Paediatric ophthalmology community to the hospital
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Paediatric Ophthalmology Community to the hospital. Siobhan Wren Consultant Ophthalmologist. Hospital Service Workload Amblyopia Visual development/assessment Evaluation of the paediatric patient Red reflex Detecting squints Red eyes. Diagnosis of Paediatric Referrals (March 09). 68%.

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Paediatric ophthalmology community to the hospital

Paediatric OphthalmologyCommunity to the hospital

Siobhan Wren

Consultant Ophthalmologist


Paediatric ophthalmology community to the hospital

Hospital Service

Workload

Amblyopia

Visual development/assessment

Evaluation of the paediatric patient

Red reflex

Detecting squints

Red eyes


Paediatric ophthalmology community to the hospital

Diagnosis of Paediatric Referrals (March 09)

68%

Possible Amblyopia present in 124

Data available for 319/337


Amblyopia

Amblyopia

  • Strabismus

  • Refractive

  • Occurrence

    • 1-3% population

    • up to 5% pre-school


Visual development

Visual development

  • 1 month

    • pupils react to light

    • defensive blink present by 6-8 weeks

    • 3 weeks onwards watches familiar nearby face when being fed

    • gaze caught and held by dangling bright toy gently moved in line of vision at 15- 25 cm


Paediatric ophthalmology community to the hospital

  • 3 months

    • very alert

    • fixes and follows toy at 15-25cm

    • converges eyes if toy brought toward eyes

  • 6 months

    • any squint now is abnormal

    • reaches out for objects

    • searches for toy once it leaves visual regard


Paediatric ophthalmology community to the hospital

  • 9 months

    • very alert to people

    • immediately grasps for toys

    • watches activities of people or animals within 3-4 metres with sustained interest for several minutes

  • 12 months

    • interest in pictures

    • points to objects of interest


Health visitor questionnaire at 8 months and 2 yr contact

Health Visitor Questionnaire at 8 months and 2½yr contact

  • Do the parents suspect a squint?

  • Are there any concerns about vision, eye lids, eye movements, pupil size or shape?

  • Is there any family history of squint, amblyopia, glasses in early childhood, or wearing a patch.

  • Are there any risk factors of squint combined with family concerns i.e. prematurity or developmental delay


Conclusions of study into fast track appointments

Conclusions of Study into Fast track appointments

  • Fast track clinic run by a highly specialised orthoptist and paediatric optometrist can successfully assess large numbers of amblyopia &/or strabismus suspects.

  • A 74% discharge rate of 1st referrals, following the protocol, has a significant impact on paediatric outpatient clinic.

  • Surgical rates within this group of patients is in line with the national surgical rates .


Making a diagnosis

HISTORY

Family history

Identify risk factors

Prematurity

Developmental delay

Juvenile Rh Arthritis

Family album

Photophobia

Redness

Discharge

Purulent, watery

EXAMINATION

External inspection

Red reflex

Corneal light reflex

Cover test

Squinting

Head tilt

Eyelid closure

Visual acuity >3 yrs

Defective ocular fixation/ interactions

Making a diagnosis


Red reflex technique

Red reflex technique

  • Sit in front of the child and parent at about arm’s length.  Set the ophthalmoscope to around +2 (green or black) 

  • Focus on the parent’s eyes to show that the test is non-invasive and recognition of the normal red reflex in that particular ethnic group.

  • Then focus on the child’s face and encourage the child to look at the light. Focus on the red reflex within the pupil.


Paediatric ophthalmology community to the hospital

The Childhood Eye Cancer Trust


Head postures

Head postures

Check motility


Conjunctivitis

Conjunctivitis

Close contacts affected

Unilateral  bilateral

Sticky discharge

Diffuse redness

Cornea and pupil normal

Chloramphenicol

Cellulitis- Refer urgently

Neonatal conjunctivitis: refer urgently

Risk of corneal perforation from n. gonorrhoea


Allergic conjunctivitis

Allergic conjunctivitis

  • Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC)

  • Vernal keratoconjunctivitis (VKC) Atopic keratoconjunctivitis (AKC)

  • Giant papillary conjunctivitis (GPC)


Symptoms

Symptoms


Signs

Signs


Management

Management

  • Allergy testing

  • Cool compress

  • Artificial tear substitutes

  • Systemic and/or topical antihistamines

  • Vasoconstrictors

  • Mast cell stabilizers

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Corticosteroids

  • Immunotherapy


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