I. Typical Behaviors & Exam Modifications:Why examine kids under 5: early intervention & prevention (vision problems assoc w/ devel delays)-VA screening isn’t effective (only 30% of 3 y/o with vision problems fail; 40% of 4 y/o; 50% of 5 y/o)

First exam: -AOA says no later than 6 months-9 months (most emmetropization is complete)-3 months if FHx, premature, condition, developmental delay, parental concern

Age groups for exams: Developmental age groups:-Birth to 2-3 -Infant: 0-1-2-3 to 5 -Toddler: 1-3-5+ -Preschooler: 3-5

Typical behaviors & exam relevance:0-6 months

-Near testing only -Not mobile -Responds to voices

- easiest age to examine 6-12 months

-Near testing only-Mobility starts-Separation anxiety & fear of strangers-Knows name and orients

13-23 months -Short attention span-No tolerance for limitations = tantrums -Negativism starts-¼ of language is understandable-Use labeled praise

II. Assessment of DevelopmentMilestones/delays:-Changes in skill development during predictable time periods (sequential & predictable)-Cognitive, social/emotional, speech/language, fine motor, and gross motor-Delay = milestones not attained in the expected time period- A delay in all areas is called a global delay

Intervention: Early intervention = better long term outcome-Free intervention services available to all children birth through school age (IDEA)-<30% of school-aged kids with delays are ID’d and receive services before starting school-Screenings do not diagnose, but do identify most kids with delays

Denver II:-Sensitivity = 83% True Positive -Specificity = 80% false positive-What: personal-social, fine motor-adaptive, language, gross motor-Who: up to age 5 (don’t screen kids who’ve already been ID’d) only test 5 and 6 year olds if concern with language with VP and AP assessment

-Adjust for prematurity if under age 2 and more than 2 weeks premature – subtract the amount of time they were premature from their real age

-Draw adjusted age line-Test 3 items immediately left of age line – if they pass all 3, test all items with blue intersected by the age line- When: just before and after dilation-Interpreting

o Normal = failure/refusal with the blue completely to the right of the age line

2-2.5 years -Independence-2/4 of language is understandable

-Distance testing is often possible 3 years

-Age of pleasing-Labeled praise very effective-3/4 of language is understandable

4 years -Motivated by simple rewards-Start to appreciate humor-4/4 of language is understandable

5 years -Love praise & can’t accept criticism-Don’t like to lose (so they’ll cheat)

6 years -Start using phoropter

o Caution = failure/refusal with age line passing through the blue; write Co Delay = failure/refusal completely to the left of the age line; write Do No opportunity; write NO

-Recordingo Normal = no delays and <1 cautiono Suspect = >2 cautions and/or >1 delayo Untestable = >1 refusal completely to the left of where age line intersects the

blue area - Denver II scale: 25% left edge; 50% mark; 75% left edge of blue; 90% right edge of blue - Denver II test is known for under referring in the language section... you may want to bump a patient into suspect

even if the test states they are normal (with one caution)

III. History- Additional history: informant and their relationship to the pt, developmental, pregnancy, and birth-Only do developmental/birth/pregnancy if preschool or with developmental/learning/visual problem-Only do immunizations for preschool

POH: LEE, previous dx, previous tx (Rx, occlusion, surgery, other tx)PMH: health status, asthma, allergies, meds, LPE, immunizations, ear infections (increased risk of language delays)-Immunizations given at birth, 2 mo, 4 mo, 6 mo, 12 mo, 15 mo, 18 or 24 mo, and 4 years-12 months = MMR, varicella, & HepA – only ones given at one year; all others are given earlier

Pregnancy & birth:-APGAR – heart rate, respiratory rate, muscle tone, reflex irritability, color normal=2; weak=1; no response=0

-<3 resuscitate immediately >7 no attention needed-1 minute is not predictive of future neurologic status; the longer the score is depressed the greater the risk of future anomalies

-Birth weight-Normal >2500 grams (5.5 lbs)-Low 1500-2500 grams (3.3-5.5 lbs)-Very low <1500 grams (3.3 lbs)-Extremely low <1000 grams (2.2 lbs)-Small for gestational age (pre-term or full-term) are at risk less than 10 percentile-Macrosomia > 4000-4500 grams (8.8-9.9 lbs), commonly caused by maternal diabetes, increased risk of neuron issues due to complications during delivery

-Length of pregnancy-Full-term = 38-41 weeks-Premature = <37 weeks-Minimum gestation for survival = 23 weeks

-Type of delivery & length of hospital stay-Vaginal = 48 hours (assisted increases risk of CN VI palsy, retinal hemorrhage, corneal damage)-Cesarean = 3-4 days; ask why

-Problems during pregnancy/delivery

Premature infants/low birth weight complications: Increased risk of CNS problems, developmental delays, and vision anomalies ROP CP – hypoxic event in preterm, low birth weight babies 9x greater risk of having a coloboma, congenital cataract or retinal anomalies

-2 in 1,000 live births-35% of babies <1500 grams develop (20x more likely than if >1500 grams)-Non-progressive motor dysfunction with variable severity (50% have cognitive impairment)-Ocular: strab (10-50%), significant RE, accommodative insufficiency, optic atrophy, nystagmus

PVH or IVH – brain bleed-Hemorrhage in white matter-18-45% of babies <35 weeks or <1500 grams develop (rare after 32 weeks)

-Doesn’t occur in full-term infants-Grades III & IV have the most complications (40% and 90%)-Ocular: strab, optic atrophy, cortical vision loss, seizures-Also associated with CP, hydrocephalus, delayed development, mental retardation

PVL-Most common ischemic (non-hemorrhagic) brain injury in premies (4-26%)-Complications are proportional to severity (CP, cognitive, cortical vision loss, strabismus, and nystagmus)

Increase in neonatal mortalityComplications with hypoxia: Meconium staining (1st bowel movement occurs in utero) Placental abruption – risk for neuro defects, placenta separates prematurely (partial/complete) Placenta previa (placenta implanted low in the uterus) – risk for SGA, hypoxia Fetal distress (decreased heart rate) associated with hypoxia

Maternal illnesses: Pre-eclampsia: (HTN >140/90) – teens and women >35 are at risk; protein in urine, generalized edema Eclampsia: pre-eclampsia with convulsions, deterioration of maternal & fetal CV, renal, hepatic, & CNS

function, and decreased placental perfusion & abruption ( fetal hypoxia, acidosis)

TORCH infections:-Virulence greatest in 1st trimester and increases with length of infection-Vision loss is primarily by chorioretinitis & cortical impairment Toxoplasmosis (undercooked meat, cat feces)

-Transplacental infection with primary (not reactivation) maternal infection-May just have low birth weight or anemia-Severe CNS may develop later (seizures, intracranial calcifications, hydrocephaly, microcephaly)

Othero Syphilis (rare, but sequelae appear as late as age 2)

-Ocular: chorioretinitis, interstitial keratitis, glaucoma-CNS anomalies, skin lesions, rhinitis, cardiac, renal

o HIV-Maternal treatment decreases risk of fetal infection (transmission = 4%); evident by age 1-Progressive encephalopathy is possible (acquired cortical vision loss)

o Gonorrhea – conjunctivitiso Group B strep

-Usually perinatal infection-Can cause meningitis cortical vision impairment

o Varicella zoster-Transplacental-CNS anomalies, low birth weight, skin lesions, limb atrophy

Rubella (rare in the U.S.)-Classic triad = deafness, cataracts, and congenital cardiac defects

Cytomegalovirus – most common fetal infection-Primary maternal infections are much more likely to pass to the fetus-Blueberry muffin baby

Herpes simplex-Most are perinatal infections-3 levels of severity: localized, CNS, and disseminated-Microcephaly, mental deficiency, seizures, vision loss

Maternal drug use: Smoking

-Hypoxia low birth weight, placental abruption-Dose-related

Illicit drugs-Hypoxia low birth weight, placental abruption, more vision anomalies, multi-system problems

Alcohol-FAS = 3 oz of alcohol daily -FAE = mild signs, binge drinking-CNS dysfunction, abnormal face (flat bridge, thin upper lip, short upturned nose), behavior-Ocular: telecanthus, slant of palpebral fissure, epicanthal folds, ptosis, RE, strab (50% - most ET), amblyopia, ON hypoplasia

Prescription drugs-Tetracycline discolored teeth-Aminoglycosides (streptomycin) CN VIII damage (ototoxicity)-ACE renal, cardia-Anti-convulsants (phenytoin, phenobarbitol, carbamazepine) craniofacial, XT-Anti-depressants (lithium) cardiac

Developmental history:-Parental/teacher/pediatrician concerns; speech (rule of 4)-Ask about milestones specifically if you don’t do a developmental screening 6 months – reaches for objects, turns to rattling sound, rolls over 12 months – shows wants, bangs 2 blocks together, Dada/Mama, pulls to stand alone 18 months – 3-6 words, walks well 24 months – points to named picture, names familiar picture, kicks ball forward 36 months – names several pictures, throws ball overhand 48 months – names 1+ colors, identifies animals based on actions -Anomalies (Down, Fragile X) have increased prevalence of high RE, strab, AI

Social history: school (including preschool), grade, achievement concerns, ECI/special services

FOH: significant RE, strab, amblyopia, inherited ocular conditions

IV. Visual AcuityPreferential Looking

Teller cards (0-12 months)-Grating (resolution) acuity by double psychophysics-Can use up to 36 months, but usually start using Cardiff at 12 months and recognition at 24 months-Gratings are in ½ octave SF steps-Space averaged luminance = background-Adjust for prematurity through 8 months of age; subtract amount of prematurity-Use 38cm test distance if 3 months or younger; use 55cm if older than 3 months-Must get ¾ trials for threshold-Normal VA = within age norms OD & OS with <1 octave difference between the eyes-May fail to detect amblyopia or unilateral VA deficit (overestimates VA in strab amblyopes)

Cardiff cards (12-24months) greater than 24 months use recognition-Use for age 12 months to 2 years-Vanishing optotype (space average luminance = background)-Overall size of figure is constant – only the stroke width varies-Must do 2AFC PL or pointing (not naming!) same picture used throughout-Test at 0.5m or 1m; At .50m BVA is 20/40; At 1.0m BVA is 20/20-Must get ¾ right-Normal = 20/40 or better (2 lines difference is significant)-Underestimates VA deficit in strab amblyopes- Overestimates VA in strabs and amblyopes

Technical MeasuresSweep VEP: VEP will always have a better acuity over Preferential Looking-Cortical response-Resolution acuity-Threshold = acuity level where you extrapolate to 0 microvolts

-Use when untestable/unresponsive with Teller, Cardiff, or recognition-Use flash VEP to determine if the patient has sight

Optokinetic nystagmus-Resolution-Not recommended b/c 20/1000 is best & subcortical pathways can be activated- Response with cortical blindness was recorded

Informal AssessmentsOverview-Only fixation response when age 1-5 months – can do vertical prism test-When >6 months, can do RTO, F&F, and vertical prism test-Target should be interesting to the child & degraded by blur-Record target used – helps with retesting reliability

Fix & follow-Is fixation central and steady?-Does one eye track more accurately or steadily?-If strabismic – get fixation with the strab eye, uncover good eye – do they switch back? = maintain-Gives same info as unilateral cover test for strabs

Interpretation-Interocular acuity difference:

RTO of one eye only or asymmetric RTO F&F with UC, US, or UM in one eye only

-Equivocal No RTO or equal RTO F&F: CS or CSM Equal or unequal VA

Sensitivity-RTO: target, age, socialization – may be fairly sensitive-F&F

CS or CSM: 20/15 – 20/200 (mean 20/34) CUSM: VA reduced to 20/30 – 20/1000 (mean 20/165) CSUM: VA reduced to 20/100 – 20/200 UCS or UCUS: Poor VA 20/200 – 20/1400 (mean 20/573) worst VA!

Vertical prism test (not a BV test)-10pd BD over 1 eye-If they don’t freely alternate, try the prism over the other eye-If they still don’t alternate, force fixation with occluding. Remove occluder. If they maintain fixation through a blink or horizontal tracking movement = freely alternate.

-Equal or near equal VA (<2 lines) if free alternation-Amblyopia/significant difference if strong fixation preference with an amblyogenic factor-Equivocal if strong fixation preference without an amblyogenic factor

Detection Tests-Age 12 months to 2-3 years (until testable with recognition) – use with informal VA assessments

Candy beads

-Estimation of VA: 1) 2)

-Sensitivity is similar to recognition VA when bead & background have low contrast

Dot VA test

-Better than Tumbling E, but not better than Candy Bead – not compelling, poor contrast issues, etc.

Development of AcuityContrast sensitivity-Resolution acuity = the high SF cut-off of the CSF-Overall sensitivity increases with age (graph shifts up) & peak sensitivity shifts to higher SF (right)-High SF cut-off shifts to the right-Near adult level at 8 months by VEP, 8 years by behavioral tests

PL norms-Rapid development in the first 6 months of life-OKN norms are similar to PL norms

-Calculation for expected VA: 1) 2)

VEP-VEP VA is better than PL at all ages-More rapid development than PL-Approaches 20/20 at 8 months-Differs from PL because the thresholds and the responses are different

Anatomy-Peripheral retina is similar to adult, but the fovea is immature at birth-Foveal depression is evolving b/c the inner layer is migrating-Central rod-free zone is more than 2x bigger than adults = low cone density-Cone segments are short and thick-Decreased quantum capture and resolution capability-At 15 months, the foveal depression is adult-like, cones segments are longer & thinner, rod-free zone is smaller, and the cone density has increased still all immature

-At 45 months, the cone segments are longer & thinner still (the inner segments are adult-like), the rod-free zone is adult-like, and the cone density has increased some more

-Optic nerve myelination is not complete at birth-Cortical synapses are not mature

V. BinocularityDevelopment-At 3 months, you expect consistent motor fusion, some sensory fusion-Convergence to 12cm by 14 weeks

Characteristics of misalignment-Up to 3 months, it’s mostly intermittent in any direction – decreases with age-Manifest XT at near (can’t converge properly)-Mismatch of accommodation and convergence cues-Prism response emerges at 8 weeks and develops over time

Clinical applications-Under 3 months: any strab that’s constant or intermittent increasing in frequency is abnormal-3 months and up: any strab is abnormal-NPC routinely starting at 6 months (3 months is OK)-Vertical prism test starting at 6 months

Sensory fusion-Emerges at 3-5 months-Very rapid development over several weeks from the 1st response to 60”-At 6 months, 60” is typicalOther

-Improvements in contrast sensitivity may be responsible for motor & sensory fusion improvement-Larger Panum’s fusional area (12-18x larger than in adults)-Risk factors: prematurity (hypoxia), FHx, hyperopia >+3.50 at 9 months, developmental delay

VI. Binocular VisionConvergence-Motor fusion is consistent and sensory fusion starts to emerge at the end of 3 months-Under-converge at 6-11 weeks-Magnitude and direction are accurate to 12-15cm at 3 months

Prism fusion test – not appropriate for infants under 6 months-Confirm motor fusion with 4BO for older kids-Look for vergence response or version then vergence = motor fusion-If only version or no movement = can’t confirm motor fusion-Use larger magnitude for infants (10pd for 6-9 months, 6pd for >9 months)

Flexibility of motor fusion – routinely assessed in patients over 3 years-12pd BO – how many cycles of fusion in 20 seconds (6-7 cycles is good)-8pd BI

Stereopsis – not appropriate under 6 months (no stereo up to 3 months)-Indirect measure of motor fusion (global stereo requires bifoveal fixation)-Don’t use filters in kids under 3 years-Good stereo doesn’t guarantee normal BV (e.g. intermittent XTs)

Stereo tests Lang – test of choice for 6 months to 3 years

-Distance = 30-40cm-Lang I is preferred b/c dots are denser and pictures are more compelling (550”)

Frisby – real depth-Used if they don’t respond to Lang-Rare response under 12 months

Stereo smile (filters) – 2AFC Randot – test of choice for over 3 years

-If they get worse than 100” on the circles, test the animals (100”) for local Random dot E (168”) – alternative test when child has trouble with Randot figures

-Distance = 1.5m-Must get 4/4 or 5/6 correct

TNO (red-green) – testability is not as good as Randot or random dot E

Summary of BV<3 months Intermittent strab normal3 months Consistent motor alignment

Convergence to 12cmVergence response to large prism (20pd)Earliest age for stereo

>3 months NPC6 months Vergence response to moderate prism (10pd)

Stereo approaches 60” in the lab (not in clinic)>6 months Stereopsis

Prism fusion test2 years Cover test at distance3 years Threshold stereopsisAny age Cover test at near

BrucknerVII. Preliminary Tests

Versions-Under 6 months do not follow well-Versions are full and comitant at birth

Pursuits-Smooth pursuits are not mature at birth – develop through 1st year of life-Horizontal develop before vertical-Pursuits are smooth to large and very low velocity targets-Often saccadic in young infants

Visual fields-Very small fields at birth-Rapid increase in field extent in the 1st 3 months-Adult-like static fields at 6-9 months; kinetic at 1 year-Assess confrontation fields in all patients-At-risk: premature (IV/PV hemorrhage, PVL), hypoxia, seizures, in-utero/early stroke, multi-challenged-Targets cannot make noise

Pupils-Pupil size increases with age-Iris muscles change a lot during the first 6 months-Sphincter develops early during the 1st trimester – any full-term infant will have fully developed sphincter-Dilator begins to develop at 6 months gestation – well developed by 2 months of age-Normal direct & consensual if full-term-Adult-like reactions by 2 months (but sluggish)

PD-Important to measure if correcting RE (may have to guesstimate or use a chart)

Color vision-Red-green response by 2 months-Blue-yellow at 4 months-No commercially available test for kids under 3 years-Color Vision Made Easy Test screens for protans and deutans-Ishihara for kids over 4 (trace numbers)

Ocular health-Hand held slit lamp for kids under 3 with a CC Corneal diameter

-Normal = 10-11mm-Micro <9mm-Megalo >11.5mm

Corneal clarity-Rule out congenital glaucoma in kids with cloudy corneas

Iris pigmentation-Final eye color develops from 6-9 months (more pigment added through 12 months)-Congenital Horner’s: lighter eye is affected eye

Posterior seg-Routine assessment beginning at 6 years

IOP-Tonopen for younger kids, NCT for older kids

VIII. Assessing Refractive ErrorHints-Dry ret even if you’re going to do a wet ret-If you think you see plus, it’s there

-Most preschoolers are slightly hyperopic, so start with a +2.50 lens to increase efficiency

Loose lens ret-Fog the eye not being refracted (1.00-2.00 diopters over what you think their RE is)-Assume eyes have equal RE-Adjust the level of the fog as the RE in the other eye increases

Cycloplegic ret-Uses: inconsistent distance fixation, ET, anisometropic, amblyopic, latent hyperopia-AOA requires cycloplegic ret on every peds patient’s first visit-Cyclopentolate is drug of choice – accommodation will be normal by the next day-Atropine used for ET occasionally (instilled 3 days prior at bedtime)-Tropicamide used for normal VA, normal dry ret, no amblyopia, low hyperopes, myopes-Refract at 30 minutes (maybe 10 minutes if blue eyes)-Still need to fog the fellow eye

Drops-Light irides: 2gtts 0.5% cyclo 5 minutes apart (infants <6 months; >6 months with previous adverse reaction)-Use 1.0% cyclo in infants >6months (if no adverse reaction)-Side effects of cyclo: sedation, nausea, flushed face, hallucinations-Dark irides: 1gtt tropicamide with 1gtt cyclo (0.5% or 1.0% depending on age)

Mohindra/near ret-Done when you can’t get distance fixation-Substitute for dry ret-Dark room with 50cm working distance-Measures the resting state/dark focus and is static-Net lens is gross -1.25-Tends to under-plus hyperopes

Autorefractor-Hand-helds have good testability on 2 year-olds and up-Underplus on dry measurements

Photorefraction-Screening tool-Flash near the edge of the lens entrance pupil; horizontal and vertical meridians-Uniform red reflex = emmetropia-Myopia if crescent on same side of pupil as light source-3 factors that affect results: distance of examiner, pupil size, distance of light source-Less sensitive with farther distances and smaller pupil

Corneal measures-Keratometry

Development of accommodation-Not assessed routinely in preschoolers-Start to see changes at 1-3 months (before, locked in at 20-25cm)-Inaccurate response to change in target distance (adult-like by 4 months)-No response to blur until 9 months-Response may not be great because VA isn’t greatAssessment of accommodation-Anti-seizure meds, ADHD, TBI, CNS anomalies, CP, Down, Fragile X, borderline hyperopia Pull-away

-3 years and up

Dynamic ret amplitude-Gradually move in to assess if they’re still accommodating-Amplitude = distance where you see an increase in motion (larger lag)-Not as accurate as pull-away

MEM-Distance is the Harmon distance-+0.50-+0.75 is normal (>+1.00 is a large lag)

IX. EmmetropizationPrescribing is guided by:1. VA (limited usefulness under 3 years)2. Signs & symptoms3. BV (strab, amblyopia)

Typical RE-Newborns: +2.00 to +2.75-12 months: - more similar to leptokurtic than normal distribution-6 years: +0.75 – typical leptokurtic curve-Range and variability decreases with age-Most emmetropization occurs in first 9-12 months

Hyperopia-Not all RE reduces-Final magnitude is influenced by initial magnitude-The more hyperopia early in life, the more rapid decrease, but they still end up more hyperopic-If the RE isn’t changing much, it’s better to see the child more often-More than +5.00 may be outside the range of effective emmetropizationMagnitude Emmetropization+3.00 to +5.00 (3 months)

Variable emmetropization by 9 months

>+5.00 (3 months) Little to no reduction in hyperopia>+3.00 (9 months) Greater odds of retaining >+2.00 at 3 years

Myopia-There is more myopia at birth than during preschool-60% of infants are myopes at birth-Emmetropization process is spread out more over time than for hyperopes-Change at a very steady rate until 3 years-Probably don’t prescribe initially, but monitor closely-Most myopes become low hyperopes during preschool years

Astigmatism-8% prevalence of astigmatism in adults (4-6% for older kids)-20-65% prevalence of astigmatism >1.00D in the 1st year of life-ATR or WTR-Correlates with corneal toricity-Adult-like astigmatism by 18-36 months-Longer time course than hyperopia-The more astigmatism you start with, the faster you lose it-Higher astigmatism as infants, higher astigmatism at 3 years

Anisometropia-14% of newborns have anisometropia (school-age kids 3.5-6%)-Prevalence reduces by the first year of life (stable at 1-4%)-Presence of aniso at 1 year doesn’t predict RE at 4 years-More than 50% of anisos are transient and not retained between 1 and 4 years

-Lower magnitudes of aniso have a greater chance of losing it-90% of infants with 3D or more aniso retain it at 10 years-Constant unilateral strabs will not emmetropize in the deviating eye

Emmetropization and prescribing (mostly completed by 9 months)-Most studies show that emmetropization isn’t affected by full or partial Rx-Theory: minus lens increases growth rate (signals that eye is too short)-As little as 1 hour without lenses prevents much/all adaptation

X. BV and Development Risk FactorsHyperopia-+5.00 is the threshold for isometropic bilateral refractive amblyopia-Moderate hyperopia can be a risk for accommodative ET-Moderate hyperopia at 9-12 months: 20-50% develop amblyopia by 3-4 years; 25% develop ET at 3 years-Strabismus is reduced from 13X to 4X with an Rx-Amblyopia is reduced from 6X to 1.6X with an Rx-Partial Rx reduces strabismus by 70% and amblyopia by 75%-Do no automatically Rx at 9-12 months-Rx if strabismic, minimal/no change in RE, >+5.00 at under 1 year, >+3.50 at 3 years, s/s, reduced VA-3 year-olds with moderate hyperopia have difficulty in matching, perceptual tasks, language development, etc.

Astigmatism->2.00 diopters of astigmatism is the threshold for isometropic (meridional) amblyopia-Isometropic amblyopia onsets by age 3-Deeper amblyopia in MA and CMA-Oblique astigmatism at 1 year is very amblyogenic all become amblyopia at 4 years

Anisometropia-Aniso >1.00 diopter is associated with amblyopia and strabismus-30% develop aniso if it’s persistent from 1-4 years

XI. Kids and ContactsIndications-High RE (bilateral high RE, accommodative refractive ET, aniso, aphakia); amblyopia (occlusion therapy); nystagmus; cosmetic/prosthetic/photophobia; bandage

Advantages: better peripheral vision, more normal appearance, reduced weight, reduced mag/mini, aniseikonia, prism, accommodative demand for hyperopes, photophobia (tinted), better chance for BV, better compliance

Disadvantages: ocular insult (abrasions 0-13%, SPK <11%, neo <6%, edema <5%, infiltrates <3%), difficulty handling lenses, psychosocial impact on family and child, frequent replacement due to parameters/lost lenses, frequent follow-ups

General considerations-Napping, decentering, greater ocular moisture, lenses must be durable and easy to handle, difficult I/R-RE can change rapidly, smaller pupil diameter, smaller corneal diameter, lacrimation-Steeper Ks (47.00-50.00 at 1-2 months; 43-00-44.00 by 4 years)

Lens materials Silicone elastomer (SilSoft) – only high + and aphakic powers

-DK = 340, durable, can use NaFl, stay on eye well-Can adhere to eye, lipid deposits, wettability, lenses last 6 months, expensive

SiHys-High dK, EW/CW, durable, easy to fit-Dryness/discomfort (lower modulus more comfortable; higher more rigid)

-Staining, tear microspheres, SEALs, limited powers, expensive-AV Advance (0.43), Oasys (0.72), Biofinity (0.80), O2Optix (1.0), Purevision (1.5), N&D (1.52)

Hydrogels-Easy to fit, comfortable, low cost, DW/EW, minimal risk of injury-Difficult handling, fragile, rubbed out, limited pedi parameters, can order custom

RGPs-Easy to handle, low cost, oxygen, durable-Difficult to fit, increased adaptation, eject/dislodge, frequent replacement, corneal injury

Fitting steps – mean K in infants = 48.50-Over-ret; add +2.00-3.00 for near/intermediate in aphakes-Recheck fit & power several times over 30 minutes

Follow-ups-Under 18 months: initially qweek, then q1-2months-18 months-6 years: q2-3 months-6 years-teen: q4-6 months

XII. Kids with Special Needs – we’re obligated to refer kids from 0 to 3 years for servicesDevelopmental delays-Mild to severe delay of 1 of more: cognitive, motor, communication, social-emotional, adaptive, self-help-Visual impairments, seizure disorders, premature, congenital CMV, FAS, any TORCH condition, family status-Milestones:

6 months: sounds, cries, & gestures to indicate needs 12 months: babble, speech/sound to get attention, respond to name, recognize some words 18 months: 25% of speech understandable, follow simple commands 24 months: 50% of speech understandable, begin using 2 word phrases 3 years: 75% of speech, follow 2-stage commands, use 4-word phrases to 4-6 word sentences 4 years: 100% of speech, 4-8 sentences with details

Developmental disability – involves more than 2 areas (above)-Severe and chronic with IQ <70 or severe delays in multiple areas

Hearing – 50% of kids with hearing loss can be ID’d by risk factors in the history-1.5-6 in 1000 live births have hearing loss-Risks: FHx, birth weight <1500 grams, APGAR <4 (1 min) or <6 (5 min), infections, otitis media, ototoxicity, craniofacial anomalies, neurodegenerative diseases, head trauma, parental concern

Down Syndrome (trisomy 21)-IQ = 50, mild cognitive impairment, very social-1 in 700 live births; 1 in 60 with maternal age over 40 (paternal age is also a factor)-50% congenital heart, hypothyroid, leukemia, hypotonia, 75% hearing loss, language delay-Moderate to high RE (do not emmetropize) -Slightly reduced VA (20/30-20/50)-Constant ET (23-80%)-Significantly under-accommodate (large lag)-Benign ocular signs: Brushfield spots on midperipheral iris, extra vessels crossing disc margin, laterally displaced oblique palpebral fissures, narrow PD, epicanthal folds

Fragile X Syndrome-Boys 1 in 1200-2000; girls 1 in 2000-4000-Poor socialization, severe mental retardation, attention deficits, tactile defensiveness-Large ears, long face, shy, hand flapping, biting, speech/language dysfunction, 25% seizure disorders-Moderate to high RE (hyperopia)-ET = XT-Nystagmus

Unspecified mental retardation – mild to moderate delays-XT > ET-RE similar to general pediatric population

CP-Non-progressive locomotor dysfunction of varying severity (delayed physical development)-1 in 1000 live births-Defect in immature brain due to hypoxia, low birth weight (20x risk), prematurity (5x risk)-Other risk factors: intrauterine infection, jaundice, Rh incompatibility-90% related to event in pregnancy or delivery-10% due to stroke, meningitis, encephalitis, brain injury-50% mental retardation-Classifications

Spastic (70-80%) – lesion in pyramidal cells & tracts-Characteristic gait-Hypotonia as a neonate (floppy baby) hypertonia at 6-9 months (spastic)-Diplegia more common (lower body), can also be hemiplegic or quadriplegic

Athetoid (10-20%) – lesion in basal ganglia-Some random movement (uncontrolled slow writhing)

Ataxic (5-10%) – lesion in cerebellum-Hypotonia, fine motor dysfunction, intention tremor

Mixed (spastic + athetoid)-78% have vision anomalies (most will be 20/20)-Hyperopia 3x more prevalent (myopia due to ROP)-Strab (ET or XT)-50% accommodative insufficiency (reduced amplitude, large lag)- Cortical visual impairment, hemianopic field loss, optic atrophy, nystagmus

Assessment and management – must refer within 2 working days-Test at developmental age-Use large print and SV for near instead of bifocals-Accommodative insufficiency – correct low hyperopia-Under 3 years, refer to ECI-3 or older, refer to school district (contact special ed department)

XIII. Differential Diagnosis of EpiphoraCongenital glaucoma – #1 DDx for epiphora-Types: primary (onset birth-3 years); juvenile (onset after 3 years); secondary-1 in 10,000 live births (5:2 M:F), 70% bilateral, 50-70% genetically isolated-Hereditary can be AD or AR, variable/incomplete penetrance, multifactorial, CYP1B1 locus GLC3A-60% diagnosed by 6 months; 80% diagnosed by 1 year-Old theory: abnormality in TM (Barkan’s membrane)-New theory: widespread anterior seg anomaly (anterior iris/CB insertion, thick/taut beams in TM, thick juxtacanalicular meshwork, not enough vacuoles in Schlemm’s canal, maldevelopment of Schlemm’s canal

-Symptoms: epiphora, photophobia, blepharospasm (glaucoma triad), irritability-Signs: buphthalmos, corneal edema, Haab’s striae (horizontal), ↑ IOP, optic atrophy, ↑ axial length, ↓ VA-Measure HVID (>12mm = buphthalmos)-Treatments for congenital glaucoma:

Goniotomy (procedure of choice) – requires clear cornea and technical skill; open 1/3 of the TM Trabeculotomy ab externo – 2 blocks of sclera, metallic thread through the canal, then trabeculatome Trabeculectomy (bleb) – increased scarring in infants Shunts – so aqueous dissipates through the conjunctiva Cyclodestructive – freezing or heat to destroy ciliary epithelium – 70% have increased pressure again

-Late complications: amblyopia, corneal scarring, strab, aniso, cataract, lens subluxation, recurrent glaucoma-Assc conditions: microphthalmos, ant seg dysgenesis, PHPV, lens anomalies, Sturge-Weber, NF, Marfan’s

Nasolacrimal duct obstruction – do not present with photophobia-6-20% incidence, NLD not patent until 9 months gestation (so more common in premies), 1/3 bilateral-Most common site of blockage is valve of Hasner (at the very end)-Upper obstruction – problems with blinking due to CN VII palsy, non-patent puncta

-Tx: none if isolated upper punctum blockage, tx if symptomatic when lower/both puncta blocked, membrane puncture with probing, cannulation with intubation

-Lower obstruction – NLDO, acute/chronic dacryocystitis-NLDO: positive reflux from sac, no infection, grade 2-3 on dye disappearance-Acute d’itis (33%): onset over 7 days, erythema, edema, reflex of pus discharge, sores-Chronic d’itis: at least 14 days, erythema, edema, consistent reflux, bacteria (55% Hemophilus, 35% staph aureus, 10% moraxella)

-Treatments: None (spontaneous resolution in 18-24 months), 96% resolve without tx by 1 year Nasolacrimal massage: hydrostatic pressure opens blockage, 41% resolve by 6 months

-1-2 strokes up, then 10-15 strokes down at least qid Probing: with anesthesia if over 6-8 months; probe through upper punctum meets probe in nose; 80-86%

initial success; can be repeated Balloon dacryocystoplasty: equally effective as probing; catheter in NLD, inflate at valve of Hasner for 60-

90 seconds; re-inflate at junction between sac and duct for 30-60 seconds; general anesthesia Nasolacrimal intubation: used after 2 failed probing procedures; left in x 3-6 months Dacryocystorhinostomy: incision in upper nose, make a hole in nasolacrimal system; last resort tx

Epiblepharon-2nd most common cause of epiphora; more in chubby and Asian babies-Extra fold of skin pushes up on lower lid; lid margin is in its normal position-Often limited to medial half of the lid-S/s: epiphora, discomfort, FB sensation, extra hz skin fold, trichiasis, keratitis-Tx: self-corrects by 2 years; lubrication; eyelid sutures; surgical skin removal; bandage CL

Bacterial conjunctivitis-Hemophilus, strep pneumo, staph (need broad spectrum antibiotics)-S/s: hyperemia, pus, lid swelling, papillae/follicles, eye stuck closed in morning, crusting

Adenoviral conjunctivitis-Adenoviruses 3, 8, 19, 37; highly infectious; incubates 2 days to 2 weeks-S/s: palliative if no SEIs; steroids; +/- prophylactic antibiotic

Seasonal allergic conjunctivitis-S/s: itching, irritation, tearing, red eyes, chemosis (conj, possibly lid)-Tx: remove allergen, cold compress, topical decongestant/anti-H/mast cell stabilizer/NSAIDs, systemic anti-H

Keratitis-Exposure, HSV, bacterial, toxic, phylectenular (inflammatory), dry eye, ulcers

Foreign body

Crocodile tears (gastrolacrimal reflex)

XIV. Child Maltreatment (3 types: physical, emotional, sexual)Physical abuse-Non-accidental injury (don’t have to have intent to injure as long as the behavior is inappropriate)-Includes substance abuse-Texas law allows reasonable corporal punishment-Federal/state governments don’t define the line between abuse and punishment-Open hand is punishment (buttocks, legs, hands); abuse occurs >3 times/day

Inspect at 2 & 5 minutes. 0 is no NaFl (patent).

Neglect-Largest group of child maltreatment-Biggest = lack of supervision or inappropriate supervision-Medical neglect – do not get medical care when they have the resources, includes specs-Confirmed maltreatment = 1% (12/1000)-1500 deaths per year from maltreatment (majority from neglect)-1.5 million harmed, 2.8 million endangered

Factors-Child factors: young age, perceived different, difficult child, foster child-Adult factors: social isolation, inappropriate expectations, emotional/psychological disorder, parent was abused, substance abuse

-Abuser is usually a parent or someone living in the home (age 20s to mid 30s)-Live-in significant others responsible for 60% of abuse & 90% of neglect

-Social factors: parental relationship, low income, parent-child relationship (more kids, young mother, corporal punishment, role reversal)

Characteristics-Child: change in behavior; overly compliant, passive, withdrawn; watchful; dirty; child reports abuse-Adult: little concern for child; perceives child as worthless, bad, burdensome; role reversal; blames child for problems at home or school; inappropriate expectations

Injuries Bruises are #1 (90%)

-1-2% prevalence in non-abuse situations in non-mobile infants-Worry about blood clotting problem-Accidental bruises over bony surfaces (chin, elbow, knee, shin, forehead, cheek bone)-Abuse bruises over soft fatty areas (cheeks, mouth, abdomen, thighs, upper arms, ears, scalp, neck, wrists/ankles)-Multiple bruises in different stages of healing

Burns are #2 (10-29%)-Uniform burns are characteristic of abuse-Peak age is 13-24 months (mean age 3 years)-Often triggered by toilet training incident

Intraocular hemorrhages (shaken baby syndrome – 34-80% have hemes)-Ocular injuries in 40% of abuse, but only 4-6% are seen by an eye doctor-Not likely for a non-mobile child to have an ocular injury-High risk for brain injuries-No external signs of head trauma; no history of trauma or it’s not consistent with findings; subdural hematoma; multiple changes in long bones

-Hemes are often posterior to the equator and in the superficial retinal layers-Can occur with CPR-Retinal hemes rarely occur with trivial accidental head injury

Reporting-Education system is #1-Medical system is #2-Must report within 48 hours-Identity is protected-Need: reporter’s name, address, phone, e-mail; child’s name, address, age, gender; why suspect; history of maltreatment; family dynamics