1. Paediatric Evaluation & Dispensing

[Audio] Orbit Eye Center for Pediatrics & Oculoplasty.

[Audio] Paediatric Evaluation & Dispensing. Paediatric Evaluation & Dispensing.

[Audio] Contents: Introduction History Visual acuity Refraction Dispensing Reference.

[Audio] Pediatric eye examinations are crucial for the early detection and treatment of vision problems that can affect a child's development. Regular eye check-ups ensure that children have the best possible vision for learning, playing, and overall development. Early identification of issues such as refractive errors, strabismus, and amblyopia can prevent long-term visual impairment and support proper visual development..

[Audio] Goals of Pediatric Eye Examination Detect Refractive Errors: Identify and correct conditions like myopia, hyperopia, and astigmatism. Assess Ocular Health: Screen for diseases or abnormalities affecting the eye's structure and function. Monitor Development: Ensure the visual system is developing correctly, tracking progress over time. Identify Strabismus and Amblyopia: Detect and manage misalignment of the eyes and lazy eye to prevent permanent vision loss. Evaluate Binocular Vision and Accommodative Function: Assess how well the eyes work together and their ability to focus on objects at different distances..

[Audio] PEDIATRIC EYE EXAMINATION HISTORY. PEDIATRIC EYE EXAMINATION HISTORY.

[Audio] Taking a detailed history is fundamental to pediatric eye care. It provides essential context for the current examination and guides the clinician in identifying potential issues. The history helps in: Identifying risk factors for eye diseases and refractive errors. Understanding the child's visual environment and habits. Gauging the impact of any visual complaints on daily activities. Tailoring the examination and treatment plan to the child's specific needs..

[Audio] Key Aspects of Pediatric Eye Examination History Birth History: Prematurity, birth weight, complications during delivery. Developmental Milestones: Age-appropriate visual and motor skills. Medical History: Chronic illnesses, medications, previous eye problems. Family History: Hereditary eye diseases like myopia, glaucoma, strabismus. Behavioral Observations: Eye rubbing, squinting, head tilting, or any signs of visual discomfort. Visual Complaints: Blurred vision, double vision, headaches, difficulty reading or seeing the board at school..

[Audio] PEDRIATRIC VISUAL ACUITY TESTING. PEDRIATRIC VISUAL ACUITY TESTING.

[Audio] Evaluating vision in children is crucial as early detection and treatment of vision problems can significantly impact their development and quality of life. The tools and techniques for assessing vision in children differ from those used in adults, as they must be adapted to the child's level of cognitive and visual development. Understanding normal visual developmental milestones is essential before assessing visual acuity (VA) in children..

[Audio] Visual acuity is the “Ability to visualize two objects as separate or the resolving power of the eye. It is defined as the smallest object that can be recognized at a particular distance.” In general, VA assessment is based on: Detection VA Resolution VA Recognition VA.

[Audio] Visual Development in Infants and Children Children’s & adult's vision evaluation differs in terms of tools and techniques (Non-verbal vs Verbal) Infants have lesser vision than normal adults & it improves rapidly in the 1st year after birth Visual ability of a child depends on the visual and cognitive development Before assessing VA of a child, one should be aware of normal Visual Developmental Milestones..

[Audio] According to AAO and the AAPOS AGE VISUAL MILESTONES VA 29 weeks POG (Period of Gestation) Pupillary reactions - Soon after Birth Blink reflex to light 6/120 (20/400) 2 week Small saccade develops, follows horizontal moving object - 2 MONTH Fixation well developed, Bifoveal fixation, - 3 MONTH Reaches out for object - 4 MONTHS Sensory fusion and accommodation begins to develop, watches own hands 6/60 (20/200) 5 months Menace reflex-blink reflex to visual threat -.

[Audio] AGE VISUAL MILESTONES VA 6 months Accommodation & Fusional Vergence well developed Stereopsis begins to develop 6/36 (20/120) 9 months Visual differentiation of objects 6/24 (20/80) 2 YEARS Picture matching 6/6 (20/20) 3 YEARS Picture or letter matching - 5 YEARS Stereopsis well developed -.

[Audio] Vision Tests in Infants CSM method LEA GRATING Teller Acuity Cards Visual Evoked Potential Optokinetic nystagmus Catford Drum test.

[Audio] 1. CSM METHOD (CENTRAL STEADY MAINTENANCE) Done with one eye fixating on an accommodative target held at 40cm Central: The infant fixates on a penlight. The examiner observes the corneal light reflex in both eyes. Normally reflected light from cornea in near the centre of cornea and it should be positioned symmetrically in both eyes. Steady: Tested with a small target (e.g., thumb-sized toy) coupled with light. The target is moved slowly in front of the child. Absence of nystagmus or oscillation indicates steady fixation. Maintained: The ability to keep the eye fixed when either eye is covered..

[Audio] 2.LEA GRATING It is based on preferentional looking. Two paddles are shown to the patient, one blank and another with stripes on it. Natural tendency of children to turn their head or eyes towards a pattern rather than a uniform (homogenous) field The width of these stripes progressively narrows. Children with better vision are able to see finer grating and will turn towards it..

[Audio] 3.TELLER ACUITY CARDS Modified form of Preferential Looking Test Simpler &rapid testing - Contains 17 cards Thickness of the stripes goes on decreasing Patients' fixation is noted by examiner through a peep hole Visual acuity from 6/60 to 6/6 (20/200 to 20/20) is recorded.

[Audio] 4. VISUAL EVOKED POTENTIAL Visual acuity = the ability to see fine detail and patterns A 'visual evoked response' (VER) or 'visual potential test is a record of the electrical activity in the brain as a response to stimulation of the retina. These signals are recorded with electrodes lightly attached to the scalp at the back of the head while the child watches patterns on a computer screen. measures the response of the brain to alternating black and white stripes or checks..

[Audio] Designed to find the finest black and white stripes that reliably produce a response Abnormal VEP may indicate a problem with the visual information reaching the cortex VEP is useful in the determination of problems such as amblyopia, cortical blindness, and visual impairment.

[Audio] 5.OPTO KINETIC NYSTAGMUS Striped patterns are presented on a video screen, OKN drum, or rotating drum. The patterns move in one direction in front of the patient. If the pattern is visible, the patient's eyeswill exhibit "railroad" nystagmus movements as they follow the stripes. The examiner determines the finest grating motion that elicits the nystagmus response..

[Audio] 6.CATFORD DRUM TEST Detection acuity test. The child observes an oscillating drum with black dots of varying sizes, ranging from 0.5 to 15 mm in diameter. These dot sizes represent vision between 6/60 and 6/6 (Snellen). The drum rotates at a distance of 60 cm from the child evokes pendular eye movements. The smallest dot that elicits pendular eye movements (not OKN) indicates the level of visual acuity. This test is considered unreliable as it tends to overestimate vision..

[Audio] VISION TEST IN 1-2 YEARS WORTH'S IVORY BALL TEST BOECK CANDY TEST STYCAR.

[Audio] 1. WORTH'S IVORY BALL TEST: Ivory balls of varying sizes, from 0.5 to 2.5 inches in diameter, are used. The balls are rolled on the floor in front of the child. The child is asked to retrieve each ball. Acuity is estimated based on the smallest size of the ball retrieved by the child at the test distance. 2. BOECK CANDY TEST • Child picks up only those candy beads which he can see easily • Beads of different sizes are shown to child and is expected to pick them up • This gives approximate estimation of visual acuity.

[Audio] 3.SCREENING TEST FOR YOUNG CHILDREN AND RETARDS [STYCAR] Based on Pursuit Eye movements Ten Balls rolled across a well illuminating contrasting floor 3m away from child Pursuit Eye movements indicate that they are seen.

[Audio] VISION TEST IN 2-3 YEARS CARDIFF ACUITY TEST MINIATURE TOY TEST COIN TEST LEA SYMBOLS.

[Audio] 1.CARDIFF ACUITY TEST Principle: vanishing optotype Target -pictures, of the same overall size, drawn in decreasing widths of white space Acuity is determined by the narrowest white band for which the target is visible to the child Child naturally prefers to look at a target figure rather than the blank end of the stimulus..

[Audio] 2.MINIATURE TOY TEST The child is shown a miniature toy. The toy is presented from a distance of 20 feet. The child is asked to name the toy or pick its pair from an assortment. 3.COIN TEST The child is asked to identify the two faces of coins of different sizes held at different distances..

[Audio] 4.LEA SYMBOL TEST The test consist of four optotypes which are apple, house, square and circle Based on Log Mar progression Can be used at 3 or 1.5 meters and near at 16 inch. Recorded in log units, Which can be converted to Snellen fraction. They are recognized easily by kids. It is arranged in combination of five symbols per line. In this test the child sees symbols at distance chart and matches symbol of different size presented on it to similar symbol on key card.

[Audio] VISION TEST IN 3-5 YEARS ALLEN'S PICTURE TEST SHERIDAN LETTER TEST LIPPMAN'S HOTV TEST.

[Audio] 1.ALLEN'S PICTURE CARDS It is recorded same as Snellen's Acuity test Instead of letters child identifies picture at a distance of 6m..

[Audio] 2.SHERIDAN LETTER TEST The child is handed a card with the letters "HOTV". The child is asked to match these letters to those on the chart. Snellen's equivalent of 6/60 to 6/6 (20/200 to 20/20) can be estimated using this method..

[Audio] 3.LIPPMANS HOTV TEST Simpler version of Sheridan's test using only 4 letters HOTV. Test distance 3 meter.

[Audio] VISION TEST IN 5-6 YEARS AND ABOVE SNELLEN’S VISUAL ACUITY CHART LOG MAR VISUAL ACUITY CHARTS TUMBLING E CHART LANDOLT BROKEN RING CHART.

[Audio] 1.SNELLENS VISUAL ACUITY TEST Used to test distant central visual acuity. Consists of a series of black capital letters on a white board. Letters are arranged in lines, each progressively diminishing in size. The lines comprising the letters have a breadth that subtends an angle of 1 minute at the nodal point. Each letter fits in a square with sides five times the breadth of the constituent lines. At a given distance, each letter subtends an angle of 5 minutes at the nodal point of the eye. The top line should be read clearly at a distance of 60 meters. Subsequent lines should be read from distances of 36, 24, 18, 12, 9, 6, 5, and 3 meters..

[Audio] 2.LOGMAR VISUAL ACUITY CHARTS Log MAR stands for "Logarithm of the Minimum Angle of Resolution.“ Based on Minimum Angle of Resolution The Log MAR chart consists of rows of letters, each line having an equal number of letters . Have regular progression in the size and spacing of the letters from one line to next It is typically used at a distance of 4 meters. It is designed to provide a more precise measurement of visual acuity compared to other charts like the Snellen chart. This makes it particularly useful in research settings..

[Audio] Based on Minimum Separable distance Task is to identify the direction in which the limb of E points Identification of the last line gives visual acuity 3. TUMBLING E TEST.

[Audio] 4.LANDOLT'S BROKEN RING CHART Most Commonly used Based on Minimum Separable distance. The rings are constructed on the same basis as that of Snellen's Child is instructed to indicate by the motion of the hand at which point each one is broken.

[Audio] REFRACTION. REFRACTION. [image] Orbit Eye Center for Pediatrics & Oculoplasty.

[Audio] Types of Pediatric Refraction Objective refraction Keratometry Ophthalmoscopy Retinoscopy Autorefraction Photorefraction Subjective refraction.

[Audio] Retinoscopy: The purpose of retinoscopy is to obtain an objective measurement of patient's refractive state. Fixation target for the patient 1. For near retinoscopy: depends on the type of retinoscopy done For 2.Dynamic retinoscopy: retinoscope head 3.For static retinoscopy: 20/200 or 6/60 in Snellen chart. Types/Techniques of Retinoscopy 1. Near Retinoscopy 2. Dynamic Retinoscopy 3. Static Retinoscopy > Dry Retinoscopy > We t Retinoscopy.

[Audio] 1.MOHINDRA (NEAR RETINOSCOPY) Near retinoscopy by Mahindra in 1977. For use in determining the refractive state of infants and children Principle: The stimulus or fixation is the dimmed light source of the retinoscope in a darkened room which provide ineffective or neutral accommodative stimulus. The retinoscope is held at a distance of 50 cm with hand-held trial lenses..

[Audio] 2.DYNAMIC RETINOSCOPY Accommodation is active No working distance power is added or subtracted from the finding Goal is to determine accommodative Response Also helps to determine the most appropriate near prescription with testing conditions Types of dynamic retinoscopy Frequently used in clinical practice are: Monocular Estimation Method (MEM) Nott retinoscopy Bell retinoscopy.

[Audio] 3.STATIC RETINOSCOPY Retinoscopy performed when the patient is asked to fixate the distance target ,with the accommodation relax Dry retinoscopy - without cycloplegic Wet retinoscopy - with cycloplegic retinoscopy performed.

[Audio] CYCLOPLEGIC REFRACTION It is the procedure to objectively determine the refractive status of the eye when the accommodative action of the eye is totally paralyzed. Purpose of cycloplegic refraction: Determination of total refractive error during temporary paralysis of ciliary muscles which doesn't manifest on subjective non-cycloplegic refraction..

[Audio] Mechanism of Action Releases acetylcholine from post ganglionic fibres Parasympathetic system Blocks the muscarine receptors of ciliary body Ciliary body is paralyzed Loss of accommodation Parasympathetic supplies sphincter pupillary muscle Doesn't work Pupil dilates.

[Audio] Indications Young patients who have symptoms but not significant refractive error Inconsistent endpoint of refraction Pseudo myopia Latent hyperopia Young children Strabismus.

[Audio] ADDITIONAL INDICATIONS:- Every nonverbal and non communicative children Patient with high heterophoria Accommodative esotropia, Accommodative asthenopia Poor reliability b/w dry retinoscopy objective finding with subjective finding..

[Audio] DISPENSING. DISPENSING. [image] Orbit Eye Center for Pediatrics & Oculoplasty.

[Audio] Glasses are the 1st line of treatment. Choosing a correct sized optical frame is critical for optimal centration of lenses. Ideal criteria for pediatric frame selection:- 1. The frame must fit correctly anatomically. 2. Pupils and lenses are correctly centered. 3. The frame should be comfortable and durable. 4. Frame must not hamper the natural development of the nose. 5.The frame must be aesthetically acceptable..

[Audio] TECHNICAL CONSIDERATIONS Young children do not have a developed nose. Characteristics of a good child’s frame include: 1.A lower crest: The crest is the dotted line. 2.Larger frontal angle: The frontal angle, sometimes known as, the “nasal” angle is the slope shown by the dotted line. 3.Larger splay: The splay can be seen from above and is shown by the dotted line. 4.Flatter pantoscopic tilt: the degree to which the side of the frame is tilted with respect to the lens is flatter in a child’s frame.

[Audio] FRAME LENGTH (FRAME FRONT/FRAME WIDTH) Measured from the left end piece to the right end piece in millimeters. Avoid too wide frames to prevent frequent falling or loosening. Avoid too small frames to prevent discomfort and skin marks. Smaller frames provide less peripheral vision distortion, beneficial for high prescriptions. FRAME HEIGHT Measured from the top to the bottom of the lens aperture. Ensure appropriate lens height for children’s higher cheek positions. Correct eye size centers lenses over pupils, minimizing distortion. Proper frame height is essential for multifocal lenses to position different zones correctly..

[Audio] NASAL BRIDGE Distance between the right and left lenses. Proper fit prevents discomfort, skin irritation, and slippage on underdeveloped noses. TEMPLE AND JOINTS Length of the arms that fit over the ears. Proper length ensures secure fit without pressure points or discomfort VERTEX DISTANCE Distance from the cornea to the back side of a lens. Altering vertex distance changes the lens's effective power. FACE FORM ANGLE Children’s faces are generally rounder, and the frame should conform to the shape of their face. Proper angle ensures a wide field of view and stability during activities..

[Audio] LENSES The ideal lens should be: Impact resistant Light and comfortable Relatively thin Relatively durable.

[Audio] References American Academy of Ophthalmology. (n.d.). Visual Acuity Assessment in Children. EyeWiki. Retrieved from https://eyewiki.aao.org Khurana, A. K. (2022). Theory and Practice of Optics and Refraction (5th ed.). New Delhi: Elsevier India. Brooks, C. W., & Borish, I. M. (2006). System for Ophthalmic Dispensing (3rd ed.). St. Louis: Butterworth-Heinemann. Harley, R. D., & Nelson, L. B. (2013). Harley's Pediatric Ophthalmology (6th ed.). Philadelphia: Lippincott Williams & Wilkins. American Academy of Pediatrics. (2014). Pediatric Ophthalmology for Primary Care (4th ed.). Itasca, IL: AAP Publishing..