A Paula Grigorian, MD...Hirschberg test. Brüchner’s test •Combined, simultaneous •corneal...
Transcript of A Paula Grigorian, MD...Hirschberg test. Brüchner’s test •Combined, simultaneous •corneal...
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A Paula Grigorian, MDPediatric ophthalmologist
Associate Professor of Ophthalmology UAMS
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No conflict of interests
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Overview
Review vision screening methods
How to do it
What you may find
What it means
When to refer
Some things you may never
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Visual development
At Birth - Poor vision 20/200-due to immature brain
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Birth to 2 mos
Poor fixation, little visual attentiveness
Frequent exotropia
Jerky eye movements- saccades
No smooth pursuit
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2 to 6 mos
Eyes should be straight
Crossing is abnormal!
Able to reaches for toys
Central fixation and smooth pursuit
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After 3 years
A normally developing cooperative child should be able to read/match an eye chart
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Screening
Is essential in preventing vision loss
It is a challenge
Nearly 4 mil newborns/yr
Preverbal, Non-verbal, Shy, Peeking, Uncooperative
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Screening
External exam
Pre term infants: RED reflex
All neonates: + corneal light reflex, fixation
Preschool-aged: + cover test
School- age: + check VA
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Anatomy
Valve of Rosenmüller
Valve of Hasner
-punctum to inferior meatus 20mm
Inferior turbinate
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Dim room light
Direct ophthalmoscope
12-18in from the child
Dial the diopter control until the red reflex comes into focus
Check each eye at a time
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Red reflex
Produced by the light reflected from the retina
Cataract, RB or retinal abnormalities dim RR = Leukocoria
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Corneal light reflexes -test
Produced by a point source of light focused by the cornea
The position of the reflex is dependent on the alignment of the eyes
Diagnose strabismus
http://one.aao.org/Flash/VisionScreening/PediatricVisionScreening.html
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Corneal light reflexes -test
Direct ophthalmoscope or penlight
A detailed near fixation target will help
Look at both eyes simultaneously
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Corneal light reflexes -
Helps distinguish b/w strabismus and pseudostrabismus
Overcomes other misleading features: epicanthal folds or eyelid asymmetry
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Hirschberg test
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Combined, simultaneous corneal light reflex
red reflex
Direct ophthalmoscope
In addition it allows evaluation of the pupil for asymmetry
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Red reflex
White reflex- media abnormalities
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White reflex- media abnormalities
Strabismus
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White reflex- media abnormalities
Strabismus
Detects refractive errors, anisometropia
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White reflex- media abnormalities
Strabismus
Detects refractive errors, anisometropia
Rapidly compares pupil size
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Guidelines for screening
AAP
RR screening by PCP w/in the first 2 mos :
Neonatal visit, 2 and 6 wks
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Cover testing
Requires fixation in each eye
Can give information about vision
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Cover testing
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Preschool vision screening
Optotype-based vision
LEA symbols, HOTV, Allen cards, Snellen letter
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Preschool vision screening
Test each eye at a time
Kids cheat!stick on patch for all children
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Acuity Test: Age 6+
Sloan letters
Five letters every line
Inverted pyramid shape
Spacing proportional to the size of
the letter
More accurate vision assessment
then Snellen
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Acuity Test Failure Criteria3 - 5 YO
Unable to read at least 20/40 with either eye.
REFER!
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Acuity Test Failure Criteria>5 YO
Unable to read 20/30 either eye
OR
Two line difference between eyes (20/20 and 20/30)
REFER!
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Depth perception (stereoacuity) testing?
Done in many schools and screening programs
Not recommended by AAPOS
Stereo Fly Test
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Vision screening devices
Photoscreenersand Autorefractors
May detect amblyogenic factors, not amblyopia itself
Expensive
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Autorefractors
Welch Allyn Suresight Nikon Retinomax
Monocular acuity screening -CPT 99173
Photoscreening99174
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Photoscreeners
Photo of the eye's red reflex to estimate
refractive error
ocular alignment
other conditions degrading or blocking line of sight (cataract)
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Things you probably will never see in
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But you better not miss them if you do
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Check red reflex of all neonates & children
Leukocoria = white pupil
Leukocoria = Retinoblastoma
www.occhioallaretina.it/Immagini/leucocoria.
JPG
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Leukocoria= Retinoblastoma
Most common intraocular tumor of childhood
200/yr
No sex or race predilection
FH 25%
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Leukocoria= Retinoblastoma
Almost always fatal w/o treatment
Survival rate >90% w/ treatment
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Leukocoria= Retinoblastoma
Mortality is directly related to the extent of dz
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Leukocoria Differential Diagnosis
Cataract
RETINOBLASTOMA
Persistent Fetal Vasculature
Coats disease
Infections- Toxocara
Retinal detachment
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Conclusion
Pediatric eye exam is just a piece of cake!