Primary Care of the Infant and Young...

9/13/2016

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Primary Care of the Infant and

Young Child

Glen T. Steele, O.D. FCOVD FAAO

Professor of Pediatric Optometry

Southern College of Optometry

How Does This-

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Relate to This?

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EACH OF US AN ISLAND

Each man is an island, cut off from the rest of the

environment. Our only links with the world around us are

our sensory systems: eyes (vision), ears (hearing), skin

(touch), mouth (taste), nose, (smell) - and our reaction to

the one force that is always there, gravity. It is only from

the information processed by these sensory systems that

we can perform in the ways that we want. William C. Lee, O.D.

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What is Vision?

"Our visual system is not there to faithfully record

the image outside, it is there to give us the necessary

information for us to behave appropriately."

From –Basic Vision – An Introduction to Visual

Perception: Robert Snowden, Peter Thompson and Tom

Troscianko - 2006

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Gesell

…. so fundamental is the sense of vision that it is

the traditional criterion of wakefulness as

opposed to sleep.

An infant does not really wake up until he

begins to look; and when he ceases to look he

goes to sleep.

Bubba – this is a clear statement about the critical

importance of vision in overall development

Activation - Awareness – Attention – Action

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Development

Developmental milestones for age

Need to have general review before going into

room

Look for typical progression within average ranges

School readiness begins at birth

What Happens without Development

Without appropriate and active visual experiences,

a child develops Perceptual malnutrition -

First described by Tole Greenstein in April 1968

and most recently reprised by Shelley Mozlin

“They didn’t digest their visual experiences very

well.”

How do we prevent “perceptual malnutrition?”

Better yet, how do we ensure appropriate

experiences?9

Elements of the Examination

History

Ocular Motility

Binocular Function

Refraction

Visual Acuity

Eye Health

Parent Education

PREPARATION

Before the Appointment

Infant History form

Mail to parent with instructions to return by mail or

FAX prior to appointment

Have the history form online or website

What to bring

Bottle, treats, pacifier, finger food

Favorite toys, security blanket

What not to bring

Siblings (unless accompanied by a designated babysitter)

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Name & Age noted

Primary concern

Special concerns & special conditions

Schedule infants in the morning

Avoid nap time

Change baby just before exam

“Special” Equipment

Toys

Fixation Targets: quiet, noisy, dynamic, large, small, light up, flash

Security toys to hold on to

Examination

Trial lenses / Lens bar

Loose prisms / Prism bar


Remove the white coat – or not?

What does staff wear?

Pediatric Exam room

Have equipment & materials ready for easy

access during the exam

Lighting will help control attention

No interruption notice

During the Examination

Be prepared to work quickly, with flexibility

Allow cool down period if the baby becomes too

fussy

Watch the baby’s reaction to your voice tone &

movements

Avoid words like “test,” “drops,” “hurt”

Talk to the baby at their eye level where it is

easiest for them

Use the name Mom & Dad use

Examination

Tactfully control the parent’s comments

Use parents as targets or as puppet masters to

hold the baby’s attention during certain

procedures

Play the game with Mom or a toy first if they

hesitate

Encourage them to touch each target

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The Baby is

Delivered

Now what

do you do?

What We Really Want to Know

Does the history suggest a problem?

Can the baby see?

Are the eyes straight?

How well do they control looking?

How engaged are they in the examination?

Assure a healthy eye!

Is intervention necessary?

Early Warning Signs? Ocular History

Chief complaint

Previous Rx

Previous treatment (patching)

Eye diseases or conditions

Injuries

Surgeries

Other conditions

OCULAR MOTILITY AND

ALIGNMENT

Binocular tests should be completed before

moving to monocular tests

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Ocular Motility

Observe as they follow the target

Ability

Stability

Release

Activation – Awareness – Attention – Action -

Release

Ocular Motility

Activation – Are they already looking?

Awareness – Do they become aware of the target

Attention – Do they attend to the target

Action – Do they reach for the target

Release – Can they let go in order to look for the

next target

Hirschberg

Binocular evaluation of reflection

Use a retinoscope for kids with dark eyes Krimsky

Prism neutralization of Hirschberg

Angle Kappa

Penlight ~50 cm; occlude one eye

Estimate reflex displacement – use form to indicate position of reflex

Alignment Hirschberg

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Why It is Important to Look!

Strabismus, amblyopia, & anisometropia

80 - 100 cm away in dim illumination

ophthalmoscope light on both eyes simultaneously

Observe color, brightness of retinal reflex

Note pupil size

Brückner Test

• Anisocoria, larger pupil is brighter

• Anisometropia: higher refractive condition is

brighter

• Strabismus: non-fixating eye brighter

• Amblyopic eye’s pupil will first constrict weakly,

then dilate immediately

• These are different from observations on

retinoscopy

Brückner Test

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Bruckner reflex: OD esotropia

Binocularity

Based upon stereo acuity development during the

first 24 months, the first year represents a sensitive

period for development of binocularity

Convergence Near Point

light up a finger puppet

Commercially available targets

Anything that lights up or has a shiny

surface

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Lang Randot Stereo test or Stereo Tower

no filter glasses required

change orientation of target to be sure

response is valid

10Δ BU prism test

Worth or Bernell Flashlight test

noises when they are touched

Binocularity

Worth Four Dot

Near Distance

Lang Stereo

Test

no filter glasses

required

change orientation

of target to be sure

response is valid

Keystone Basic

Binocular Test

(KBB)

Can be used

beginning at

about six months

of age

My preferred for

infants and

young children

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Visual Acuity and

Refractive Conditions

Visual Acuity

Is acuity normal & equal

(Interocular Acuity Difference - IAD)

Best Tests

High contrast optotypes

Forced choice or matching

Decreased test distance (<= 10 ft)

Candy bead (>1yr)

Reaction to occlusion

Fix and Follow

Fixation Preference with 10Δ BU

Alternates fixation equally

Holds briefly but one eye dominates

Can be done at the same time as binocularity testing

Visual Acuity

Visual Acuity

Preferential looking cards

Stripe Cards best for < 1 yr but can be useful with older

toddlers (Teller or Patti Pics)

Richman Face Dot Paddles

IAD > 2 sequential cards for Teller/Keeler PL cards is

significant

Risk of Amblyopia development increases with

high ametropia, anisometropia or constant

unilateral strabismus

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Richman Face-Dot - PL Lea Gratings

Forced Choice Preferential

Looking Test Forced Choice Preferential

Looking Test

59 60

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Teller Cards

Potential Acuity

Preferential Looking Technique

6 mo 20 / 200

1 yr 20 / 100

2 yrs 20 / 20

Visual Evoked Potential

6 mo 20 / 20

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Retinoscopy

Pediatric Trial Frame

Loose lenses, skiascopy lens bar

+2.00 working distance glasses for toddlers

Mohindra, dynamic, wall cartoon

MY preference – loose lenses in pairs looking at

both eyes with a retinoscope

Refraction

Myopia, hyperopia and astigmatism can vary

considerably throughout the first year

Refraction may vary as much as

6.00 - 8.00 Diopters and still be normal

Frequent re-assessment is indicated until it is determined that the refraction is stable over a three month period

You don’t have to prescribe on the first visit

3 X 3 Rule

Emmetropization

Usually born with moderate hyperopia

May also show myopia and astigmatism

Gradually moves toward emmetropia

Allow this process to take place

3 X 3 Rule

Majority of emmetropization is completed during

the first year resulting in reduction of the high

levels of hyperopia and astigmatism common in

infancy

Emmetropization may be delayed in ROP and

other at-risk babies such as those with Down

Syndrome

Emmetropization Mohindra Retinoscopy

Non-cycloplegic distance assessment

Monocular

Child fixates retinoscope light

Dark room at 50 cm

Correction factor:

-0.75 D for infants; -1.00 D after age 2 yrs

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Cycloplegic retinoscopy results can be used to

help analyze refractive status

Be careful about prescribing directly from

cycloplegic findings on problem babies,

especially when used with an autorefractor –

cycloplegic retinoscopy is just another piece of

information

Cycloplegia

Do other retinoscopy findings first

Be aware of the emmetropization process

“Pushing plus” should be reserved for

minimization of the angle for ET or for specific

amblyogenic factors

Cycloplegia

Refractive Compensation should be considered for

stable refractive conditions of abnormal degree or

when significant anisometropia or ametropia is

present increasing the risk for amblyopia

3 x 3 rule

If you don’t prescribe glasses, it does not mean you

don’t do anything – prescribing involves more than

glasses

Prescribing

Significant refractive conditions in children

12 months and younger (AOA Clinical

Practice Guidelines):

> + 5.00 D hyperopia in any meridian

> - 8.00 D myopia (20% with ROP)

> 2.50D astigmatism

> 1.00 – 1.50 D anisometropia (esp. if

higher ametropic eye is >+3.00D)

Prescribing

“Partial corrections” are generally recommended for

infants and toddlers

greater range of refractive condition is normally

present

there may be harm associated with removing blur

completely

measurements are often less valid, unreliable

Most importantly, allow development to take place

Prescribing

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A good clinical guide is to use developmental

guidelines as the primary marker

Bubba’s Rule – Start where you get the first

brightening on near retinoscopy

3X3 Rule – see the baby three times three months

apart before prescribing to ensure stable refraction

But give them activities to do at home!!

Prescribing

Ocular Health

Ocular Health

• General observation

• Anterior segment

• Pupils

• Intraocular pressure measurement

• Visual fields

• Posterior segment

Clinical pearl: Always instill a drop in the eye

that is closer to parent’s chest first

Medications

Medication Dosage

Polytrim q3h for 7-10 days

Erythromycin Ung Qid

Tobrex ung and drops Qid

Sulfacetamide q2-3h

Moxeza >4 mos

Vigamox and Zymar used byMost approved beyond one

Bid x 7 days

many but not “approved”year

Antibiotic Agents – approved for

infants

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Anti-allergy Agents

Many if not most approved beyond age three –

check package insert

Case Management

Follow-up for problem cases

What is being followed

Why

What are the possible outcomes

What might be the consequences

What are the next steps

Case Management

Mechanism for follow-up (U&C)

Pre-appoint with postcard reminder

Telephone reminder

Documentation

Note Tx and F/U recommendations

Note No Show (NS) or Reschedule (RS)

Case Management

In the event that treatment is necessary at a later

date

Room for improvement AND emmetropization

Compliance

Glasses (polycarbonate)

Consultation (OD, other health provider)

What We Really Want to Know


Can the baby see?




Case Disposition

Is this child’s visual development normal?

Do we need to intervene?

When should we see this child again?

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Cases

Patient SR 7 months

History - Parents note no problems

Ocular health - shows expected appearance

Ocular motility - full EOM with sustained fx

Binocularity – alignment on Hirschberg - Global

stereo on KBB

Refraction - +0.25 with 0.75 cyl

Visual Acuity – FDL at 26”

THIS IS THE TYPICAL

PATIENT SEEN IN YOUR

OFFICE

Patient MF 11 months

OU +7.50D without strabismus

Had been scheduled as a routine visit

Are we concerned?

Why are we concerned?

What are the areas of concern?

Is this child at risk?

What should we do?

Follow up in 3 months

Give looking activities to do at home

Pre-appoint for follow-up

Explain risk factors.

Explain consequences of not following up.

At follow up visit, review history. Is there any

evidence of an eye turn? Re-refract? Is the high

hyperopia still there?

Look for initial brightening on near retinoscopy

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3 Months Later…..

If the patient is still +7.00D OU- now what?

If the patient is +3.00D – now what?

RL age seven mos.

Born at 26 weeks

Released by Retina Clinic

Ocular health: normal

Full EOM

Alignment - IXT dist and ortho at near

Ret: OD: - 11.00 OS: - 11.00

Visual Acuity - FDD at 8”

Why are we concerned?

What are the areas of concern?

Is this child at risk?

What should we do?

R.L. Post Script

Hold on Rx

LOTS of movement activities

Monitor frequently

After six months the baby was now showing -7.00 OU

Parent was very aware of the child’s activities and abilities

Rx when the child begins to have difficulty with ADL

This was at age two – Rx - 5.00

TM - age 12 mos

Taken from birth parents at age six

months

“Shaken Baby Syndrome” dx

Previous dx of subretinal hemorrhage in the

macular area of the right eye

Intermittent RXT with increasing frequency

reported by foster parent

Visual acuity – OD FDL at 12”

OS FDL at 50”

AD

Patient is a -2.00D OU- do we prescribe?

Nine months

Three years

Six years

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Prescribing

We do not need to prescribe the entire amount of

plus, minus or astigmatism - just enough to allow

for normal visual development. Prescribe enough

plus to remove the amblyogenic factors yet leave

them under-corrected in a normal range for infants.

Patient KM 9 months


Ocular health - shows expected appearance


Binocularity – alignment on Hirschberg - CT ortho

D & N

Refraction - OU +5.25 - 1.25 X 90

Visual Acuity – F & F, tolerates occlusion

Patient EM 11 months


Ocular health - slightly small corneal diameters


Binocularity – alignment on Hirschberg - CT ortho D & N

Refraction - OD +8.00 - 1.50 X 180 OS +8.50 - 1.50 X 180

Visual Acuity – Monocular PLT OD & OS 20/200

A.S. - three years

Showing eye crossing for three months

Went to Dr._________ who prescribed glasses

Eyes are straight with glasses but eye REALLY

turns when she takes them off

Cannot see airplanes taking off from Memphis

Bumps into walls with current glasses

Parents don’t know what to do

A.S. - three years

Rx OD +7.00 + 0.50 X 090

OS +8.50 + 1.00 X 090

Does not like to wear her glasses!!

Distance ret – runs up in plus to +7.00 to +8.00

First change at +5.00

Near ret – stable at +3.00

A.S. - three years

Ocular motility normal

Four Dots

Positive response on KBB without Rx

No apparent movement with 10 pd prism

CT aligned w/o Rx on penlight

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A.S. - three years

Goes to ET when accommodative target is

used

Maintains alignment on accommodative target

when current Rx is used

Maintains alignment with +3.50 at nearpoint

Dilated fundus examination - normal

WHAT IS YOUR PLAN?

A.S. three years

Rx - +3.50 OU FTW

Binasal patches

Three week follow-up

A.S. three years – Follow-up

Does not bump into things

Does not show ET unless she takes her glasses

off

Positive response on KBB

No suppression on R/G testing

Continue Rx and follow in six weeks

A.S. three years – Follow-up

Last seen at age 15

Wearing +0.75/+1.00 add

Wanted contact lenses

Went into CTL with Pl/+1.00 add

Straight A student

Plays on basketball team and does not use

glasses

CASE C.J.

Age three

Has been seeing Dr. _____ for six months

Left eye began turning when she looked at

objects very close

When asked “How close?” the parent replied –

“About three inches”

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CASE C.J.

See eye turn less than 10% of the day but only

when working up close

Has glasses Rx but not filled

+4.50 + 1.50 X 090

+4.50 + 1.50 X 090

Wanted second opinion

C.J.

Hirschberg – aligned throughout examination w

and w/o Rx

Excellent response on KBB

Retinoscopy - +2.00 at nearpoint

Does release into more plus on occasion

Full EOM – no tropia visible

Dilated fundus exam normal

WHAT IS

YOUR

PLAN?

PLAN - C.J.

No Glasses

Guidance activities

Follow in three months but return

immediately if ET increases in frequency

C.J. – post script

Now age 21

Wears Pl/+0.75 add

Reading well above grade level

Monitoring every year

4 year old twins

Jonathan all over the room

Jalen sits in the chair, not watching or engaged

What behaviors do you expect with twins

Jalen and Jonathan

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Jonathan

Jalen

Jonathan

(+2.50)

Jalen (+9.00)

Jalen in six months after glasses (+4.00)

Jonathan +2.50 OU

Jalen +9.00 OU

Six months after wearing glasses (+4.00), Jalen

was running around the room with Jonathan.

Parent was well aware of the difference in social

interaction

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Jalen and Jonathan What We Really Want to Know


Can the baby see?


How well do they control looking?

How engaged are they in the examination?



Contact Information

Glen T. Steele, O.D. FCOVD FAAO

[email protected]

mailto:[email protected]

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