How to Survive a Pediatric Eye Exam
Lernik Torossian, OD, FAAO 1450 San Pablo Street Los Angeles, CA 90033 [email protected] Susan Cotter, OD, MS, FAAO 2575 Yorba Linda Boulevard Fullerton, CA 92831 [email protected]
Outline
I. Introduction
A. Course Objectives
● Examination strategy
● Age-appropriate evaluation methods
● Clinical tips
B. Rationale for eye examinations
● Early detection & treatment to maximize child’s potential
● Prevent vision loss and/or loss of binocularity
● Detect and treat vision problems that can potentially affect development or learning
● Treatment often easier at this age because of plasticity of visual system
C. Screening vs. Examination
● USPSTF
● Current Issues
● AOA Position and recommendations for first eye exam for at risk and no risk patients
D. Who is at risk?
● Risk factors for amblyopia
● Risk factors for strabismus
● Risk factors for refractive error
● Literature support for risk factors (MEPEDS/BPEDS data)
II.
Examination Strategy
A. General Guidelines for Establishing Rapport
● Scheduling considerations
● Office set-up considerations
● Necessary equipment
● White coat vs. no white coat debate
● Tips for chair-side manner and how to engage children
● Patient’s seating position
● Reward systems
B. Case History
● Variations/additions from adult patients
● Keeping child busy/ distracted while discussion is occurring with parent
C. Routine Examination - Minimum data base (no stereopsis or color vision for infants)
● Monocular visual acuities
● Refraction
● Ocular alignment
● Stereopsis
● Color vision
● Visual fields
● Ocular health
D. Stereopsis
● Random dot vs. lateral disparity
● Pass stereotest
● Lang Stereotest
● Other stereotests
E. Color Vision
● Color Vision Testing Made Easy Test
● Waggoner HRR
● Ishihara
F. Visual Acuity
● Objective: Determine if visual acuity is equal and normal for child’s age?
− Direct Measure
− Indirect – exclude etiological conditions necessary for amblyopia development & ocular pathology /
structural anomalies which would cause decreased vision
● Desirable characteristics of preschool VA test
− High contrast, single, surrounded optotypes
− 2-alternative forced choice or matching
− Avoid necessity of verbal or directional response
− Reduced (3 meter) test distance
● Procedure
− Clinical tips for measurement
o Adhesive eye patch
o Fun Frame Occluder Glasses Set
o Electronic charts
● VA assessment methods for Infants
− Teller acuity cards
− Patti pics
− LEA paddles
− Fixation preference
− Resistance to occlusion
− Fix and follow
● VA assessment for Toddlers
− Cardiff cards
● VA Assessment for Preschool Children
− HOTV
o Testability (MEPEDS, AJO 2007)
o Norms
− LEA
o Testability (VIP Studies)
o Norms
− Others:
o Snellen appropriate for some children; consider single line
o Historical: tumbling E, Allen figures, Lighthouse, Broken Wheel
− Visual Acuity Norms (Pan et al, OVS 2009)
G. Refractive Error Assessment
● Cycloplegic retinoscopy
− Indications
− Procedure: appropriate medication / timing of drops
− Use of topical anesthetic?
− Tips for successful instillation of drops with minimal to no discomfort
− Tropicamide a good cycloplegic option?
● Autorefraction
● Mohindra Near Retinoscopy (not a substitute for cycloplegic)
− Indications
− Procedure
− Accuracy
H. Ocular Alignment Assessment
● Objective
● Direct observation
− Strabismus vs. pseudostrabismus
● Cover testing
− Controlling fixation and accommodation
● Hirschberg/Kappa
− Procedure
− Interpretation
● Krimsky
− Procedure
− Interpretation
● Brückner
− Procedure
− Interpretation
− Recent research (Huang & MEPEDS)
● Extraocular muscles
− Move target or child’s head
I.
Ocular Health Assessment
● Timing
● Proper positioning and tools for better results
● Pupils
● Intraocular pressure – necessary?
− Non-contact
− TonoPen
− iCare
− Goldmann
● Anterior segment
− 20D lens and BIO or 20D lens and transilluminator
− Bluminator®
● Fundus Evaluation
− Tips for infants
− Direct and indirect ophthalmoscopes
− Panoptic
J.
Supplemental testing
● Near visual acuity
● Saccades and pursuit eye movements
● Accommodation
− Amplitude (monocular)
− Accuracy
● Second degree fusion
− Worth 4 dot
− Pediatric flashlight - preferred
● Vergence ranges – prism bar; NPC
● Developmental screening
III. Practice Management Considerations / Clinical Tips
A. Recommendation of examination intervals
B. Discussion of possible symptoms
C. Examination for siblings, particularly if at risk
D. Availability of pediatric eyewear
E. Report to child’s pediatrician
F. Consideration of participating in Infant SEE
G. Difficult Situations
● The difficult child
● The difficult parent
● Malingering
H. Referrals and co-management opportunities with optometrists and ophthalmologists
How to Survive a Pediatric Eye Exam
Disclosures
● Financial: SAC & LT none
● Research Funding: SAC from NIH/NEI
Lernik Torossian, OD, FAAO
(Formerly Lernik Mesropian)
Susan A. Cotter, OD, MS, FAAO
Course Objectives
For infants, toddler, preschool eye exams
Rationale for
Examination?
Rationale for Examination
● Examination strategy
● Age-appropriate evaluation methods
● Prevention
● Clinical tips
● Early Detection
● Early Treatment
Screening vs. Examination
● USPSTF: Children 3-5 yrs be screened at
least 1x to detect amblyopia &
amblyogenic risk factors
● Current Issues
Who is at Risk?
Amblyogenic Refractive Error?
Anisometropia
Hyperopia
Myopia
Astigmatism
MEPEDS/BPEDS: 5704 AA, Hispanic, White Children 30-72 months
>1.00 D
>3.00 D
>1.50 D
Bilateral SE Hyperopia
>5.00 D
>8.00 D
Astigmatism
>2.50 D
Odds Ratio*
95% CI
1.37
0.63 – 2.99
<0.0 D
Isoametropia
Hyperopia
Myopia
Risk of Bilateral Decreased VA Associated with Hyperopia
AOA Clinical Practice Guideline on Amblyopia
*Consensus opinion & does not address if age dependent
0.0 to <+1.0 D (reference)
1.0
---------
+1.0 to <+2.0 D
0.37
0.13 – 1.02
+2.0 to <+3.0 D
1.02
0.36 – 2.85
+3.0 to <+4.0 D
1.64
0.51 – 5.24
≥+4.0 D
11.45
5.01 – 26.18
Adjusted for age, astigmatism, gestational age.
*Significant Odds Ratio’s in bold. Level of hyperopia defined by least hyperopic eye.
Tarczy-Hornoch et al. MEPEDS/BPEDS Ophthalmology 2011
Risk of Esotropia Associated with Bilateral Hyperopia
Risk Factors for Strabismus
Risk Factor
(MEPEDS/BPEDS: n= 9970)
Maternal Smoking
ET
XT
✔
✔
Gestational age <33 wks
✔
✔
Older age (48-72m)
✔
✔
Female sex
✔
Family Hx of Strabismus
Anisometropia
✔
✔
Astigmatism
SE Hyperopia
✔
✔
Cotter et al. Ophthalmology 2011;118(11):2251-61
AOA Position: Eye Exams Only
MEPEDS/BPEDS: 9970 AA, Hispanic, White Children 6-72 months
Bilateral SE Hyperopia
95% CI
Odds Ratio*
0.0 to <+1.00 D
reference
------
<0.00 (myopia)
2.48
0.89 – 6.91
+1.00 to <+2.00 D
1.81
0.71 – 4.62
+2.00 to <+3.00 D
6.38
2.56 – 15.93
+3.00 to <+4.00 D
23.06
9.65 – 55.61
+4.00 to <+5.00 D
59.81
23.61 – 151.52
≥ +5.00 D
122.24
49.86 – 299.70
†Based on multivariate stepwise logistic regression model; adjusted for age,
anisometropia, maternal smoking, gestational age.
*Significant Odds Ratio’s (OR) in bold. * Level of hyperopia defined by less
hyperopic eye
Cotter et al. Ophthalmology 2011;118(11):2251-61
No Screening – Only Eye Exam
● Asymptomatic / no risk:
- 6 months
- 3 years
- Before first grade
● Readily recognized eye abnormalities
● At risk:
- By 6 months or as recommended
- 3 years or as recommended
- Annually or as recommended ≥ 6yrs
● Systemic diseases or meds known to cause eye
disorders
● Known neurodevelopmental disorders (e.g., hearing
impairment, CP, Down syndrome, cognitive
impairment, autism, speech delay)
● Positive family history: first-degree relative with
strabismus or amblyopia
● Prematurity (<32 weeks)
● Parent thinks vision-related problem present
Patient Scheduling Considerations
Are You Ready??
• Appointment time
• Bottle, snacks, favorite toy/blanket
• Caretaker for young siblings
Helpful Hints
in
Preparation
WaitingRoom
Room/Area
Waiting
Considerations
Waiting Room
White Coat?
Picture hello kitty
Examination Equipment
You Can’t Have Too Many
The Working Position
The Working Position
Other Considerations
● Staff assistance: distance target, recording….
● Cool down period if baby too fussy
Positive Reinforcement
Case History
● Reason for visit
● Symptoms
● Eye history
- Treatment history
● Medical history (patient & family)
● Medications / allergies to meds
❖ Developmental delays
❖ Academic performance
Routine Eye Examination
Minimum Data Base
■ Eye Alignment
■ Visual Acuity
■ Refraction
■ Ocular Health
■ Color (Preschoolers)
Minimum Data Base?
Routine Eye Examination
Eye Alignment
Stereopsis Tests
Random Dot vs. Lateral Disparity
Visual Acuity
Minimum Data Base
■ Eye Refraction
Alignment
■ Visual Acuity
Ocular Health
■ Refraction
■ Ocular Health
Color & Stereo
■ Color (Preschoolers)
(preschoolers)
Minimum Data Base
Randot Stereotest
● RandotLang I/II
● Random Dot E
● Randot Preschool
● Randot LEA
● PASS
Titmus Fly
Random Dot E Stereotest
Lang Stereotest
Randot Preschool Stereotest
Pass Stereotest
Lang Stereotest
Random Dot Test (LEA)
Color Vision Testing Made Easy Test
Waggoner HRR Test
Cotter, Lee, French. Optometry & Vision Science 1999;76(9):631-6.
Visual Acuity
● Normal for age & equal?
● Assess directly or indirectly
Preschool Visual Acuity
Monocular Distance
Not recommended
Preschool Visual Acuity
Monocular Distance
Visual Acuity
Preschool VA test
Desirable Characteristics ● High contrast, single, surrounded optotypes
● LogMAR progression
● Reduced (3 meter) test distance
● 2-alternative forced choice or matching
● Avoid necessity of verbal or directional response
Demonstration & Matching Card
LEA Symbols
Screening with HOTV & Lea
Testability & Agreement (3-5 yrs)
● Testability = 99% for both
● Identical results for 67%
- When different, 3 yrs better VA on LEA
VIP. Optom Vis Sci 2004;81:678-683
M&S System
Problem Charts
Visual Acuity: Toddlers
Infants: Teller Acuity Cards
Cardiff Cards
Visual Acuity: Infants
Teller Acuity Cards
Teller Acuity Cards
Lea Grating Paddles
Patti Stripes™ Square Wave Grating Paddle
Fixation Preference Testing
● Apparent manifest strabismus
● No manifest strabismus or ≤10∆: Induced Tropia Test (12∆BD)
Sensitivity/Specificity of FP Testing
● For detecting:
- Any amblyopia = 31%
- Anisometropic amblyopia = 20%
- Strabismic amblyopia = 80%
● False positives
- Many strabismic children
- Of strabismic kids with grade C/D, only 32%
had amblyopia
Cotter et al MEPEDS. Ophthalmology 2009; 116(1):145-53
Other Indirect Measures: Vision
• Fix and follow
• Resistance to occlusion
20/20
20/25
20/32
20/16
20/40
20/50
20/63
20/70
Pan et al., MEPEDS; Optometry and Vision Science 2009;86(6):607-12.
Mean logMAR Visual Acuity and Thresholds for Lowest
5thPercentile
†Nearest Snellen-equivalent line tested by ATS HOTV protocol. † † Alternate threshold is next better VA level.
Determine
Refractive Error
Pan et al., MEPEDS; Optom Vis Sci 2009;86(6):607-12.
Cycloplegic Refraction?
Eye Drops
Time for Eye Drops
Cycloplegic Refraction
Assess Ocular Health
● Topical anesthetic
● 2 drops cyclopentolate
● Tropicamide (0.5%) or phenylephrine (2.5%) for
DFE
● Pupils
● 30 minutes refraction
● Posterior segment
● Anterior segment
Retinoscopy – In or Out?
Toy After Eye Drops
Autorefraction?
Mohindra Retinoscopy
● Dark room
● Monocular
● 50cm working distance
● Patient looks at retinoscope
light
● Neutralize primary meridians
● Transpose to spherocylindrical
form
● Subtract 1.25D from sphere
Ocular Alignment
● Observation
● Random dot stereopsis
● Cover testing
● Hirschberg/Krimsky
● Brückner
● EOM’s
Cover Testing - Distance
Cover Testing at Near
Target Choice for Near
Alternate Cover Testing - Near
Hirschberg Testing
Hirschberg Testing
Krimsky Test
Brückner Test
Brückner Test
Brückner Test
The Brückner Test Detection of Strabismus &
Anisometropia in Infants & Young Children
Huang K, MEPEDS et al.
Optom Vis Sci 2011; 89:E-abstract 120023
American Academy of Pediatrics Policy Statement*
● “The Brückner test can detect amblyogenic conditions,
such as asymmetric refractive error and strabismus”
● “If one reflex is different from the other, there is a high
likelihood that an amblyogenic condition exists”
*American Academy of Ophthalmology, American Association for
Pediatric Ophthalmology and Strabismus
Study Objective
● Evaluate ability of Brückner test to detect strabismus
and anisometropia in population-based cohort of
infants / young children
Methods
Sensitivity and Specificity Strabismus
● 8601 children
Strabismus
● Performed before eye examination
● Data analysis
- Without spectacle correction
- Constant strabismus at near
- Anisometropia
(+) Brückner
(-) Brückner
No Strabismus
23
208
true positives
false positives
25
8259
false negatives
true negatives
Sensitivity = 47.9%
97.5%
Strabismus by Magnitude
< 10 PD
10-30 PD
>30 PD
(+) Brückner
2
11
4
(-) Brückner
3
15
Sensitivity
40.0%
42.3%
Specificity =
Anisometropia by Magnitude
≥ 1D
≥ 2D
≥ 3D
(+) Brückner
84
33
9
2
(-) Brückner
540
42
9
66.7%
Sensitivity
(Specificity)
13.5%
(98.0%)
44.0%
(97.5%)
50.0%
(97.3%)
Brückner Test
● Ability to…
- IDENTIFY: leaves many children undiagnosed
- PREDICT: Less than half of children with a (+)
Brückner will have strabismus or anisometropia
Brückner Test: Conclusion
● Not sufficiently sensitive as screening test for
strabismus and anisometropia in children 6 to
72 months of age
Pseudoesotropia
Versions for EOMs
• 32% of pts coded for ET in peds ophthalmology
practice
• Follow up: 10% later diagnosed w/ ET
Versions
Silbert et al. AAPOS 2012 ;16(2):118-9.
Versions for EOMs
Eye Health
Evaluation
Fundus Evaluation
Posterior Segment
Panoptic
Posterior Segment
ICare Tonometer
Intraocular Pressure
www.parkfamilyeyecare.com
Minimum Data Base
Other testing
● Eye Alignment
● Refraction
● Visual Acuity
● Ocular Health
● Color Vision
Difficult Situations
Co-management or Referrals
● Malingering
● The difficult child
● The difficult parent
Practice Management Considerations
● Recommendation of exam intervals
● Discussion of possible symptoms
● Examination for siblings, particularly if at risk
● Availability of pediatric eyewear
● Report to child’s pediatrician
● Pediatric ophthalmologist
● Pediatric optometrist / VT
Finish! Reward Time