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PROJECT VIETNAM FOUNDATION

PROJECT VIETNAM FOUNDATION. Online Training Series For Vietnam Medical Professionals. Steve Prepas MD. HOAG HOSPITAL Newport Beach. 25 humanitarian trips 11 countries. Quynh Kieu MD. University of Saigon, class of 1975. Eye & Vision Screening. The Role Of The Pediatrician

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PROJECT VIETNAM FOUNDATION

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  1. PROJECT VIETNAM FOUNDATION Online Training Series For Vietnam Medical Professionals

  2. Steve Prepas MD HOAG HOSPITAL Newport Beach 25 humanitarian trips 11 countries

  3. Quynh Kieu MD University of Saigon, class of 1975

  4. Eye & Vision Screening The Role Of The Pediatrician Project Vietnam Foundation Online Training Series Created by Sheryl Handler, M.D. Encino, CA Presented by Steven Prepas, M.D., CA

  5. Eye & Vision Screening • Purpose of eye & vision screening • To identify serious eye problems in children as early as possible • Then to refer them for comprehensive evaluation and treatment • Monitoring ocular health should begin at birth and continue throughout childhood

  6. Vision Screening: Vietnam Goal • Increase vision screening among younger preschool children

  7. Vision in Preschoolers Percentage • Vision Impairment 10 • Strabismus 4 • Amblyopia 3 - 4 • Total Strabismus/Amblyopia 5 - 7 • Significant Refractive Errors 5 - 7

  8. Why Do Eye & Vision Screening ? • 5 – 7 % of children have amblyopia/strabismus • 1 – 2 % of all children have unsuspected amblyopia/strabismus • Anisometropia (different refractive errors in each eye) and small angle strabismus are the leading causes of undetected amblyopia

  9. Eye & Vision Screening • Problems can present at any time during infancy & early childhood • Life-threatening diseases • Retinoblastoma (may be autosomal dominant) • Vision threatening conditions • ROP • Cataracts • Glaucoma • Amblyopia • Strabismus

  10. Other Childhood Ocular Conditions Percentage • Congenital cataract            0.06 • Congenital glaucoma         0.01 • Retinoblastoma                    0.005 • ROP (in infants < 750 g) 52.00

  11. Cataract

  12. Congenital Glaucoma

  13. Retinoblastoma

  14. Refractive Errors • Hyperopia – far-sightedness • Normal children are slightly far-sighted • Normal children accommodate (focus) it away • In children excessive far-sightedness causes strabismus +/or amblyopia in children • Myopia – near-sightedness • Blurriness at distance • Astigmatism • Blurriness at all distances

  15. Refractive Errors • Hyperopia – far-sightedness • The eyeball axis is short

  16. Refractive Errors • Myopia – near-sightedness • The eyeball is too long

  17. Childhood Refractive Errors • Visually significant refractive errors Percentage • Pre-school children 5 – 7 • 10 year olds 10 – 12 • 18 year olds 25 – 30  The increase is due to the development of myopia (near-sightedness)

  18. Eyeglasses • Optical correction should be considered to: • Prevent amblyopia • Treat amblyopia • Treat strabismus • Improve visual acuity • Improve visual discomfort

  19. Strabismus • Strabismus • Ocular misalignment • Esotropia • Inwardly deviating eyes - “crossed eyes” • Exotropia • Outwardly deviating eyes - “wall-eyed”

  20. Esotropia

  21. Esotropia Exotropia

  22. Amblyopia • Develops in critical period • Birth to 7 years • Young children need to learn how to see • Any cause that interferes with learning how to see can lead to amblyopia • Vision loss is lifelong – if not treated

  23. Amblyopia • Not a primary condition but secondary to: • Strabismus • Need for glasses • Structural abnormality decreasing vision • May be “invisible” • May be unilateral or bilateral

  24. Amblyopia • Early detection key to effective treatment • Best treated in early childhood • Recent data show that amblyopia may be somewhat treatable even into the teen age years

  25. Amblyopia Statistics • > 6 million Americans have amblyopia • Amblyopia is responsible for loss of vision in more people ≤ 45 years old than all other causes combined • The prevalence is 6 times greater in children with developmental delay • The prevalence is increased with family history

  26. Amblyopia Statistics • Screening for amblyopia reduces prevalence in the adult population by 50% • Patients with amblyopia are more likely to lose vision in the good eye from trauma -50% work related trauma • Amblyopia increases the lifetime risk of developing bilateral visual impairment from 10% to 18%

  27. Amblyopia Causes • 50 % • Strabismus (mainly esotropia) • 50% • Visual deprivation • Anisometropia - asymmetric refractive errors • High refractive errors • Ptosis, hemangioma, etc. • Structural ocular problems • Optic nerve, retinal, etc.

  28. Amblyopia Treatment • Glasses - provide a clear retinal image • Patching • Occlusion therapy of the good eye • Stimulates the weak eye • Prevents suppression by good eye

  29. Eye & Vision Screening by Pediatricians History & Examination • Family eye history & patient history • Important eye information should be included on new patient information form • Newborn & infancy eye examination • Structural abnormalities • Infancy & beyond eye examination • Add amblyopia & strabismus

  30. Eye & Vision Screening History • Prematurity • Medical problems – past & present • Family history • Retinoblastoma • Congenital cataract • Congenital glaucoma • Metabolic or genetic disease • Strabismus &/ or amblyopia • Glasses in family members < 5 years of age • Visual complaints • Eye complaints

  31. Methods for Eye & Vision Screening • Red reflex • Brückner red reflex test • Pupil examination • Corneal light reflection • External inspection • Fix and follow • Alternate occlusion – cover testing • Visual acuity (monocular)

  32. Eye Exam in Infants & Children by Pediatricians • Newborn – 6 months • Ocular History • Red Reflex • Pupil Exam • External inspection of the eyes & lids • Ocular motility assessment • Vision assessment • Referral Criteria • Infants with an abnormal red reflex • Infants who do not track well > 3 mo of age • Infants with strabismus > 3 mo of age • Infants with a FH of retinoblastoma, congenital cataract, childhood glaucoma in a parent or sibling

  33. Eye Exam in Infants & Children by Pediatricians • 6 months to 3 ½ years - add • Ophthalmoscopy • Photoscreening / autorefraction • Referral criteria • Infants with strabismus • Infants with chronic tearing or discharge • Photoscreening / autorefraction failures • Children with a FH of strabismus or amblyopia in a parent or sibling

  34. Eye Exam in Infants & Children by Pediatricians • ≥ 3 ½ years - add • Visual acuity testing (preferred) • Or photoscreening / autorefraction • Referral criteria • ≤ 20/50 (< 20/40) with either eye • ≥ 5 years – repeat screening every 1 – 2 yrs • Visual acuity testing (drop photoscreening) • Referral criteria • ≤ 20/40 (< 20/30) with either eye • Children not reading at grade level

  35. Red Reflex • The red reflex is a test to identify clarity of the ocular media • It is performed by looking at each eye with a direct ophthalmoscope from a distance of about 18 inches • Perform prior to discharge from the nursery and at all subsequent health supervision visits • Consider dilation with Cyclomydril

  36. Red Reflex • Questions to consider: • 1. Is there a red reflex from each eye? • 2. Are the red reflexes when viewed both individually and simultaneously equivalent in color, intensity, and clarity with no opacities or white spots (leukocoria)

  37. Brückner Red Reflex Test • Binocular red reflex test • Superior to the conventional red reflex test • Detects abnormalities of the red reflex • Assesses alignment • Assesses large and/or asymmetric refractive errors

  38. Brückner Red Reflex Test • The binocular red reflex test is performed in a dimly lit room with the examiner at a distance of about 18 inches from the child • The examiner overlaps both pupils simultaneously creating a binocular red reflex with the largest circular light of a direct ophthalmoscope set to focus on the ocular surface - usually at “0” • The examiner then assesses the quality of the “redness” seen within the child’s pupils.

  39. Brückner Red Reflex Test • Normal • The red reflex from each eye should be of the same color and brightness • Abnormalities • Asymmetric reflexes with one reflex being duller or a different color • A white reflex • A partially or totally obscured reflex • Crescents present in the reflex

  40. Brückner Test – Binocular Red Reflexes

  41. Amblyogenic Anisometropic Hyperopia (+6.50 od, 1.00 os)

  42. Left Congenital Cataract

  43. Yellow Reflex Due to Coat’s Disease, a Potentially Blinding Childhood Retinal Vascular Disorder, Left Eye

  44. Bilateral Retinoblastoma Causing Leukocoria

  45. Red Reflex Referrals • Refer all absent or abnormal red reflexes • Refer all abnormal Bruckner red reflexes • Refer if parents or observers describe a history suspicious for possible leukocoria • Infants in high-risk categories should have red reflex testing performed in the nursery and also be referred • Refer to a Pediatric Ophthalmologist

  46. Eye Screening Examination (cont) • Pupil examination • Irregular shape • Unequal size • Poor or unequal reaction • Corneal light reflection – asymmetric • Strabismus • Inspection • Ocular anomalies • Strabismus

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