Peds Lab Final

  1. what happens if development is delayed?
    vision maybe affected, and if vision if reduced, development may be affected

    Development and vision go hand in hand
  2. 5 areas MUST included in Peds exam
    • 1. Acuity
    • 2. Binocularity
    • 3. Refractive Error
    • 4. Ocular Heath (internal & external)
    • 5. Development
  3. Infant VA Exams
    • Fixation and Follow
    • Teller Acuity Cards
    • Face Dot
    • OKN Drum
    • VEP
  4. Fixation and Follow
    • just estimate VA,
    • cover one eye with mothers thumb,
    • pick smallest target and see if patient follows

    Note: if the child gets overly distressed over occlusion -> possible amblyopia
  5. Teller Acuity Cards
    • Image Upload 1
    • (infant 38cm / toddler 55cm / 5+ 84cm)
    • forced choice preferential looking;
    • asses grating acuity by presenting child with high constrast grating of varying SF along with a blank card
  6. Face Dot
    • Image Upload 2
    • (40cm)
    • forced choice preferential looking;
    • preverbal or nonverbal children;
    • contrast sensitivity;
    • eyes follow the paddle with higher contrast
  7. OKN drum
    • 2m
    • spin temporapl to nasal first
    • +response implies finger counting @3-5ft
  8. Visual Evolked Potentials
    • measures the summed occipital cortical response to a pattern stimulus
    • good assessment of macular function
  9. Infant Binocularity Tests
    • Vertical Prism Test
    • Hirschberg
    • Krimsky
    • UCT and ACT
    • Bruckner's
    • NPC
    • EOMs
    • 4BO test
  10. Vertical Prism Test
    • can maintain fixation? Both eyes move when introduce prism?
    • follows Herring's Law of Equal Innervation
  11. Hirscheberg
    • 50cm
    • alignment of purkinje images.
    • normal reflex is +0.5mm nasal
    • nasal = +
    • temporal = -
    • 1mm = 22pd or 15pd
  12. Krimsky
    • finding the amount of prism that makes the light reflex in the deviating eye appear like the light reflex in the fixating eye
    • nasal = exo
    • temporal = eso
  13. Unilateral and Alternating Cover Test
    if the child needs to blink after the CT, and they take a while = poor binocularity
  14. Bruckner's
    • test for equally bright corneal light reflex
    • Bruckner's and Hirshberg done at the same time
    • if the eye is brigher (whiter) = deviated eye
    • red eye = fixating eye
    • you can tell if they are amblyopic or strab
    • the longer it takes to p ick up fixation = poor bino
  15. NPC
    • target can be wolff wand @ harmon distance
    • notice if there is an eye turn or if can maintain OU fixation till nose
    • should be 2-3inches from note at 3-4 months old
  16. EOMs
    • colorful and birght target
    • note how well cross midline
    • if strab, then have jerkyness when moving past midline
  17. 4BO Test
    • infants 4-6 months or older only;
    • detect foveal suppression;
    • note if there is or isn’t a movement to refixate after introduce prism, if no movement then suppressing
    • and didn’t notice fusion was broken by prism
  18. Infant Ocular Health Tests
    • Shadow Test
    • Burton Lamp
    • MIO
  19. Shadow Test
    • use 20D lens and transilluminator
    • check to see if angle is open. if open, should be able to see halo on the other side
  20. Burton Lamp
    • Image Upload 3
    • +5D mag that allows view of each eye at same time, and ant. seg eval
  21. MIO
    • direct view, erect, not reservesed/flipped
    • 5x mag, 20 deg field of view
  22. Infant Refractive Error Tests
    • Mohindra
    • Cardiff Cards
  23. Mohindra
    • dark, at 50cm
    • gives estimate of distance VA
    • subtract 1.25D from sphere finding
  24. Cardiff Cards
    • Image Upload 4
    • at 1m
    • forced-choice preferential looking test- places targets vertically bc easier for doctor to detect vertical movement
  25. Toddler VA Tests
    • Teller
    • LEA symbols D and N
    • Broken Wheel
    • HOTV test
    • Allen Pictures
    • Tumbling E
    • Visibility Acuity
  26. LEA symbols
    • Image Upload 5
    • at 10ft
    • good for minimal language skills; naming shapes; matching puzzle
  27. Broken Wheel
    • Image Upload 6
    • at 10ft
    • hold cards 3ft apart
    • ask which “O” on the car has the broken wheel and looks more like an incomplete “C”
  28. HOTV test
    • Image Upload 7
    • (3+ old at 10ft) ask child if the letter is H, O, T, or V
  29. Allen Pictures
    • Image Upload 8
    • 2 or older
    • some language development
    • ask child what the pictures is of
  30. Tumbling E
    Image Upload 9

    • at 10 ft
    • some language development
    • ask which direction E is pointing
  31. Toddler Binocularity Test
    • Stereo Smile
    • Random Dot E
    • Lang
    • Touch Point
    • Keystone Basic Bino Test
  32. Stereo Smile
    • Image Upload 10
    • (PASS test- Preschool Assessment of Stereopsis with a Smile)
    • at 40cm
    • require polaroid glasses
    • global stereopsis;
    • ask child to point at smiley face;
    • have 720secarc if successful
  33. Random Dot E
    • 40cm
    • requires Polaroid glasses;
    • global stereopsis;
    • ask which one contains the E
  34. Lang
    • Image Upload 11
    • to illicit a bifoveal response without polaroid glasses

    • random dot stereograms;
    • ask patient to point to each picture identified
  35. Ocular Motility Pursuit/Saccades
    • For Toddlers
    • (harmon distance) use wolfwands;
    • assess if can cross midline/assess
    • FROM/asses under or overshoot
  36. Confrontational Fields
    • For Toddlers
    • use 2 toys and bring in from periphery and note when child first notices, or bring out from fixation and note when child turns head
  37. Toddler Development
    3 figure board
  38. 3 Figure Board
    • just observe what patient is doing (hand
    • used, where looks, effect of reversing board)
  39. Toddler Ret Tests
    • Just Look
    • MEM
    • Book
    • Bell
    • Near Ret
    • Stress Point

    For all of these: notice the change in retinal reflex (optics, attention, neural signal); all dynamic ret helps doctor decide if Rx for patient is adequate or not
  40. Just Look Ret
    not about finding a number, but just see how behavior and attention affects change in reflex
  41. MEM Ret
    • looks for lag
    • tells you if the prescription you want to give them is the best for them
    • dip the lens
    • done in bright light at harmon distance
    • use MEM cards and ask child to read words aloud one at a time and estimate amoint of with or against motion seen neutralize with lenses
    • [know: high lag over +0.75 means give more plus in Rx]
  42. Book Ret
    • not looking for a number
    • looking for quality of the reflex (with the prescription you want to give them)
    • assess attention and comprehension;
    • based on fact that ret changes based on level of involvement child has with verbal stimulus;
    • Goodnight Moon
    • a. Easy reading: neutral
    • b. Instructional level: slight with to slight against as interest peaks
    • c. Frusteration level: lots of against but shift to with when “digging for info”
    • d. No rapport level: dull red and considerable with
  43. Bell Ret
    • use moving target;
    • info on 1)accommodative lab, 2)flexibility, 3)eye
    • fixation ability, 4)gross NPC;
    • first take yardstick and place retinascope at 20inch mark;
    • move WolfWand toward patient until the “with” motion changes to “against” and then note when it shifts back
    • the diopter difference between with and against motion = lag
  44. Preschool VA test
    same as toddler or use Snellen
  45. Preschool Binocularity Test
    • Worth 4-dot
    • Randot or Stereo fly/butterfly
    • TNO stereo Test
    • Frisby Stereo Test
  46. Worth 4 Dot
    • (40cm & 3 feet with RG-filters) hold up flashlight, report #dots seen [said would be on practical]
    • red dots to left of 3 green = exo/crossed
    • green dots to left of 2 red = eso/uncrossed
  47. Randot or Stereo Fly/Butterfly
    • (40cm with Polaroid filters) global stereopsis; L, R, or M circlepopping out?;
    • do “animal section” if do poorly on test
    • Fly = local stereo
    • Global stereo = have to have bifoveation
  48. TNO stereo test
    • Image Upload 12
    • 40cm with RG glasses
  49. Frisby Stereo Test
    • Image Upload 13
    • 40cm without glasses
    • distance will determine the steo acuity
  50. Preschool Refractive Error
    • distance ret
    • near ret - 20inches when suspect latent hyperopia
    • MEM
    • Book ret
    • Bell Ret
    • Mohindra - less reliable after infant and toddler age
  51. Preschool Ocular Health
  52. Preschool Development Tests
    • Areas of visual perfection/development evaluation
    • Gross motor
    • Visual spatial
    • Visual analysis
    • Visual motor integration
    • visual analysis testing via Visual Perceptual/Developmental Evaluation-Motor ->motor guiding vision ->vision guiding motor ->visualization

    Gross Motor skills lay the foundation for vision
  53. Gross Motor
    standing balance,chalkboard circles, alternate hopping, standing angels in the snow
  54. Visual Spatial
    • (observe how patient organizes their visual space)
    • 3&6-figure foam board, Incomplete Man, Sized blocks,
    • Key form board (important for visual discrimination; if child can discern small differences and distinguish letters “bdpq” from “mwnh”)
  55. Visual Analysis
    • Monroe Visual I - tell you how they analyze visual stuff
    • more than 50% of 5 year olds get 10 or more correct, by 6, 98% get 10 correct
  56. Visual Motor
    • Gesell Visual Copy Forms - the skills necessary to duplicate the copy forms has a direct relationship to the ability to reproduce numbers and letters of the laphabet. (“eye-hand coordination”; will draw “diagonals” if child ready for
    • school)
    • Grooved Pegboard - a lot like the key form board. (time dominant vs. non-dominant hand to assess “fine motor skills” & “visual attention”)
  57. Peek-A-Boo Series
    • know: screening vision test for Pre-schoolers done BEFORE exam to get idea of what to expect during exam
    • Cards put into Telebinocular
    • Evaluates via different cards: object identification, VA near/far, Phoria near/far, 1st or 2nd degree fusion, distance stereo, vertial phoria near/far
  58. Keystone Visual Skills Series
    • measurement of habitual responses and demands no conscious effor except that of a response of that patient is seeing
    • cards put in Telebinocular
    • Evaluates via diff cards: gross suppression/simultaneous
    • perception, hyperphoria/vertical imbalance, lateral phoria/posture/stability, binocular fusion/stereopsis,
    • color, usable vision & VA OU/OD/OS ->only other test besides vectogram that can measure monocular VA in
    • binocular situation
  59. School Age
    • Areas of visual perception/development evaluation->score sheets and evaluation sheets are provided for each test analysis
    • 1. Gross motor—standing balance, chalkboard
    • circles, alternate hopping, standing angels in the snow
    • 2. Visual spatial—Piaget RL awareness (laterality
    • [L->R on person] & directionality[L->R in space])
    • 3. Visual analysis—Monroe Visual III (efficiency of person evaluating and using visual info—have patient look at shapes, then hide them, ask patient to draw from memory, time)
    • 4. Visual motor integration (eye-hand coordination)—World sentence Copy Test (ask patient to copy sentence via written), Beery-Buktenica Developmental Test of Viual Motor Integration (ages 2-11 to 18-0; ask child to draw 27 items, but stop if get 3 in a row wrong)
Card Set
Peds Lab Final
Peds Lab Final