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)

■IrrigateImmediately!
■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

■Cornealopacity
■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

■Rightaway!
■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

■Ismy 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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