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12/5/2018 1 Pediatric Ophthalmology: Practical Pearls for Your Clinical 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 1 12/5/2018 CHECKING VISION ■Patch the eyes – kids peek! ADHESIVE EYE PATCHES 2 12/5/2018 CHECKING VISION ■Children uncertain with new tasks CHECKING VISION ■Poor confidence = poor performance CHECKING VISION ■ENCOURAGE as they perform 3 12/5/2018 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 4 12/5/2018 CHECKING FOR STRABISMUS CHECKING FOR STRABISMUS ■ Hirschberg Test CHECKING FOR STRABISMUS 5 12/5/2018 CHECKING FOR STRABISMUS DIAGNOSIS? PSEUDOSTRABISMUS 6 12/5/2018 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 7 12/5/2018 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 8 12/5/2018 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 9 12/5/2018 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 10 12/5/2018 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 11 12/5/2018 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 12 12/5/2018 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. 13 12/5/2018 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 14 12/5/2018 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 15 12/5/2018 CAN BE A CATARACT OCULAR MEDIA OPACITY – REFRACTIVE ERROR OCULAR MEDIA OPACITY - RB 16 12/5/2018 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 17 12/5/2018 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 18 12/5/2018 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 19 12/5/2018 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! 20 12/5/2018 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 21 12/5/2018 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 22 12/5/2018 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. 23 12/5/2018 Bonus Youtube video https://www.youtube.com/watch?time_contin ue=1&v=_oXE8TDVpD4 24.
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