THE MOST SIMPLE BUT COMPACT WAYS OF HANDLING A 3-YEAR-OLD PATIENT. YOU SHOULD NOT MISS THIS! CLINICAL CASE PRESENTATION FOR A 3-YEAR-OLD PATIENT WITH THE COMPLAINT OF DIFFICULTY TO RECOGNISE FAR OBJECTS. Stay tuned for another presentation.

1. Every child is a
DIFFERENT kind
of .
All together,
They make this world
a
.
CLINICAL CASE ANALYSIS
PRESENTATION:
CASE 27
ANNERA LEA BANUS
HS246 5A
OPT560

2. CASE HISTORY
A 3-year-old boy came for an eye examination with his mother.
The mother reported that he had difficulty recognising far
object, testing on him while they were on a road trip. The boy
also tend to squeeze his eyes when looking far. He watched
TV at a 1-meter distance. He had normal birth history
(Cesarean) at 37 week. He had good motor, fine and gross
development. He has no record of ocular disorders. His father
wears spectacle.

3. CASE HISTORY
A 3-year-old boy came for an eye examination with his mother.
The mother reported that he had difficulty recognising far
object testing on him while they were on a road trip. The boy
also tend to squeezes his eye when looking far. He watched
TV at a 1-meter distance. He had normal birth history
(Cesarean) at 37 week. He had good motor, fine and gross
development. He has no record of ocular disorders. His father
wears spectacle.
1ᵒ complaint
Associated symptom
Patient’s way for relief

4. CHIEF COMPLAINTS
1ᵒ : Object recognising difficulty at distance.
2ᵒ : Watched TV too close at 1 meter
1. Hyperopia
2. Myopia
3. Astigmatism
Uncorrected
Refractive error
1. Suspected AI
2. Suspected CI
BV Problems
1. Cataract
2. Juvenile
glaucoma
3. Traumatic
glaucoma
Pathological in fundus
1 2 3
DDX

5. ABNORMAL FINDINGS
0-1 years old
Venus has a very
beautiful name, but it’s
terribly hot
1-2 years old
Mercury is the closest
planet to the Sun and
the smallest one
Normal finding:
6/9-6/6 OU
Average rx (3yo): +1.00D)
Normal:
Break: 5cm +/- 2.5
Rec: 7cm +/-3.0

6. ABNORMAL FINDINGS
Normal: =/> 10mm
Normal IOP (Paediatric patient)
• Up to 10y.o IOP: 0.71 x age (years) + 10
Similar findings:
i. Shiota et al’s works for 0-12y.o patient: 12.02mmHg +/- 3.74mmHg
ii. Jafar and Kazi’s works for patient below 5y.o: mean= 5.89mmHg (Perkins)
Normal: Mean= 12.13mmHg

7. ABNORMAL FINDINGS
Normal:
Break: 5cm +/- 2.5
Rec: 7cm +/-3.0

8. 1. Uncorrected hyperopic astigmatism
RE: +1.75/-1.00 x 5 (6/6)
LE: +1.50/-1.25 x 180 (6/6)
2. Suspected AI & suspected CI
3. Suspected glaucoma (juvenile or
traumatic)
Chief complaint
DIAGNOSES
Differential
diagnosis
Abnormal
findings

9. SHORT-TERM MANAGEMENTS
2.Patient education and consultation with the parent.
i. Visual hygiene
• 20-20-20 rule when doing near task such as playing with 4 pieces puzzle
• Watch TV at an appropriate distance (5-6 feet) and hold gadget at 16-18inches
• Limit screen time <2 hours (1hour/day) and must be co-viewed
• Video of choice must be interactive to promote child’s development, non-violent, educational and pro-
social.
ii. Inform parents regarding the child’s visual development and what they can do to
support it.
• Help the child to practice visual memory like playing with cards and improve pursuit with puzzles
• Strengthen eye tracking skills and hand-eye-coordination by allowing the child to play games like peg
board. Parent can show child how to move each pieces in right left pattern.
1.History taking: Further questions to the parents:
i. Any recent history of ocular trauma to the patient?
ii. Do any family member has glaucoma or any ocular condition?

10. LONG-TERM MANAGEMENT:
TCA 3 MONTHS
i. Monitor patient’s refractive status according to normal development
milestones of a 3 year old to check if prescription is needed
- VA (6/9 to 6/6 BE)
- Normal present refractive status: +1.00DS
3
2
1
Consideration of prescription: 2-4 year old
1. Hyperopia (+3.50DS)
2. Astigmatism (-2.00DC)
-Partial prescription (leaving +1.2D uncorrected)
-Frame criteria: full non-metal frame, spring hinges, low bridge,
frame support at ears, character of choice
-Lens criteria: Polycarbonate (high index:1.586), MUST have AR-coating

11. SHORT-TERM MANAGEMENT:
TCA 3 MONTHS
3
2
1
ii. Re-assess stereopsis test using Titmus stereo fly test or The Frisby Test to
determine the extent of the patient’s depth of perception for BV test
iii. Monitor IOP, perform SLB to check the anterior chamber angle and ophthalmoscopy
to confirm suspected glaucoma. If confirmed then referral to the Ophthalmologist
within 1 week will be done for treatment (medicine prescription).
iv. If spectacle is prescribed, patient education regarding compliance will be done. The
spectacle needs to be worn full time to support visual demand of the patient.
TCA 6 MONTHS:
i. Assess patient’s refractive status for any visual acuity improvement
(reaching to 6/6 BE).
ii. If spectacle was prescribed during first TCA, then patient’s oculo-visual
needs to be assessed to monitor adaptation to the prescription

12. SHORT-TERM MANAGEMENT:
3
2
1
TCA 1 YEAR
i. Yearly eye examination to monitor VA, RX, ocular health
ii. Assess BV development to reconfirm or rule out suspect of CI and AI
(stereopsis, pupillary response,CV) since BV is well developed at 4yo.
iii. If spectacle was prescribed the both ocular health and visual performance
will be re-assessed (Changes in power/VA/Stereoacuity)
At the age of 6, patient’s binocular vision will be assessed
using:
1. Accommodation development: MEM
2. Convergence: NPC with modification
3. Heterophoria: PCT
4. Suppression test: Worth 4 Dot

13. Thank you
If we experienced life
through the eyes of a
child, everything would be
magical and extraordinary.
-Arkiane Kramarik-