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Peadiatric Eye Conditions
1. Pediatric Eye Conditions
Vishakh Nair
M.Optom,FIACLE(Australia)
Sr.Faculty. Doctor of Optometry (OD),
Ministry of Higher Education ,KSA.
Ex- Associate Professor, Bharati Vidyapeeth University
Medical College – Optometry Dept.
2. Essential Pediatric Skills
• Knowledge of Growth and Development
• Development of a Therapeutic Relationship
• Communication with children and their parents
• Understanding of family dynamics and parent-child
relationships: IDENTIFY KEY FAMILY MEMBERS
• Knowledge of Health Promotion & Disease Prevention
• Patient Education and Anticipatory Guidance
• Practice of Therapeutic and Atraumatic Care
• Patient and Family Advocacy
• Caring, Supportive & Culturally Sensitive Interactions
• Coordination and Collaboration
• CRITICAL THINKING
4. The single most important part of
the health assessment is……
the
5. History
Bio-graphic Demographic Past Medical History
• Name, Date of Birth, Age •Allergies
•Past illness
• Parents & siblings info
•Trauma / hospitalizations
• Cultural practices •Surgeries
• Religious practices •Birth history
• Parents’ occupations •Developmental
• Adolescent – work info •Family Medical/Genetics
Current Health Status
•Immunization Status
•Chronic illnesses or conditions
•What concerns do you have today?
6. Review of Systems
• Ask questions about each system
• Measurements: weight, height, head
circumference, growth chart, BMI
• Nutrition: breastfed, formula, favorite
foods, beverages, eating habits
• Growth and Development: Milestones
for each age group
9. HEENT: Head & Neck, Eyes, Ears,
Nose, Face, Mouth & Throat
• Head: Symmetry of skull and face
• Neck: Structure, movement, trachea, thyroid,
vessels and lymph nodes
• Eyes: Vision, placement, external and
internal fundoscopic exam
• Ears: Hearing, external, ear canal and
otoscopic exam of tympanic membrane
• Nose: Structure, exudate, sinuses
• Mouth: Structures of mouth, teeth and pharynx
10. Cranial Nerves
C1 - Smell
C2 - Visual acuity, visual fields, fundus
C3, 4, 6 - EOM, 6 fields of gaze
C5 - Sensory to face: Motor--clench teeth,
C5 & C7 - Corneal reflex
C7 - Raise eyebrows, frown, close eyes tight, show teeth,
smile, puff cheeks, taste--anterior 2/3 tongue
C8 - Hearing & equilibrium
C9 – say "ah," equal movement of soft palate & uvula
C10 - Gag, Taste, posterior 1/3 tongue
C11 - Shoulder shrug & head turn with resistance
C12 - Tongue movement
11. Glasgow Coma Scale
1 2 3 4 5 6
N/A N/A
EYES Does not Opens eyes Opens Opens eyes
open eyes in response eyes in spontaneously
to painful response
stimuli to voice
N/A
VERBAL Makes no Incomprehen Utters Confused, Oriented,
sounds sible sounds inappropri disorientated converses
ate words normally
MOTOR Makes no Extension to Abnormal Flexion / Localizes Obeys
movements painful stimuli flexion to Withdrawal to painful commands
painful painful stimuli stimuli
stimuli
Source :Wikipedia
12.
13.
14. • To see clearly, light rays
must be bent or refracted by
the cornea and lens so they
can focus on the retina (layer
of light-sensitive cells lining
the back of the eye).
• Retina sends image to the
brain through optic nerve.
15. Children’s Vision
• Approximately 75%
of learning comes
through the eyes
• Good vision is
critical to a child’s
early educational,
functional, and
social development
16. Vision Examinations for Children
The Eye experts recommends that
children get a comprehensive eye
exam:
At 6 months of age
At 3 years of age
Before beginning 1st grade
Every 1-2 years thereafter as indicated
17. Some Signs of Poor Vision
• Trouble seeing the blackboard
• Difficulty reading /loses place often
• Jerky eye movements
• Frequent blinking /watering
• Squinting / Redness / Rubbing
18. Some signs of poor vision (cont.)
• Tilts the head when looking at
something
• Over-sensitive to light
• Covers one eye while reading
• Sits very close to the TV
• Sees double
• Poor concentration
19.
20. Fixation and Following of light should be looked for and
documented before 4 months of age
Fixation should be Central, Steady and Maintained
22. In hospital Electrophysiological
measures such as the Visual
Evoked potential (VEP) may be
used. VEPs are electrical signals
produced in the visual system
when a target is seen. These
signals are recorded with
electrodes lightly attached to
the scalp at the back of the
head while the child watches
patterns on a computer screen.
These visual acuity tests
measure ’resolution acuity’.
24. Preferential looking- teller acuity
charts
Young children or those with communication difficulties
can be tested using methods that don’t require the
patient to speak or point. Most commonly looking
responses are assessed to estimate visual acuity
28. Examination Visual Acuity in
Children
• Children > 6 years old
• Use standard Snellen
Chart at 20 ft (6 mtrs)
• Most common ocular
condition in this age
group is myopia
– blurred vision at distance
– can develop over several
months
30. Examples of visual acuity charts:
(A) Snellen, (B) HOTV, (C) Lea, (D) Allen
31. Color Vision Test
• Detects difficulty in ability to recognize color
• Children with color blindness are not actually
blind to color, but simply have difficulty
identifying and distinguishing between
different colors
• Color Deficiencies are usually hereditary and
affect 1 in 12 boys but only 1 in 200 girls
33. Color Vision Test
• Equipment:
– Occluder
– Pseudo-Isochromatic
Test Plates
• Referral Criteria
– Student fails if does
not correctly identify
the number on the
card
34. creening the red reflex- Bruckners test
The quality of red reflex should be assessed by pediatricians
efore discharging newborn babies.
35. Assessment of Red Reflex
Gross difference in the quality of red reflex of both eyes
is indicative of refractive errors and strabismus
38. Pupillary Examination
• Direct penlight into eye while patient
looking at distance
• Direct
– Constriction of ipsilateral eye
• Consensual
– Constriction of contralateral eye
39. Summary of steps in eye exam
• Visual Acuity
• Pupillary examination(PERRLA)
• Visual fields by confrontation
• Extraocular movements
• Inspection of
– lid and surrounding tissue
– conjunctiva and sclera
– cornea and iris
• Anterior chamber depth
• Lens clarity
• Tonometry
• Fundus examination
– Disc
– Macula
– Vessels
41. Amblyopia
• Amblyopia: poor vision in an eye
that did not develop normal sight
during early childhood;
sometimes called “lazy eye.”
• While usually only one eye is
affected by amblyopia, both eyes
can be “lazy.”
Amblyopia is common,
affecting 2 or 3 out of every
100 people
• Best time to correct amblyopia is
during infancy/early childhood.
42. AMBLYOPIA
• Reduced Central Vision in the absence of an
organic cause
• Pathophysiology:
– Obstruction of visual axis
– Strabismus
– Anisometropia
– Severe Ametropia
43. Causes of amblyopia
• Cloudiness in the normally
clear eye tissues.
• Cataract in one or both eyes
can lead to amblyopia;
surgery may be necessary.
Cloudy corneas
• Any factor that prevents a
clear image from being
focused inside the eye can
lead to development of
amblyopia.
44.
45. Treating Amblyopia
• Weaker eye must be made
stronger; child must be made to
use the weak eye.
• Patching: patch placed over better-
seeing eye to make child use and
develop good vision in “lazy eye.”
• Eyedrops: Atropine placed in
better-seeing eye daily to blur
vision; forces the child to use “lazy
Patching the eye
eye.”
47. The corneal light reflex test involves
shining a light onto the child's eyes
from a distance and observing the
reflection of the light on the cornea
with respect to the pupil. The location
of the reflection from both eyes
should appear symmetric and
generally slightly nasal to the center
of the pupil.
(A) Normal corneal light reflex.
(B) Corneal light reflex in Esotropia.
(C) Corneal light reflex in Exotropia.
63. VITAMIN A DEFICIENCY
• Xerophthalmia
Bitots spots
Night blindness
Corneal Xerosis
Corneal ulcer[Keratomalacia]
Treatment of Keratomalacia
For children older than 1 year- oral vit A 200,000
IU on day one, 200,000 IU on second day and
additional dose repeated 2-4 weeks later
Less than 1 year – Half the above dose
64. Cataracts in Paediatric patients
• Opacity in lens
• Can be: Visually significant or not
Stable or Progressive
Congenital or Acquired
Unilateral or Bilateral
Partial or Complete
• Congenital: incidence 6/10 000
10% of childhood blindness
68. Evaluation
• Screen newborns with red reflex test
• History : Family
Maternal infections
• Examination: systemic diseases or syndromes
• Workup: Bilateral cases without known hereditary basis
TORCH screen
s-glucose
s-calcium, phosphate
Urine: reducing substances (galactosaemia)
amino acids ( Lowe syndrome)
haematuria (Alport syndrome)
69. Ocular examination
• Formal estimate of vision not possible in neonate
Special tests: Preferential looking test, visually evoked
potentials
• Density and position of cataract
• Morphology
• Associated ocular pathology
• Indicators of severe visual impairment : No fixation
Nystagmus
Strabismus
70. The visually significant
cataract
• In central visual axis, bigger than 3mm
• Posterior cataract
• No clear zones in between
• Retinal details not visible with direct
ophthalmoscope
• Nystagmus or strabismus present
• Poor central fixation after 8 weeks
71. Treatment
• Surgery: Cataract extraction and intraocular lens
implantation for visually significant cataract
• By 6 weeks of age
• Bilateral cases: 1 week apart
• Non visually significant cases : careful observation,
possible pupillary dilation
73. Topical Drugs Used for
Diagnosis:
Fluorescin Dye
• Fluorescein strip: Orange yellow dye
– water soluble
Cobalt blue light
Eye with corneal ulcer Orange becomes green
74. Anesthetics
• Example:
– Propracaine Hydrochloride 0.5% (Alcaine)
– Tetracaine 0.5%
• Uses:
– Anesthetize cornea within 15 sec, last 10 mins
– Remove corneal foreign bodies
– Perform tonometry
– Examine damaged corneal surface
• Side effects:
– Allergy: local or systemic
– Toxic to corneal epithelium ( inhibit mitosis, migration)
79. The Power of Nursing
Never doubt how vitally important you are;
never doubt how important your work is –
and never expect anyone to acknowledge it
before you do.
Every moment, in everything you do,
you are making a difference.
In fact, you are in the business of making a
difference in other people’s lives.
In that difference lies their healing
and your power.
Never forget it.
A child is not simply a miniature adult. Children’s eyes as well as their visual needs tend to differ from those of adults in a number of important ways: Vision is critical to a child’s early educational, functional, and social development. For the most part, children have different lifestyles than adults. Children spend more time outside than adults, experiencing up to three times more sun exposure. Children are the most physically active of any age group with a higher risk for sports-related eye injuries. Computer and video game use create special demands on vision. These differences make the approach to vision and eye care quite different in the child than in the older patient.
It can be difficult for kids to articulate a vision problem. (A more extensive list of telltale signs is available on the VCA’s Check Yearly See Clearly Website.) Although it is beneficial for parents to be aware of the indicators of a vision problem, they should also know that not all problems can be observed by them; and that only an eye doctor has the training and equipment to diagnose an issue.
In addition to the information available through Transitions, there are many other resources in the industry that offer information on kids’ eyesight: AllAboutVision.com is a consumer-focused Website owned by Access Media Group. The site's content is broadly-focused, but it has a guide for parents with useful information written by a team of journalists who have extensive experience in the eyecare field. CheckYearly.com , is another Website for consumers, sponsored by the Vision Council of America. While its content is not solely focused on kids either, it provides a section on kids’ eyes, an interactive “Kids Zone,” and a section for teachers with information on the “ABC's of Eyecare” and “What Students Should Know About Eye Care.” Sponsored by two eyecare practices located in Kansas, ChildrensVision.com is a Website that exists to educate parents and teachers about frequently overlooked vision problems in the hopes of helping those children who struggle unnecessarily because of undiagnosed vision disorders. The site provides many free articles that cover the full spectrum of children’s eye health needs and Opticianry / Optometry extensive materials. InfantSEE is a public health program designed to ensure that eye and vision care becomes an integral part of infant wellness care to improve a child's quality of life. Created by members of the American Optometric Association in partnership with The Vision Care Institute of Johnson & Johnson Vision Care, the program’s Website features information-packed sections for parents, doctors and the media. Since 1908, Prevent Blindness America has been the nation's leading volunteer eye health and safety organization with the sole mission of preventing blindness and preserving sight. The organization’s Website features tips for parents on taking their child to the eye doctor and keeping their eyes safe from injury, as well as home eye tests for children.
