1. MORNING REPORT KAREN ESTRELLA H. PEDS PGY-2 SBH DEC/2010

2. AAP GUIDELINES EYE EXAMINATION IN INFANS, CHILDREN AND YOUNG ADULTS BY PEDIATRICIANS

3. INTRODUCTION Early detection and treatment of ocular disorders in children is important to avoid life-long visual impairment. Retinal abnormalities Cataracts Glaucoma Retinoblastoma Strabismus Neurologic disorders

4. TIMING OF EXAMINATION AND SCREENING Newborn Every WCC 1 st visual acuity at 3y/o WHEN TO REFER? Very premature Fhx: congenital cataracts, Rb, metabolic or genetic diseases Developmental delay Neurologic difficulties Systemic disease associated with eye abnormalities Any child unable to be tested after 2 attempts Abnormal eye exam

5. PROCEDURES FOR EVALUATION BIRTH TO 3Y/O-Ocular hx -Vision assessment -External inspection of the eyes and lids -Pupil examination -Ocular motility assessment -Red reflex examination 3y/o AND OLDER-Same PLUS: -age-appropriate visual acuity measurement -attempt at opthalmoscopy

6. Ocular History Does your child seem to see well? Does your child hold objects close to his or her face when trying to focus? Do your child’s eyes appear straight or do they seem to cross or drift or seem lazy? Do your child’s eyes appear unusual? Do your child’s eyelids droop or does 1 eyelid tend to close? Have your child’s eye(s) ever being injured? FHX: early childhood use of glasses in parents or siblings

7. Vision Assesment Age 0-3y/o Evaluating the child’s ability to fix and follow objects. Binocularly and then monocularly Awake and alert

8. Older children Visual acuity: 2-4y/o LH symbols or Allen cards >4y/o: Snellen letters, Tumbling E test and the HOTV test

9. How to do it? Child should be comfortable and in good health On parent’s lap Or sitting on a chair At 10 feet from wall chart Keep eyeglasses exc if only for reading Good occlusion of eye Non-literate: matching

10. Tell child to keep both eyes opened Cover the left eye first Start with the top line and continue downward showing one letter/symbol per line. If the child reaches the 10/10 line, show the remaining (3) letters/symbols *Be careful not to cover up any part of the box surrounding the letters with your finger as this can affect the sensitivity of the test. If the child misses a letter/symbol, go to the line above and show 4 different letters/symbols If the child matches all of them, proceed downward. The number recorded for vision acuity is the smallest line the child can read correctly Literate

11. Vision acuity

12. External Examination (lids/orbit/cornea/iris) Penlight evaluation of lids, conjuntiva, sclera, cornea and iris Persistent d/c or tearing (ocular infection, allergy, Glaucoma) MOST COMMON: Lacrimal duct obstruction Ptosis Unilateral: amblyopia Bilateral: myasthenia

13. Pupils Should be equal, round and reactive to light BL] Slow or poorly reactive: retinal or optic nerve dysfunction Asymmetry: Horner sd (sympathetic) or 3 rd nerve palsy

14. Ocular motility Evaluate for strabismus The eyes are not aligned with each other Esotropia (ET): The eyes are turned inwards Exotropia (XT): The eyes are turned outwards Eso/Exo-phoria: Phorias are eye deviations that are only present some of the time, usually under conditions of stress, illness, fatigue, or when binocular vision is interrupted. Evaluation; Corneal light reflex test Cross cover test

15. Corneal Light Reflex test Penlight 2 feet in front of the face

16. Red Reflex Detect opacities: cornea, lens or retina HOW TO DO IT? Darkened room Direct ophtalmoscope focused on each eye(12-18inches away) and then both eyes simulataneoulsy at 3feet away

17. Cross cover test Child looking ahead 10 feet from object Eye chart Toy As child looks for the object, cover the eye and see movement of other eye Any movement in or out when shifting the cover indicates a strabismus is present

19. References http://aappolicy.aappublications.org/cgi/content/full/pedi atrics;111/4/902 http://aappolicy.aappublications.org/cgi/content/full/pedi atrics;111/4/902 http://www.health.state.mn.us/divs/fh/mch/webcourse/vi sion/mod6c.cfm http://www.health.state.mn.us/divs/fh/mch/webcourse/vi sion/mod6c.cfm http://www.allaboutvision.com/parents/infants.htm http://www.ophthobook.com/chapters/pediatrics