11/7/14 Eye Exams for Infants & Young Children The Do’s & Don’ts Disclosures Commercial: none Photos removed for handout File too large even as PDF Salary Support: NIH/NEI Susan Co@er, OD, MS Southern CA College of Optometry Marshall B Ketchum University Fullerton, CA Course ObjecRves For infants, toddler, preschool eye exams •  RaRonale for eye exam / risk factors •  ExaminaRon strategy •  Age-­‐appropriate evaluaRon methods •  Clinical Rps US Preventive Services Task Force •  Children 3-­‐5 yrs be screened at least 1x to detect amblyopia & amblyogenic risk factors Which Kids Need Eye Exams? American Optometric AssociaRon Eye ExaminaRon RecommendaRons For asymptomaRc children • 6 months • 3 years • ≥ 6 yrs -­‐ annually or as recommended United States PrevenRve Services Task Force. Pediatrics 2011;127:340-­‐6. Pediatric Eye & Vision Examination: AOA Optometric Clinical Practice Guideline 1 11/7/14 Direct Referral Guidelines* •  Children at high risk for vision disorders
•  Readily recognized eye abnormalities
*NaRonal Expert Panel (NEP) to NaRonal Center for Children’s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraRon, US Dept of Health & Human Services. In press: Optometry & Vision Science Direct Referral Guidelines •  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 may have a vision-related
problem *NaRonal Expert Panel (NEP) to NaRonal Center for Children’s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraRon, US Dept of Health & Human Services. In press: Optometry & Vision Science Direct Referral Guidelines •  Neurodevelopmental disorders
–  Hearing impairment
–  Cerebral palsy
–  Down syndrome
–  Cognitive impairment
–  Autism spectrum disorders
–  Speech delay
–  Etc.
*NaRonal Expert Panel (NEP) to NaRonal Center for Children’s Vision & Eye Health, sponsored by Prevent Blindness, funded by Maternal & Child Health Bureau of the Health Resources & Services AdministraRon, US Dept of Health & Human Services. In press: Optometry & Vision Science What Are We Looking For? Children ≤ 6 years • Amblyopia or risk factor • Strabismus • Significant RefracRve Error • Color Vision Defect • Eye Health Disorder Risk of Bilateral Decreased VA Associated with Hyperopia Amblyogenic RefracRve Error? Anisometropia Hyperopia
>1.00 D Myopia
>3.00 D AsRgmaRsm >1.50 D Myopia
AsRgmaRsm Bilateral SE Hyperopia
Odds Ratio*
95% CI
1.37
0.63 – 2.99
<0.0 D
0.0 to <+1.0 D (reference)
1.0
---------
>5.00 D +1.0 to <+2.0 D
0.37
0.13 – 1.02
>8.00 D +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
Isoametropia Hyperopia MEPEDS/BPEDS: 5704 AA, Hispanic, White Children 30-72 months
>2.50 D AOA Clinical Practice Guideline on Amblyopia
*Consensus opinion & does not address if age dependent Adjusted for age, asRgmaRsm, gestaRonal age. *Significant Odds RaRo’s in bold. Level of hyperopia defined by least hyperopic eye. Tarczy-­‐Hornoch et al. MEPEDS/BPEDS Ophthalmology 2011 2 11/7/14 Risk Factors for Strabismus Risk Factor
(MEPEDS/BPEDS: n= 9970) Maternal Smoking GestaRonal age <33 wks ET ✔ ✔ Family Hx of Strabismus Anisometropia XT ✔ ✔ ✔ ✔ AsRgmaRsm ✔ ✔ SE Hyperopia ✔ Co@er et al. Ophthalmology 2011;118(11):2251-­‐61 Scheduling ConsideraRons • 
• 
• 
• 
Risk of Esotropia Associated with Bilateral Hyperopia MEPEDS/BPEDS: 9970 AA, Hispanic, White Children 6-72 months
Odds
Ratio*
Bilateral SE Hyperopia
95% CI
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 mulRvariate stepwise logisRc regression model; adjusted for age, anisometropia, maternal smoking, gestaRonal age. *Significant Odds RaRo’s (OR) in bold. * Level of hyperopia defined by less hyperopic eye Co@er et al. Ophthalmology 2011;118(11):2251-­‐61 WaiRng Room ConsideraRons Appointment Rme Ask parent to bring bo@le/snacks/favorite toys Caretaker for siblings May need addiRonal help –  Recording, holding fixaRon targets ExaminaRon Equipment Establishing Rapport •  FixaRon targets / toys accessible •  Talk or play with child prior to examinaRon 3 11/7/14 The Working PosiRon Special Needs Kids: ConsideraRons •  SensiRviRes –  TacRle –  Light –  Sound •  Likes & Dislikes PosiRve Reinforcement Case History •  Reason for visit •  Symptoms •  Eye history –  Treatment history •  Medical history (paRent & family) –  Pre and peri-­‐natal history • 
• 
• 
• 
Eye Alignment Visual Acuity RefracRon Ocular Health Color & Stereo (preschoolers) MedicaRons / allergies to meds Developmental history Academic history Therapies or IntervenRons? Ocular Alignment •  ObservaRon •  Random dot stereopsis •  Cover tesRng •  Hirschberg/Krimsky •  Brückner •  EOM’s Minimum Data Base 4 11/7/14 Stereopsis Tests Random Dot vs. Lateral Disparity Head Tilt or Turn? Chin Tip? • 
• 
• 
• 
• 
• 
• 
Titmus Fly – lateral disparity only Randot Test Preschool Randot RDE PASS test Lang Stereotest Random Dot LEA RDS: No monocular cues; typically must be bifoveal Cover TesRng Use an AccommodaRve* Target *Small and detailed Hirschberg Test Krimsky Test 5 11/7/14 Brückner Test Pseudoesotropia
•  Ability to… –  IDENTIFY: leaves many children undiagnosed –  PREDICT: <50% with (+) Brückner will have strabismus or anisometropia •  Not sufficiently sensiRve as screening test for strabismus & anisometropia in children 6 to 72 months of age • 10-­‐19% later diagnosed with esotropia •  Serial examinaRons & parent educaRon recommended Anwar et al. Strabismus 2012; 20(3):124-­‐26;Silbert et al. AAPOS 2012;16(2):118-­‐9. Huang K, Co@er SA., MEPEDS et al. Optom Vis Sci 2011; 89:E-­‐abstract 120023 Versions: Extraocular Muscles Color Vision TesRng Made Easy Co@er, Lee, French. Optometry & Vision Science 1999;76(9):631-­‐6. Visual Acuity TesRng Waggoner HRR Test •  Normal for age? •  RE & LE equal? 6 11/7/14 Preschool VA Test Desirable CharacterisRcs • 
• 
• 
• 
• 
Demonstrate & Use Matching Card High contrast, single, surrounded optotypes LogMAR progression Reduced (3 meter) test distance 2-­‐alternaRve forced choice or matching Avoid necessity of verbal or direcRonal response LEA Symbols HOTV or LEA Symbols LEA Near VA Screening with HOTV & Lea Testability & Agreement (3-­‐5 yrs) •  Testability = 99% for both •  IdenRcal results for 67% –  When different, 3 yrs be@er VA on LEA VIP. Optom Vis Sci 2004;81:678-683
7 11/7/14 Vision Screening: Untestable Preschool Children Problem Charts •  Ina@enRve or uncooperaRve •  Will not allow one eye to be covered •  Not appear to understand screening task ……Are twice as likely to have a vision problem than those who pass a screening VIP Group. InvesRgaRve Ophthalmology & Visual Science 2007; 48: 83-­‐7. Visual Acuity: Toddlers Cardiff Cards Cardiff Acuity Norms Age (months) Monocular Visual Acuity 12 to <18 20/160 – 20/50 18 to <24 20/100 – 20/25 24 to <30 20/63-­‐20/25 30 to 36 20/40-­‐20/20 Adoh & Woodhouse (1994). The Cardiff Acuity Test Used for Measuring Visual Acuity Development in Toddlers. Vision Research 34(4): 555-­‐560 Infant Visual Acuity Lea GraRng Paddles •  Teller Acuity Cards •  Children <1 year of age 8 11/7/14 Pax Stripes™ Square Wave GraRng Paddles FixaRon Preference TesRng •  Apparent manifest strabismus •  No manifest strabismus or ≤10∆: –  Induced Tropia Test (12∆BD) Methods: FixaRon Preference Grade
A
B
Holds
Well
C
Holds
Momentarily
D
Does Not Hold
Fixation Preference Criteria
Observation made by doctor
1. Spontaneous alternation
2. When switching prism to fellow eye causes FP to reverse
Fixation held with non-preferred eye for:
• ≥3 seconds, OR
• during a smooth pursuit, OR
• through a blink
before refixation to preferred eye
Fixation held with non-preferred eye for 1-<3 seconds
Immediate (<1 sec) refixation with preferred eye when occluder
removed from preferred eye
SensiRvity/Specificity of FP TesRng •  For detecRng – Any amblyopia = 31% – Anisometropic amblyopia = 20% – Strabismic amblyopia = 80% •  False posiRves – Many strabismic children – Of strabismic kids with grade C/D, only 32% had amblyopia CoBer et al MEPEDS. Ophthalmology 2009; 116:145-­‐53 Other Indirect Measures: Vision •  Fix and follow •  Resistance to occlusion Defining Normal Visual Acuity Frequency DistribuRon -­‐ logMAR VA by Age 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. 9 11/7/14 Mean logMAR Visual Acuity and Thresholds for Lowest 5th PercenRle Cycloplegic RefracRon • Topical anestheRc • 2 drops cyclopentolate • Tropicamide (0.5%) or phenylephrine (2.5%) -­‐ DFE • 30 minutes refracRon †Nearest Snellen-­‐equivalent line tested by ATS HOTV protocol. † † Alternate threshold is next be@er VA level. Pan et al., MEPEDS; Optom Vis Sci 2009;86(6):607-­‐12. Determine RefracRve Error AutorefracRon? Determine RefracRve Error Eye Health EvaluaRon ExaminaRon of External Ocular Structures • 
• 
• 
• 
20D Lens & BIO 20D Lens and transilluminator Bluminator Hand-­‐held slit lamp 10 11/7/14 Intraocular Pressure ReRnal ExaminaRon •  iCare Tonometer Other TesRng • 
• 
• 
• 
• 
• 
Reward Time NPC AccommodaRve amplitude MEM BI & BO vergences Pursuits Saccades 11