Disclosures. Exam Frequency. Which Kids Need Eye Exams? Nystagmus (Jiggly Eyes) Eye Exams: High Priority 9/1/15

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1 Vision & Young Children: 10 Things Every Optometric Assistant Should Know Disclosures Commercial: none Salary Support: NIH/NEI Susan CoEer, OD, MS Southern CA College of Optometry Marshall B Ketchum University Fullerton, CA Exam Frequency Which Kids Need Eye Exams? Age Infants and Toddlers (Birth to 24 months) Preschool Children (2 to 5 years) School- aged children (6 to 19 years) Examina+on Frequency First exam 6-9 months At least 1 eye exam Annual Eye Exams: High Priority Nystagmus (Jiggly Eyes) Readily recognized eye abnormalities Children at high risk for vision disorders VIDEO *Na\onal Expert Panel (NEP) to Na\onal Center for Children s Vision & Eye Health. CoEer et al. Optometry & Vision Science 2015; 92(1):

2 Ptosis (Droopy Lid) Leukocoria (White Pupil) Pupil Irregularity Strabismus (Eye Turn) Head Tilt or Turn? Chin Tip? Symptoms & Signs 2

3 Squin\ng / Blinking / Rubbing Redness / Discharge / Swelling Children at High Risk for Vision Problems Neurodevelopmental disorders Hearing impairment Cerebral palsy Down syndrome Cognitive impairment Autism spectrum disorders Speech delay Etc. Children at High Risk for Vision Problems 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 has vision-related problem *Na\onal Expert Panel (NEP) to Na\onal Center for Children s Vision & Eye Health CoEer et al. Optometry & Vision Science 2015; 92(1): 6 16 *Na\onal Expert Panel (NEP) to Na\onal Center for Children s Vision & Eye Health CoEer et al. Optometry & Vision Science 2015; 92(1): 6 16 Eye Exams for Infants & Young Children What Are We Looking For? Children 6 years Amblyopia or risk factor Strabismus Significant Refrac\ve Error Color Vision Defect Eye Health Disorder 3

4 Strabismus (Eye Turn) Constant Strabismus IntermiEent Strabismus Refrac\ve Error Refrac\ve Error Refrac\ve Error 4

5 Amblyopia Reduced visual acuity in one or both eyes Not from ocular pathology & not correctable with op\cal correc\on Most common cause of vision loss in children Amblyopia Causes Amblyogenic factors prior to age 6 year Strabismus Anisometropia High refrac\ve error in both eyes Depriva\on (1 or both eyes) Eye Disease Eye Exams for Young Children How To? You Can Help Ini\ally Prepara\on for exam Posi\ve reinforcement Scheduling Considera\ons Appointment \me Parent bring boele/snacks/favorite toys Caretaker for siblings May need addi\onal help Recording, holding fixa\on targets 5

6 Posi\ve Reinforcement Eye Exams for Young Children Rou\ne Eye Examina\on Eye Alignment Visual Acuity Minimum Data Base n Eye Alignment Refrac\on n Visual Acuity n Refrac\on Ocular Health n Ocular Health n Color Color (Preschoolers) & Stereo (not infants) Minimum Data Base Color Vision Tes\ng Made Easy Eye Alignment Rule out strabismus Test muscle func\on Measure (stereopsis) depth percep\on CoEer, Lee, French. Optometry & Vision Science 1999;76(9): Cover Tes\ng to Check for Strabismus Use an Accommoda\ve* Target *Small and detailed 6

7 Corneal Reflex Test for Strabismus Hirschberg (Corneal Reflex) Test Hirschberg (Corneal Reflex) Test Krimsky Test Es\mate Magnitude of Strabismus Test Extraocular Muscle Func\on Versions: Extraocular Muscles 7

8 Randot Preschool Stereotest Random Dot E Stereotest Pass Stereotest Lang Stereotest Visual Acuity Tes\ng Monocular Visual Acuity Normal for age? RE & LE equal? Not recommended 8

9 Monocular Visual Acuity Adhesive Patch Recommended Best Bet Problem Charts Preschool Visual Acuity Tes\ng High contrast, single surrounded optotypes 2- alterna\ve forced choice or matching (lap card) Avoid necessity of verbal or direc\onal response Shorter test distance (3 m) Environment quiet and free of distrac\on H! Demonstrate & Use Matching Card HOTV or LEA Symbols 9

10 LEA Symbols LEA Near VA Infants: Teller Acuity Cards Infant Visual Acuity Teller Acuity Cards Children <1 year of age Visual Acuity: Infants Teller Acuity Cards Teller Acuity Cards 10

11 Visual Acuity: Toddlers Cardiff Cards A Public Health Program for America s Youngest Pa+ents Eye Drops for Dila\on/Cycloplegia Determine Refrac\ve Error How Do I Get Drops in the Eyes??? Eye Drop Tips Remain calm Child in supine posi\on Ins\lla\on strategies Describe feeling of drops Count to 10 Close eyes Use flavored drops Drop on child s hand Enlist another 11

12 Determine Refrac\ve Error Determine Refrac\ve Error Eye Health Evalua\on Anterior Segment Biomicroscopy Examina\on of External Ocular Structures Intraocular Pressure icare Tonometer Tonopen & Others 12

13 Re\nal Examina\on Re\nal Examina\on Reward Time Vision Screening vs. Eye Exams Vision Screening Visual Acuity Vision Screening: Instrument- based Autorefractors & photorefractors es\mate refrac\ve error Good data only for Sure Sight and Re\nomax; data s\ll out for all others 13

14 Treatments Bangerter Filters Do They Work as Well as Patching? Refrac\ve Error Amblyopia Strabismus Photo: Courtesy of R. Rutstein PEDIG. Ophthalmology 2010;117: Amblyopia Treatment Op\ons Refrac\ve correc\on Patching 2-6 hours /day Atropine drops in sound eye Bangerter foil Vision therapy An\- suppression treatment Age not a limi\ng factor, but tx more difficult when older Treatment Op\ons for Strabismus Refrac\ve correc\on Added Lenses Bifocals for ET Overminus for XT Prism in glasses Occlusion Vision therapy Muscle surgery Monitoring All op\ons are not necessarily appropriate for all pa\ents What is Vision Therapy? School- age Children Eye Teaming Eye Focusing Ability Accuracy Flexibility Eye Tracking 14

15 Symptoms Associated with Eye Teaming or Focusing Problems frequent loss of place loss of concentra\on double vision blurred vision headaches reading slowly eyestrain \red eyes sleepiness trouble remembering what was read need to re- read same line of words CITT- ART Study Does treatment of symptoma\c convergence insufficiency with vision therapy result in improvements in reading and aeen\on in school- age children? 15