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:  2-2.5 years 0-6 months -Independence -Near testing only -2/4 of language is understandable -Not mobile -Distance testing is often possible -Responds to voices  3 years - easiest age to examine -Age of pleasing  6-12 months -Labeled praise very effective -Near testing only -3/4 of language is understandable -Mobility starts  4 years -Separation anxiety & fear of strangers -Motivated by simple rewards -Knows name and orients -Start to appreciate humor  13-23 months -4/4 of language is understandable -Short attention span  5 years -No tolerance for limitations = tantrums -Love praise & can’t accept criticism -Negativism starts -Don’t like to lose (so they’ll cheat) -¼ of language is understandable  6 years -Use labeled praise -Start using phoropter II. Assessment of Development Milestones/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 o Caution = failure/refusal with age line passing through the blue; write C o Delay = failure/refusal completely to the left of the age line; write D o No opportunity; write NO -Recording o Normal = no delays and <1 caution o Suspect = >2 cautions and/or >1 delay o 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 mortality Complications 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)  Other o 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 – conjunctivitis o 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 Acuity Preferential 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 Measures Sweep 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 Assessments Overview -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 bead size -Estimation of VA: 1) tan  2)  * 60 * 20  Snellen denominator test distance -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 Acuity Contrast 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 600 -Calculation for expected VA: 1) Age in months  cpd 2) Snellen denmoninator  cpd

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. Binocularity Development -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 typical Other -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 Vision Convergence -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 normal 3 months Consistent motor alignment Convergence to 12cm Vergence response to large prism (20pd) Earliest age for stereo >3 months NPC 6 months Vergence response to moderate prism (10pd) Stereo approaches 60” in the lab (not in clinic) >6 months Stereopsis Prism fusion test 2 years Cover test at distance 3 years Threshold stereopsis Any age Cover test at near Bruckner VII. 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 Error Hints -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 great Assessment 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. Emmetropization Prescribing is guided by: 1. VA (limited usefulness under 3 years) 2. Signs & symptoms 3. 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 emmetropization Magnitude Emmetropization +3.00 to +5.00 (3 Variable emmetropization by 9 months 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 Factors Hyperopia -+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 Contacts Indications -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 services Developmental 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 Epiphora Congenital 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 Inspect at 2 & 5 -Lower obstruction – NLDO, acute/chronic dacryocystitis minutes. 0 is no NaFl -NLDO: positive reflux from sac, no infection, grade 2-3 on dye disappearance (patent). -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 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