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Dwight Parker, MD PGY-3

Pediatric
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Ophthalmology
Pearls
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If you ask a group of pediatricians what to


do when “my child’s eye is…”
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Don’t think, just refer

 Most of my experience in clinic is using the automated


Welch Allyn Spot screener

 Don’t forget all the developmental milestones that are


also excellent indicators for normal visual development

 What’s important? Eye vital signs


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Eye Vitals
 Visual acuity - Have to check monocular vision. NO LIGHT
getting to the other eye (face-palm).
 For young patients: Check light in dim room, then light in
light room, then following your face, then an exciting toy as
last resort. Think fix and follow.

 Visual fields - Nose to nose.

 Pupils: Symmetric? Reactive as expected? Odd size? Odd


shape?

 Motility: Can hold infant head and exploit dolls-eye reflex if


needed

 Pressure. Don’t be afraid to even just gently palpate the globes


and try to see if they are symmetric any time you are
considering sending somebody to the ED. When not to: If you
are concerned they have a ruptured globe.
 Technique:
 z Ophthalmoscope, dark room, 18 inches away, projected into
Direct
both eyes at same time
 Light  clear media of patient’s eye  reflects off retina  back out
through clear media of patient’s eye  aperture of ophthalmoscope
 examiner’s eye

 Variation in normal red reflex between different racial/ethnic groups with


different levels of pigmentation

 Causes of an Abnormal / Asymmetric Red Reflex:


 Abnormalities in tear film (e.g. mucous, foreign bodies)
 Corneal opacities
 Aqueous opacities
 Abnormal pupil aperture
 Cataracts
 Vitreous opacities
 Retinal abnormalities (e.g. tumors, chorioretinal colobomas,
detached retina from ROP)
 Unequal or High refractive errors
 Strabismus Red Reflex
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NORMAL
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UNEQUAL
REFRACTION
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STRABISMUS
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NO REFLEX
CATARACT
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FOREIGN BODY
ABRASION
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Strabismus
z Light reflex
 Hirschberg Test = corneal light reflex
 Hold a muscle light to elicit corneal light reflex simultaneously
on both eyes
 Assess the position of the light reflex in relation to the pupil of
each eye
 Reflex is more nasal  exotropia
 Reflex is more temporal  esotropia
 1 mm of displacement = 15PD of tropia
 Orthotropic: no misalignment!

 Krimsky Test = corneal light reflex with prisms


 Loose prisms are usually better for younger kids
 Hold the prism over the deviated eye, pointing towards the
deviation
 Increment the prism power as necessary
to center the corneal light reflex
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PEARLS
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Pearls
Bruchner test: Easy way to pick up on refractive error in the young child (hyperopia, myopia, or anisometropia
if asymmetric)

 Send all hyphemas for same day evaluation with ophtho (or ED if ophtho clinic not feasible). Don’t be lured by
an otherwise normal eye exam

 Your direct ophthalmoscope is your best friend... NOT. Think about all the information about the visual system
you can get from watching a patient and asking them to do some simple tasks (or asking parents what they do
at home).

 Don’t get intimidated by the fundoscopic exam

 Remember your aperture and optic disc orientation before you move in. Large aperture for large pupil, small
aperture for small pupil

 Optic disc 15 degrees towards nose when you are oriented temporally and at the correct height

 When checking visual acuity you MUST have one eye completely occluded without any light reaching it

 OK to use sounds when checking EOMs but soundless for acuity (kids are like bats – they will cheat and try
and triangulate position with sound)

 Every parent worried about their cross-eyed kid has photos to prove it (or make you look even smarter when
you show them why it’s pseudostrabismus)

 Not every tearing newborn eye is lacrimal duct stenosis – don’t miss a case of congenital glaucoma (if they
have huge pupils/large corneal diameters think twice)
INFERIOR CRESCENTS

MORE PEARLS
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More pearls
 Remember that the painful eye differential is grouped in 3 categories:
 Surface pathology (pain dissipates with proparacaine)
 Inflammation (slit lamp)
 Pressure

 Photophobia = intraocular inflammation

 Pain with eye movement and decreased vision: optic neuritis

 Sudden painless vision loss: Vascular/retina (sometimes neuritis)

 Transient painless vision loss: TIA/stroke workup

 Relative afferent pupillary defect: optic nerve disease

 Flashes and floaters in a myope such as myself: Retinal detachment


EVEN
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 Refer every baby with strabismus persisting beyond 4 months


(even if intermittent). In reality if it is happening less than half the
time during the day ophtho will likely monitor with serial exams
but it often gets worse

 4 yo seeing 20/40 is fine. Should be 20/20 by age 5-6.

 Don’t touch a ruptured globe. Diagnose it with Seidel test

 3 main categories of amblyopia etiology

 Deprivation (the worst and hardest to correct)

 Strabismus (often easily corrected but may require multiple


surgeries)

 Refractive (easily corrected)

 OD = Oculus dextrus, OS = Oculus sinister, OU = Oculus


uterque

 Ophthobook.com is a great free resource by Dr. Tim Root.

 www.morancore.utah.edu is still being developed but has lots of


outlines/literature/videos to get you started

 https://www.aao.org/interactive-tool/strabismus-simulator is great
(but challenging) in trying to figure out strabismus

 Wear glasses!