12/5/2018
Pediatric Ophthalmology: Practical Pearls For Your Clinical Practice
Financial Disclosures
I have no conflict of interests or financial disclosures
Overview of Talk
Overview of the eye exam Common clinical conditions with practical pearls Update on referring to ophthalmology
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CHECKING VISION
■Patch the eyes – kids peek!
ADHESIVE EYE PATCHES
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CHECKING VISION
■Children uncertain with new tasks
CHECKING VISION
■Poor confidence = poor performance
CHECKING VISION
■ENCOURAGE as they perform
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Checking Vision Pearls
Recheck vision if failed vision screen Have MA encourage child When in doubt, ok to refer
Failed Vision: When to refer
A difference of 2 lines of greater between the eyes I expect a 3 year old 20/50 or better I expect a 4 year old 20/40 or better If child clearly uncooperative, recheck within 6 months before referral If child older than 5 years and no other ocular issue, refer to optometry
CHECKING FOR APD
■Can be difficult in pigmented irises ■Helpful tip: Use direct ophtalmoscope
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CHECKING FOR STRABISMUS
CHECKING FOR STRABISMUS
■ Hirschberg Test
CHECKING FOR STRABISMUS
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CHECKING FOR STRABISMUS
DIAGNOSIS?
PSEUDOSTRABISMUS
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PSEUDOESOTROPIA VS ESOTROPIA
STRABISMUS
■Any strabismus beyond 12 weeks is abnormal ■Any CONSTANT strabismus before 12 weeks is abnormal ■Sudden onset constant strabismus is abnormal at any age ■Children do not “grow out” of strabismus
THE RED EYE
■Infection VS Inflammation
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THE RED EYE
■Itchy (eye rubbing) – usually allergy
❑Artifical tears (put in the fridge if needed)
❑Zaditor ❑Oral antihistamine and cool compresses
THE RED EYE
■Clear discharge – viral
❑Supportive therapy with artificial tears
THE RED EYE
■Purulent discharge: Bacterial conjunctivitis ■Polytrim 4 times a day to the eye for a week
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THE RED EYE – CHEMICAL INJURY
■History will make it obvious (usually) ■Irrigate Immediately! ■Alkaline injury more serious ■Stain with fluorescein and give antibiotic if there is an epithelial defect.
THE RED EYE
■Chronic redness, crusting but not really tearing or discharge: blepharitis
SHOULD I ADD STEROID?
■Steroid helpful if we suspect chronic inflammatory issue (allergy, blepharitis) ■Can be harmful if infectious ■If chronic red eye, infection reasonably ruled out, and NO epithelial defect on fluorescein stain, ok to try low dose steroid (FML tid for a week then once a day for a week then STOP). ■NO REFILLS
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WHEN DO I REFER?
■Pain ■Corneal opacity ■Blurred vision ■Worsening despite treatment
Dacryostenosis (Blocked Tear Duct)
Excessive tearing usually due to nasolacrimal duct obstruction Usually resolve within first year of life
Dacryostenosis (Blocked Tear Duct)
Crigler Massage
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Dacryostenosis: When to refer
Tearing past 12 months (90 % resolve) Recurrent dacryocystitis can prompt earlier referral
Bonus slide : Dacryocele
Can present as enlargement of lacrimal sac and bluish discoloration overlying skin first few weeks of life
“Blinking”
Usually there is nothing wrong with the child Can be an early tic, or just stress, dry eye
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Stye/Chalazion – my approach
Aggressive medical therapy 3 weeks
Hot compress minimum 30 min a day
Sock trick
1 gram omega 3 fatty acid per day (dosing not clear – some recommend 200mg/year of life, max 1 gram) If no improvement sign up for surgery
Stye/Chalazion: Prevention
Flax seed oil 1 gram a day Daily hot compresses and lid hygiene Avoid eye rubbing
Barlean’s Omega Swirl
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Torticollis
Children’s brains are smart: if the head tilt driven by the eyes, there should be some advantage for the child
Things I look for
Strabismus? Ptosis? Nystagmus? Glasses?
Exam
If head position straightens with eye patch, more likely to be an eye issue Try moving head in opposite direction to see if strabismus becomes more manifest.
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PTOSIS
■Concern is of deprivational amblyopia ■Even when pupil not occluded, there can be astigmatism causing refractive amblyopia
HEADACHES
■Often not related to the eye ■Refractive error and convergence insufficiency can be ocular causes ■Ask if they are diplopic when reading
CONGENITAL GLAUCOMA
■Sometimes missed because family thinks large eyes are cute
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WHEN TO REFER
■Right away! ■Tearing, photophobia, corneal clouding, large eyes are concerning signs
OCULAR MEDIA OPACITIES
■Examination red reflex important part of exam ■ Unilateral infant cataracts must be operated upon in the first 6 weeks of life for optimal results ■Leukocoria can be due to retinoblastoma as well
OCULAR MEDIA OPACITY
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CAN BE A CATARACT
OCULAR MEDIA OPACITY – REFRACTIVE ERROR
OCULAR MEDIA OPACITY - RB
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WHEN TO REFER
■Immediately
Myopia Epidemiology
WHO has identified Myopia as 1 of 5 immediate priorities for Elimination of Avoidable Blindness (Cataract, Trachoma, Onchocerciasis) Prevalence in US has increased from 25% to 41% over 30 year period
Why the increase?
Change in lifestyle? Debate over mechanism
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Why Should We Care?
Diseases associated with increased myopia
Retinal detachment
Myopic degeneration
Choroidal neovascularization
Natural History Axial Eye Length
Key Points Axial Eye Length:
Most of the growth in first year of life
4mm AEL growth in first 6 months
Ages 2-5 and 5-13 slower growth AEL (1mm each phase)
Natural History
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PROTECT OUR PATIENTS
■Vision Therapy ■Orthokeratology
Vision Therapy
Confusion for our parents Vision therapy has been rigorously studied and is only proven for convergence insufficiency exotropia. If patients ask about VT, can refer to peds ophtho. If someone else is recommending it to parents, parents should ask that provider to show them the evidence that it works for their child’s condition.
VISION THERAPY
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VISION THERAPY
Options to Slow Progression
Bifocals Orthokeratology Atropine (high dose, moderate dose, low dose) Pirenzepine Peripheral defocus modifying contact lens Prismatic bifocal spectacle lens Soft contact lens Timolol Under-correction of Myopia Outdoor Activity
Show me the Evidence!
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ATOM1 and ATOM2
How to use this clinically
Minimize screen time, encourage outdoor activity If parents worried about myopia progression, recommend low dose atropine (not ortho K) Can send to optometry and they will CC chart to Ashish or I and we will put in the Rx. Increased sunlight may be helpful
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Tele-Ophthalmology
Use Dr. Advice for external pictures Same workflow as for dermatology: upload picture and send to ophthalmology Pediatric ophthalmology will review the picture and give advice Especially useful for external eye questions
Dr. Advice
Eye emergency
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COMMON QUESTIONS
■Is my child likely to inherit my need for eyeglasses? ■Will sitting to close to the TV hurt my child’s eyes? ■Will too much I-pad/computer hurt my child’s eyes? ■Do eye exercises improve vision?
COMMON QUESTIONS
■Will reading in dim light hurt my child’s eyes? ■Is it harmful to use my eyes too much? ■If one eye is damaged, does it put strain on other eye?
Final thoughts
If you are ever unsure, or if you have a challenging parent that requires reassurance, don’t hesitate to send the child over for an eye exam.
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Bonus Youtube video
https://www.youtube.com/watch?time_contin ue=1&v=_oXE8TDVpD4
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