2. Objectives Understand the basics of pediatric ophthalmology. Define the role of a pediatric ophthalmologist. Rationalize why children need a different structure for eye care. Justify the Importance of pediatric vision screening Review normal ophthalmic milestones. Outline basic techniques for examining child's eye’s. Outline age specific screening and Newer pediatric vision screening technology. Describe select pediatric ophthalmic conditions -Refractive errors, cataract, coloboma, retinoblastoma, retinopathy of prematurity. Describe etiology, risk factors, presentation,diagnoses and management for amblyopia and strabismus

3. Basics of Pediatric ophthalmology What is Pediatric ophthalmology? It is a sub-speciality of ophthalmology concerned with eye diseases, visual development, and vision care in children. What is the Role of Pediatric ophthalmologists? They focus on the development of the visual system and the various diseases that disrupt visual development in children. Pediatric ophthalmologists also have expertise in managing the various ocular diseases that affect children. Pediatric ophthalmologists are qualified to perform complex eye surgery as well as to manage children's eye problems using glasses and medications.

4. Children are Different & need a different structure for eye care Developing cortical connections Window of opportunity for diagnosis and treatment…just like with language development

5. Ophthalmic Milestones Blink to light 30 weeks - Blink to light Pupils react 31 weeks - Pupils react Early fixation 2 to 3 weeks - Early fixation Birth Horizontal gaze - Birth 2 months Vertical - 2 months 3 months Fixate - Birth to 3 months 3 months Follow - 3 months

6. Color ? (3 months) Six Months Visual acuity 20/30–20/40 Binocularity well developed Field – Adult-like 1 year

7. Basic Techniques for Examining Children’s Eyes Age specific Start with HISTORY – Moms are great diagnosticians! Common EXAM components – Assessment of vision – External anatomy – Pupil function – Motility – Ocular fundus/Red Reflex testing

8. Ocular History Does child appear to see well distance and near? Any crossing? Family history of eye disorders? Recurrent discharge or redness? Extreme photophobia? NOT to worry about: – “Sits close to TV a lot”

9. External Examination Are eyelids symmetric? Pupil symmetry? Any redness, inflammation, or discharge? Cornea clear? Are the eyes aligned?

10. Pupil Exam Are the pupils round? Symmetric? – If asymmetric, is it more asymmetric in dark or light? Reactive to light?

11. Motility Assessment Is the pupil light reflex central? Do the eyes move fully in all directions? Pseudostrabismus vs. true strabismus

12. Vision Assessment Infants: Eye contact, follows face, smiles Toddlers: Cover each eye and follows objects (fix and follow) Verbal: Visual acuity screening with appropriate optotype (symbol/letters) AAPOS Vision Screening Kit

13. Child abuse is a significant social problem which is associated with a high morbidity and mortality. “Shaken Baby Syndrome” (SBS) is one form of physical child abuse, a non-accidental traumatic brain injury. In 6% of reported cases of child abuse, an ophthalmologist is responsible for initially recognizing the abuse. Perhaps the greatest diagnostic clue is a detailed history that is incompatible with the extent and severity of the injuries found on dilated fundus exam.

14. Newer / improved Pediatric Vision Screening Technology Photoscreening Automated refractors VEP screening Retinal birefringence

15. The Importance of Pediatric Vision Screening Amblyopia affects up to 5% of the population (>10 million Americans). In the first 4 decades of life amblyopia causes more vision loss than all other ocular diseases combined! Amblyopia has a “window period” for treatment in early childhood. Screening can prevent otherwise fatal disorders such as retinoblastoma.

16. Periodicity Table for Screening Periodicity Schedule for Visual System Assessment in Infants and Children Newborn to 6 months 6 months to 12 months 1 to <3 years 3 to < 5 years5 years and older Ocular HistoryxxXxx External inspection of lids and eyes xxxxx Red Reflex Testingxxxxx Pupil examination xxxx Ocular Motility Assessment xxxx Instrument Based Screening x+x+ x+x+ * Visual Acuity Fix and follow xx Visual Acuity age-appropriate optotype assessment x∆x∆ x∆x∆ +: Bill using CPT 99174 ∆: Bill using CPT 99173 *: If unable to test visual acuity monocularly with age appropriate linear optotypes, instrument-based screening is suggested.

17. Age Specific Screening: NEWBORN External evaluation for obvious ocular malformations and infections – NOTE: Too young to evaluate alignment!!! RED REFLEX TEST—preferably prior to discharge from newborn nursery – Very important to r/o retinoblastoma or congenital cataracts If congenital cataracts not removed in first 2 to 3 months of life, permanent loss of sight occurs

18. Bruckner Reflex

19. Leukocoria is an Urgency!  Diff Dx include cataract, glaucoma, PHPV, Retinoblastoma, Retinal detachment, etc.  In addition to sending a consult, CALL ophthalmologist to make sure the patient is seen ASAP!

22. Pediatric Refractive Errors Nearsighted Farsighted Astigmatism Anisometropia

23. Myopia (Near-sightedness)  Eyeball too long  Can’t see far away  Correct with specs, contact lens, or excimer laser (older children)

24. Hyperopia (Far-sightedness)  The eyeball is too short  “Accommodation” will increase the effective lens power in the eye and focus at both near and far  Crossing may occur Glasses Accommodation

25. Astigmatism  “Warpage” of the cornea like a football  Light rays in one axis are not focused the same as in opposite axis  Corrected with glasses

26. Congenital cataract refers to a lens opacity present at birth. Congenital cataracts cover a broad spectrum of severity: whereas some lens opacities do not progress and are visually insignificant, others can produce profound visual impairment.

27. Coloboma (from the Greek koloboma, meaning defect, is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc. The hole is present from birth and can be caused when a gap called the choroid fissure, which is present during early stages of prenatal development, fails to close up completely before a child is born.

28. Retinoblastoma (Rb) is a rapidly developing cancer that develops from the immature cells of a retina, the light-detecting tissue of the eye and is the most common malignant tumor of the eye in children. The most common and obvious sign of retinoblastoma is an abnormal appearance of the pupil, leukocoria, also known as amaurotic cat's eye reflexleukocoria Leucokoria Cross eye

29. Retinopathy of prematurity (ROP) or Terry syndrome, previously known as retrolental fibroplasia (RLF), is a disease of the eye affecting prematurely-born babies generally having received intensive neonatal care, in which oxygen therapy is often used and advantageous. It is thought to be caused by disorganized growth of retinal blood vessels which may result in scarring and retinal detachment. ROP can be mild and may resolve spontaneously, but it may lead to blindness in serious cases. As such, all preterm babies are at risk for ROP, and very low birth weight is an additional risk factor. Both oxygen toxicity and relative hypoxia can contribute to the development of ROP. Dragged optic disc of ROP

30. Amblyopia The Physician sees nothing and the Patient very little

31. What is Amblyopia? Unilateral or bilateral decrease of visual acuity caused by form vision deprivation and/or Abnormal binocular interaction for which no organic cause can be detected

32. Amblyopia…In Other Words: The camera (eye) is capable of taking the picture but the computer (brain) doesn’t recognize that there is an image. “Either use it or lose it!”

33. Screen for Causes of Amblyopia Refractive errors Obstruction of optical pathway (e.g. cataract or corneal scar) Strabismus Other—anything that blocks input of visual information to the brain Remember in the pre-verbal child, the only way to detect amblyopia is to indirectly detect the risk factors. Remember in the pre-verbal child, the only way to detect amblyopia is to indirectly detect the risk factors. (Refractive errors, Media opacities, Strabismus)

34. Treatment Amblyopia The clinician must first rule out an organic cause and treat any obstacle to vision (eg, cataract, occlusion of the eye from other etiologies). Remove cataracts in the first 2 months of life, and aphakic correction must occur quickly Treatment of anisometropia and refractive errors must occur next The next step is forcing the use of the amblyopic eye by occlusion therapy

35. STRABISMUS occurs when both eyes do not look at the same place at the same time; the eyes are unable to align properly under normal conditions eye(s) may turn in, out, up, or down can be present in one or both eyes often referred to as: cross-eyed, crossed eyes, cockeye, weak eye, wall-eyed, wandering eyes, and/or eye turn

36. CAUSES OF STRABISMUS lack of coordination between the muscles of the eye responsible for eye movement and keeps both eyes from gazing at the same point problems with the nerves that transmit information to the eye muscles problems with the control center in the brain that directs eye movement in adults, can be caused by stroke, thyroid problems, brain injury, or other trauma

37. RISK FACTORS family refractive errors—extreme farsightedness (hyperopia) can develop strabismus due to the amount of eye focusing necessary to keep vision clear medical conditions—Down syndrome,cerebral palsy,stroke or head injury from: Strabismus.com

38. TYPES OF STRABISMUS Esotropia—inward turning of the eye Exotropia—outward turning of the eye Hypertropia—upward turning of the eye Hypotropia—downward turning of the eye from: American Optometric Association

39. ESOTROPIA The left eye is turned inward—note that the light reflection in the eyes is not symmetric

40. EXOTROPIA The right eye is turned outward—again, not the light reflection in the eyes is not symmetrical

41. HYPERTROPIA The right eye is turned upward—light reflection not symmetrical

42. HYPOTROPIA The right eye is turned downward-light reflection in eyes is not symmetric

43. WHEN DOES IT OCCUR? congenital—developing during infancy; 50% of children with strabismus are born with it acquired—developing in adulthood from: Strabismus.com

44. DIAGNOSIS A comprehensive eye exam is necessary with focus on the following: patient history visual acuity refraction alignment and focusing eye health exam from: American Optometric Association

45. TREATMENT there is no cure for strabismus with treatment, the effects of strabismus may be corrected the goal of treatment is to help the patient achieve as close to normal binocular vision as possible in every direction of gaze and at all distances

46. TREATMENT Eye Patch The stronger eye is patched to force the brain to interpret images from the strabismic eye. Eye patches will not change the angle of the strabismus. Typically, eye patching is used only if amblyopia is present.

47. TREATMENT Eyeglass or Contacts Eyeglasses or Contacts are used to improved the positioning of the eye(s) by modifying the patient’s reaction to focus. Eyeglasses and Contacts can also redirect the line of sight, which can help straighten the eye.

48. TREATMENT Prisms Prisms are used to modify the way light and images hit the eye. The lenses provide comfort and can help prevent double vision from developing.

49. TREATMENT Vision Therapy A non-surgical method of therapy that treats the eye and the brain. An optometrist will oversee the therapy, which is designed to strengthen or develop visual skills. The optometrist may also use eyeglasses, prisms, eye patches and computerized medical devices during the therapy.

50. TREATMENT Eye Surgery Surgery may be necessary in an attempt to align the eyes by modifying one or more muscles in the eye. During surgery, the muscle positions will be changed or the length of the muscles will be changed. Surgery may follow a period of eye patching and then eyeglasses may be used after surgery to help treat strabismus. Surgery on medial rectus muscle of the left eye.

51. UN- CONVENTIONAL-ALTERNATIVES