Download Pediatrics for the Primary Care Optometrist 2

Pediatrics for the Primary Care Optometrist
2-hour Lecture Outline
I.
Basic “tools of the trade”
a. Shopping list for tests and fixation targets
II. Infant and pre-school eye exam
a. History
b. Visual acuity
i. Light detection
ii. Object detection
iii. Preferential looking tests – Lea Gratings and Teller cards
iv. Recognition tests – Broken wheel, Lea Symbols
c. Binocular Vision Assessment
i. Bruckner test
ii. Hirschberg test
iii. Krimsky prism test
iv. Vertical prism test
v. Cover testing
vi. NPC
vii. Modified Thorington Card
d. Color Vision
i. Color Vision Testing Made Easy
ii. H.R.R. pseudoisochromatic plates
e. Anterior Segment Exam
i. Penlight
ii. Burton lamp
iii. Hand-held slit lamp
iv. TRADE SECRET #1: “EYE DOCTOR MOTORCYCLE”
f.
Retinoscopy/refraction – dry and cycloplegic
i. Need loose lenses, lens bars
ii. Mohindra method
iii. Cycloplegia - when to use 1.0% cylcopentolate (and when not to use)
g. Dilated fundus exam
i. Tricks of the trade to successfully instill drops
ii. Best positions of child for exam success
iii. TRADE SECRET #2: SPINNING LIGHT TARGETS
III. Prescribing glasses for infants and pre-schoolers
a. Brief review of when to prescribe
b. Main goals – prevent amblyopia, allow normal vision development
c. TRADE SECRET #3: NON-BREAKABLE FRAMES (Miraflex, Solo Bambini, etc.)
IV. Amblyopia
a. Types/Causes
i. Refractive – isometropic and anisometropic types
ii. Strabismic – constant and unilateral most common cause
iii. Deprivational – ptosis, cataract common causes
b. Treatment
i. Full spectacle correction
ii. Occlusion therapy
1. TRADE SECRET #4: HOMEMADE FOAM PATCHES
iii. Optical penalization
iv. Pharmacologic penalization
v. Vision therapy – home and/or office
V. Strabismus
a. Define by comitancy, frequency, laterality, magnitude, direction, distance/near
relationship
b. Esotropia
i. Common types and treatment
1. accommodative
2. convergence excess
3. infantile
4. pseudo-ET
c. Exotropia
i. Common types and treatment
1. constant/basic XT
2. intermittent
3. convergence insufficiency
d. Vertical strabismus
i. Hyper/hypotropia
ii. Congenital superior oblique palsy
1. Head tilt cause: palsy vs. torticollis
e. Non-comitant strabismus
i. Diagnose by thorough motility testing
ii. Most common types
1. Duane Syndrome
2. Brown Syndrome
VI. Common Causes of Ocular Pathology
a. Nasolacrimal duct obstruction
i. Most common cause of infant epiphora
ii. High percentage (~90%) resolve spontaneously by age 12 months
iii. Wait to probe until after age 12 months, if possible
b. Optic nerve hypoplasia
i. Unilateral or bilateral
ii. Range of vision impairment in affected eye/s
iii. Work-up to include ruling out other CNS malformations and endocrine problems
c. Leukocoria
i. Differential diagnosis
1. Congenital cataract
a. Unilateral or bilateral
b. Early extraction to avoid amblyopia
c. Fit with high plus (aphakic) contact lenses
2. Retinal pathology
a. Retinoblastoma
b. Coat’s Disease
d. Optic Atrophy
i. Often profound acuity loss caused by event in –utero like hypoxia or stroke
ii. Associated also with visual field defects
iii. Common causes
1. Hydrocephalus - #1 cause (increased by failed shunt episodes)
2. Tumor
3. Intracranial hemorrhage
e. Retinopathy of Prematurity
i. Stages 1 to 5
1. Laser treatment indicated at stage 3 (neovascularization at demarcated
ridge)
ii. Profound vision loss caused by dragged (ectopic) macula and retinal detachment
f.
Cortical Vision Impairment
i.
ii.
iii.
iv.
Profound bilateral acuity loss
Caused by cerebral insult to optic radiations of visual cortex
Diagnose by flash VEP
Characterized by certain visual behaviors
1. Lack of visual attention
2. Roving eye movements
3. Variable visual responses