The challenges The challenges The well- -baby vision baby vision The well � Span of concentration Span of concentration � examination examination � Best management Best management � � Communication Communication � � � Equipment Equipment Franç çoise oise Rateau Rateau Fran Australia Australia Casual Inspection Casual Inspection � Look well? Look well? � � � Developmental normal? Developmental normal? � Structural defects � Structural defects � � Head posture; strabismus; nystagmus Head posture; strabismus; nystagmus � Healthy eyes & ocular adnexa Healthy eyes & ocular adnexa � � Discharge Discharge � � Photophobia; eye rubbing Photophobia; eye rubbing � � Visually aware; eye contact � Visually aware; eye contact 1
The aim of the examination The aim of the examination What could we measure? What could we measure? � Prevention of strabismus/amblyopia Prevention of strabismus/amblyopia � Casual inspection Casual inspection � Accommodation: Accommodation: � � � near ret, near ret, � Cover test and Cover test and � Prevention of vision problems that can Prevention of vision problems that can � � motilities; NPC motilities; NPC � Stereo Stereo � affect development & learning; quality of affect development & learning; quality of � Pupils Pupils � Visual fields Visual fields life issues life issues � � � Vision Vision - - FPL FPL � Slit lamp Slit lamp � � � Detection of pathology (primary and � Detection of pathology (primary and secondary), neurological disorders (eg secondary), neurological disorders (eg � Refractive status: � Refractive status: � Internal � Internal dry, wet nystagmus, ptosis) and congenital nystagmus, ptosis) and congenital dry, wet � Developmental � Developmental malformations malformations � � Fusional ranges Fusional ranges tests; reflexes tests; reflexes My baby examination My baby examination History History � Casual inspection Casual inspection � Near ret Near ret � � � Presenting complaint and who notices Presenting complaint and who notices � � � Visually aware Visually aware � Cycloplegic ret � Cycloplegic ret this? this? � � Fix & Follow Fix & Follow � External � External � Well? � Well? � DFE DFE � � Equal avoidance to Equal avoidance to � � Development wnl? � Development wnl? cover cover � Birth history; Apgar score Birth history; Apgar score � � Motilities FROM � Motilities FROM � Medications Medications � � Pupils � Pupils � FOH FOH � � Ortho to cover test Ortho to cover test � 2
FOH of strabismus and amblyopia FOH of strabismus and amblyopia FOH of strabismus and amblyopia FOH of strabismus and amblyopia Ingram & Walker 1979: Siblings of strabismus/amblyopia children Ingram & Walker 1979: Siblings of strabismus/amblyopia children Aurell and Norsell 1990 Aurell and Norsell 1990 A longitudinal study of children with a family history of strabismus A longitudinal study of children with a family history of strabi smus � N=215 preschool siblings of children who N=215 preschool siblings of children who � presented with strabismus/amblyopia presented with strabismus/amblyopia � If 1 parent or sibling has ET then 17% If 1 parent or sibling has ET then 17% � � If no hyperopia/astigmatism/anisometropia If no hyperopia/astigmatism/anisometropia � chance of child getting ET and 38% chance of child getting ET and 38% present in sibling at age 1, they have 10% present in sibling at age 1, they have 10% chance of being >+4.00D at 1 year chance of being >+4.00D at 1 year chance of developing strab/amb. chance of developing strab/amb. � � If >+4.00D and FOH of ET then 46% If >+4.00D and FOH of ET then 46% ≥ +2.00D sph in both eyes and/or ≥ 1.5D of If ≥ +2.00D sph in both eyes and/or ≥ � If 1.5D of � chance of ET chance of ET astigmatism, now have 40% chance of being astigmatism, now have 40% chance of being found later to have strab/amb found later to have strab/amb � (CT, VA <6/12 linear or >1line IOD (CT, VA <6/12 linear or >1line IOD ) ) � 3
Case History- Case History - JB, IB JB, IB � JB JB May 2000 May 2000 ; 8 mo. ; 8 mo. � IB May 2002 IB May 2002 ; 9 mo ; 9 mo � � � ?Intermittent ET; CT0 ?Intermittent ET; CT0 � Near ret +0.75 +1.75 Near ret +0.75 +1.75 � � � Near ret +0.25OU Near ret +0.25OU � Cyclo +7.00 +7.50 Cyclo +7.00 +7.50 � � � Cyclo +4.50D � Cyclo +4.50D � 20BO fused and � 20BO fused and released released � June 2003 � June 2003 � Oct 2002 � Oct 2002 � Dry dist +2.00 +1.50 � Dry dist +2.00 +1.50 � Dist dry ~+4.00 OU � Dist dry ~+4.00 OU � Near ret +1.00/ Near ret +1.00/- -0.50 0.50 � Near ret 1.00 → → +2.00 � Near ret 1.00 +2.00 � � Cyclo +4.50;Rx near Cyclo +4.50;Rx near � � +8 +8.00/ .00/- -1D +9.50/ 1D +9.50/- -1D 1D � � 2004 2004 dry+4.25 4.00 dry+4.25 4.00 � Case history DB Case history DB Referral sources to our practice Referral sources to our practice � Sept 2005 Sept 2005 ; 7 mo. ; 7 mo. � Mum: Mum: � 58% Maternal and Child Health nurses 58% Maternal and Child Health nurses � � � � Dist dry +2.00 OU Dist dry +2.00 OU pl/- -4.00 +0.75/ 4.00 +0.75/- -4.75 4.75 � pl/ � 30% Family in care 30% Family in care � � Near ret +0.50 to Near ret +0.50 to � � 9% Friends 9% Friends � +2.00 +2.00 � � Dad Dad � 3% Other 3% Other � � � Cyclo +6.50 +7.00/ Cyclo +6.50 +7.00/- - +8.25/- +8.25/ -1.25 +7.75/ 1.25 +7.75/- -1.25 1.25 � N=33, ages 2 � N=33, ages 2- -19 months, median 8 19 months, median 8 0.75 0.75 Strab Sx age 3 yrs Strab Sx age 3 yrs months (SD4.5) months (SD4.5) Orthotrope Orthotrope No fly No fly 4
Why do they present Why do they present Cycloplegic refraction Cycloplegic refraction � Term to 12 months 0.5% Term to 12 months 0.5% � 64% ET/XT (usually ET) 64% ET/XT (usually ET) � � cyclopentolate (Hatch); cyclopentolate (Hatch); � 9% routine 9% routine � punctal occlusion punctal occlusion � 9% presumed ptosis 9% presumed ptosis � � (also toddlers with heart � (also toddlers with heart � 6% eyes don � 6% eyes don’ ’t move together t move together arrhythmias, Down arrhythmias, Down syndrome, hepatic syndrome, hepatic � 3% (1/33) nystagmus; photophobia; � 3% (1/33) nystagmus; photophobia; problems etc) problems etc) rubbing eyes; poor awareness of rubbing eyes; poor awareness of � Preterm 0.2%; after 4 Preterm 0.2%; after 4 � environment; roving eyes; watery eyes; environment; roving eyes; watery eyes; months 1% (Repka) months 1% (Repka) FOH ref error FOH ref error Near and cycloplegic retinoscopy Near and cycloplegic retinoscopy Comparing noncycloplegic with cycloplegic Comparing noncycloplegic with cycloplegic data from our practice retinoscopy in Pre- retinoscopy in Pre -School children School children data from our practice � Maino J et al Maino J et al � Gwiazda:1996 Half the � Gwiazda:1996 Half the � Retinoscopy- near and cyclo children with infantile children with infantile Noncycloplegic vs Noncycloplegic vs sph equiv’ ’s <+0.50D s <+0.50D 8 sph equiv cycloplegic cycloplegic 7 are myopic at age are myopic at age retinoscopy in Pre- - retinoscopy in Pre 6 9to16 years (vs 20%) 9to16 years (vs 20%) 5 School children School children � Atkinson 1996 � Atkinson 1996 4 Dioptres 1984 1984 “ “little little Videorefractive images cyclo Videorefractive images 3 near without cycloplegia without cycloplegia agreement agreement 2 Accommodative lag Accommodative lag 1 between the two between the two strongly predictive of strongly predictive of 0 findings findings” ” 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 hyperopia ( ≥ ≥ +3.50) +3.50) -1 hyperopia ( (Mohindra) (Mohindra) -2 under cycloplegia under cycloplegia Patients 5
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