1. Paediatric Ophthalmology Community to the hospital Siobhan Wren Consultant Ophthalmologist

2. Hospital Service Workload Amblyopia Visual development/assessment Evaluation of the paediatric patient Red reflex Detecting squints Red eyes

3. Diagnosis of Paediatric Referrals (March 09) Data available for 319/337 68% Other includes ptosis/NF/retinal abN Possible Amblyopia present in 124

4. Amblyopia Strabismus Refractive Occurrence – 1-3% population – up to 5% pre-school

5. 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

6. 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

7. 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

8. Health Visitor Questionnaire at 8 months and 2½yr contact 1.Do the parents suspect a squint? 2.Are there any concerns about vision, eye lids, eye movements, pupil size or shape? 3.Is there any family history of squint, amblyopia, glasses in early childhood, or wearing a patch. 4.Are there any risk factors of squint combined with family concerns i.e. prematurity or developmental delay

9.  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 1 st 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. Conclusions of Study into Fast track appointments

10. 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

11. 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.

12. The Childhood Eye Cancer Trust

15. Head postures Check motility

17. 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

18. Allergic conjunctivitis Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC) Vernal keratoconjunctivitis (VKC) Atopic keratoconjunctivitis (AKC) Giant papillary conjunctivitis (GPC)

19. Symptoms ItchingTearing Rubbing eyes 0AbsentAbsent No desire 1TraceTransientRare 2MildMildOccasional 3ModerateModerateFrequent 4SevereSevereConstant

20. Signs RednessEyelid/ Conjunctiva swelling Sub-tarsal 0AbsentAbsentNormal 1MildMild Uniform ‘velvety’ papillae appearance 2ModerateModerate Non uniform with papillae 3SevereSevere Giant papillae

21. Management Allergy testing Cool compress Artificial tear substitutes Systemic and/or topical antihistamines Vasoconstrictors Mast cell stabilizers Nonsteroidal anti- inflammatory drugs (NSAIDs) Corticosteroids Immunotherapy

22. Otrivine-antistin BD/TDS £2.35 antazoline & xyometazoline antihistamine and vasoconstrictor (weak) >5yrs NB sympathomimetic Optilast QDS £6.40 azelastine Antihistamine >4yrs 6 weeks Emadine BD £7.49 Relestat BD £14.00 emadastineEpinastine Antihistamine >3 yrs Antihistamine >12 yrs 8 weeks Sodium chromoglycate QDS £3.08 (many other names eg Optichrom) sodium chromoglycate mast sell stabiliser (weak); very safe Rapitil BD/QDS £5.12 nedocromil sodium mast sell stabiliser >6yrs 12 weeks Alomide QDS £5.48 lodoxamide mast sell stabiliser >4 yrs Zaditen BD £9.75 ketotifen mast sell stabiliser >3 yrs Opatanol BD £4.11 olopatidine mast sell stabiliser >3 yrs 16 weeks Acular £5.00 ketorolac prostoglandin inhibitor Ocufen £37.15 fluriprofen prostoglandin inhibitor Voltarol £6.68 diclofenac prostoglandin inhibitor