Transcript Eye and Vision Exams in the Outpatient Clinic

Eye and Vision Exams in the
Outpatient Clinic
Erika Beard-Irvine MD
LCDR MC (FS) USN
Objective
 AAP practice parameters for red reflex and
vision screening
 Techniques for red reflex and vision
screening
 Disease processes
 Referral criteria
Terminology
 Myopia
http://www.ophthobook.com/chapters/pediatrics
http://www.childrenshospital.org/az/Site1517/mainpageS1517P0.html
Terminology
 Myopia
 Hyperopia
http://www.childrenshospital.org/az/Site1517/mainpageS1517P0.html
Terminology
 Myopia
 Hyperopia
 Astigmatism
http://www.childrenshospital.org/az/Site1517/mainpageS1517P0.html
Terminology
 Myopia
 Hyperopia
 Astigmatism
 Amblyopia
 Anisometropia
http://www.ohioamblyoperegistry.com/
Red Reflex Examination
 Newborn examination
 All routine health supervision visits
http://www.bartsandthelondon.nhs.uk/forgps/checking_for_the_red_reflex_in_children.asp
http://seeweimer.com/eye-anatomy/
Technique
 Ophthalmoscope power to 0
 Lights off
 Simultaneously at 2-3 feet away
 Separately at 12-18 inches away
http://www.ophthobook.com/chapters/pediatrics
Leukocoria
http://www.daisyseyecancerfund.org/rb/eye/index.html
http://www.orphancancer.org/ORbIT/leukocoria.html
http://www.nature.com/onc/journal/v25/n38/fig_tab/1209622f1.html
Differential of Leukocoria
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 Congenital cataract •
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 ROP
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 PFV
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 Coloboma
 Retinoblastoma
Uveitis
Toxocariasis
Coats’ disease
Vitreous hemorrhage
Retinal dysplasia
Absent Red Reflex
http://www.peds.ufl.edu/peds2/research/debusk/pages/page7_61.html
Absent Red Reflex
http://www.bartsandthelondon.nhs.uk/forgps/checking_for_the_red_reflex_in_children.asp
Asymmetric Red Reflex
http://www.abcd-vision.org/vision-screening/red-reflex.html
Asymmetric Red Reflex
http://www.abcd-vision.org/vision-screening/bruckner.html
Asymmetric Red Reflex
Mills, MD. “The eye in childhood,” Am Fam Physician. 1999 Sep 1;60(3):907-916.
Eye Evaluation
 Ocular history
 Vision assessment
 External inspection of the eye and lids
 Ocular motility assessment
 Pupil examination
 Red reflex examination
 Attempt at opthalmoscopy (>3 yo)
Ocular History
 Does you child seem to see well?
 Does your child hold objects close to his/her face when
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trying to focus?
Do your child’s eyes seem to cross or drift?
Do your child’s eyes appear unusual?
Do your child’s eyelids droop or does 1 eyelid tend to
close?
Have your child’s eyes ever been injured?
Family history of eye disorders or early eyeglass wear.
Vision Assessment
 Fix and follow
 Visual acuity measurement (>3 yo)
 Photoscreening
Photoscreening
 Screening for amblyogenic factors:
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Strabismus
Media opacities
Significant refractive errors
 Evaluate photo of red reflex and pupillary light
reflex
 AAP says it could be helpful but recommends
more study
External Examination
 Tearing or discharge
 Corneal clouding
http://www.mps1disease.com/en/patients/about/signs-and-symptoms/corneal-clouding.aspx
External Examination
 Tearing or discharge
 Corneal clouding
 Ptosis
http://www.cosmeticeyesandface.com/Pediatrics.html
External Examination
 Tearing or discharge
 Corneal clouding
 Ptosis
 Iris abnormalities
http://www.glaucomaconsultantsnorthwest.com/glaucoma%20in%20children.html
http://www.med.umn.edu/ophthalmology/faculty/schimmenti/home.html
Ocular Motility
 Corneal reflex test
 Extra-ocular movements
 Cover-uncover test
 Random dot E stereo test
Corneal Light Reflex
http://www.wahajr.com/hajrvb/showthread.php?t=402925749&page=4
Mills, MD. “The eye in childhood,” Am Fam
Physician. 1999 Sep 1;60(3):907-916.
http://health.utah.gov/cshcn/HSVS/photo.html
Mills, MD. “The eye in childhood,” Am Fam
Physician. 1999 Sep 1;60(3):907-916.
Ocular Motility
 Corneal reflex test
 Extra-ocular movements
 Cover-uncover test
 Random dot E stereo test
Ocular Motility
 Corneal reflex test
 Extra-ocular movements
 Cover-uncover test
 Random dot E stereo test
Random Dot E
http://health.minnesota.gov/divs/fh/mch/webcourse/vision/mod7a.cfm
Pseudostrabismus
http://www.sarawakeyecare.com/Atlasofophthalmology/paediatric/paediatricophthalmologytpicture4.htm
Pupil Exam
http://www.atlasophthalmology.com/atlas/photo.jsf?node=5832&locale=en
Referral Criteria
 Leukocoria or absent red reflex
 Any abnormality on exam
 Persistent torticollis or head tilt
 FHx of retinoblastoma
 FHx corrective lenses in preschool or “lazy
eye”
 Parent concern