PROJECT VIETNAM FOUNDATION

PROJECT VIETNAM FOUNDATION

Online Training Series

For Vietnam Medical Professionals

Steve Prepas MD

HOAG HOSPITALNewport Beach

25 humanitarian trips11 countries

Quynh Kieu MD

University of Saigon, class of 1975

Eye & Vision Screening

The Role Of The PediatricianProject Vietnam Foundation

Online Training Series

Created bySheryl Handler, M.D. Encino, CA

Presented by Steven Prepas, M.D., CA


• Purpose of eye & vision screening

– To identify serious eye problems in children as early as possible

– Then to refer them for comprehensive evaluation and treatment

– Monitoring ocular health should begin at birth and continue throughout childhood

Vision Screening: Vietnam

Goal –Increase vision screening among

younger preschool children

Vision in Preschoolers

Percentage

• Vision Impairment 10

– Strabismus 4

– Amblyopia 3 - 4

– Total Strabismus/Amblyopia 5 - 7– Significant Refractive Errors 5 - 7

Why Do Eye & Vision Screening ?

• 5 – 7 % of children have amblyopia/strabismus

• 1 – 2 % of all children have unsuspected

amblyopia/strabismus

• Anisometropia (different refractive errors in each eye) and small angle strabismus are the leading causes of undetected amblyopia


• Problems can present at any time during infancy & early childhood

– Life-threatening diseases• Retinoblastoma (may be autosomal dominant)

– Vision threatening conditions• ROP• Cataracts• Glaucoma• Amblyopia• Strabismus

Other Childhood Ocular Conditions

Percentage

• Congenital cataract 0.06

• Congenital glaucoma 0.01

• Retinoblastoma 0.005

• ROP (in infants < 750 g) 52.00

Cataract

Congenital Glaucoma

Retinoblastoma

Refractive Errors• Hyperopia – far-sightedness

– Normal children are slightly far-sighted– Normal children accommodate (focus) it away– In children excessive far-sightedness causes

strabismus +/or amblyopia in children

• Myopia – near-sightedness– Blurriness at distance

• Astigmatism – Blurriness at all distances

Refractive Errors

• Hyperopia – far-sightedness

• The eyeball axis is short

Refractive Errors

• Myopia – near-sightedness

• The eyeball is too long

Childhood Refractive Errors

• Visually significant refractive errors Percentage

– Pre-school children 5 – 7 – 10 year olds 10 – 12 – 18 year olds 25 – 30 The increase is due to the development of

myopia (near-sightedness)

Eyeglasses

• Optical correction should be considered to:– Prevent amblyopia– Treat amblyopia– Treat strabismus– Improve visual acuity – Improve visual discomfort

Strabismus

• Strabismus – Ocular misalignment

• Esotropia– Inwardly deviating eyes - “crossed eyes”

• Exotropia – Outwardly deviating eyes - “wall-eyed”

Esotropia

Esotropia Exotropia

Amblyopia

• Develops in critical period – Birth to 7 years– Young children need to learn how to see – Any cause that interferes with learning how to

see can lead to amblyopia

• Vision loss is lifelong – if not treated

Amblyopia

• Not a primary condition but secondary to:– Strabismus– Need for glasses– Structural abnormality decreasing vision

• May be “invisible”• May be unilateral or bilateral

Amblyopia

• Early detection key to effective treatment

• Best treated in early childhood

• Recent data show that amblyopia may be somewhat treatable even into the teen age years

Amblyopia Statistics

• > 6 million Americans have amblyopia

• Amblyopia is responsible for loss of vision in more people ≤ 45 years old than all other causes combined

• The prevalence is 6 times greater in children with developmental delay

• The prevalence is increased with family history

Amblyopia Statistics

• Screening for amblyopia reduces prevalence in the adult population by 50%

• Patients with amblyopia are more likely to lose vision in the good eye from trauma

-50% work related trauma

• Amblyopia increases the lifetime risk of developing bilateral visual impairment from 10% to 18%

Amblyopia Causes

• 50 %

– Strabismus (mainly esotropia)

• 50%

– Visual deprivation• Anisometropia - asymmetric refractive errors• High refractive errors• Ptosis, hemangioma, etc.

– Structural ocular problems• Optic nerve, retinal, etc.

Amblyopia Treatment

• Glasses - provide a clear retinal image

• Patching – Occlusion therapy of the good eye– Stimulates the weak eye– Prevents suppression by good eye

Eye & Vision Screening by Pediatricians

History & Examination

• Family eye history & patient history– Important eye information should be included on new

patient information form • Newborn & infancy eye examination

– Structural abnormalities

• Infancy & beyond eye examination– Add amblyopia & strabismus

Eye & Vision Screening History

• Prematurity• Medical problems – past & present • Family history

– Retinoblastoma– Congenital cataract– Congenital glaucoma– Metabolic or genetic disease– Strabismus &/ or amblyopia– Glasses in family members < 5 years of age

• Visual complaints• Eye complaints

Methods for Eye & Vision Screening

• Red reflex

• Brückner red reflex test

• Pupil examination

• Corneal light reflection

• External inspection

• Fix and follow

• Alternate occlusion – cover testing

• Visual acuity (monocular)

Eye Exam in Infants & Children by Pediatricians

• Newborn – 6 months– Ocular History – Red Reflex– Pupil Exam– External inspection of the eyes & lids– Ocular motility assessment– Vision assessment

• Referral Criteria– Infants with an abnormal red reflex– Infants who do not track well > 3 mo of age– Infants with strabismus > 3 mo of age– Infants with a FH of retinoblastoma, congenital

cataract, childhood glaucoma in a parent or sibling


• 6 months to 3 ½ years - add– Ophthalmoscopy

– Photoscreening / autorefraction

• Referral criteria– Infants with strabismus – Infants with chronic tearing or discharge– Photoscreening / autorefraction failures

– Children with a FH of strabismus or amblyopia in a parent or sibling


• ≥ 3 ½ years - add– Visual acuity testing (preferred) – Or photoscreening / autorefraction

• Referral criteria– ≤ 20/50 (< 20/40) with either eye

• ≥ 5 years – repeat screening every 1 – 2 yrs– Visual acuity testing (drop photoscreening)

• Referral criteria– ≤ 20/40 (< 20/30) with either eye

– Children not reading at grade level

Red Reflex

• The red reflex is a test to identify clarity of the ocular media

• It is performed by looking at each eye with a direct ophthalmoscope from a distance of about 18 inches

• Perform prior to discharge from the nursery and at all subsequent health supervision visits

• Consider dilation with Cyclomydril

Red Reflex

• Questions to consider:

– 1. Is there a red reflex from each eye?

– 2. Are the red reflexes when viewed both individually and simultaneously equivalent in color, intensity, and clarity with no opacities or white spots (leukocoria)

Brückner Red Reflex Test

• Binocular red reflex test

• Superior to the conventional red reflex test

– Detects abnormalities of the red reflex– Assesses alignment– Assesses large and/or asymmetric refractive errors

Brückner Red Reflex Test• The binocular red reflex test is performed in a dimly lit

room with the examiner at a distance of about 18 inches from the child

• The examiner overlaps both pupils simultaneously

creating a binocular red reflex with the largest circular light of a direct ophthalmoscope set to focus on the ocular surface - usually at “0”

• The examiner then assesses the quality of the “redness” seen within the child’s pupils.

Brückner Red Reflex Test

• Normal– The red reflex from each eye should be of the same

color and brightness

• Abnormalities – Asymmetric reflexes with one reflex being duller or a

different color– A white reflex– A partially or totally obscured reflex– Crescents present in the reflex

Brückner Test – Binocular Red Reflexes

Amblyogenic Anisometropic Hyperopia (+6.50 od, 1.00 os)

Left Congenital Cataract

Yellow Reflex Due to Coat’s Disease, a Potentially Blinding Childhood Retinal Vascular Disorder, Left Eye

Bilateral Retinoblastoma Causing Leukocoria

Red Reflex Referrals • Refer all absent or abnormal red reflexes

• Refer all abnormal Bruckner red reflexes

• Refer if parents or observers describe a history suspicious for possible leukocoria

• Infants in high-risk categories should have red reflex

testing performed in the nursery and also be referred

• Refer to a Pediatric Ophthalmologist

Eye Screening Examination (cont)

• Pupil examination– Irregular shape– Unequal size– Poor or unequal reaction

• Corneal light reflection – asymmetric– Strabismus

• Inspection– Ocular anomalies– Strabismus

Evaluation of Strabismus

• Manifest strabismus– Corneal light reflection asymmetry

–Bruckner test – red reflex asymmetry

• Latent or manifest strabismus– Cover test

Cover Test

• Cover test– Can detect latent or manifest strabismus

• Use target with visual detail

• Cover one eye (the fixing eye if apparent)

– If manifest strabismus (cover test)• Watch for the other eye to move to the target

– If latent strabismus (cover-uncover test)• Watch for a recovery movement of the covered eye

after it is uncovered

Vision Screening

• Look for abnormal visual behavior– Inattentiveness– Nystagmus – Squinting– Eye closure – Abnormal head position– Parental concern

Abnormal Head Position for High Hyperopia

Preschool Vision Testing Objective Vision Screening

• Significant value in assessing younger children (ages 6 mo – 3 ½ years)

• Photoscreeners– MTI Photoscreener

• Autorefractors– Welch Allyn SureSight– Nikon Retinomax– Plusoptix S 09

What is a Photoscreener?

• An instrument that takes a photo of the eye's red reflex to estimate refractive error (prescription of the eye), ocular alignment and other conditions degrading or blocking line of sight (cataract)

Crossed Eye Straight Eye

Red Reflex is brighter in the crossed eye

Photoscreeners Can Detect Strabismus

Autorefractors

• An instrument that determines the prescription of an eye (refractive error)

• High or asymmetric refractive errors may cause strabismus and/or amblyopia

• Other conditions that block the visual axis (cataracts) may also be detected

• Are held close to the eyes and the panel indicates the refractive error of each eye

WelchAllyn SureSight

Autorefractors – are held close to the eyes and the panel indicates refractive error of each eye

Nikon Retinomax

Acuity Testing

• Vision Charts are still the “Gold Standard” – As opposed to photo or autorefractors

• Letters must be presented in a line – Single letters can be inaccurate - over estimate vision

• Test one eye at a time with other eye patched or carefully occluded– Kids cheat!

Subjective Visual Acuity Chart Testing

• Types of acuity tests recommended– Lea symbols– HOTV – Snellen letters

SCHOOL VISION TESTING

Lea Symbols & HOTVAges 3 & 4

Subjective Visual Acuity Chart Testing

• Testing at 10 feet may be better for 3 – 4 y.o.

• 3 - 4 year olds can match or identify– Lea pictures – HOTV

• Use letters as soon as the child knows them

• Use “crowded” optotypes or linear V.A.

Occlusive Patch for Monocular Testing

Current Vision Screening Policy AAP

• Visual acuity testing should begin at 3 yrs

• Poor cooperation or untestable if age 3 - 4– Retest in 4 - 6 months (do not wait 1 yr)

• Poor cooperation or untestable ≥ age 4– Retest in 1 month

Vision Test Failures & Untestables

• All vision screening failures – Refer

• Children who are untestable – Refer or – Repeat screening could be attempted

• Retesting may eliminate 30% of false positives• Do not wait until yearly check-up

Preschool Referrals

• Refer 3 – 4 year olds

– ≤ 20/50 (<20/40)– 2 or more lines difference between the eyes

(even within the passing range –

i.e. 20/20 and 20/40)

• Refer 5 year olds if

– ≤ 20/40 (<20/30)– 2 or more lines difference between the eyes

School Age Referrals

• Refer ≥ 6 year olds if – ≤ 20/30

– Children not reading at grade level

• Up to 70% of children may not read the 20/20 line until age 7

Mandated Exam Concerns

• Significant percentage of children were prescribed glasses outside guidelines and were probably “unnecessary”

Indications for Referral for a Comprehensive Pediatric Ophthalmic Evaluation

Risk Factors – specific examples • Prematurity ≤1500 g & ≤ 32 weeks• ROP• IUGR• Perinatal complications• Neurological problems• Craniofacial abnormalities

– Cleft palate


Risk Factors – specific examples • Diabetes Mellitus• JRA/JIA• Thyroid disease• Systemic syndromes• Chronic systemic corticosteroid therapy• Suspected child abuse


• Family history – specific examples • Retinoblastoma• Childhood cataract• Childhood glaucoma• Retinal dystrophy/degeneration• Strabismus• Amblyopia• Eyeglasses in early childhood• Sickle cell anemia• Systemic syndromes with known ocular manifestations• Any history of childhood blindness in a parent or sibling


• Signs & Symptoms – specific examples• Defective ocular fixation or visual interactions• Abnormal corneal light reflex• Abnormal red reflex• Abnormal Bruckner red reflexes• Abnormal or irregular pupils• Large and/or cloudy eyes• Droopy eyelid• Lumps or swelling around the eyes


• Signs & Symptoms – specific examples• Ocular alignment or movement abnormality• Nystagmus• Persistent tearing & ocular discharge• Abnormal persistent or recurrent redness• Persistent light sensitivity• Squinting/eye closure• Persistent head tilt• Learning disabilities or dyslexia

Eye Problems with ROP

• Retinal Detachment• Amblyopia• Strabismus• High Myopia• Anisometropia• Pupillary Block Glaucoma

Referral Plan

• URGENT REFERRAL– Abnormal red reflex– Suspected severe eye injury– Severe eye pain– Sudden loss of vision

Referral Plan

• SEMI-URGENT REFERRAL– New onset of strabismus or diplopia– Visual acuity < 20/200– Severe or new onset ptosis– Anisocoria

Referral Plan

• STANDARD REFERRAL– Abnormal visual acuity for age– Untestable children– Strabismus or suspected strabismus

It’s Never Too Early To Screen

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