Paedriatics

Question 1

Normative VA values for children under 4 years of age are:

Answer 1

• Uniocular acuities of 0.100 LogMAR (6/7.5 Snellen) or better with an intraocular difference of no more than 0.050 LogMAR (two pictures).

Question 2

Normative VA values for children aged 4 and five years are:

Answer 2

• Uniocular acuities of 0.050 LogMAR ( 6/6-2 Snellen) or better, with an intraocular difference of no more than 0.025 LogMAR (one picture).
• Generally in Scotland if either eye is 0.200 or less then referral should be considered
• An intraocular difference of 0.100 may be indicative of mild amblyopia, an intraocular difference of 0.200 should warrant referral

Question 3

responsibilities of the optom in paeds patients

Answer 3

• Cycloplegic refraction – with the appropriate cycloplegic agent
• Ocular examination – using an appropriate technique
• Other tests you deem appropriate
• If patient is discharged from HES they ARE NOT under the care of HES anymore and duty of care lies with you
• You need a full GOS test and are your clinical responsibility

Question 4

when do we refer for strabismus paeds

Answer 4

– If under age 8 and you detect a strabismus which is not fully accommodative and has not been seen at ophthalmology then to ophthalmology
– If patient over age 8 or has been discharged from HES you may manage in the community
– Refer if amblyopia suspected and within visual plasticity period
– e.g. a decrease of 0.2 LogMar compared to age matched normal, or an interocular difference of 0.2
– e.g. over age 4-5 refer if VA worse than 0.2 LogMar either eye

Question 5

when do we refer for nystagmus paeds - and how

Answer 5

– Nystagmus which has not previously been investigated refer to ophthalmology to ensure no pathological cause
– Oscillopia (suggests nystagmus recent onset) consider urgent referral, absence of oscillopia routine referral

Question 6

when is a cyclo refraction required

Answer 6

– First visit to your practice
– All children under age 8
– Under age 8 with significant refractive error (may be done every year)
– Suspicion of latent hyperopia at any age (eye strain common symptom for even people in 20s)
– Reduced VA
– All children with evidence of strabismus – even if VA appears normal

Question 7

When is a cyclo not required

Answer 7

– Children age 6-8 who have had a cycloplegic refraction in the past and are cooperative i.e. can answer questions during subjective refraction well
– Older children
– Myopia over age 8 (since cannot hide underlying myopia)

Question 8

what % of cyclo to use for different ages and for what irises

Answer 8

– Cyclopentalate 0.5% for under age 1
– Cyclopentalate 1% for age 1-8
– 0.5% can be used in older children age 12/13…. If light irises
– If poor VA, patient has very dark irides and insufficent cycloplegia with 1% (after another drop put in) then refer to HES for atropine refraction
– No published evidence that 2x1% cyclopentalate leads to more effective cycloplegia than 1%

Question 9

contraindications of cyclo

Answer 9

– Children with Down’s syndrome – high proportion of heart defects (safer done in HES if complications)
– Children with congenital heart problems

Question 10

when to prescribe rx in paeds

Answer 10

• VA reduced
• Significant Refractive error (prescribe full rx)
• Strabismus and significant refractive error present
• Amblyopia and significant refractive error
• If you find significant refractive error and you need to refer for strabismus and or amblyopia prescribe full plus Rx prior to referral to improve the visual outcome

Question 11

Normal levels of hyperopia in infants

Answer 11

– 3 months = +2.16 ± 1.30 D (mean ± sd)
– 1 year = +1.46 ± 1.01D (mean ± sd)
Be very cautious about prescribing spectacles below age 1 as emmetropisation is taking place

Question 12

– The kinds of prescriptions for infants which should be prescribed for are:

Answer 12

• highly hyperopic infants e.g. +8.00 to +10.00,
• infants with infantile esotropia and a hyperopic Rx
• highly myopic infants -5.00 plus (under correct by 2D as emmetropisation can occur in myopes)

Question 13

when to prescribe for Age 2-5? myopia, hyperopia, and astigmatism

Answer 13

– Prescribe for hyperopia ≥ +3.50DS if assymptomatic
– Prescribe for myopia >-2.00DS (reduce by 0.50-1.00D until school age) – don’t want to prescribe full myopic prescription in very young children – minimize growth in eyes
– Prescribe for astigmatism ≥ 1.50DC

Question 14

when to prescribe for Age 5 plus myopia, hyperopia, and astigmatism

Answer 14

– Hyperopia > +1.50DS
– Myopia > -0.50DS prescribe full correction if improves VA
– Prescribe for astigmatism ≥ 0.75DC

Question 15

when to prescribe when there is anisometropia

Answer 15

– ≥1.00D if aged 1-8 and anisometropia is persistent after 4-6 months

Question 16

Most common childhood anterior eye conditions

Answer 16

• Allergic eye conditions – might be first presentation
• Conjunctivitis – very common in kids under 5
• Chalazion/ hordeolum – very common and can last months
• Cataract – less common, major visual consequences

Question 17

3 most common conjunctivitis in paeds

Answer 17

• Vernal conjunctivitis (less common in UK) – black ethnicity more common, more common in boys, atopic conditions, asthma, larger cobblestone papillae, ptosis may be seen since lids are swollen, stringy discharge, trantas dots – inflam infiltrates around the edge of the cornea (very symmetrical and round)
• Acute allergic conjunctivitis – slightly different than in adults, unilateral, sudden response, oedema is the key features, and usually very swollen, indirect response to an allergn. No papillae, no corneal involvement
• Seasonal allergic conjunctivitis (most common) – might have not presented before, small papillae, watery discharge, rhinitis, lid chemosis, bilateral,

Question 18

VKC management

Answer 18

• In a child it is a on going issue so steroids for a long time, worries about cataract development and IOP changes so referred to HES
• corneal involvement needs referral in most cases, can start px with sodium cromoglycate qds and cold compresses

Question 19

does acute allergic conjunctivits have papillae

Answer 19

no

(also no corneal involvement)

Question 20

systemic antihistmaines for children (and age restrictions)

Answer 20

– loratidine/claritin licensed from age 2
– piriton/chlorphenamine licensed from age 6
– Sodium cromoglicate - no minimum age for generic (POM), but minimum age 6 for opticrom (P)!
(Piriton is drowsy systemic antihistamine)
Try to give non drowsy meds first

Question 21

In babies what 2 types of infection should we suspect and when

Answer 21

Chlamydia (5-14days) or gonorrhoea (2-5 days) more likely to happen in first 2 weeks of like – unlikely to be seen by optom

Question 22

from what age is chlamydial or gonorrhoea conjunctivitis unlikely

Answer 22

From age 3 months unlikely to be chlamydial or gonorrhoea conjunctivitis since these are caught from the mother when giving birth, unless had previously or ongoing issue

Question 23

new born babies also get bacterial conjunctivits - so what is done

Answer 23

so antibiotics (chloramphenicol) given but if no improvement then chlamydial conjunctivitis
Urgent referral to ophthalmologist !!

Question 24

adv given to 2 y/o px with bacterial conj, and what would be checked? pharm tx?

Answer 24

• Cold compress and lid hygiene, boil water and cool it down and and clean with cotton pads the crusting and gunk
• Artificial tears
• Review
• Advice infectious and self-resolve, might get worse before it gets better – may progress to the other eye, don’t share towels, advice more likely to start to get better around day 5, antibiotics could be given if px comes to you in first few days as there is evidence that it would reduce the time period of px having the conjunctivitis and less likely to spread in nursery (chloramphenicol) – if presented later then no reason to give anti bacterial drugs sinc won’t reduce time period
• Chloramphenicol would be given – ointment 3x a day until resolution
• If chlaromphenicol drops then Every 2 hours for 48 hours and then 4x a day after ( but a lot more work for child so ointment better suited)
• Could be preseptal – check pupils and motility to be sure and review important

Question 25

chalazion in kids - why so common

Answer 25

Slow chronic inflammation, less red, granulomatous mass, gland of zeiss (eyelash base), more likely meibomian glands (in the tarsal), tarsal plate in children is very thin and can break through which is why is appears bigger and more pink and red. Kids can have regular chalazions

Question 26

hordeolum

Answer 26

- Hordeolum is an infection, happens more quickly, red and painful , glands or zeiss or glands of moll

Question 27

chalazion management

Answer 27

- Refer if not resolving, recurrent or if inducing astigmatism (could interrupt the visual development) - Most often self resolving, treat any associated bleph and advice hot compress - Given parents realistic expectations, recall in a month for reassurance, can take like 3 months

Question 28

hordeolum management

Answer 28

- Normally hot compress and lid hygiene - May prescribe topical antibiotics if copious discharge – be careful of px’s age

Question 29

Symptoms of undiagnosed cataracts kids

Answer 29

strabismus, nystagmus, clumsy behaviours

Question 30

catarct management

Answer 30

- Urgent referral is not prev diagnosed in an infant - If discharged from HES refractive correction – IOL then need multi focal but only in eyes with IOL if unilateral, if cataract in situ the full refractive correction and assess accommodative function - Eg some px’s in 20s may need varifocal in one eye and normal SV in the other

Question 31

kids have squint what do we need to make sure

Answer 31

that it is concomitant and not incomitant

Question 32

5 common childhood posterior eye conditions

Answer 32

- Optic disc hypoplasia (most common) – it is a spectrum – some patients very affected by it and some not as much - Ocular albinism - Foveal hypoplasia - Retinopathy of prematurity (RoP) - Autosomal dominant optic atrophy

Question 33

5 most common causes of childhood blindness in USA

Answer 33

- Cortical visual impairment - RoP - Optic nerve hypoplasia - Albinism - Optic atrophy

Question 34

Other childhood posterior eye conditions

Answer 34

- Tilted and torsional optic discs - Optic disc hypoplasia – less good quality of vision - Optic disc Coloboma - Optic disc drusen - Autosomal dominant optic atrophy - Papilloedema - Retinoblastoma - Retinal dystrophies - Albinism

Question 35

which conditions give a stable VF defect

Answer 35

Tilted and torsional discs often have a stable visual field defect, 10% of population have stable vf defects which are physiological

Question 36

Optic disc hypoplasia features and cause

Answer 36

can you fit the disc in 3 or more times to the macula then suspect this, refer if suspected * Diminished number of nerve fibres in the optic nerve * Relatively rare * Unilateral or bilateral * Linked to teratogenic agents – Agents which the mother is exposed to during pregnancy which can cause birth defects – Quinine, PCP(Phenylcyclidine), LSD, Cocaine, Heroin, Alcohol, Dilantin, Maternal diabetes

Question 37

optic disc hypoplasia associations

Answer 37

* Numerous systemic associations – Septo-optic displasia – Developmental midline brain defects – Pituitary and hypothalamic defects * Ocular associations – Aniridia, VF loss, foveal hypoplasia, microphthalmos and AMBLYOPIA

Question 38

Optic disc hypoplasia symptoms

Answer 38

– If severe can present with roving eye movements nystagmus in infancy – If unilateral, or less severe may present with strabismus or decreased VA at visual screening – Mild cases may be asymptomatic

Question 39

Optic disc hypoplasia signs

Answer 39

– VA from normal to LP – An RAPD if unilateral and severe and sluggish pupil responses bilaterally if both discs severely hypoplastic – Smaller than normal disc – measure using slit lamp if possible – A foveal to disc centre which is three or more times the disc diameter highly suggestive of hypoplasia

Question 40

optic disc coloboma features

Answer 40

Congenital, non progressive, unilateral or bilateral In more pronounced cases may affect ability to meet visual field driving standard vision can be normal, VF defect possibly

Question 41

optic disc drusen features

Answer 41

* Often first noted in childhood * In younger children are often buried and may present as pseudopapilloedema, if unsure refer and discuss with ophthalmology * In early teens drusen often become more visible as pearly raised areas on the disc * Can cause visual field loss which may be progressive, but is rarely sight threatening

Question 42

optic disc dursen management

Answer 42

– Assess automated visual fields for progression where possible – OCT to assess/monitor RNFL and to assess drusen – Refer if struggle to tell if optic disc drusen or papilloedema… may wish to discuss with opthalmology urgency of referral based on individual patient circumstances

Question 43

papilloedema signs

Answer 43

– Headache, worse in the morning – Nausea and projectile vomiting – Diplopia due to 6th nerve palsy – Pulsatile tinnitus (whooshing sounds), – Swollen optic nerve – Visual obscuration lasting up to 30 seconds – Reduced Vision – Absence of spontaneous venous pulsation, if there is spontaneous venous pulsating then sign disc is healthy (does not occur in Papilloedema) but not everyone has it – Emergency referral to ophthalmology

Question 44

Autosomal dominant optic atrophy features and signs

Answer 44

Usually temporal atrophy of disc * Hereditary disorder – most common heriditary optic neuropathy * Presentation in 1st and Second decade of life with progressive vision loss * Most patients maintain VA above 6/60 * Colour vision disorders * VA loss is symmetrical, insidious, slow and gradual * Typically temporal wedge shaped atrophy but can be diffuse atrophy of the NRR

Question 45

Retinoblastoma what is it

Answer 45

most common ocular cancer, look very carefully, causes white reflex Rare childhood condition, however it is the most common ocular childhood cancer. 1 in 18,000 live births

Question 46

symptoms and signs of retinoblastoma

Answer 46

Can be unilateral (60%) or bilateral Symptoms – White pupil – Strabismus – Associated painful red eye with secondary glaucoma Signs – Dome shaped white elevation(s) – White elevation of the retina which project into the vitreous – Subretinal mass(es) causing an overlying retinal detachment Management - Urgent referral to ophthalmology phone call

Question 47

types of retinal dystrophies

Answer 47

* Stargardts disease - fundus appearance often out of proportion in early stages, colour vision defects, poor dark adaptation central VA will eventually drop sharply from 6/12 to 6/6-0 before stabilising * Bests disease loss of central vision as disease progresses though childhood/early teens * Retinitis Pigmentosa - poor dark adapatation, notice peripheral vision deficits prior to any central visual loss, visual symptoms start later (if at all) in childhood) * Ushers syndrome - associated hearing loss * Lebers severe vision loss from birth, fundus appearance may be confused with albinism - ERG confirms diagnosis * Bardet- Biedl syndrome - lots of non ocular feature such as extra digits * Management - Referral to Opthalmology for definitive diagnosis

Question 48

albinism features

Answer 48

may only have ocular symptoms – can have normal pigmentation everywhere else, get photophobia more than others Some Caucasians may have light retinas – make sure with the other signs like foveal OA – ocular albinism OCA – oculocutaneous albinism

Question 49

signs of albinism

Answer 49

– Foveal hypoplasia – lack of an observable foveal pit, or underdeveloped foveal pit – Poor VA – Translucent pinkish blue irides – Nystagmus - typically pendular and horizontal – Lack of fundus pigmentation with visbility of choroidal vessels – Abnormal VEP’s as fewer uncrossed fibres at chiasm – High RX – Strabismus – Poor stereo

Question 50

managment of albinism

Answer 50

– Photochormatic lenses for everyday use – Sunglasses for summer – Advise use of hats with brim, especially in summer – Low vision aids – Referral to ophthalmology if previously undiagnosed