reaching for objects, following toys, alignment should be central and stable by 3 months General health medical problems and any regular medications Birth and perinatal history Problems in pregnancy, any prematurity, problems at birth particularly asphyxia, APGAR scores, any time in special or intensive care units Family History Early onset vision problems, cataract, glaucoma, strabismus etc

6 History Visual developmental milestones Aware of people in the room, reaching for objects, following toys, alignment should be central and stable by 3 months General health medical problems and any regular medications Birth and perinatal history Problems in pregnancy, any prematurity, problems at birth particularly asphyxia, APGAR scores, any time in special or intensive care units Family History Early onset vision problems, cataract, glaucoma, strabismus etc

7 History Visual developmental milestones Aware of people in the room, reaching for objects, following toys, alignment should be central and stable by 3 months General health medical problems and any regular medications Birth and perinatal history Problems in pregnancy, any prematurity, problems at birth particularly asphyxia, APGAR scores, any time in special or intensive care units Family History Early onset vision problems, cataract, glaucoma, strabismus etc

8 Visual acuity assessment - Neonates poor visual responses for the first 4-6 weeks - Babies fix and follow, 100s and 1000s, fixation preference/alternation, preferential looking tests (Cardiff Cards, Teller cards)

9 Visual Acuity Assessmnet - From yrs Picture tests (Kay pictures, Lea symbols)

10 Visual Acuity Assessment - From yrs Letter matching (Sheridan-Gardner), Tumbling Es, Landoldt Cs - From yrs Snellen acuities

11 Crowding Phenomenom crowding is created by have lines of pictures/letters or confusion bars on single letters/pictures An amblyopic eye struggles more with crowding so is often a line or several lines poorer with crowding

12 Visual Field testing Visual attention A toy in front and bring another toy in from each quadrant. How far into the field does the toy have to come for the child to saccade to it? Useful for homonymous or bitemporal defects Automated visual fields Feasible only in older children

13 Binocular vision tests Stereo tests With monocular clues Titmus fly, Randot Without monocular clues Lang, Frisby

14 Amblyopia (Dull Eye) Poorer development of the visual cortex due to a blurred visual input. A brain not an eye problem The younger the child the greater the risk but also a greater the likelihood of successful Rx System relatively fixed and treatment less successful after 7-8 years of age

15 Causes of Amblyopia Refractive anisometropia (unequal focus between the two eyes) > astigmatism > hyperopia > myopia Strabismus - treating amblyopia prior to surgery improves stability of outcome Stimulus deprivation e.g.: cataract, overpatching

16 Amblyopia Treatment Patching : Good eye is occluded (patched) Research shows 2 hrs per day = 6 hrs Compliance is the key Usually check every 3 months to monitor progress Penalization : good eye is blurred with Atropine.

17 Referrals for reduced vision < 4 years old - ophthalmology > 5 years old - community optometrist Secondary screening Orthoptic - optometry clinics filter out 90% of reduced vision referrals

18 Assessing Strabismus Corneal Light Reflex Test Reflexes should be symmetrical just nasal to visual axis Reflex displaced temporally = Esotropia Reflex displaced nasally = Exotropia Westhealth April 2010

19 Pseudoesotropia Broad epicanthic folds Medial sclera is buried with lateral gaze so the eyes look esotropic / convergent Corneal light reflex and cover test confirms straight One of the only Strabismus problems a child will grow out of

20 Assessing Strabismus Cover Test cover straight eye if other eye moves it was deviated if it moves in = exotropia / divergence if it moves out = esotropia / convergence Westhealth April 2010

21 Cover Testing Westhealth April 2010

22 Prism cover testing

23 Checking the Red Reflex Use Direct Ophthalmoscope Set to +3 dioptres White light Smaller aperture size 1/3 metre from patient Directly in front Harder to see in dark eyes If in doubt then refer ASAP

24 Retinoblastoma Malignant. 1 in 20,000 Mutation of tumour suppressor gene at 13q % sporadic, 25 % heritable, 10 % inherited with FHx 1/3 bilateral Rx gives high survival Risk of other malignancies with heritable forms

25 Leukocoria (White Pupil) Any opacity in the visual axis Corneal e.g.: glaucoma, metabolic, trauma Aqueous and vitreous e.g.: uveitis Lens e.g.: cataract Retinal e.g.: retinoblastoma, retinopathy of prematurity, retinal inflammatory disease

26 Congenital Cataract Occurs in about 1 in % sporadic 20% inherited 15% systemic or ocular problems e.g.: Down s, Peter s

27 Congenital Cataract Surgery ideally performed by 4-6 weeks Vision corrected with contact lenses Implants possible down to 6 months

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