Dorothy Reynolds, MD 4/1/2013

Prior to Beginning This Lecture On and In The Pediatric Patient… Amblyopia and Strabismus In The Pediatric Patient  Pediatric exam will be outlined (to supplement Basic lecture) Dorothy Reynolds, MD  NO recorded lecture accompanies these Stony Brook Medicine initial slides on the Pediatric Eye Exam Department of and Strabismus

Pediatric Ocular History External Inspection  Inspection of the head, face, lids, orbits may  A history of any of the following may warrant Ophthalmology evaluation: identify: – – (tearing) – Amblyopia (reduced best-corrected vision not fully attributable to a structural issue in the eye) – Blepharospasm (blinking) – Strabismus (eye misalignment) – (sensitivity to light) – (droopy ) – (pale pupillary on casual observation or in – Eyelid issue (mass, malposition, asymmetry, or photos) droop) – Ocular tearing, irritation/redness, rubbing –Eye trauma – Proptosis (forward “bulging” of eye(s)) – Previous – Facial asymmetry – Parental concern about the – Family history of eye disorder (especially one presenting in infancy – (jiggle of the eyes) or childhood) – Head position (head tilt or turn, chin up or down)

External Inspection Red Reflex Test

 Eye or orbital abnormality on external inspection  To identify leukocoria (pallor or whitening of the often requires Ophthalmology evaluation pupillary red reflex)  Dim the room lights  The clinical triad of photophobia, tearing, and  From 1 meter away, view both eyes of child through blepharospasm in an infant or child may be the direct ophthalmoscope paying attention to the red signs of Infantile or Juvenile and reflex require prompt evaluation with Ophthalmology – Look for symmetry, and a full regular reflex – Dark spots, asymmetric color, white reflex, absent reflex,  Penlight inspection of the anterior segment diminished reflex are of concern – Abnormality or asymmetry of the anterior segment of  Abnormal or absent red reflex requires the eye requires ophthalmology evaluation ophthalmology evaluation – Discussed in Basic Eye Examination  Discussed further in lecture that follows

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Corneal Light Reflex Test . Objective assessment of ocular alignment . May suggest an ocular misalignment . Helpful in evaluation of pseudostrabismus (appearance of strabismus  with normal ocular alignment) Swinging flashlight test . Hold penlight at 33 cm (fixation target)  Pupils should be equal in size, round, and . Compare position of corneal light reflex in both eyes equally react to light . Normal: symmetric corneal light reflex located slightly nasal to center of  There should NOT be an afferent pupillary both pupils defect . Asymmetric corneal light reflex may indicate ocular misalignment . ***Must evaluate further with cover testing to confirm  Assess for:  Discussed further in lectures: – Symmetric constriction to light  Sluggish or poor reactivity, asymmetric size, or afferent – Basic Eye Examination pupillary defect (Marcus Gunn ) require – Lecture that follows Ophthalmology evaluation  Discussed further in Basic Eye Examination

Strabismus Tests Vision Testing

 Corneal light reflex test  Divided primarily by age – A guesstimate that may suggest ocular misalignment –Infancy – Evaluate further with cover testing – Preverbal  Cover testing –Verbal – Movement of either eye on cover-uncover test is suggestive  MONOCULAR test of strabismus   Abnormality on corneal light reflex test or cover Tested with glasses in place testing is suggestive of strabismus and requires  improves after birth with visual ophthalmology evaluation maturation, so referral criteria are age dependent

Vision Testing: Vision Testing: Verbal Child

Infants and Preverbal Children  Best corrected monocular vision with glasses in place – May sometimes need to encourage child to guess  Infancy (first 2 to 3 months of life) – Use a patch or the parent’s hand to cover one eye (children peek) – Assess blink to light in each eye  Use the highest cognitive test the child is able to perform (child – Muscle light or direct ophthalmoscope on high and swing light over eye must be able to identify the tested symbols)  Blinks to light vision (normal) – Snellen letters (highest cognitive difficulty)  Poor blink to light (abnormal) --> requires ophthalmology evaluation – Snellen numbers  Preverbal (age 2 to 3 months to around 3 years of age) – Tumbling E – Check each eye for fixation and ability to follow –HOTV – Interesting object or toy held in front of one eye – Allen pictures or LEA symbols (least cognitive difficulty) – Cover the other eye with your hand)  – Move toy in various directions noting the child’s fixation and ability to maintain Test vision with ROW of symbols that the child understands fixation and follow the toy – Can have parent point to each symbol along the line if child has difficulty – Assess for: progressing along the row

 Preference of one eye --> requires ophthalmology evaluation

 Inability to fix or follow with one or both eye(s) -->requires ophthalmology evaluation – Discussed further in lecture that follows

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Vision Testing: Verbal Child Extraocular Motility

 Age based referral criteria ****  Examined in 9 positions of gaze – Age less than or equal to 5 years: two line  Head is stabilized in primary position difference between the eyes and/or less than 20/40 vision in one or both eyes  Move interesting object/toy into one position of – Age 6 years and older: two line difference gaze and then return to primary position between the eyes and/or less than 20/30 vision in  Note overactions (excess movement) and one or both eyes underactions (lagging movement) of muscles  Discussed further in lecture that follows  May identify nerve palsy or restriction of eye(s)  Discussed further in lectures: – Basic Eye Examination – Lecture that follows

And now the lecture…

 Please proceed to the recorded Lectures Amblyopia and Strabismus In which include images on slideshow The Pediatric Patient

Dorothy Reynolds, MD Stony Brook Medicine Department of Ophthalmology Pediatric Ophthalmology and Strabismus

Objectives Amblyopia and Strabismus

 Obtain examination skills to screen for  Amblyopia amblyopia and strabismus – Reduced best-corrected vision not fully  Identify clinical signs of amblyopia inducing attributable to a structural issue in the eye risk factors, and clinical characteristics of  Strabismus amblyopia and strabismus – Eye misalignment  Understand importance of early identification  “Lazy eye” and treatment of amblyopia and strabismus – Lay term for amblyopia, strabismus, or ptosis  Become familiar with ophthalmology  Amblyopia can result in strabismus, AND treatment protocol for amblyopia and strabismus can result in amblyopia… strabismus

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Amblyopia Amblyopia

 Decreased best-corrected vision in one (or both) eyes  Decreased best-corrected vision in one (or both) eyes  Reduced vision is not directly attributable to a  Reduced vision is not directly attributable to a structural issue of the eye or posterior vision pathways structural issue of the eye or posterior vision pathways – i.e., if structural abnormality is corrected the amblyopic eye’s – i.e., if structural abnormality is corrected the amblyopic eye’s vision would still be sub-normal (needs treatment) vision would still be sub-normal (needs treatment)  Develops PRIOR to maturity of the  Develops PRIOR to maturity of the visual system  Generally unilateral (can be bilateral)  Generally unilateral (can be bilateral) – Difference in best-corrected vision of more than 2 lines – Difference in best-corrected vision of more than 2 lines between the two eyes on vision testing between the two eyes on vision testing  Common vision problem in children  Common vision problem in children – Responsible for more vision loss in children than – Responsible for more vision loss in children than combination of all other causes combination of all other causes  If detected early and treated early, can be correctable  If detected early and treated early, can be correctable

Amblyopia Onset Amblyopia  Amblyopia develops PRIOR to maturity of the visual system  Secondary to:  Normal visual development: –Strabismus – Continuous process beginning at birth progressing  Most common through age 8 to 9 years –  Most vulnerable period is during the first 2 years of life,  Second most common particularly the first 3 months after birth – Stimulus deprivation – During the vision “learning” period the visual  Least common…. More about these later… pathways are “plastic” – Visual development requires ONGOING stimulation of vision receptors in the , from birth onward

Development of Amblyopia

 Visual stimulation/input is DISRUPTED in an eye during immature visual system period Three Major Types of Amblyopia – Earlier the age of onset the worse the potential amblyopia if not corrected  Strabismic amblyopia  Eye with an amblyopia-inducing risk factor sends a – Ocular misalignment distorted or blurred image to brain   Refractive amblyopia  Brain selectively ignores/suppresses the – Glasses need distorted/blurred input from that eye   Anisometropic (unequal glasses need)  Isometropic (high glasses need in both eyes)  Brain prefers/favors other eye with better vision  Stimulus deprivation amblyopia  Vision pathways from amblyopic eye do not develop normally (anatomic changes occur in the brain) – Occlusion of visual axis… More about these later…  Ultimately, this interruption of the normal developmental process results in amblyopia

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Diagnosis of Amblyopia

 IDENTIFICATION of amblyopia inducing risk factor(s) and Amblyopia and Strabismus reduced best-corrected vision  Diagnosis through vision screening  Amblyopia can result in strabismus, AND  PCP vision screening strabismus can result in amblyopia… – Red reflex  Early detection allows for timely treatment – Fixation pattern and visual acuity (identify monocular preference) – Strabismus evaluation (cover testing)  Early identification by the primary care – +/- Photoscreening to identify risk factors provider allows for further early evaluation with pediatric ophthalmology (including a full eye exam) with subsequent initiation of treatment in a timely manner  Without treatment in a timely basis, may not be correctable and could persist for a lifetime

Examination Red Reflex Test

 Red reflex and corneal light reflex  = Bruckner test  Pupils  With room lights dimmed (pupils will dilate allowing improved view of larger reflex)  Visual acuity  View both eyes of child through the direct  Cover testing ophthalmoscope paying attention to the red reflex  Head position – Look for symmetry, and a full regular reflex – Dark spots, asymmetric color, white reflex, absent reflex,  Extraocular motility diminished reflex are of concern  Fundus exam

. Objective assessment of ocular alignment  Red reflex test: Corneal Light . May suggest an ocular Leukocoria – Screening evaluation to misalignment (must further assess Reflex Test with cover testing to confirm) identify sign of visual . Penlight held at 33 cm (fixation axis opacity or posterior target) segment anomaly . Compare position of corneal light  Focus direct reflex in both eyes ophthalmoscope onto . Normal alignment suggested by pupils from 1 meter away symmetric corneal light reflex – Normal red reflex: located slightly nasal to center of the pupil  Symmetric . Asymmetric corneal light reflex – Abnormal red reflex: may indicate ocular misalignment . Fixing “normal” eye  Asymmetric . corneal light reflex is slightly nasal  Irregular to central pupillary axis . Strabismic eye  Pale/whitened (leukocoria) . corneal light reflex is deviated either nasally or temporally…. . ***Must evaluate further with cover testing to confirm

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Red Reflex “See Red” . Criterion for pediatric ophthalmology referral: . Abnormal red reflex  Alfred G. Smith, MD . Absent red reflex  Red Reflex Examination in . Concern for leukokoria (white pupil) Neonates, Infants, and Children. American Academy of . Family history of high-risk eye issues (even if normal , Section on red reflex): Ophthalmology, American . Association for Pediatric . Infantile Ophthalmology and . Infantile or pediatric problem Strabismus, American . Infantile or pediatric glaucoma Academy of Ophthalmology, . Other concerning eye issue and American Association of Certified Orthoptists. Pediatrics December 2008; 122:6 1401- 1404; doi:10.1542/peds.2008- 2624

Vision Testing Vision Testing

 Normal ocular alignment does not mean  If preverbal, check for fixation preference normal vision in both eyes – Cover each eye and check fixation and following for other eye  Monocular visual acuity testing is – Assess ease of one eye following necessary to assess for signs of an interesting object (e.g., toy) – Assess for objection to cover --> amblyopia suggests preference of covered eye  Child may less consistently follow object  Child may move head to peek around cover  Child may cry with covering of one eye

 If verbal, optotype vision Vision Testing testing  Ensure child knows the Vision Testing images being tested  Best corrected vision  Criterion for pediatric ophthalmogy referral: (test WITH glasses)  Poor blink to light in preverbal infant or child  One eyed testing  Fixation preference during vision testing – ***Tape a patch over  Difference in best-corrected vision between the two eyes of non-tested eye (no 2 lines or more peeking)  Poor performance on vision testing in one or both eyes (age-based criteria)  LINE vision  Age based referral criteria **** – Age less than or equal to 5 years: two line difference between the eyes – Not single optotypes and/or less than 20/40 vision in one or both eyes (over-estimates vision in – Age 6 years and older: two line difference between the eyes and/or amblyopia) less than 20/30 vision in one or both eyes

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Cover Testing

. Cover-uncover test: . Performed with glasses in place Cover-Uncover Test Eyes appear to be straight . Fixate on distant interesting accommodative object, and then repeat with a near target (interesting colorful noise-making toy or eye . Movement of either eye on cover- chart) . : uncover test is suggestive of . Occluder is used to cover the right eye and watch for refixation strabismus and requires pediatric Cover testing  Left eye covered movement of the uncovered left eye . Then cover the left eye … ophthalmology evaluation . On covering of one eye any movement of non-occluded other eye indicates tropia . Uncover test: . Cover the right eye and watch for refixation movement of the right eye when the cover is removed . Then cover the left eye … . Movement of occluded eye on removal of cover from that eye And uncovered  Left indicates phoria, or intermittent tropia

. May assume head position… Anomalous Head . Head tilt and/or Position (Torticollis) . Face turn . To compensate for: Torticollis . Strabismus . Horizontal muscle palsy  head turn into field of paralytic muscle  Consider eye etiology, as this may .  head tilt towards opposite side of paresis be a compensatory mechanism for . Eyes straight on anomalous head position, with strabismus noted on amblyopia inducing issue such as head straightening (check with cover test) strabismus, refractive error, or . Nystagmus (jiggling of eyes) ptosis, which would warrant . Ptosis (drooping of eyelid) . Refractive error (glasses need) pediatric ophthalmology evaluation . Non-ocular etiologies include: . Bony malformations of the cervical vertebrae . Abnormalities of the sternocleidomastoid

Extraocular Motility Continued on Next Lecture

H H, And up, down Motility evaluation to assess for signs of over-/under-action Of the

Check versions, Then ductions PRN

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Strabismic Amblyopia  Ocular misalignment Three Major Types of Amblyopia – Most common form of amblyopia – Unilateral  Strabismic amblyopia  Two eyes are not simultaneously directed at the object of regard --> –Ocular misalignment  Brain cannot fuse two different images   Refractive amblyopia  During the visually immature period brain will – Glasses need compensate by ignoring the image from one eye   Anisometropic (unequal glasses need)  Isometropic (high glasses need in both eyes)  Brain develops a preference to input of fixing eye with  Stimulus deprivation amblyopia reduced responsiveness to input from misaligned eye – Occlusion of visual axis – Cortical – Adaptation of ignoring the image from the misaligned eye also results in interruption of the ongoing visual stimulation required for normal visual development --> amblyopia

Strabismus (a few definitions) 6 Extraocular . Orthophoria = straight eyes . Strabismus = misalignment of the eyes Muscles . Affects about 4% of US population (plus Levator Palpebrae)  Horizontal rectus muscles . Direction of deviation (in, out, up, down) – Medial rectus (CN III)  Adduction . Horizontal: Eso (= In), Exo (= Out) – Lateral rectus (CN VI) . Vertical: Hyper (= Up), Hypo (= Down)  Abduction . Frequency (phoria, tropia) . Phoria = Latent tendency toward eye deviation  Vertical rectus muscles . Controlled by fusion under binocular viewing (both eyes open) – Superior rectus (CN III) . Present when covering one eye  Elevation, incyclotorsion, adduction . Tropia = Manifest eye deviation – Inferior rectus (CN III) . Present under binocular viewing (both eyes open)  Depression, excyclotorsion, adduction

. Intermittent = present part of the time  Vertical oblique muscles . Constant = always present . Amount of the deviation (measured in prism diopters) – Superior oblique (CN IV)  Incyclotorsion, depression, abduction . Etiology of the strabismus – Inferior oblique (CN III) . Paralytic  neurologic cause  Excyclotorsion, elevation, abduction . Non-paralytic . A neuromuscular abnormal control of (majority of strabismus)  Innervation: . Special forms and restrictive – “LR 6, SO 4 (rest are 3)”

Strabismus Deviations Some Strabismus Risk Factors .  Prematurity . Convergent deviation  inward crossing of eye(s)  Positive family history . “cross-eyes”  . Exotropia  Developmental delay – Incl. , . Divergent deviation  outward drifting of eye(s)  Certain neurological disorders . “wall-eyes” – Eg., brain tumors, stroke .  Certain genetic disorders . Elevated eye  Certain systemic disorders . Hypotropia  Trauma . Depressed eye – Incl. orbital fracture, traumatic brain injury, shaken baby syndrome

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Pseudostrabismus . In the differential of true strabismus Pseudostrabismus . “Appearance” of strabismus BUT eyes are not truly misaligned Pseudostrabismus Versus True Esotropia . Note the normal corneal light reflex . ***May have superimposed true strabismus (need to always check with cover testing to rule-out true strabismus) . Commonly illusion of esotropia due to skin covering of normally visible nasal . Most commonly secondary to . Prominent epicanthal skin folds of the . Wide and flat nasal bridge Note the corneal light reflex ***Must perform cover testing to confirm***

. Onset < 6 months age Infantile/ . Familial Esotropia Congenital . Large constant convergent deviation Esotropia . Alternate eye fixation . Differential includes Cranial Nerve VI palsy . Treatment: Convergent ocular deviation . Refractive correction PRN . Amblyopia treatment PRN . ** . EARLY: Around 6 months of age or earlier . Recurrent (70% require additional surgery)

Accommodative . = Refractive Esotropia Acquired . = Non-refractive Esotropia . Onset 6 mos. to 7 yrs. . Onset > 6 months age Esotropia . Convergent ocular deviation associated Esotropia with effort of focusing . Deviation: . Moderate to high hyperopia . EQUAL at distance & near . Background (Normal): . Symptoms: . Focus at near  lenticular . & simultaneous normal amount of ocular convergence . Refractive error: . Accommodative Esotropia: . Insignificant hyperopia . Work of focusing (accommodating) --> . Differential: results in over-convergence through multiple mechanisms . CNS lesion . Treatment: . Cranial Nerve VI Palsy . Refractive correction -->relax focusing . Treatment: effort  decrease over-convergence . Consider neuro work-up . Eyes often still cross without glasses . Refractive correction PRN . +/- Bifocals if more crossing at near . Amblyopia treatment PRN . Amblyopia treatment PRN . Strabismus surgery PRN . Strabismus surgery PRN

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. Most common exodeviation Intermittent (except at near) Exotropia . Onset usually < 5 years Exotropia . Deviation: . Initially intermittent and greater at distance --> progresses… . Apparent during visual At times the eyes are straight inattentiveness, fatigue, stress (often more notable later in the day) And then… . Signs: . Squinting Divergent ocular deviation . Closing one eye in bright sunlight . Rubbing of the eyes Right eye out . Treatment: . Refractive correction PRN . Amblyopia treatment PRN . Monitor with frequent exams . Watch for increased angle & Left eye out frequency (signs of deterioration) . Strabismus surgery PRN

Intermittent Intermittent Exotropia

Eyes straight Exotropia Intermittent Exotropia  May Progress to Exotropia  Remember to perform cover testing*** Cover testing  Left eye covered

And uncovered  Left Exotropia

Congenital . Rare Exotropia Exotropia . Onset < 6 months age Divergent ocular deviation . Deviation: . Large constant exotropia . Often associated with: . **Neurologic impairment . Craniofacial disorders . Treatment: . Work-up . Refractive correction PRN . Amblyopia treatment PRN . Strabismus surgery . As early as 6 months of age

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Hypertropia Incomitant Strabismus

 Ocular misalignment varies with gaze – Extraocular muscle issue – Extraocular nerve issue – Mechanical restriction issue Left Hypertropia  Some etiologies OR Right Hypotropia – Restrictive strabismus (Depends on fixing eye) – Orbital disease – Paralytic strabismus –Systemic disease h

Third Nerve . Cranial Nerve III innervates Fourth Nerve CN IV innervates medial/superior/inferior . Palsy rectus and inferior oblique Palsy superior oblique . Exotropia usually with . Hypertropia of paretic hypotropia eye . Paretic eye is down and out .+/- head tilt towards . If complete palsy  associated opposite side of paretic ptosis and pupillary dilation eye . Etiology: . In children, congenital etiology . Etiology: is more common than acquired . Congenital . However may still require . Acquired (head trauma) work-up, especially if pupil – May require work-up involvement or other

Sixth Nerve . Cranial nerve VI innervates Strabismus Palsy lateral rectus (limited abduction) . Criterion for pediatric ophthalmology referral: .paretic eye is esotropic, . Any ocular misalignment still present after one (to especially at distance and in three) months of age gaze towards the affected . Unless: eye . Large angle deviation  refer earlier . May assume a head turn . Constant deviation  refer earlier toward the paretic eye to . Preference of one eye --> refer avoid need for abduction of . Associated with abnormal red reflex or other ocular that eye anomaly/signs/symptoms refer on presentation . Etiology: . Poor blink to light (infancy) or poor vision --> refer . Usually acquired (trauma or . If uncertain --> refer CNS lesion/elevated ICP) . Other (based on history, associated medical condition) --> refer . Congenital is rare . Remember, strabismus may be a sign of a more serious  Requires work-up condition (e.g., glioma, CNS tumor, elevated ICP, retinoblastoma….) and may result in amblyopia

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Strabismus Treatment Three Major Types of Amblyopia

 All patients require a full eye  Strabismic amblyopia exam (including dilation) – Ocular misalignment  Refractive correction PRN  Amblyopia treatment PRN  Refractive amblyopia – Occlusion therapy of preferred eye –Glasses need  Patching  Anisometropic (unequal Post-operative orthophoria  Strabismus surgery PRN – Recession (weakening glasses need) procedure) – Resection (strengthening or Isometropic (high glasses tethering procedure) –Other need in both eyes)  Stimulus deprivation amblyopia – Occlusion of visual axis

Refractive Amblyopia

 Anisometropic Refractive Amblyopia (unequal Refractive Amblyopia glasses need) – Second most common form of amblyopia  Isometropic Amblyopia (high glasses – Unilateral need in both eyes) – Unequal amount of refractive error in two eyes – Blurred image for both eyes  Eye with less refractive error --> clear(er) image – Bilateral  Eye with higher refractive error --> constantly out of focus with image distortion – Eye with clearer vision is “favored,” and other eye is susceptible to amblyopia

Refractive Amblyopia Treatment Three Major Types of Amblyopia  All patients require a full eye exam (including dilation)  Strabismic amblyopia  Refractive correction – Ocular misalignment (glasses) full-time  Refractive amblyopia  Amblyopia treatment PRN – Glasses need  Usually more responsive to  Anisometropic (unequal glasses need) treatment, HOWEVER often  Isometropic (high glasses need in both eyes) diagnosed much LATER  Stimulus deprivation amblyopia while no external signs of issue –Occlusion of visual axis  Identification is often dependent on vision screening

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Stimulus Deprivation Amblyopia Stimulus  Visual axis occlusion or obstruction disrupts visual development in the Deprivation involved eye(s) Amblyopia – Least common form of amblyopia  Stimulus deprivation amblyopia is – Often most difficult to treat most commonly secondary to a – May be unilateral or bilateral congenital or acquired cataract  (s) will blur the –Secondary to: image to one or both eyes during  Media opacity (, , vitreous, retina) most visually after – Cataract birth--> so early detection is critical to prompt surgical – /scar management and early visual – rehabilitation – Retinal lesion  Red reflex test  Ptosis (congenital, secondary to lid lesion such as a hemangioma) – Look for leukocoria

Stimulus Deprivation Amblyopia Amblyopia --> Sensory Strabismus . Congenital account for 10% of all visual loss in children worldwide . Incidence: 1/250 newborns (50% U/L, 50% B/L) . Variety of hereditary & etiologic factors U/L strabismus secondary to decreased vision/amblyopia in affected eye . Visual significance: . Size, location & density of opacity . Any central opacity or surrounding lenticular distortion 3 mm + in size is visually significant . Treatment: . Early lensectomy +/- implantation . Post-op refractive correction . . Glasses . Aggressive post-op amblyopia treatment (occlusion therapy) for 10 years . Visual outcome H/O Congenital Cataract right eye, . Best visual acuity if surgery prior to 2 months age, Secondary glaucoma right eye, followed by compliance with amblyopia management . Bilateral aphakes do better than unilateral secondary to Dense amblyopia right eye, competition (amblyopia) Sensory exotropia right eye

. Unilateral strabismus secondary Sensory Esotropia to decreased monocular visual or Exotropia acuity in affected eye Organic Amblyopia . Develop preference for other eye & amblyopia in affected eye, and then strabismus in amblyopic eye . Etiology (examples):  Amblyopia in presence of ADDITIONAL vision loss . Refractive error/ from uncorrectable structural abnormality of the eye . Corneal opacities (scar) – Eye has poorer vision because of structural issue and . Lenticular opacities (cataract) secondarily develops amblyopia . Optic nerve atrophy/hypoplasia H/O Congenital cataract left eye, . Macular lesions  Optic nerve anomaly Aphakic left eye, . Intraocular tumor –Hypoplasia Non-compliant with glasses, . (chronic) – . Treatment: Dense amblyopia left eye,  Retinal lesion/anomaly Sensory esotropia left eye . Management of primary disorder . Refractive correction PRN –Scar . Amblyopia treatment – Coloboma . Strabismus surgery PRN  Trial of amblyopia treatment is “ALWAYS” indicated

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Organic  Check for leukocoria  Retinoblastoma And Then… Amblyopia  Red reflex test – Most common malignant ocular – Screening evaluation to tumor of childhood identify sign of visual axis . Incidence: 1/15,000 opacity or posterior segment . Diagnosed by age anomaly . 1 year in familial or B/L cases

 Focus direct ophthalmoscope . 1 – 3 years in sporadic U/L cases onto pupils from 1 meter away . Signs: Abnormal reflex – Normal red reflex: . **Leukocoria (most common) Left eye  Symmetric Total . +/- Strabismus (25%) – Abnormal red reflex: Retinal . +/- Vitreous hemorrhage, , inflammation, glaucoma, proptosis,  Asymmetric Detachment  Irregular . Requires aggressive emergent  Pale/whitened treatment

. Prompt treatment can be life-saving

Amblyopia Treatment Amblyopia Treatment  May require occlusion therapy of preferred eye to force brain to  Treatment is more successful prior to development of use image from the amblyopic eye mature visual system – Enhances stimulus to the visual cortex and strengthens the pathways – Early (earlier) treatment is best  Patching of preferred eye forces child to fix with amblyopic eye – Adhesive eye patches, NOT pirate patch  Generally, the younger the age the more successful the treatment – More effective when performing near activities during patching – Less substantial improvement in vision often after the age of  Pharmacologic penalization with atropine eye drops to blur image in the preferred eye 8 to 9 years  “” does not treat amblyopia or strabismus, and  Optimize the retinal image in the amblyopic eye may in fact delay initiation of appropriate treatment – Clear the visual axis by clearing any obstacle to vision  If strabismus, treat amblyopia first (strabismus surgery PRN) – Clear the image that the eye presents to the brain by  Close follow-up is necessary to assess response to amblyopia correcting any significant refractive error (glasses) treatment and compliance – GOAL is best-corrected 20/20 vision in either eye, or Snellen acuity  Force use of the amblyopic eye (occlusion therapy) vision that differs by one line or less between the two eyes – Requires “work” by family; compliance can be difficult – ***Window of opportunity for treatment (earlier is better)  Amblyopia may recur and sometimes requires maintenance treatment

Conclusions  Goal: EARLY IDENTIFICATION of amblyopic risk Strabismus Treatment factors – If congenital etiology there is a short window for intervention (first few weeks of life)  Treat any co-existing conditions  Goal: EARLY DIAGNOSIS of amblyopia and  Refractive correction PRN strabismus  Amblyopia treatment PRN  Goal: EARLY INTERVENTION  Strabismus surgery PRN – Allowing for more successful treatment  Criterion for complete ophthalmology evaluation  Always best to intervene when strabismus is intermittent, PRIOR to – Amblyopia –Strabismus decompensating to a constant deviation –Leukocoria… with development of suppression  If dense amblyopia or amblyopia treatment is not successful, must PROTECT the preferred eye – Polycarbonate glasses full-time and sports goggles

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Thank you

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