The Eye of the Child: When to Refer April 19, 2012

1. The Eye of the Child: When to Refer April 19, 2012 Todd A. Goldblum, MD, FAAO, FAAP Pediatric Ophthalmology Albuquerque

2. Disclosure • I have no financial interest in any of the material presented.

3. Outline • Visual Development and Amblyopia • Vision Screening • The Red Eye • Learning Disabilities and Vision

4. Part 1Visual development and Amblyopia

5. Normal Visual Development

6. Forced Preferential Looking • Newborns: 20/400 • 18-24 mos: 20/20

7. Normal Maturation of Vision • Retina: fovea not mature until 4 mos • Optic nerve: myelination not complete at birth • Cortical maturation: approx 2 years

8. Normal visual development proceeds only if the brain receives an EQUALLY CLEAR image from EACH EYE

9. Quiz: What is the leading cause of vision loss in children?

10. Answer: • Amblyopia • Amblyopia • Amblyopia

11. Amblyopia • Visual loss due to significant interruption of normal visual development • Can be permanent and severe if not recognized early • LEADING CAUSE OF VISUAL LOSS IN U.S. CHILDREN

12. Amblyopia • Childhood vision loss • Affects 2% of U.S. Population • Usually unilateral • Can be bilateral and severe!

14. Hubert and Weisel:The Critical Period

21. Visual Development • The first few weeks are critical! • No child with a congenital cataract in one eye ever achieved vision better than 20/50 if treated after 17 weeks of life

22. Types of Amblyopia • Deprivation • Strabismic • Refractive

23. Deprivation Amblyopia • The eye is deprived of light/image • Can be extremely severe if not treated early • Examples: cataract, ptosis, eyelid tumor

27. Strabismic Amblyopia • The brain “turns off” the eye which is not straight • Can be permanent and severe

32. All children with strabismus have amblyopia until proven otherwise

33. Refractive Amblyopia • Farsightedness or astigmatism • Image is poorly focused • One or both eyes

35. Amblyopia: Treatment • Remove cause if possible • Correct refractive errors • Penalization

36. Amblyopia: Treatment • Optical Alone • Patching: FT vs PT • Atropine • Optical penalization

37. An Evaluation of Treatment of Amblyopia in Children 7-<18 Years Old Supported by the National Eye Institute ATS3

38. Rationale • Amblyopia is a common cause of monocular vision • loss in children and adults • Data on the natural history of amblyopia and • success rates of its treatment in older children are • retrospective and uncontrolled • Previous studies and a PEDIG pilot study suggest • that treatment of amblyopia can be effective in older • children ATS3

39. Study Design • Randomized, controlled multi-center clinical trial • Sample size: >360 children (>90 in each of 4 age groups) • Treatment groups: • Control Group:Optical correction only • Active Group:Optical correction • Patching plus near activities • Atropine (patients <13 yrs only) • Primary analysis: Comparison of proportion of treatment • responders between treatment groups ATS3

40. Conclusions • Amblyopic eye vision improves with optical correction alone in about ¼ of 7 to <18 year olds. • In 7 to < 13 year olds, additional improvement is seen with patching/atropine regardless of whether amblyopia was previously treated. In 13 to <18 year olds, additional improvement may occur with patching if amblyopia was not previously treated, but may not occur if previously treated. • Most amblyopic eyes have remaining visual deficit. • Persistence of effect after treatment cessation is currently being evaluated.

41. Results Summary

42. Strabismus • Definition: eye misalignment • Esotropia: inward • Exotropia: outward • Hypertropia: upward • Hypotropia: downward

43. Neonatal Eye Alignment • Exotropia commonly seen • Esotropia less common • Eyes should be straight by 4-6 months of age

45. Strabismus is never normal after 6 months of age

46. Strabismus • Children never outgrow strabismus • ALWAYSsuspect amblyopia

47. Esotropia

48. Accommodative Esotropia • Farsightedness = focus • Focusing causes eyes to turn inward • Rx: relax focusing with glasses

50. Infantile Esotropia • Begins before 6 months of age • Usually large angle • Surgery