Eye examination in infants children and young adults by pediatricians
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Eye examination in infants, children and young adults by pediatricians. Ronit Friling Pediatric Ophthalmology Unit, Schneiders Childrens Medical Center of Israel, Petah Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Eye evaluation in the physician’s office.

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Eye examination in infants, children and young adults by pediatricians

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Eye examination in infants, children and young adults by pediatricians

Ronit Friling

Pediatric Ophthalmology Unit,

Schneiders Childrens Medical Center of Israel, Petah Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel


Eye evaluation in the physician’s office

Birth to three years

  • Ocular history

  • Vision Assessment

  • External inspection of the eyes and lids

  • Ocular motility assessment

  • Pupil examination

  • Red reflex examination


Ocular history

  • Does your child hold objects close to his or her face?

  • Does your child’s eyes appear straight or crossed?

  • Relevant family history regarding eye disorders


Vision Assessment

Age 0-3 years

To determine whether each eye can fixate on an object, maintain fixation and follow the object into various gaze positions.

The assessment should be performed binocularly and then monocularly.


Visual Acuity Measurement

Older than 3 years

Picture tests such as (LEA symbols) and Allen cards can be used for children 2-4 years of age


External Examination

Consists of penlight evaluation of the lids, conjunctiva, sclera, cornea and iris.

Persistent discharge or tearing may be attributed to ocular infection, allergy or glaucoma but the most common cause is lacrimal duct obstruction.


Ocular Motility

The most common cause of pseudostrabismus is prominent epicentral lid folds that cover the medial portion of the sclera on both eyes


Pupils

The pupils should be equal, round, and reactive to light in both eyes


Red Reflex Test

The red reflex can be used to detect opacities in the visual axis such as cataract or corneal abnormality and abnormalities of the back of the eye such as retinoblastoma or retinal detachment


Visual Acuity Test

Snellen Acuity Cards

HOTV Test

The test consists of a wall chart composed of H,O,T,V

The child is provided a board containing a large H,O,T,V

Allen Cards

Consists of 4 cards containing 7 schematic figures

LEA Symbols

The LH Symbol test is made of

house, apple, circle, square


Amblyopia


Amblyopia

The most common cause of monocular visual impairment in children

A substandard correct visual acuity without evidence of organic eye disease Prevalence 2-2.5% in general population


Causes

  • Strabismus

  • Anisometropia

  • Visual deprivation


Compliance

  • 49% - 87%

  • Skin imitation

  • Social reasons


Pharmocologic Penalization

  • Instillation of a long acting topic cycloplegic agent (atropine) into the sound eye

  • Prevents accommodation

  • Blurring the sound eye at near fixation


  • Penalization has been advocated only for mild and moderate amblyopia 6/18 or better

  • Because the blurring effect on the sound eye may be insufficient when visual acuity in the amblyopic eye is worse that 6/18


419 Patients215 - Patching group204 - Atropine group


6 hours 43% of patients 8 hours 30% of patients

10 hours 7% of patients

12 hours 20% of patients

A drop of atropine per day

Patching GroupAtropine Group


Results on VA in the amblyopic eye

  • Improvement in VA from base line in both patching and atropine groups


Results (cont)

  • Mean change in V.a. from baseline

  • 3.16 lines - patching group

  • 2.84 lines - atropine group


VA in the sound eye

  • At six-month examination

  • VA in the sound eye was decreased from baseline by 1 line

  • 7% - patching group

  • 15% atropine group


Side effects

  • Patch - skin irritation

  • Atropine - light sensitivity 18%

  • Lid - irritation 4%


Treatment

  • Encouragement of visual development making the patient use the amblyopic eye by reducing the visual stimulation of the fellow eye


Success rates of penalization therapy


Criteria for combined optical atropine penalization treatment (COAT)

  • Lack of compliance with conventional full-time total occlusion

  • Failed to show an expected improvement (doubling in VA) after apparent compliance


Criteria for COAT

  • A hypermetropic refractive error of at least 1,75D in the fellow eye (the eye to be penalized)

  • The prescription for the fellow eye was replaced with a plano lens


Follow-up

  • Treatment was continued until the VA in the amblyopic

    eye was either equal to that of the fellow eye or had not improved


Pharmacologic penalization

  • Ease of administration

  • Reliable assessment of compliance

  • Relative cheapness


Disadvantage

  • Potential toxicity

  • Duration of effect if reverse amblyopia is detected


Results

  • The mean VA in the fellow eye at the end of treatment was not significantly different from that of the commencement of treatment

  • The change in VA after COAT was much higher than after occlusion


Results (cont)

  • COAT for previously foiled FTO produced a success rate of 76% success is defined as doubling of VA of the amblyopic eye


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