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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