Pediatric Vision Screening and Common Ocular Disorder for School Nurses James B. Ruben, MD Pediatric Ophthalmologist, Kaiser Permanente Clinical Professor, UC Davis

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Importance of Screening: •

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Ambyopia affect up to 5% of the population (over 10 million people) •

In first 4 decades of life, amblyopia responsible for more vision loss than all other ocular diseases combined!

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Treatable only in early childhood

Refractive errors can make learning difficult Eye problems can be a window to systemic Dz

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School Nurses are a child’ child’s last line of defense!

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How to screen: „

External examination „ „

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Ocular adnexae Alignment

Visual Acuity testing „

Anything that affects visual pathway will decrease vision „ Refractive

error, cornea problems, retinal problems, optic pathway and brain abnormalities

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VA testing tests the whole package 5

Basic Eye Anatomy

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Anatomy: Eye muscles

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Making an image in the brain „

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Clear optical media (cornea, ac, lens, vit) vit) Retina = film in camera Optic nerve = coaxial cable Visual cortex = computer All must function normally to have perfect vision 8

Refractive error

Myopia (Near-sightedness) „ „ „

Eyeball too long Can’ Can’t see far away Correct with specs, contact lens, or excimer laser (adults) (adults)

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Refractive error

Hyperopia (Far(Far-sightedness) „ „

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The eyeball is too short “Accommodation” Accommodation” will increase the effective lens power in the eye and focus at both near and far Crossing may Accommodation occur

Glasses

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Refractive error

Astigmatism „

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“Warpage” Warpage” of the cornea like a football Light rays in one axis are not focused the same as in opposite axis Corrected with glasses 11

Refractive error

ANISOMETROPIA „

When each eye focuses at a different point in space the brain can stop using the eye that is more out of focus Right eye hyperopic

Left eye emmetropic

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VA Testing- Technique „

Snellen letters, tumbling E, HOTV, Allen pictures, Lea symbols

Pre-Literate Charts

Literate Child 13

VA testing - technique „ „ „

Patch one eye Generally test at 10 feet Referral criteria (AAP, AAO, AAPOS): „

Age 33-5 years „

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fewer than 4 out of 6 objects correct on the 10/20 (aka (aka.. 20/40) line or >2 line difference between eyes

Age 6 or older „

2 line difference between eyes

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Checking visual acuity

The 3 common errors: „ Child

peaks „ Child memorizes „ Examiner fails to display full eye chart (crowding phenomenon)

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What Does 20/20 mean?

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What is 20/20 VA „

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A 20/20 E subtends 5 minutes of arc at a distance of 20 feet. 20/40 the same 5 minutes of arc at 40 ft.

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How Often are Spectacles Rx’ Rx’d to “Normal” Normal” Preschool Children? „

Donahue, JAAPOS 2004 „ Analyzed f/u data from a Tennessee photoscreening study of over 100,000 children „ Rate of unnecessary spectacle Rx

OD 35% Oph 12%

PedsOph 2% 18

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Causes of Amblyopia:

Strabismus

Exotropia

Esotropia

Hypertropia 19

Alignment Testing „

Must know where a child is looking to measure alignment „ „

Papillary light reflex Cover Testing

Crossed Eyed ??

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NO !!

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Light Reflex

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Pseudostrabismus

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True Strabismus

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Nystagmus „ „

“Tremor of the eye” eye” Common causes: „

Sensory causes: „ Decreased

vision in early infancy from any cause eg. eg. Cats, ON hypoplasia „ Retinal dz: dz: eg rodrod-cone degenerations „ Albinism „

Neurological causes: „ Alignment

control centers in brain 25

Pink Eye = Conjunctivitis: Diff Dx „ „

Allergic = itching Viral „ „

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Bacterial „ „

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Adeno herpetic Non GC GC

MasquaradeMasquarade- Iritis

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“Pink Eye” – Viral Conjunctivitis „ „ „ „

ViralViral- often accompanied by URI NOT affected by antibiotic drops Highly contagious Self limitedlimited- generally does not need to see ophthalmologist

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Chalazion Plugged meibomian gland Lid scrubs with baby shampoo „ Surgical drainage (last resort) „

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Treatment

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NotNot-contagious

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Warm soaks

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Ocular Trauma „

Corneal Abrasion Cornea like “plywood” plywood” „ Top veneer peels off „ Very painful „ TreatmentTreatmentantibiotic ointment „

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Ocular Trauma „

Evaluation: „ „

Check vision Inspect eye „ Is

cornea clear?

„ Conjunctiva? „ Pupil

round? chamber?

„ Anterior

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Ocular Trauma

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Hyphema Retinal detachment Ruptured globe

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Chemical Injury „

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Alkali worse than acid Irrigate, irrigate, irrigate, irrigate, irrigate

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Summary School nurses are a vital component of America’ America’s education AND health care system Screening as last line of defense for amblyopic and systemic disorders manifest in the eye „ Infection control „ Emergency care „

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