Download Peds exams the why when and how

I. Typical Behaviors & Exam Modifications:
Why examine kids under 5: early intervention & prevention (vision problems assoc w/ devel delays)
-VA screening isn’t effective (only 30% of 3 y/o with vision problems fail; 40% of 4 y/o; 50% of 5 y/o)
First exam:
-AOA says no later than 6 months
-9 months (most emmetropization is complete)
-3 months if FHx, premature, condition, developmental delay, parental concern
Age groups for exams:
-Birth to 2-3
-2-3 to 5
-5+
Typical behaviors & exam relevance:
0-6 months
-Near testing only
-Not mobile
-Responds to voices
- easiest age to examine
 6-12 months
-Near testing only
-Mobility starts
-Separation anxiety & fear of strangers
-Knows name and orients
 13-23 months
-Short attention span
-No tolerance for limitations = tantrums
-Negativism starts
-¼ of language is understandable
-Use labeled praise
Developmental age groups:
-Infant: 0-1
-Toddler: 1-3
-Preschooler: 3-5
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2-2.5 years
-Independence
-2/4 of language is understandable
-Distance testing is often possible
3 years
-Age of pleasing
-Labeled praise very effective
-3/4 of language is understandable
4 years
-Motivated by simple rewards
-Start to appreciate humor
-4/4 of language is understandable
5 years
-Love praise & can’t accept criticism
-Don’t like to lose (so they’ll cheat)
6 years
-Start using phoropter
II. Assessment of Development
Milestones/delays:
-Changes in skill development during predictable time periods (sequential & predictable)
-Cognitive, social/emotional, speech/language, fine motor, and gross motor
-Delay = milestones not attained in the expected time period
- A delay in all areas is called a global delay
Intervention: Early intervention = better long term outcome
-Free intervention services available to all children birth through school age (IDEA)
-<30% of school-aged kids with delays are ID’d and receive services before starting school
-Screenings do not diagnose, but do identify most kids with delays
Denver II:
-Sensitivity = 83% True Positive
-Specificity = 80% false positive
-What: personal-social, fine motor-adaptive, language, gross motor
-Who: up to age 5 (don’t screen kids who’ve already been ID’d) only test 5 and 6 year olds if concern with language
with VP and AP assessment
-Adjust for prematurity if under age 2 and more than 2 weeks premature – subtract the amount of time they were
premature from their real age
-Draw adjusted age line
-Test 3 items immediately left of age line – if they pass all 3, test all items with blue intersected by the age line
- When: just before and after dilation
-Interpreting
o Normal = failure/refusal with the blue completely to the right of the age line
o Caution = failure/refusal with age line passing through the blue; write C
o Delay = failure/refusal completely to the left of the age line; write D
o No opportunity; write NO
-Recording
o Normal = no delays and <1 caution
o Suspect = >2 cautions and/or >1 delay
o Untestable = >1 refusal completely to the left of where age line intersects the blue area
- Denver II scale: 25% left edge; 50% mark; 75% left edge of blue; 90% right edge of blue
- Denver II test is known for under referring in the language section... you may want to bump a patient into suspect
even if the test states they are normal (with one caution)
III. History
- Additional history: informant and their relationship to the pt, developmental, pregnancy, and birth
-Only do developmental/birth/pregnancy if preschool or with developmental/learning/visual problem
-Only do immunizations for preschool
POH: LEE, previous dx, previous tx (Rx, occlusion, surgery, other tx)
PMH: health status, asthma, allergies, meds, LPE, immunizations, ear infections (increased risk of language delays)
-Immunizations given at birth, 2 mo, 4 mo, 6 mo, 12 mo, 15 mo, 18 or 24 mo, and 4 years
-12 months = MMR, varicella, & HepA – only ones given at one year; all others are given earlier
Pregnancy & birth:
-APGAR – heart rate, respiratory rate, muscle tone, reflex irritability, color normal=2; weak=1; no response=0
-<3 resuscitate immediately
>7 no attention needed
-1 minute is not predictive of future neurologic status; the longer the score is depressed the greater the risk of
future anomalies
-Birth weight
-Normal >2500 grams (5.5 lbs)
-Low 1500-2500 grams (3.3-5.5 lbs)
-Very low <1500 grams (3.3 lbs)
-Extremely low <1000 grams (2.2 lbs)
-Small for gestational age (pre-term or full-term) are at risk less than 10 percentile
-Macrosomia > 4000-4500 grams (8.8-9.9 lbs), commonly caused by maternal diabetes, increased risk of neuron
issues due to complications during delivery
-Length of pregnancy
-Full-term = 38-41 weeks
-Premature = <37 weeks
-Minimum gestation for survival = 23 weeks
-Type of delivery & length of hospital stay
-Vaginal = 48 hours (assisted increases risk of CN VI palsy, retinal hemorrhage, corneal damage)
-Cesarean = 3-4 days; ask why
-Problems during pregnancy/delivery
Premature infants/low birth weight complications:
 Increased risk of CNS problems, developmental delays, and vision anomalies
 ROP
 CP – hypoxic event in preterm, low birth weight babies
 9x greater risk of having a coloboma, congenital cataract or retinal anomalies
-2 in 1,000 live births
-35% of babies <1500 grams develop (20x more likely than if >1500 grams)
-Non-progressive motor dysfunction with variable severity (50% have cognitive impairment)
-Ocular: strab (10-50%), significant RE, accommodative insufficiency, optic atrophy, nystagmus
 PVH or IVH – brain bleed
-Hemorrhage in white matter
-18-45% of babies <35 weeks or <1500 grams develop (rare after 32 weeks)
-Doesn’t occur in full-term infants
-Grades III & IV have the most complications (40% and 90%)
-Ocular: strab, optic atrophy, cortical vision loss, seizures
-Also associated with CP, hydrocephalus, delayed development, mental retardation
 PVL
-Most common ischemic (non-hemorrhagic) brain injury in premies (4-26%)
-Complications are proportional to severity (CP, cognitive, cortical vision loss, strabismus, and nystagmus)
 Increase in neonatal mortality
Complications with hypoxia:
 Meconium staining (1st bowel movement occurs in utero)
 Placental abruption – risk for neuro defects, placenta separates prematurely (partial/complete)
 Placenta previa (placenta implanted low in the uterus) – risk for SGA, hypoxia
 Fetal distress (decreased heart rate) associated with hypoxia
Maternal illnesses:
 Pre-eclampsia: (HTN >140/90) – teens and women >35 are at risk; protein in urine, generalized edema
 Eclampsia: pre-eclampsia with convulsions, deterioration of maternal & fetal CV, renal, hepatic, & CNS
function, and decreased placental perfusion & abruption ( fetal hypoxia, acidosis)
TORCH infections:
-Virulence greatest in 1st trimester and increases with length of infection
-Vision loss is primarily by chorioretinitis & cortical impairment
 Toxoplasmosis (undercooked meat, cat feces)
-Transplacental infection with primary (not reactivation) maternal infection
-May just have low birth weight or anemia
-Severe CNS may develop later (seizures, intracranial calcifications, hydrocephaly, microcephaly)
 Other
o Syphilis (rare, but sequelae appear as late as age 2)
-Ocular: chorioretinitis, interstitial keratitis, glaucoma
-CNS anomalies, skin lesions, rhinitis, cardiac, renal
o HIV
-Maternal treatment decreases risk of fetal infection (transmission = 4%); evident by age 1
-Progressive encephalopathy is possible (acquired cortical vision loss)
o Gonorrhea – conjunctivitis
o Group B strep
-Usually perinatal infection
-Can cause meningitis  cortical vision impairment
o Varicella zoster
-Transplacental
-CNS anomalies, low birth weight, skin lesions, limb atrophy
 Rubella (rare in the U.S.)
-Classic triad = deafness, cataracts, and congenital cardiac defects
 Cytomegalovirus – most common fetal infection
-Primary maternal infections are much more likely to pass to the fetus
-Blueberry muffin baby
 Herpes simplex
-Most are perinatal infections
-3 levels of severity: localized, CNS, and disseminated
-Microcephaly, mental deficiency, seizures, vision loss
Maternal drug use:
 Smoking
-Hypoxia  low birth weight, placental abruption
-Dose-related
 Illicit drugs
-Hypoxia  low birth weight, placental abruption, more vision anomalies, multi-system problems
 Alcohol
-FAS = 3 oz of alcohol daily
-FAE = mild signs, binge drinking
-CNS dysfunction, abnormal face (flat bridge, thin upper lip, short upturned nose), behavior
-Ocular: telecanthus, slant of palpebral fissure, epicanthal folds, ptosis, RE, strab (50% - most ET), amblyopia,
ON hypoplasia
 Prescription drugs
-Tetracycline  discolored teeth
-Aminoglycosides (streptomycin)  CN VIII damage (ototoxicity)
-ACE  renal, cardia
-Anti-convulsants (phenytoin, phenobarbitol, carbamazepine)  craniofacial, XT
-Anti-depressants (lithium)  cardiac
Developmental history:
-Parental/teacher/pediatrician concerns; speech (rule of 4)
-Ask about milestones specifically if you don’t do a developmental screening
 6 months – reaches for objects, turns to rattling sound, rolls over
 12 months – shows wants, bangs 2 blocks together, Dada/Mama, pulls to stand alone
 18 months – 3-6 words, walks well
 24 months – points to named picture, names familiar picture, kicks ball forward
 36 months – names several pictures, throws ball overhand
 48 months – names 1+ colors, identifies animals based on actions
-Anomalies (Down, Fragile X) have increased prevalence of high RE, strab, AI
Social history: school (including preschool), grade, achievement concerns, ECI/special services
FOH: significant RE, strab, amblyopia, inherited ocular conditions
IV. Visual Acuity
Preferential Looking
Teller cards (0-12 months)
-Grating (resolution) acuity by double psychophysics
-Can use up to 36 months, but usually start using Cardiff at 12 months and recognition at 24 months
-Gratings are in ½ octave SF steps
-Space averaged luminance = background
-Adjust for prematurity through 8 months of age; subtract amount of prematurity
-Use 38cm test distance if 3 months or younger; use 55cm if older than 3 months
-Must get ¾ trials for threshold
-Normal VA = within age norms OD & OS with <1 octave difference between the eyes
-May fail to detect amblyopia or unilateral VA deficit (overestimates VA in strab amblyopes)
Cardiff cards (12-24months) greater than 24 months use recognition
-Use for age 12 months to 2 years
-Vanishing optotype (space average luminance = background)
-Overall size of figure is constant – only the stroke width varies
-Must do 2AFC PL or pointing (not naming!) same picture used throughout
-Test at 0.5m or 1m; At .50m BVA is 20/40; At 1.0m BVA is 20/20
-Must get ¾ right
-Normal = 20/40 or better (2 lines difference is significant)
-Underestimates VA deficit in strab amblyopes
- Overestimates VA in strabs and amblyopes
Technical Measures
Sweep VEP: VEP will always have a better acuity over Preferential Looking
-Cortical response
-Resolution acuity
-Threshold = acuity level where you extrapolate to 0 microvolts
-Use when untestable/unresponsive with Teller, Cardiff, or recognition
-Use flash VEP to determine if the patient has sight
Optokinetic nystagmus
-Resolution
-Not recommended b/c 20/1000 is best & subcortical pathways can be activated
- Response with cortical blindness was recorded
Informal Assessments
Overview
-Only fixation response when age 1-5 months – can do vertical prism test
-When >6 months, can do RTO, F&F, and vertical prism test
-Target should be interesting to the child & degraded by blur
-Record target used – helps with retesting reliability
Fix & follow
-Is fixation central and steady?
-Does one eye track more accurately or steadily?
-If strabismic – get fixation with the strab eye, uncover good eye – do they switch back? = maintain
-Gives same info as unilateral cover test for strabs
Interpretation
-Interocular acuity difference:
 RTO of one eye only or asymmetric RTO
 F&F with UC, US, or UM in one eye only
-Equivocal
 No RTO or equal RTO
 F&F: CS or CSM
 Equal or unequal VA
Sensitivity
-RTO: target, age, socialization – may be fairly sensitive
-F&F
 CS or CSM: 20/15 – 20/200 (mean 20/34)
 CUSM: VA reduced to 20/30 – 20/1000 (mean 20/165)
 CSUM: VA reduced to 20/100 – 20/200
 UCS or UCUS: Poor VA 20/200 – 20/1400 (mean 20/573)  worst VA!
Vertical prism test (not a BV test)
-10pd BD over 1 eye
-If they don’t freely alternate, try the prism over the other eye
-If they still don’t alternate, force fixation with occluding. Remove occluder. If they maintain fixation through a
blink or horizontal tracking movement = freely alternate.
-Equal or near equal VA (<2 lines) if free alternation
-Amblyopia/significant difference if strong fixation preference with an amblyogenic factor
-Equivocal if strong fixation preference without an amblyogenic factor
Detection Tests
-Age 12 months to 2-3 years (until testable with recognition) – use with informal VA assessments
Candy beads
-Estimation of VA: 1) tan  
bead size
test distance
2)  * 60 * 20  Snellen denominato r
-Sensitivity is similar to recognition VA when bead & background have low contrast
Dot VA test
-Better than Tumbling E, but not better than Candy Bead – not compelling, poor contrast issues, etc.
Development of Acuity
Contrast sensitivity
-Resolution acuity = the high SF cut-off of the CSF
-Overall sensitivity increases with age (graph shifts up) & peak sensitivity shifts to higher SF (right)
-High SF cut-off shifts to the right
-Near adult level at 8 months by VEP, 8 years by behavioral tests
PL norms
-Rapid development in the first 6 months of life
-OKN norms are similar to PL norms
-Calculation for expected VA: 1) Age in months  cpd
2) Snellen denmoninat or 
600
cpd
VEP
-VEP VA is better than PL at all ages
-More rapid development than PL
-Approaches 20/20 at 8 months
-Differs from PL because the thresholds and the responses are different
Anatomy
-Peripheral retina is similar to adult, but the fovea is immature at birth
-Foveal depression is evolving b/c the inner layer is migrating
-Central rod-free zone is more than 2x bigger than adults = low cone density
-Cone segments are short and thick
-Decreased quantum capture and resolution capability
-At 15 months, the foveal depression is adult-like, cones segments are longer & thinner, rod-free zone is smaller, and
the cone density has increased  still all immature
-At 45 months, the cone segments are longer & thinner still (the inner segments are adult-like), the rod-free zone is
adult-like, and the cone density has increased some more
-Optic nerve myelination is not complete at birth
-Cortical synapses are not mature
V. Binocularity
Development
-At 3 months, you expect consistent motor fusion, some sensory fusion
-Convergence to 12cm by 14 weeks
Characteristics of misalignment
-Up to 3 months, it’s mostly intermittent in any direction – decreases with age
-Manifest XT at near (can’t converge properly)
-Mismatch of accommodation and convergence cues
-Prism response emerges at 8 weeks and develops over time
Clinical applications
-Under 3 months: any strab that’s constant or intermittent increasing in frequency is abnormal
-3 months and up: any strab is abnormal
-NPC routinely starting at 6 months (3 months is OK)
-Vertical prism test starting at 6 months
Sensory fusion
-Emerges at 3-5 months
-Very rapid development over several weeks from the 1st response to 60”
-At 6 months, 60” is typical
Other
-Improvements in contrast sensitivity may be responsible for motor & sensory fusion improvement
-Larger Panum’s fusional area (12-18x larger than in adults)
-Risk factors: prematurity (hypoxia), FHx, hyperopia >+3.50 at 9 months, developmental delay
VI. Binocular Vision
Convergence
-Motor fusion is consistent and sensory fusion starts to emerge at the end of 3 months
-Under-converge at 6-11 weeks
-Magnitude and direction are accurate to 12-15cm at 3 months
Prism fusion test – not appropriate for infants under 6 months
-Confirm motor fusion with 4BO for older kids
-Look for vergence response or version then vergence = motor fusion
-If only version or no movement = can’t confirm motor fusion
-Use larger magnitude for infants (10pd for 6-9 months, 6pd for >9 months)
Flexibility of motor fusion – routinely assessed in patients over 3 years
-12pd BO – how many cycles of fusion in 20 seconds (6-7 cycles is good)
-8pd BI
Stereopsis – not appropriate under 6 months (no stereo up to 3 months)
-Indirect measure of motor fusion (global stereo requires bifoveal fixation)
-Don’t use filters in kids under 3 years
-Good stereo doesn’t guarantee normal BV (e.g. intermittent XTs)
Stereo tests

Lang – test of choice for 6 months to 3 years
-Distance = 30-40cm
-Lang I is preferred b/c dots are denser and pictures are more compelling (550”)

Frisby – real depth
-Used if they don’t respond to Lang
-Rare response under 12 months

Stereo smile (filters) – 2AFC

Randot – test of choice for over 3 years
-If they get worse than 100” on the circles, test the animals (100”) for local

Random dot E (168”) – alternative test when child has trouble with Randot figures
-Distance = 1.5m
-Must get 4/4 or 5/6 correct

TNO (red-green) – testability is not as good as Randot or random dot E
Summary of BV
<3 months
3 months
>3 months
6 months
>6 months
2 years
3 years
Any age
Intermittent strab normal
Consistent motor alignment
Convergence to 12cm
Vergence response to large prism (20pd)
Earliest age for stereo
NPC
Vergence response to moderate prism (10pd)
Stereo approaches 60” in the lab (not in clinic)
Stereopsis
Prism fusion test
Cover test at distance
Threshold stereopsis
Cover test at near
Bruckner
VII. Preliminary Tests
Versions
-Under 6 months do not follow well
-Versions are full and comitant at birth
Pursuits
-Smooth pursuits are not mature at birth – develop through 1st year of life
-Horizontal develop before vertical
-Pursuits are smooth to large and very low velocity targets
-Often saccadic in young infants
Visual fields
-Very small fields at birth
-Rapid increase in field extent in the 1st 3 months
-Adult-like static fields at 6-9 months; kinetic at 1 year
-Assess confrontation fields in all patients
-At-risk: premature (IV/PV hemorrhage, PVL), hypoxia, seizures, in-utero/early stroke, multi-challenged
-Targets cannot make noise
Pupils
-Pupil size increases with age
-Iris muscles change a lot during the first 6 months
-Sphincter develops early during the 1st trimester – any full-term infant will have fully developed sphincter
-Dilator begins to develop at 6 months gestation – well developed by 2 months of age
-Normal direct & consensual if full-term
-Adult-like reactions by 2 months (but sluggish)
PD
-Important to measure if correcting RE (may have to guesstimate or use a chart)
Color vision
-Red-green response by 2 months
-Blue-yellow at 4 months
-No commercially available test for kids under 3 years
-Color Vision Made Easy Test screens for protans and deutans
-Ishihara for kids over 4 (trace numbers)
Ocular health
-Hand held slit lamp for kids under 3 with a CC
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Corneal diameter
-Normal = 10-11mm
-Micro <9mm
-Megalo >11.5mm

Corneal clarity
-Rule out congenital glaucoma in kids with cloudy corneas

Iris pigmentation
-Final eye color develops from 6-9 months (more pigment added through 12 months)
-Congenital Horner’s: lighter eye is affected eye

Posterior seg
-Routine assessment beginning at 6 years

IOP
-Tonopen for younger kids, NCT for older kids
VIII. Assessing Refractive Error
Hints
-Dry ret even if you’re going to do a wet ret
-If you think you see plus, it’s there
-Most preschoolers are slightly hyperopic, so start with a +2.50 lens to increase efficiency
Loose lens ret
-Fog the eye not being refracted (1.00-2.00 diopters over what you think their RE is)
-Assume eyes have equal RE
-Adjust the level of the fog as the RE in the other eye increases
Cycloplegic ret
-Uses: inconsistent distance fixation, ET, anisometropic, amblyopic, latent hyperopia
-AOA requires cycloplegic ret on every peds patient’s first visit
-Cyclopentolate is drug of choice – accommodation will be normal by the next day
-Atropine used for ET occasionally (instilled 3 days prior at bedtime)
-Tropicamide used for normal VA, normal dry ret, no amblyopia, low hyperopes, myopes
-Refract at 30 minutes (maybe 10 minutes if blue eyes)
-Still need to fog the fellow eye
Drops
-Light irides: 2gtts 0.5% cyclo 5 minutes apart (infants <6 months; >6 months with previous adverse reaction)
-Use 1.0% cyclo in infants >6months (if no adverse reaction)
-Side effects of cyclo: sedation, nausea, flushed face, hallucinations
-Dark irides: 1gtt tropicamide with 1gtt cyclo (0.5% or 1.0% depending on age)
Mohindra/near ret
-Done when you can’t get distance fixation
-Substitute for dry ret
-Dark room with 50cm working distance
-Measures the resting state/dark focus and is static
-Net lens is gross -1.25
-Tends to under-plus hyperopes
Autorefractor
-Hand-helds have good testability on 2 year-olds and up
-Underplus on dry measurements
Photorefraction
-Screening tool
-Flash near the edge of the lens entrance pupil; horizontal and vertical meridians
-Uniform red reflex = emmetropia
-Myopia if crescent on same side of pupil as light source
-3 factors that affect results: distance of examiner, pupil size, distance of light source
-Less sensitive with farther distances and smaller pupil
Corneal measures
-Keratometry
Development of accommodation
-Not assessed routinely in preschoolers
-Start to see changes at 1-3 months (before, locked in at 20-25cm)
-Inaccurate response to change in target distance (adult-like by 4 months)
-No response to blur until 9 months
-Response may not be great because VA isn’t great
Assessment of accommodation
-Anti-seizure meds, ADHD, TBI, CNS anomalies, CP, Down, Fragile X, borderline hyperopia

Pull-away
-3 years and up


Dynamic ret amplitude
-Gradually move in to assess if they’re still accommodating
-Amplitude = distance where you see an increase in motion (larger lag)
-Not as accurate as pull-away
MEM
-Distance is the Harmon distance
-+0.50-+0.75 is normal (>+1.00 is a large lag)
IX. Emmetropization
Prescribing is guided by:
1. VA (limited usefulness under 3 years)
2. Signs & symptoms
3. BV (strab, amblyopia)
Typical RE
-Newborns: +2.00 to +2.75
-12 months: - more similar to leptokurtic than normal distribution
-6 years: +0.75 – typical leptokurtic curve
-Range and variability decreases with age
-Most emmetropization occurs in first 9-12 months
Hyperopia
-Not all RE reduces
-Final magnitude is influenced by initial magnitude
-The more hyperopia early in life, the more rapid decrease, but they still end up more hyperopic
-If the RE isn’t changing much, it’s better to see the child more often
-More than +5.00 may be outside the range of effective emmetropization
Magnitude
Emmetropization
+3.00 to +5.00 (3
Variable emmetropization by 9 months
months)
>+5.00 (3 months)
Little to no reduction in hyperopia
>+3.00 (9 months)
Greater odds of retaining >+2.00 at 3 years
Myopia
-There is more myopia at birth than during preschool
-60% of infants are myopes at birth
-Emmetropization process is spread out more over time than for hyperopes
-Change at a very steady rate until 3 years
-Probably don’t prescribe initially, but monitor closely
-Most myopes become low hyperopes during preschool years
Astigmatism
-8% prevalence of astigmatism in adults (4-6% for older kids)
-20-65% prevalence of astigmatism >1.00D in the 1st year of life
-ATR or WTR
-Correlates with corneal toricity
-Adult-like astigmatism by 18-36 months
-Longer time course than hyperopia
-The more astigmatism you start with, the faster you lose it
-Higher astigmatism as infants, higher astigmatism at 3 years
Anisometropia
-14% of newborns have anisometropia (school-age kids 3.5-6%)
-Prevalence reduces by the first year of life (stable at 1-4%)
-Presence of aniso at 1 year doesn’t predict RE at 4 years
-More than 50% of anisos are transient and not retained between 1 and 4 years
-Lower magnitudes of aniso have a greater chance of losing it
-90% of infants with 3D or more aniso retain it at 10 years
-Constant unilateral strabs will not emmetropize in the deviating eye
Emmetropization and prescribing (mostly completed by 9 months)
-Most studies show that emmetropization isn’t affected by full or partial Rx
-Theory: minus lens increases growth rate (signals that eye is too short)
-As little as 1 hour without lenses prevents much/all adaptation
X. BV and Development Risk Factors
Hyperopia
-+5.00 is the threshold for isometropic bilateral refractive amblyopia
-Moderate hyperopia can be a risk for accommodative ET
-Moderate hyperopia at 9-12 months: 20-50% develop amblyopia by 3-4 years; 25% develop ET at 3 years
-Strabismus is reduced from 13X to 4X with an Rx
-Amblyopia is reduced from 6X to 1.6X with an Rx
-Partial Rx reduces strabismus by 70% and amblyopia by 75%
-Do no automatically Rx at 9-12 months
-Rx if strabismic, minimal/no change in RE, >+5.00 at under 1 year, >+3.50 at 3 years, s/s, reduced VA
-3 year-olds with moderate hyperopia have difficulty in matching, perceptual tasks, language development, etc.
Astigmatism
->2.00 diopters of astigmatism is the threshold for isometropic (meridional) amblyopia
-Isometropic amblyopia onsets by age 3
-Deeper amblyopia in MA and CMA
-Oblique astigmatism at 1 year is very amblyogenic  all become amblyopia at 4 years
Anisometropia
-Aniso >1.00 diopter is associated with amblyopia and strabismus
-30% develop aniso if it’s persistent from 1-4 years
XI. Kids and Contacts
Indications
-High RE (bilateral high RE, accommodative refractive ET, aniso, aphakia); amblyopia (occlusion therapy);
nystagmus; cosmetic/prosthetic/photophobia; bandage
Advantages: better peripheral vision, more normal appearance, reduced weight, reduced mag/mini, aniseikonia,
prism, accommodative demand for hyperopes, photophobia (tinted), better chance for BV, better compliance
Disadvantages: ocular insult (abrasions 0-13%, SPK <11%, neo <6%, edema <5%, infiltrates <3%), difficulty
handling lenses, psychosocial impact on family and child, frequent replacement due to parameters/lost lenses,
frequent follow-ups
General considerations
-Napping, decentering, greater ocular moisture, lenses must be durable and easy to handle, difficult I/R
-RE can change rapidly, smaller pupil diameter, smaller corneal diameter, lacrimation
-Steeper Ks (47.00-50.00 at 1-2 months; 43-00-44.00 by 4 years)
Lens materials

Silicone elastomer (SilSoft) – only high + and aphakic powers
-DK = 340, durable, can use NaFl, stay on eye well
-Can adhere to eye, lipid deposits, wettability, lenses last 6 months, expensive

SiHys
-High dK, EW/CW, durable, easy to fit
-Dryness/discomfort (lower modulus more comfortable; higher more rigid)


-Staining, tear microspheres, SEALs, limited powers, expensive
-AV Advance (0.43), Oasys (0.72), Biofinity (0.80), O2Optix (1.0), Purevision (1.5), N&D (1.52)
Hydrogels
-Easy to fit, comfortable, low cost, DW/EW, minimal risk of injury
-Difficult handling, fragile, rubbed out, limited pedi parameters, can order custom
RGPs
-Easy to handle, low cost, oxygen, durable
-Difficult to fit, increased adaptation, eject/dislodge, frequent replacement, corneal injury
Fitting steps – mean K in infants = 48.50
-Over-ret; add +2.00-3.00 for near/intermediate in aphakes
-Recheck fit & power several times over 30 minutes
Follow-ups
-Under 18 months: initially qweek, then q1-2months
-18 months-6 years: q2-3 months
-6 years-teen: q4-6 months
XII. Kids with Special Needs – we’re obligated to refer kids from 0 to 3 years for services
Developmental delays
-Mild to severe delay of 1 of more: cognitive, motor, communication, social-emotional, adaptive, self-help
-Visual impairments, seizure disorders, premature, congenital CMV, FAS, any TORCH condition, family status
-Milestones:

6 months: sounds, cries, & gestures to indicate needs

12 months: babble, speech/sound to get attention, respond to name, recognize some words

18 months: 25% of speech understandable, follow simple commands

24 months: 50% of speech understandable, begin using 2 word phrases

3 years: 75% of speech, follow 2-stage commands, use 4-word phrases to 4-6 word sentences

4 years: 100% of speech, 4-8 sentences with details
Developmental disability – involves more than 2 areas (above)
-Severe and chronic with IQ <70 or severe delays in multiple areas
Hearing – 50% of kids with hearing loss can be ID’d by risk factors in the history
-1.5-6 in 1000 live births have hearing loss
-Risks: FHx, birth weight <1500 grams, APGAR <4 (1 min) or <6 (5 min), infections, otitis media, ototoxicity,
craniofacial anomalies, neurodegenerative diseases, head trauma, parental concern
Down Syndrome (trisomy 21)
-IQ = 50, mild cognitive impairment, very social
-1 in 700 live births; 1 in 60 with maternal age over 40 (paternal age is also a factor)
-50% congenital heart, hypothyroid, leukemia, hypotonia, 75% hearing loss, language delay
-Moderate to high RE (do not emmetropize)
-Slightly reduced VA (20/30-20/50)
-Constant ET (23-80%)
-Significantly under-accommodate (large lag)
-Benign ocular signs: Brushfield spots on midperipheral iris, extra vessels crossing disc margin, laterally displaced
oblique palpebral fissures, narrow PD, epicanthal folds
Fragile X Syndrome
-Boys 1 in 1200-2000; girls 1 in 2000-4000
-Poor socialization, severe mental retardation, attention deficits, tactile defensiveness
-Large ears, long face, shy, hand flapping, biting, speech/language dysfunction, 25% seizure disorders
-Moderate to high RE (hyperopia)
-ET = XT
-Nystagmus
Unspecified mental retardation – mild to moderate delays
-XT > ET
-RE similar to general pediatric population
CP
-Non-progressive locomotor dysfunction of varying severity (delayed physical development)
-1 in 1000 live births
-Defect in immature brain due to hypoxia, low birth weight (20x risk), prematurity (5x risk)
-Other risk factors: intrauterine infection, jaundice, Rh incompatibility
-90% related to event in pregnancy or delivery
-10% due to stroke, meningitis, encephalitis, brain injury
-50% mental retardation
-Classifications

Spastic (70-80%) – lesion in pyramidal cells & tracts
-Characteristic gait
-Hypotonia as a neonate (floppy baby)  hypertonia at 6-9 months (spastic)
-Diplegia more common (lower body), can also be hemiplegic or quadriplegic

Athetoid (10-20%) – lesion in basal ganglia
-Some random movement (uncontrolled slow writhing)

Ataxic (5-10%) – lesion in cerebellum
-Hypotonia, fine motor dysfunction, intention tremor

Mixed (spastic + athetoid)
-78% have vision anomalies (most will be 20/20)
-Hyperopia 3x more prevalent (myopia due to ROP)
-Strab (ET or XT)
-50% accommodative insufficiency (reduced amplitude, large lag)
- Cortical visual impairment, hemianopic field loss, optic atrophy, nystagmus
Assessment and management – must refer within 2 working days
-Test at developmental age
-Use large print and SV for near instead of bifocals
-Accommodative insufficiency – correct low hyperopia
-Under 3 years, refer to ECI
-3 or older, refer to school district (contact special ed department)
XIII. Differential Diagnosis of Epiphora
Congenital glaucoma – #1 DDx for epiphora
-Types: primary (onset birth-3 years); juvenile (onset after 3 years); secondary
-1 in 10,000 live births (5:2 M:F), 70% bilateral, 50-70% genetically isolated
-Hereditary can be AD or AR, variable/incomplete penetrance, multifactorial, CYP1B1 locus GLC3A
-60% diagnosed by 6 months; 80% diagnosed by 1 year
-Old theory: abnormality in TM (Barkan’s membrane)
-New theory: widespread anterior seg anomaly (anterior iris/CB insertion, thick/taut beams in TM, thick
juxtacanalicular meshwork, not enough vacuoles in Schlemm’s canal, maldevelopment of Schlemm’s canal
-Symptoms: epiphora, photophobia, blepharospasm (glaucoma triad), irritability
-Signs: buphthalmos, corneal edema, Haab’s striae (horizontal), ↑ IOP, optic atrophy, ↑ axial length, ↓ VA
-Measure HVID (>12mm = buphthalmos)
-Treatments for congenital glaucoma:

Goniotomy (procedure of choice) – requires clear cornea and technical skill; open 1/3 of the TM

Trabeculotomy ab externo – 2 blocks of sclera, metallic thread through the canal, then trabeculatome

Trabeculectomy (bleb) – increased scarring in infants

Shunts – so aqueous dissipates through the conjunctiva

Cyclodestructive – freezing or heat to destroy ciliary epithelium – 70% have increased pressure again
-Late complications: amblyopia, corneal scarring, strab, aniso, cataract, lens subluxation, recurrent glaucoma
-Assc conditions: microphthalmos, ant seg dysgenesis, PHPV, lens anomalies, Sturge-Weber, NF, Marfan’s
Nasolacrimal duct obstruction – do not present with photophobia
-6-20% incidence, NLD not patent until 9 months gestation (so more common in premies), 1/3 bilateral
-Most common site of blockage is valve of Hasner (at the very end)
-Upper obstruction – problems with blinking due to CN VII palsy, non-patent puncta
-Tx: none if isolated upper punctum blockage, tx if symptomatic when lower/both puncta blocked, membrane
puncture with probing, cannulation with intubation
Inspect at 2 & 5
-Lower obstruction – NLDO, acute/chronic dacryocystitis
minutes. 0 is no NaFl
-NLDO: positive reflux from sac, no infection, grade 2-3 on dye disappearance
(patent).
-Acute d’itis (33%): onset over 7 days, erythema, edema, reflex of pus discharge, sores
-Chronic d’itis: at least 14 days, erythema, edema, consistent reflux, bacteria (55% Hemophilus, 35% staph
aureus, 10% moraxella)
-Treatments:

None (spontaneous resolution in 18-24 months), 96% resolve without tx by 1 year

Nasolacrimal massage: hydrostatic pressure opens blockage, 41% resolve by 6 months
-1-2 strokes up, then 10-15 strokes down at least qid

Probing: with anesthesia if over 6-8 months; probe through upper punctum meets probe in nose; 80-86%
initial success; can be repeated

Balloon dacryocystoplasty: equally effective as probing; catheter in NLD, inflate at valve of Hasner for 60-90
seconds; re-inflate at junction between sac and duct for 30-60 seconds; general anesthesia

Nasolacrimal intubation: used after 2 failed probing procedures; left in x 3-6 months

Dacryocystorhinostomy: incision in upper nose, make a hole in nasolacrimal system; last resort tx
Epiblepharon
-2nd most common cause of epiphora; more in chubby and Asian babies
-Extra fold of skin pushes up on lower lid; lid margin is in its normal position
-Often limited to medial half of the lid
-S/s: epiphora, discomfort, FB sensation, extra hz skin fold, trichiasis, keratitis
-Tx: self-corrects by 2 years; lubrication; eyelid sutures; surgical skin removal; bandage CL
Bacterial conjunctivitis
-Hemophilus, strep pneumo, staph (need broad spectrum antibiotics)
-S/s: hyperemia, pus, lid swelling, papillae/follicles, eye stuck closed in morning, crusting
Adenoviral conjunctivitis
-Adenoviruses 3, 8, 19, 37; highly infectious; incubates 2 days to 2 weeks
-S/s: palliative if no SEIs; steroids; +/- prophylactic antibiotic
Seasonal allergic conjunctivitis
-S/s: itching, irritation, tearing, red eyes, chemosis (conj, possibly lid)
-Tx: remove allergen, cold compress, topical decongestant/anti-H/mast cell stabilizer/NSAIDs, systemic anti-H
Keratitis
-Exposure, HSV, bacterial, toxic, phylectenular (inflammatory), dry eye, ulcers
Foreign body
Crocodile tears (gastrolacrimal reflex)
XIV. Child Maltreatment (3 types: physical, emotional, sexual)
Physical abuse
-Non-accidental injury (don’t have to have intent to injure as long as the behavior is inappropriate)
-Includes substance abuse
-Texas law allows reasonable corporal punishment
-Federal/state governments don’t define the line between abuse and punishment
-Open hand is punishment (buttocks, legs, hands); abuse occurs >3 times/day
Neglect
-Largest group of child maltreatment
-Biggest = lack of supervision or inappropriate supervision
-Medical neglect – do not get medical care when they have the resources, includes specs
-Confirmed maltreatment = 1% (12/1000)
-1500 deaths per year from maltreatment (majority from neglect)
-1.5 million harmed, 2.8 million endangered
Factors
-Child factors: young age, perceived different, difficult child, foster child
-Adult factors: social isolation, inappropriate expectations, emotional/psychological disorder, parent was abused,
substance abuse
-Abuser is usually a parent or someone living in the home (age 20s to mid 30s)
-Live-in significant others responsible for 60% of abuse & 90% of neglect
-Social factors: parental relationship, low income, parent-child relationship (more kids, young mother, corporal
punishment, role reversal)
Characteristics
-Child: change in behavior; overly compliant, passive, withdrawn; watchful; dirty; child reports abuse
-Adult: little concern for child; perceives child as worthless, bad, burdensome; role reversal; blames child for
problems at home or school; inappropriate expectations
Injuries

Bruises are #1 (90%)
-1-2% prevalence in non-abuse situations in non-mobile infants
-Worry about blood clotting problem
-Accidental bruises over bony surfaces (chin, elbow, knee, shin, forehead, cheek bone)
-Abuse bruises over soft fatty areas (cheeks, mouth, abdomen, thighs, upper arms, ears, scalp, neck, wrists/ankles)
-Multiple bruises in different stages of healing

Burns are #2 (10-29%)
-Uniform burns are characteristic of abuse
-Peak age is 13-24 months (mean age 3 years)
-Often triggered by toilet training incident

Intraocular hemorrhages (shaken baby syndrome – 34-80% have hemes)
-Ocular injuries in 40% of abuse, but only 4-6% are seen by an eye doctor
-Not likely for a non-mobile child to have an ocular injury
-High risk for brain injuries
-No external signs of head trauma; no history of trauma or it’s not consistent with findings; subdural hematoma;
multiple changes in long bones
-Hemes are often posterior to the equator and in the superficial retinal layers
-Can occur with CPR
-Retinal hemes rarely occur with trivial accidental head injury
Reporting
-Education system is #1
-Medical system is #2
-Must report within 48 hours
-Identity is protected
-Need: reporter’s name, address, phone, e-mail; child’s name, address, age, gender; why suspect; history of
maltreatment; family dynamics