Ординатура / Офтальмология / Английские материалы / Pediatric Ophthalmology Current Thought and A Practical Guide_Wilson, Saunders, Trivedi_2008

16.Ferguson RE Jr, Vasconez HC (2005) Laser treatment of congenital nevi. J Craniofac Surg 16:908–914

17.Kwon JW, Jeoung JW, Kim TI, Lee JH, Wee WR (2006) Argon laser photoablation of conjunctival pigmented nevus. Am J Ophthalmol 141:383–386

18.Shields CL, Shields JA (2004) Tumors of the conjunctiva and cornea. Surv Ophthalmol 49:3–24

19.Kim TI, Yoon J, Choi J, Tchah H (2005) Flipped scleral flap surgery for reduction of ocular pigmentation in oculodermal melanosis. Cornea 24:482–485

20.Gomi CF, Robbins SL, Heichel CW, Gross RD, Granet DB (2005) Conjunctival diseases. In: Harley RD (ed) Pediatric ophthalmology, 5th edn. Lippincott Williams and Wilkins, Baltimore, pp 201–216

21.Watts P, Michaeli-Cohen A, Abdolell M, Rootman D (2002) Outcome of lamellar keratoplasty for limbal dermoids in children. J AAPOS 6:209–215

22.Shen YD, Chen WL, Wang IJ, Hou YC, Hu FR (2005) Full-thickness central corneal grafts in lamellar keratoscleroplasty to treat limbal dermoids. Ophthalmology 112:1955

23.Hanna D, Hatami A, Powell J, Marcoux D, Maari C, Savard P, Thibeault H, McCuaig C (2006) A prospective randomized trial comparing the efficacy and adverse effects of four recognized treatments of molluscum contagiosum in children. Pediatr Dermatol 23:574–579

24.Cunningham BB, Paller AS, Garzon M (1998) Inefficacy of oral cimetidine for nonatopic children with molluscum contagiosum. Pediatr Dermatol 15:71–72

25.Brown J, Janniger CK, Schwartz RA, Silverberg NB

(2006) Childhood molluscum contagiosum. Int J Dermatol 45:93–99

26.Toutous-Trellu L (2004) Treatment of cutaneous human papilloma virus, poxvirus and herpes simplex virus infections with topical cidofovir 1% in HIV positive patients. Ann Dermatol Venereol 131:445–449

27.Fransen L, Klauss V (1988) Neonatal ophthalmia in the developing world. Epidemiology, etiology, management and control. Int Ophthalmol 11:189–196

28.Yip TP, Chan WH, Yip KT, Que TL, Lee MM, Kwong

NS, Ho CK (2007) Incidence of neonatal chlamydial conjunctivitis and its association with nasopharyngeal colonisation in a Hong Kong hospital, assessed by polymerase chain reaction. Hong Kong Med J 13:22–26

29.Isenberg SJ, Apt L, Yoshimori R, Leake RD, Rich R (1994) Povidone-iodine for ophthalmia neonatorum prophylaxis. Am J Ophthalmol 118:701–706

30.Isenberg SJ, Apt L, Wood M (1995) A controlled trial of povidone-iodine as prophylaxis against ophthalmia neonatorum. N Engl J Med 332:562–566

31.Isenberg SJ, Apt L, Del Signore M, Gichuhi S, Berman NG (2003) A double application approach to ophthalmia neonatorum prophylaxis. Br J Ophthalmol 87:1449–1452

32.Richter R, Below H, Kadow I, Kramer A, Muller C, Fusch C (2006) Effect of topical 1.25% povidone-iodine eyedrops used for prophylaxis of ophthalmia neonatorum on renal iodine excretion and thyroid-stimulating hormone level. J Pediatr 148:401–403

33.Buznach N, Dagan R, Greenberg D (2005) Clinical and bacterial characteristics of acute bacterial conjunctivitis

in children in the antibiotic resistance era. Pediatr Infect Dis J 24:823–828

34.Høvding G (2007) Acute bacterial conjunctivitis. Acta

Ophthalmol Scand 29: [Epub ahead of print]

35.Gigliotti F (1995) Acute conjunctivitis. Pediatr Rev 16:203–207

36.Block SL, Hedrick J, Tyler R, Smith A, Findlay R, Keegan E, Stroman DW (2000) Increasing bacterial resistance in pediatric acute conjunctivitis (1997–1998). Antimicrob Agents Chemother 44:1650–1654

37.Weiss A (1994) Acute conjunctivitis in childhood. Curr Probl Pediatr 24:4–11

38.Mah F (2006) Bacterial conjunctivitis in pediatrics and primary care. Pediatr Clin North Am 53(suppl 1):7–10

39.Patel PB, Diaz MC, Bennett JE, Attia MW (2007) Clinical features of bacterial conjunctivitis in children. Acad Emerg Med 14:1–5

40.Rose P (2007) Management strategies for acute infective conjunctivitis in primary care: a systematic review. Expert Opin Pharmacother 8:1903–1921

41.Everitt H, Little P (2002) How do GPs diagnose and manage acute infective conjunctivitis? A GP survey. Fam Pract 19:658–660

42.Committee on Infectious Diseases (2006) The use of systemic fluoroquinolones. Pediatrics 118:1287–1292

43.Chalumeau M, Tonnelier S, D’Athis P, Tréluyer JM, Gendrel D, Bréart G, Pons G; Pediatric Fluoroquinolone

Safety Study Investigators (2003) Fluoroquinolone safety in pediatric patients: a prospective, multicenter, comparative cohort study in France. Pediatrics 111:e714–e719

44.Protzko E, Bowman L, Abelson M, Shapiro A; AzaSite

Clinical Study Group (2007) Phase 3 safety comparisons for 1.0% azithromycin in polymeric mucoadhesive eye drops versus 0.3% tobramycin eye drops for bacterial conjunctivitis. Invest Ophthalmol Vis Sci 48:3425–3429

45.Cochereau I, Meddeb-Ouertani A, Khairallah M, Amraoui A, Zaghloul K, Pop M, Delval L, Pouliquen P, Tandon R, Garg P, Goldschmidt P, Bourcier T (2007) 3-day treatment with azithromycin 1.5% eye drops versus 7-day treatment with tobramycin 0.3% for purulent bacterial conjunctivitis: multicentre, randomised and controlled trial in adults and children. Br J Ophthalmol 91:465–469

46.American Academy of Pediatrics (2003) Red Book: 2003 Report of the Committee on Infectious Diseases, 26th edn. American Academy of Pediatrics, Grove Village, IL, pp 141–142

47.Pring-Akerblom P, Adrian T (1994) Typeand group-spe- cific polymerase chain reaction for adenovirus detection.

Res Virol 145:25–35

48.Saitoh-Inagawa W, Oshima A, Aoki K, et al. (1996) Rapid diagnosis of adenoviral conjunctivitis by PCR and restriction fragment length polymorphism analysis. J Clin Microbiol 34:2113–2116

49.Morris DJ, Bailey AS, Cooper RJ, et al. (1995) Polymerase chain reaction for rapid detection of ocular adenovirus infection. J Med Virol 46:126–132

50.Elnifro EM, Cooper RJ, Klapper PE, et al. (2000) Multiplex polymerase chain reaction for diagnosis of viral and chlamydial keratoconjunctivitis. Invest Ophthalmol Vis Sci 41:1818–1822

51.Cooper RJ, Yeo AC, Bailey AS, Tullo AB (1999) Adenovirus polymerase chain reaction assay for rapid diagnosis of conjunctivitis. Invest Ophthalmol Vis Sci 40:90–95

52.Madhavan HN (1999) Laboratory investigations on viral and Chlamydia trachomatis infections of the eye:

Sankara Nethralaya experiences. Indian J Ophthalmol

47:241–246

53.Koidl C, Bozic M, Mossböck G, et al. (2005) Rapid diagnosis of adenoviral keratoconjunctivitis by a fully automated molecular assay. Ophthalmology 112:1521–1528

54.Sambursky R, Tauber S, Schirra F, Kozich K, Davidson R, Cohen EJ (2006) The RPS adeno detector for diagnosing adenoviral conjunctivitis. Ophthalmology 113:1758–1764

55.Phipatanakul W (2005) Allergic rhinoconjunctivitis: epidemiology. Immunol Allergy Clin North Am 25:263–281, vi

56.Finegold I, Granet DB, D’Arienzo PA, EpsteinAB (2007) Efficacy and response with olopatadine versus epinastine in ocular allergic symptoms: a post hoc analysis of data from a conjunctival allergen challenge study. Clin Ther 28:1630–1638

57.Van Gysel D, Govaere E, Verhamme K, Doli E, De Baets

F (2007) The influence of bedroom environment on sensitization and allergic symptoms in schoolchildren. J Investig Allergol Clin Immunol 17:227–235

58.Isolauri E, Huurre A, Salminen S, Impivaara O (2004)

The allergy epidemic extends beyond the past few decades. Clin Exp Allergy 34:1007–1010

59.Strachan DP (1989) Hay fever, hygiene, and household size. BMJ 299:1259–1260

60.Kemp A, Bjorksten B (2003) Immune deviation and the hygiene hypothesis: a review of the epidemiological evidence. Pediatr Allergy Immunol 14:74–80

61.Romagnani S (2004) The increased prevalence of allergy and the hygiene hypothesis: missing immune deviation, reduced immune suppression, or both? Immunology 112:352–363

62.Galatowicz G, Ajayi Y, Stern ME, Calder VL Ocular anti-allergic compounds selectively inhibit human mast cell cytokines in vitro and conjunctival cell infiltration in vivo. Clin Exp Allergy 37:1648–1656

63.Avunduk AM, Tekelioglu Y, Turk A, Akyol N (2005) Comparison of the effects of ketotifen fumarate 0.025% and olopatadine HCl 0.1% ophthalmic solutions in seasonal allergic conjunctivities: a 30-day, randomized, dou- ble-masked, artificial tear substitute-controlled trial. Clin

Ther 27:1392–1402

64.Berdy GJ, Spangler DL, Bensch G, Berdy SS, Brusatti RC

(2000) A comparison of the relative efficacy and clinical performance of olopatadine hydrochloride 0.1% ophthalmic solution and ketotifen fumarate 0.025% ophthalmic solution in the conjunctival antigen challenge model. Clin Ther 22:826–833

65.Yaylali V, Demirlenk I, Tatlipinar S, Ozbay D, Esme A, Yildirim C, Ozden S (2003) Comparative study of

0.1% olopatadine hydrochloride and 0.5% ketorolac tromethamine in the treatment of seasonal allergic conjunctivitis. Acta Ophthalmol Scand 81:378–382

66.Berdy GJ, Stoppel JO, Epstein AB (2002) Comparison of the clinical efficacy and tolerability of olopatadine hydrochloride 0.1% ophthalmic solution and loteprednol etabonate 0.2% ophthalmic suspension in the conjunctival allergen challenge model. Clin Ther 24:918–929

67.Butrus S, Greiner JV, Discepola M, Finegold I (2000)

Comparison of the clinical efficacy and comfort of olopatadine hydrochloride 0.1% ophthalmic solution and nedocromil sodium 2% ophthalmic solution in the human conjunctival allergen challenge model. Clin Ther 22:1462–1472

68.U.S. Food and Drug Administration (2007) New drug application (NDA) approved labels. Available at: http:// www.fda.gov/cder/foi/label/1999/21066lbl.pdf, http:// www.fda.gov/cder/foi/label/2004/021545lbl.pdf, http:// www.fda.gov/cder/foi/label/2000/21127lbl.pdf. Accessed December 21, 2007

69.Ilyas H, Slonim CB, Braswell GR, Favetta JR, Schulman M (2004) Long-term safety of loteprednol etabonate 0.2% in the treatment of seasonal and perennial allergic conjunctivitis. Eye Contact Lens 30:10–13

70.Libório AM, Nishiwaki-Dantas MC, Mimica LM, Dantas

PE, Lima AL (2005) [Conjunctival microbiota in patients with ocular allergy.] Arq Bras Oftalmol 68:824–827

71.Lapid-Gortzak R, Rosen S, Weitzman S, Lifshitz T (2002) Videokeratography findings in children with vernal keratoconjunctivitis versus those of healthy children. Ophthalmology 109:2018–2023

72.Dantas PE, Alves MR, Nishiwaki-Dantas MC (2005) Topographic corneal changes in patients with vernal keratoconjunctivitis. Arq Bras Oftalmol 68:593–598

73.Dada T, Konkal V, Tandon R, Singh R, Sihota R (2007) Corneal topographic response to intraocular pressure reduction in patients with vernal keratoconjunctivitis and steroid-induced glaucoma. Eye 21:158–163

74.Solomon A, Zamir E, Levartovsky S, Frucht-Pery J (2004) Surgical management of corneal plaques in vernal keratoconjunctivitis: a clinicopathologic study. Cornea 23:608–612

75.Cetinkaya A, Akova YA, Dursun D, Pelit A (2004) Topical cyclosporine in the management of shield ulcers. Cornea 23:194–200

76.Spadavecchia L, Fanelli P, Tesse R, Brunetti L, Cardinale

F, Bellizzi M, Rizzo G, Procoli U, Bellizzi G, Armenio L (2006) Efficacy of 1.25% and 1% topical cyclosporine in the treatment of severe vernal keratoconjunctivitis in childhood. Pediatr Allergy Immunol 17:527–532

30.2Services Provided by a Transdisciplinary

Team  . . . . . . . . . . . . . . .   462

30.2.1The Ophthalmologist’s Role . . . . . . . . . . . .   462

30.2.2Educational Services/Intervention  . . . .   462

30.2.3Early Intervention Services

(Newborn to Age 3)  . . . . . . . . .   463

30.2.4Preschool (3–5 Years)  . . . . . . . . .   463

30.2.5 School Age (Kindergarten to 12th Grade)  .   464

30.2.6Role of Schools for the Blind  . . . . . .   464

30.3Evaluation by the Ophthalmologist

as a Member of the Educational/

Rehabilitation Team  . . . . . . . . .   464

30.3.1Introduction and Overview  . . . . . . .   464

30.3.2Pediatric Functional Vision Assessment  . . .   465

30.3.3History Taking for the Visually Impaired

Child  . . . . . . . . . . . . . . .   465

30.3.6Refraction  . . . . . . . . . . . . .   467

30.3.9Motility/Binocular Vision  . . . . . . . . . . . . . .   468

30.3.10Visual Fields  . . . . . . . . . . . .   468

30.3.11Color Vision  . . . . . . . . . . . .   468

30.4.1Correction of Refractive Errors: A Key Part

Core Messages

•The goal of pediatric low vision services is to help each child achieve maximum potential, regardless

of diagnosis or disability.

•Visual impairment in the first years of life requires immediate attention, just as any other developmental delay.

•Children with visual impairment or who are blind have a right to education.

•Visual acuity does not equal visual functioning. Each aspect of the evaluation of a visually impaired child must take this into consideration.

30.1 Introduction

A child with a visual impairment is one who has impaired visual functioning even after treatment and/or standard refractive correction, but who uses, or is potentially able to use, vision for the planning or execution of a task [7]. Training as ophthalmologists in the clinical, acute care setting may not provide adequate preparation for the evaluations and recommendations that are needed in the educational/rehabilitation setting. Every child is a unique individual, with the adaptation for low vision or blindness unique for each.

In order for the child to receive the maximum benefit from educational and rehabilitation services, the ophthalmologist must learn how to partner effectively with the other members of the educational/rehabilitation team. Without the support, advocacy, and medical advice from the ophthalmologist, the team will not be able to properly individualize the services, interventions, and training to the unique needs of each visually impaired child.

30.2Services Provided

by a Transdisciplinary Team

30.2.1 The Ophthalmologist’s Role

The ophthalmologist is responsible for the initial ophthalmic diagnoses and for the prescribing of medical and surgical interventions for the infant/child with low vision or blindness. The ophthalmologist is also responsible for referring the child/family to appropriate intervention/educational services. Eye examination information needs to be communicated to the parents and the rehabilitation team by the ophthalmologist in a comprehensive and family-centered manner. The ophthalmic information combined with other pertinent medical information will enable the rehabilitation team plan and implement services that are specifically designed to meet the child’s individualized needs. The ophthalmologist should provide ocular and visual system related medical information for the team, but delegate the interventions to those who are professionals in the field of education and rehabilitation. This should be applied for each child, regardless of abilities. The child needs to have access to the entire (core) school curriculum, not only

for literacy (reading, writing, and communication), but also to include physical education, arts and music education, etc. The final aim is to increase independence and improve quality of life.

Expected information from the ophthalmologist in regards to the pediatric low vision evaluation is covered later in the chapter. However, in general terms, the following advice is offered so that the ophthalmologist can help set the stage for the rehabilitation program that will follow.

Be positive in your approach with the child and family, they will remember what you say to them for the rest of their lives. Allow the family and child time to ask and have questions answered.

The ophthalmologist is the expert of, and the best teacher of how the ocular pathology and visual system and neurological development affect the child’s use of vision. Encourage, as appropriate, the attendance of a teacher of students who are blind or visually impaired

(TVI; previously TVI was defined as teacher for visually impaired), classroom and special education teachers, paraprofessionals, or a therapist at examinations with parent and child. This facilitates communication among the team, and allows for quicker institution of recommendations. Write down the diagnoses and the recommended interventions, and anything else you feel important for the parents and the team, in clear and concise language. A form is helpful.

The more the ophthalmologist knows about the educational and rehabilitation services process, the better able he/she will be to provide useful medical information and help guide the parents and the team.

30.2.2Educational Services/Intervention

Educational services and interventions for the visually impaired child vary from state to state, and even from community to community. In some states a Functional Vision Assessment must be completed to determine eligibility. Although states are allowed to set some parameters about who is eligible, all states participating in part C of the Individuals with Disabilities Education Act (IDEA) must provide services to children who have an established disability [5].

The visually disabled child may have additional mul-

tiple disabilities which must be planned for when the individualized education and rehabilitation program is designed.

Family, educators, and therapists are all part of the educational team. This may also include community health nurses, social workers and case managers, occupational therapists to assist with feeding issues and fine motor development, physical therapists for mobility, TVIs, early childhood special education teachers, and orientation and mobility instructors.

Children who are visually impaired are often classified into four groups for educational purposes. They are: (1) the very young, (2) Braille readers, (3) children with low vision, and (4) children with additional disabilities [3].

30.2.3Early Intervention Services (Newborn to Age 3)

The group of children with additional disabilities is the fastest growing group of infants/toddlers with visual impairment. This is influenced by the high survival rate of very low birth weight and premature infants, as well as increased survival rates of infants and children with other types of brain injury. The latest statistics from Babies Count [1], the national registry for children with visual impairment, birth to 3 years, shows out of 2,155 children in the registry, 26% had cortical visual impairment (CVI) as the main reason for visual disability, and 18% had retinopathy of immaturity (ROP). In infants and toddlers with CVI, 35% had developmental delay, 61% cerebral palsy, and 67% brain injury. In children with ROP as the primary cause of visual delays, 48% also were diagnosed with developmental delays, and 13% with cerebral palsy. The leading diagnosed conditions associated with visual loss require a transdisciplinary team.

The Individual Family Service Plan (IFSP) is the intervention plan for infants and toddlers (birth to 3 years) with disabilities who are served under part C of IDEA (1997) [6]. Part C Infant-Toddler Services may provide funding that can be used for vision services. In some states, the Infant-Toddler Services may be coordinated by the Department of Health and Environmental Services, or by the Department

of Social and Rehabilitative Services. Each state is different. IFSPs were first mandated by Public Law

99-457 in 1986 to assure that families would be included in the development and implementation of early intervention services. A multidisciplinary team that includes the family should develop the IFSP. Early intervention services are to be provided within the child’s natural environment. This is generally a home-based service for the infant and his/her family. The pediatrician, family doctor, community health nurses, and the ophthalmologists may make referrals to the child/family’s early intervention program. Early referral will help direct the team’s interventions based on priorities set in partnership with the family. These interventions aim to support and promote the child’s growth and development. The local team may consult a TVI. A TVI is a special educator, with either a certification in visual impairment, or with Masters or PhD level training, who specializes in consulting/ coaching the early interventionist and the educational team. These teachers are typically part of the local school system’s regional services centers, cooperatives, or are part of the state school for the blind.

The ophthalmologist, at the initial assessment can suggest or endorse interventions for the child with vision loss, especially those with CVI. Some of the adaptations that can be made are reducing visual clutter, increasing or decreasing lighting depending on the pathology, and allowing the child plenty of time to respond to the stimulation offered. Toys may need to be placed in closer proximity, at the level the child can see them, and in consistent order. The child needs to be encouraged to reach beyond himself/herself and to explore and control the environment.

30.2.4 Preschool (3–5 Years)

The federal definition in IDEA states that visual impairment including blindness means impairment in vision that, even with optical correction, adversely affects a child’s educational performance. This term applies to both partial sight and blindness. All children with low vision or blindness deserve an Individualized Educational Plan (IEP) developed by the educational team. The ophthalmologist should ask the parent specifically if there has been an IEP, and what the team discussed. Be sure the team has the

30.2.5School Age

(Kindergarten to 12th Grade)

The older child can vocalize what they are able to see in the classroom and what services they are receiving. The IEP is individualized, specialized, and has curriculum modifications. There may be experimental learning, and teaching of compensatory skills. Parents and professionals can enhance the learning opportunities and advocate for the best learning environments.

30.2.6 Role of Schools for the Blind

The trend in education is from institutionalization to integration in the child’s hometown local school. However, state schools for the blind, special schools for students with visual impairments, continue to have a valuable role. Enrollment, at no charge to the parents, is recommended by the IEP team with in-

30.3.1 Introduction and Overview

As stated earlier, the ophthalmologist is an integral part of the transdisciplinary team that will determine the best rehabilitation plan for each visually impaired child. It is crucial that the ophthalmologist provide the best possible explanation of the child’s visual condition and prognosis. In addition, the evaluation and examination may need to be structured differently than it is for children without permanent visual disability. In addition to the information available from the standard pediatric ophthalmology examination note, several special requests will be made of the ophthalmologist. The educational/rehabilitation team will specifically want to know how secondary visual conditions will affect the primary visual condition. An example would be a child with visual loss from ROP who also has strabismus or aphakia. The ophthalmologist will need to make a statement about whether there are any activity restrictions resulting from the visual condition. Any advice with regard to lighting, positioning, and magnification will be very helpful. The ophthalmologist may refer the child to a low vision center for further assessment or may feel

comfortable providing the initial low vision services himself/herself. Medical information from the ophthalmologist should be in a form that is legible, and in lay terms that parents, educational, and rehabilitation teams can understand and utilize.

Another concept to remember is the “four-leaf clover” of vision. Vision is used for:

1.Communication and interaction

2.Activities of daily life

3.Orientation and moving in space

4.Sustained near vision tasks [7]

This may sound obvious, but in the ophthalmic evaluation, the emphasis may be on treating the disease rather than how the disease affects the overall functioning, not only of the eye itself and visual system, but also of the entire child.

30.3.2Pediatric Functional Vision Assessment

Visual function does not necessarily correlate with visual acuity. Visual acuity measures the function of the eye; functional assessment measures the use of vision. The clinical eye examination in a child with low vision is different than simply assessing pathology. Diagnosis, prognosis, and visual acuity may not reflect how the child uses his/her vision in the environment within activities of daily life. The visual system is immature at birth, and children’s neurological systems, including vision, may develop at different rates. Visual acuity, refraction, motility, binocular visual acuity, contrast, color vision, visual fields, and examination of ocular structures are all important to evaluate and record as part of the pediatric functional low vision assessment.

Pediatric low vision assessment starts at the time of diagnosis or suspicion of delays in visual development and continues at regular intervals, independent of ocular pathology. At a minimum, low vision evaluations should be at the child’s transition times in the educational system. This would start with the early intervention services at newborn to age 3, next at admission to preschool (3–5 years), then at the beginning of elementary school (age 6). In the 3rd and 4th

grades, print in textbooks gets smaller, and the child moves from learning to read, to reading to learn. Middle school, high school, and entry into university or vocational training are additional transition times. The child’s environment is continually changing, so the evaluations and modifications to maximize vision and learning also need continuous reevaluation.

The pediatric low vision assessment should be performed in a consistent manner. The low vision assessment is in addition to the comprehensive ophthalmologic examination that prescribes medical and surgical interventions, and not meant to replace it.

30.3.3History Taking for the Visually Impaired Child

The initial step in any assessment is history. For the infant or child with low vision, this should include pertinent medical and ocular history as well as social and educational histories.

Ocular history should include the age at onset of symptoms, as well as results from prior eye examinations. An example would be eye poking, which indicates retinal etiology rather than neurological or optic nerve. What are the responses to light? Night blindness may indicate retinal dystrophy. Photophobia and light gazing may indicate CVI. What is the response to parent’s face, to toys, or other objects? Is the child aware of or will they track a favorite color?

Medical history affects the overall development of the infant and the visual functioning. Perinatal history of the mother and baby are both important. For the maternal history, what was the estimated date of confinement? How was mother’s general health?

What drugs were taken either prescribed or illegal? Alcohol intake, trauma, multiple births, infections, steroids, hypertension, preeclampsia, and nutritional status during pregnancy are all important questions. History of the baby includes gestational age at birth and birth weight. Did the baby move in utero? Was the prenatal growth normal or was there intrauterine growth retardation (IUGR)? How was the birthing process, and was resuscitation required?

The postnatal history adds additional information. How was the nursery stay? Risk factors for ROP in-

clude sepsis, transfusions, unstable nursery course, and mechanical ventilation. Risk factors for CVI include the same, as well as history of intraventricular hemorrhage. What were the findings on head ultrasounds, or other forms of neuroimaging (such as CT, MRI)?

Current medical conditions should be identified such as seizure disorders, traumatic injuries, congenital anomalies, “birth marks,” attention-deficit hyperactivity disorder (ADHD), hearing deficiency, or speech delay. Hospitalization, frequent visits to the doctor, surgeries, and other diagnoses should be noted. What other medications including steroids, seizure medications, chronic antibiotics, and other chronic medications is the child taking?

Family history may provide more clues to etiologiesoflowvision.Specificquestionsaboutfamilialor inherited eye diseases should be elicited. This should include strabismus, amblyopia, and refractive errors, eye patching, or thick glasses as a child. Knowing about familial medical problems or disabilities and the results of examination of family members may help in identifying underlying pathology.An example is a history of deafness in relatives. This may help identify those with Usher’s syndrome or Waardenburg’s syndrome. Children with these diagnoses may have combined hearing and vision losses which would require modified interventions.

Taking the developmental history is a skill the ophthalmologist and his/her office team may have to improve on. It is important to identify visual, motor, cognitive, and hearing delays. For example, an infant may initially raise its head, but this developmental milestone may regress in a baby with severe visual impairments. Developmental assessments completed by professionals on the infant-child teams specifically trained in developmental assessments are important to gather. The pediatrician may also provide some of this information.

Educational history and terminology is an area that the ophthalmologist who takes care of children, especially with vision loss should become familiar with. How is the child performing in school? What type of school is the child attending and what is the classroom setting? Does the child have an IFSP, and IEP, or a 504 plan? Other related or educational services the ophthalmologist needs to ask about are: is the child receiving occupational therapy, physical therapy, and/or speech therapy, vision services by a TVI, orientation and mobility instruction? Does the

child use low vision aid devices, or an augmentative communication device? If the child is not getting timely low vision evaluations, the optical and nonoptical devices may be outdated for the education level and tasks of the child.

30.3.4 General Assessment of the Child

Assess the child’s overall physical appearance. The examiner can assess overall muscle tone, head control, and fixation by holding the infant. Assessment of the infant’s vision can be performed by using the examiner’s face as a target. Watching the child move from lap or chair, or walk in the room is helpful. How does the child interact with the environment, with the parent, with the examiner? The examination should be performed quickly, keeping the child engaged, and in a compassionate manner.

30.3.5 Visual Acuity Testing

Visual acuity should not be the only measure to determine eligibility for service. If the child’s functional vision, even with correction, adversely affects his/her educational performance, this information should be used to determine eligibility and entitlement to educational services. There is a difference between tests of visual acuity and visual function. Testing should be age and ability dependent.

There are different types of acuity measurements. Always measure the child’s distance and near acuity.

Try binocular vision first, then separate eyes for acuity measurement. Remember the four-leaf clover of vision; near acuity is used for sustained near tasks, distance acuity for functioning in the larger environment and for orientation and mobility.

Recognition acuity consists of Snellen charts (which are age, visual acuity, and culture dependent), as well as LEA and Lighthouse symbols (Pediatric Low Vision Care (LV11), Lighthouse International, 111 E. 59th Street, New York, USA), the logMar (early treatment of diabetic retinopathy study; ETDRS) chart, and matching charts using the letters H, O, T, and V. These can be used in prereaders or non-verbal children if they can perform matching.

Fig. 30.1  Grating paddles can be used to resolution acuity in infants

Resolution acuity is often tested using a forced choice preferential looking method. These include

Teller cards, or the less expensive, grating paddles

(Fig. 30.1).

In general, there is central, steady, and maintained fixation by 3months, binocular vision by 3–7 months, and by 3–5 years the visual acuity should reach 20/20 on a Snellen chart. For infants at birth to 18 months, object awareness develops beginning with lighted objects and human faces. Preferential looking with the Teller cards and grating paddles gives a baseline to communicate with the intervention team. For toddlers, 18 months to 3 years, matching or naming objects such as LEA or Lighthouse symbols, matching tests such as HOTV, or Teller acuity cards can be used. Grating paddles can be used in young children who may not have the communication or developmental skills to match or name letters. In preschool, ages 3–5 years, LEA and Lighthouse symbols, matching tests with the HOTV, or naming objects may be used. Near acuity can be measured using the same. For children with disabilities, including visual disabilities, school age is considered age 5–21. For distance visual acuity testing, ETDRS/Lighthouse charts are used, and Snellen acuity may be able to be measured. For near acuity, Lighthouse cards, HOTV, and numbers may be used.

Visual evoked potential (VEP), electroretinography (ERG), and electro-oculography (EOG) have some usefulness in the assessment of low vision or

blindness. However, these tests are often inaccessible in the average community and may be expensive and time consuming.

30.3.6 Refraction

All visually impaired children should have a cycloplegic refraction. Dry retinoscopy or dynamic retinoscopy gives a rough estimate only. When using dilating and cycloplegic drop combinations, phenylephrine may need to be left off in a medically fragile child. Current nursing manuals for babies in the intensive care unit recommend holding feedings for 4 hours before dilation because of the anticholinergic effects of the drops. Phenylephrine may cause tachycardia and a rise in blood pressure when used in the very young. Atropine and cyclopentolate may have side effects in children with neurological disease. Flushing is very common with the use of cyclopentolate, and occasionally children have hallucinations when these drops are administered.

30.3.7 Assessment of Ocular Pathology

For the ophthalmologist, it is imperative to know the extent of the pathology of the ocular and visual systems, to properly evaluate and recommend low vision interventions.

For the anterior segment, the direct ophthalmoscope is an underutilized tool for rapid assessment. The red reflex, clarity of media, pupillary reactions, and fixation can be quickly evaluated. The baby can be held up to the slit lamp or a handheld slit lamp can be used. The indirect ophthalmoscope, with a 20D lens used as a simple magnifier, can provide a view of the anterior segment. Surgical loupes can also be used for this purpose. Intraocular pressure can often be measured using a Tono-Pen or a handheld applanation tonometer in the infant while he/she is sucking on a pacifier or while being bottle-fed in its mother’s arms.

Examination of the posterior segment after pupil dilation should always be performed. Indirect examination of the fundus is performed using a 28D and/or 20D aspheric lenses. Subtle optic nerve atrophy and

macular dragging from regressed ROP are two common findings that may affect visual functioning.

30.3.8 Eye Movements

It is important to evaluate for nystagmus. A face turn or head tilt may help the child compensate. The educational team is often very concerned about these mannerisms, and may try to discourage them. They need to understand that this is part of the child’s compensatory mechanism. Children with torticollis should be evaluated for congenital fourth cranial nerve palsy and for nystagmus. Infants may have already been referred to early intervention programs for therapy for the torticollis, when the real problem is ocular dysmotility. Shift of gaze, localization of objects, fixation on the caregiver’s face, versions and ductions, smooth pursuits, and convergence all have a bearing on the child’s overall development.

30.3.9 Motility/Binocular Vision

Stereopsis testing, using the Titmus fly, may be performed even at age 1 with coaxing and patience. A child with a significant chin up position from congenital ptosis may actually have difficulty with tripping over objects, and present as a child with visual impairment. A head turn may be a compensatory movement for Duane’s syndrome, or other duction defects.

30.3.10 Visual Fields

Full visual fields are not present at birth. Test by confrontation for a younger child with a face, toy, or lighted object. Babies will often follow the light spot from a direct ophthalmoscope around the room if the examiner makes a game of it. If the child can sit, rolling color balls to the child from his/her peripheral field can be used. Older children can do automated perimetry. Try automated perimetry early, even by age 5. Let the technician introduce the child to the

perimetry machine. Have a practice session when there is no rush for time. Inferior visual field defects are often found in children with brain injury, and this can affect the approach of all other midline functions, such as eating, playing with toys, reading, use of communication devices, and mobility. A child with an inferior visual field defect may have good visual acuity, but require a cane for safe and independent travel, or need reading material on a slant board to bring into the useful field of vision. Scanning techniques can be taught.

30.3.11 Color Vision

Accurate color vision testing can be usually be achieved by age 3. Eight percent of males have difficulty with red/green color vision. This has no bearing on visual acuity. Identification is important so the educational team can be notified. Color may also impact how a child uses vision. Red and yellow may be preferred colors for children with CVI. The mechanism for this is not well defined. Color preference can help promote the use of vision in the intervention setting.

30.3.12 Contrast Sensitivity

There are symbol tests for young children to measure contrast sensitivity. For infants, an object such as a piece of tan-colored cereal on the examiner’s hand can be used to measure contrast. This is important in the early intervention and classroom setting, as far as suggestions for lighting and contrast for reading material. The examiner may be able to predict contrast difficulties based on the underlying pathology.

30.4Pediatric Low Vision Interventions

Following the assessment, the visually impaired child should have appropriate interventions and referrals. The ophthalmologist should obtain or design a form