lynn e. lawrence, cmsgt(ret) cpot, aboc. child growth and development vision and learning early...
TRANSCRIPT
CHILDREN EYE SCREENINGS AND EXAMS
Lynn E. Lawrence, CMSgt(ret)
CPOT, ABOC
OVERVIEW Child growth and
development Vision and Learning Early detection Hormones and vision School screenings
and state requirements
Clinic screenings and Exams
Inform and educate
FIRST VISITS – GOOD MEMORIES Schedule extra
time to allow yourself an opportunity to establish rapport with the child
Reassure the parents
FACTS
As stated from the 2000 AOA clinical practice guidelines for Pediatric Vision reported that there were 72.3 million under the age of 18 (26% of the overall population) and a growth rate of 13.7%
Vision disorders 4th most common disability in US There are approx 39,000 practicing O.D.s = 1846
children per practice Only 31% of children rec’d comprehensive exams Vision is developing from birth to 20, from 20-40
vision is the most stable and after 40…well
REGARDLESS OF AGE
Considering a SOAPE Format
Subjective: COVD-QOL: Clinical with some validity and reliability
Objective: Chair Skills, DEM, Wold Sentence, Copy, Beery, Motor Free
Assessment: Low Areas Based on Standardized Norms
Plan: Lenses, Hygiene, Vision Therapies
Education: Signs-No Symptoms—Do Nothing?
3 THINGS TO REMEMBER Each child is
different
Each parent is different (genes)
Treat each child as an individual
BABY FACTS The diagnosis of disease in infants and toddlers
is more difficult than other patient categories, they have no idea of what good vision looks like.
Standard procedures (i.e. biomicroscopy, tonometry, and indirect ophthalmoscopy) are more difficult on this population
You must keep the exam interesting to keep fixation with this population (don’t over stimulate)
2010 Public Health Assoc recommended 6 mon, 2 yrs, and 4 years (urged Pediatricians to advocate)
BABY AT 1 MONTH
Stares vacantly at surroundings Briefly follows a moving stimulus Regards examiner’s face momentarily Quiets when gazes toward light of window
or bright moving object Fixes objects brought into visual scope Eye and head movements are not
synchronized Hands predominantly fisted Head predominantly rotated to a preferred
side
2 MONTHS Holds head bobbingly erect Eyes follow a moving person and near object
beyond the midplane Vocalization other than crying Lying supine, looks downward and sideward but
not upward to follow retreating figure Myelination of macula by 6 weeks Direct regard and facial response to person’s face Seeks light areas Coordinate compensation eye movements well
established Retains rattle briefly First begins to observe his hand in action
3 MONTHS Lying supine, tilts head backward and
rolls eyes upward to follow retreating figure
Eyes follow moving objects in all planes (blinking and jerky eye movements)
Searches for sound with eyes Regards own hand spontaneously Vigorous body movements Anticipates feeding upon sight of bottle
with activity change Cooing and chuckling
4 MONTHS Head rotates with increasing freedom in supine
position Hands engage at midline Grasps pencil with both hands and holds briefly Rolls from side to side but not completely over Enjoys play activity Eyes move in active inspection: Regards own hand,
toy, surround In sitting, holds head steady and set forward, looks
down at table top, at own hand, and at an object Fleetingly regards 7mm pellet on tabletop. Contacts
it with out-stretched fingers. No grasp Initiates smiling and laughs aloud.
5 MONTHS Holds head erect
in sitting Grasps cube on
contact Maintains
attention within area close to body
6 MONTHS
Begins awareness that objects and people are permanent and present even if hidden
Sits with minimal support with stable back and head Lifts cup Attempts to attain toy held beyond reach Responds to image in mirror. Begins to imitate facial
expressions and actions Rolls over, supine to prone position Localizes source of sound when bell is rung at side Differentiates strangers from family Babbles in more than two distinct sounds Turns objects to observe them upside-down and sideways
while exploring them visually Transfers objects from one hand to the other Plays Peek-a-boo and pat-a-cake
8 MONTHS
Begins to recognize his own image in mirror Begins creeping skills forward and backward Strong bilateral use of hands in approach, grasp and
manipulation and in simultaneous holding of two objects
Aware of surround, easily distracted. Watches activity around him Looks for toy he has had Reaches and grasps object, then visually inspects it
by turning object about in hands to explore it Holds one cube and manipulates another Begins to pull himself up on familiar objects Begins fear of strangers – fear of separation from
mother/parents
History and General Development
QuestionnaireInterviewBehavioral ObservationsInteraction
Reason for VisitHistory of Present IllnessPastFamilySocialReview of Systems
Developmental Milestones – see Infant and Toddler Development ChecklistSitStandCrawlWalkFirst Words
Developmental Milestones - see Infant and Toddler Development ChecklistBegins to speak in sentencesBegins to runVery inquisitive
Motility and Binocularity
Light Sourcedirect ophthalmoscope,penlight, finger puppet, or other appropriate target
BrucknerHirschbergKrimskyCover TestVersionsNPCVertical Prism Test
Symmetry of reflex: ophthalmoscope or retinoscopeEstimation of strabismusAlignment Avoidance of coverRange of movementGross convergence
Pursuits and saccadesStereopsis Keystone Basic Binocular Lang Randot
Refractive Status Retinoscope Retinoscopy Near Dynamic Mohindra Cycloplegic
Will show large ranges – see AOA Clinical Practice Guidelines (CPG)Retinoscopy Mohindra - Add (-)0.75 to gross sphereUse 0.5% Cyclopentolate if using cycloplegia
See AOA CPGAutorefractorRetinoscopy - Mohindra Add(-)1.25 to gross sph - 0.5% to 1.0% Cyclopentolate if using cycloplegiaAccommodation Near dynamic retinoscopy
Visual Acuity TargetPreferential Viewing Test
Fixation PreferenceFix and FollowPreferential Looking
Avoidance of occlusion on one side Broken WheelLea SymbolsHOTV
Ocular Health ObservationMagnifying lensDirect, Monocular, or Binocular Indirect OphthalmoscopeDilation
Anterior segmentPosterior segmentPupillary responsesConfrontation fieldsTonometry – DP, Tonopen, Pulsair
Most common:Blocked tear ductBacterial conjunctivitis
Most common:ConjunctivitisAccommodative Esotropia
CHAIRSIDE GUIDE TO INFANT AND TODDLER EYE AND VISION EXAMINATION Issues and Methods Additional Issues and
Area Tools Methods and Tools for 0 – 18 mos Methods for 18-36 mosThis Quick Reference Guide should be used in conjunction with AOA’s Optometric Clinical Practice Guideline on Pediatric Eye and Vision Examination (April 25, 2002). It provides a summary and is not intended to stand alone in assisting the clinician in making patient care decision. These recommendations include but are not limited to the areas, procedures and recommendations listed. Professional judgment and individual symptoms, findings and developmental level may significantly influence the nature and course of the examination.
INFANTSEE 30-50% of infants (under 12 months)
have significant astigmatism Age 2-18 months (avg Rx 2 diopters
hyperopia)
Children 6-9 months follow lights InfantSee Program Shaking Baby Syndrome (SBS)
Neurological problems Excessive refractive error Eye alignment (strabismus) Early morning or after naps are
most effective for exams Recommend parent bring a
bottle
BABY (0-1 YEAR) EXAM FREQUENCY
First exam – 6 months or first sign of eye trouble
Black and white contrast
1 ft is the focusing dist Consider sleep schedule Don’t overwhelm or
over-stimulate Dim room highlight
target
EXAMINATION TABLE FOR INFANTS Patient/family
health history Developmental
history Family eye history Visual acuity
(fixation) Obvious defects Teller Acuity Cards Auto-refraction
BABY LEARNING (1 FOOT) Games
Learning Learning games Colors (black and white)
Parents Eye contact (ease into) Sound (not too loud) Room lights on target Caution with over-
stimulation
Mobiles Face down to baby Baby safe mirrors
Crib Car Play area
INFANTS SAMPLE TEST
Tracking and fixation training for infants
GROWTH AND DEVELOPMENT Children are not
born knowing the difference between good and bad vision
Early Detection and Prevention is a must
6 months, 3 years, and prior to starting school are the recommended intervals
TOP 5 MILESTONES IN VISION DEVELOPMENT1. Focusing ability Most infants can focus accurately by two to
three months of age. The ability to focus requires special eye muscles to change the shape of the lens in order to form clear images. Before two months of age, an infant is capable of focusing objects both near and far, but not very well. It takes time for the eye muscles to learn how to avoid focusing "too close" or "too far away" from near or far objects.
2. Eye Coordination and Tracking A baby usually develops the ability to track
and follow a slow-moving object by three months of age. Before this time, an infant will follow large, slow-moving objects with jerky motions. A three-month-old can usually track an object quite smoothly. A baby should begin to follow moving objects with the eyes and reach for things at around four months of age.
3. Depth Perception Depth perception is the ability to judge
objects that are nearer or farther than other objects. Depth perception is not present at birth. It is not until the third to fifth month that the eyes are capable of working together to form a three-dimensional view of the world.
4. Seeing color An infant's color vision is not as sensitive
as an adult's. It is hard to tell if babies can distinguish colors because their eyes might be attracted by the brightness, the darkness, or the contrast of an object against its surroundings, and not by the color alone. By two to six weeks of age, however, a baby can distinguish two highly contrasted colors, such as black and white.
5. Object and face recognition An infant is born with the ability to see
facial features at arm's length, but is attracted instead to high-contrast borders of objects. For example, a baby will gaze at the edge of a face or the hairline when looking at a human face. By two to three months of age, a baby will begin to notice facial features, such as the nose and mouth. By three to five months, most babies can differentiate between mother's face and a stranger's face.
Source: Infant Vision Lab, The Eunice Kennedy Shriver Center. Milestones in Visual Development University of
Massachusetts Medical School. 08 Jun 2007
PRE-SCHOOL CHILDREN Have the necessary
psychological development
Use matching task @ 6 meters
3 diopter of astigmatism 30-50% loses
astigmatism by age 5 Low amts of
anisometropia Static retinoscopy Cycloplegic retinoscopy
Monocular Estimation Method (MEM)
Color Vision Test Pease Allen Color Test (PACT), Mr. Color Test, Color Vision Made Easy,
Visual Acuity Lea Symbols chart Broken Wheel Acuity
Cards HOTV Test Denver Developmental
Screening Test (DDST) Developmental Test of
Visual Motor Integration (DTVMI)
EXAMINATION TABLE FOR PRE-SCHOOLER’S Lea Symbols
HOTV Test
CHILDREN
Cover Test Muscle-H Test Near Point of Convergence
(NPC) Positive and negative
fusional vergences Accommodative amplitude
and facility MEM retinoscopy Stereopsis Versions rule out non-commitant deviation
Stability of fixation, saccadic movement, and pursuit function
AC/A and facility
EXAMINATION TABLE FOR CHILDREN
Establish rapport Ask the child if
the know their ABCs
Eliminate distractions
Always encourage
Broken Wheel Acuity Test
TEENS Most children with
vision problems have accommodative or binocular anomalies
School performance: Eyestrain, blurred
vision Double vision, loss of
place, skipped lines, and reading defects
EXAMINATION TABLE FOR TEENS
Teens communicate
More conscience about looks
Prefer contacts Fashion is a must May experience
growth spurts, hormones can impact vision
VISION AND LEARNING Give the child
things that are exciting for them, things that keep their attention
Routine practice
HORMONES AND VISION
Affects male and females alike
Hormones affect vision
Growth spurts can have a significant impact during childhood development
SCHOOL SCREENINGS AND STATE REQUIREMENTS Each state has its own set of
medical requirements, you must your state requirements
Pediatricians perform screenings
American Public Health Association recommends exams at 6months, 2 and 4 yrs of age
Healthy People 2010 to improve national health
LEARNING
Learning Related Problems Developmentally Delayed Attention Deficit Disorder
(Amphetamines)
• Attention Hyperactivity Deficit Disorder Learning Disabled Fetal Alcohol (Drug) Syndrome
Autism Spectrum
Acquired Brain Injury (ABI) Stroke Trauma Shaking Baby Syndrome (SBS)
CLINIC SCREENINGS AND EXAMS
Cover Test (not as reliable, child must participate, is a position of gaze test)
Hirschberg Test (most successful in children 6 months or younger)
Krimsky Test (prisms with Hirschberg test)
Bruckner Test (presence of Bruckner Reflex identifies positive for strabismus)
Versions (tracking a target, binocular assessment)
Near Point Convergence (tracking a target in toward the child)
Pupillary Response Test (tracking a target in toward the child)
FASHION IS IMPORTANT The Look
STYLEFITSizing
Peer pressureFirst Impression
Affordability Economy Return visit
PARENT AND CHILD EDUCATION
Build your future patients understanding for the need of appropriate eye care
Patient’s do always know
Grow the industry through developing an understanding of the different “O”s
CHILDREN ARE OUR FUTURE
Vision And Academics: Prospective Study
Maples. Visual factors that significantly impact academic performance
Optometry 2003;74:35-49.
3 year prospective study on 550 elementary school children (1,2,3—2,3,4---3,4,5 grades)
6 examinations (Fall and Spring) Standardized Iowa Test of Basic Skills
(ITBS) All Visual Findings Significant In Some
Area Robust Predictors: Visuo-Motor, Ocular
Motor, Perception Variance=correlation squared
PSYCHOLOGY AND RAPPORT
Immediately get on the child’s level
Explain everything
Treat every patient with CRS
Don’t rush the exam… schedule more time
STORY
El Savador -16D Never seen moms
face Was never going to
sit in a class and learn like other kids
Sunland Optical sent glasses free of charge
Vision van
REMEMBER Children are
born knowing the difference with good vision
They need your help
They need your professionalism and patience
AOA RECOMMENDED EXAM INTERVALS Asymptomatic
Birth – 24 months by 6 months
2- 5 years at age 3
6 – 18 years before first grade and every two years thereafter
At Risk childrenBy 6 months or as
recommended
At 3 years or as recommended
Annually or as recommended
