2016 tmc refraction pretest with answers

E X E R C I S E S E T TMC , MAR CH 1 6 , 2 0 1 6

EYEGLASSPRESCRIBINGINCHILDREN

PRESENTEDBY:APSANTIAGO,MD

PRESCRIBINGEYEGLASSESIN

CHILDRENEXERCISESA P S AN T I AGO , MD

TMC,16March2016

CASE1A

Ø Orthotropic

Ø Age2years

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:-3.00OD,-3.5OS

Ø CycloplegicrefracTonOD-1.50D OS-2.00D

Whatwillyoudo?

1.  PrescribemanifestrefracTon?

2.  PrescribecycloplegicrefracTon?

3.  Observefornowbecauseachild’sworldisatnear?

4.  PrescribecycloplegicrefracTonascontactlenses?

5.  Giveatropinetohaltprogressionofmyopia?

CASE1B

Ø IntermiZentexotropia

Ø Age2

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:-3.00OD,-3.50OS

Ø CycloplegicrefracTonOD-1.50D OS-2.00D

Ø Whatwillyoudo?

1.  PrescribemanifestrefracTon?

2.  PrescribecycloplegicrefracTon?

3.  Observefornowbecauseachild’sworldisatnear?

4.  PrescribecycloplegicrefracTonascontactlenses?

5.  Giveatropinetohaltprogressionofmyopia?

CASE1C

Ø Esotropic,intermiZent

Ø Age2yr

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:-3.00OD,-3.50OS

Ø CycloplegicrefracTonOD-1.50D OS-2.00D

Ø Whatwillyoudo?

1.  PrescribemanifestrefracTon?

2.  PrescribecycloplegicrefracTon?

3.  Observefornowbecauseachild’sworldisatnear?

4.  PrescribecycloplegicrefracTonascontactlenses?

5.  Giveatropinetohaltprogressionofmyopia?

CASE2A

Ø 3/Ffailedapreschoolvisionscreening

Ø VA:OD20/50linearAllen,

20/30singlefigures

OS20/30linearandsinglefigures

Ø Orthotropic

Ø ManifestrefracTonØ OD:-3.00D

Ø OS:-1.00D

Ø CycloplegicrefracTonØ OD:-2.50D

Ø OS:-1.00D

Ø Whatwillyoudo?

1.  Observefornow,child’sworldatnear.

2.  PrescribemanifestrefracTon,childisstarTngschool.

3.  PrescribecycloplegicrefracTon

4.  PrescribecycloplegicrefracTonandstartamblyopiatherapy.

5.  RepeatrefracTonin3months.

CASE2B

Ø 3yrsold,recentonset30PDE(T)’

Ø Neurologically,systemicallynormal

Ø VA:OU,fixes,follows,canCSM

Ø OnlyleaeyealwaysturnsinintermiZently

Ø Manifest:+0.50-1.00x90OU

Ø CycloplegicrefracTon:(cyclopentolate1%)

Ø +3.00-1.00x90OU

Ø Whatwillyoudo?

1.  PrescribemanifestrefracTon

2.  Cutplusby1.0DfromcycloplegicrefracTon:+2.00-1.00x090OU

3.  GivecyclopentolatecycloplegicrefracTon

4.  DoatropinerefracTonandprescribethis

5.  PrescribecycloplegicrefracTonwithbifocals.

6.  PaTent’scaserequiressurgery.

CASE2CØ 3/Fwith25PDofX(T)

Ø VAOU:20/20eithereyeoccluded,unaided

Ø Eithereyedeviatesoutwardwithnoobviouseyepreference

Ø DryManifestRefracTon:+2.00-1.00x180

Ø UnabletocooperateforsubjecTverefracTon

Ø CycloplegicrefracTon+3.00-1.00x180

Ø Whatwillyoudo?

1.  NoprescripTonifpaTentdoesnotwantsurgery.

2.  PrescribeRxevenifpaTentdoesnotwantsurgery.

3.  Dosurgeryfor25PDXTandprescribeRxaaersurgeryforunder-orovercorrecTon

4.  DoatropinerefracTonandprescribethisifpaTentwantssurgery.

ENDOFPRETEST

PRESCRIBINGEYEGLASSESFORCHILDREN

AN SWER S T O P R E T E S T

CASE1A

Ø Orthotropic

Ø Age2years

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:about-3.0OD,-3.5OS

Ø CycloplegicrefracTonØ OD-1.50D OS-2.00D

1A:WHATWILLYOUDO?

Ø Age2:potenTalforamblyopia

Ø Myopia<-2.0DlesspotenTalforamblyopiaalthoughmaysTllbe“amblyogenic”

Ø Child’sworldisatnear

Ø Nomisalignment

1A:LOGICALMANAGEMENT

Ø ObserveØ Child’sworldatnearØ LowpotenTalforamblyopia

Ø Butneedtomonitorclosely

Ø Willnotinterferewith“emmetropizaTon”

Ø GivecycloplegicrefracTonØ PotenTalforamblyopiaandsymptomstodeveloplater

CASE1A,1A:2Y,ORTHO,MYOPIA<-2.0D

Ø Orthotropic

Ø Age2years

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:-3.00OD,-3.5OS

Ø CycloplegicrefracTonOD-1.50D OS-2.00D

Whatwillyoudo?

1.  PrescribemanifestrefracTon?

2.   PrescribecycloplegicrefracRon

3.   Observefornowbecauseachild’sworldisatnear

4.  PrescribecycloplegicrefracTonascontactlenses?

5.  Giveatropinetohaltprogressionofmyopia?

CASE1B

Ø IntermiZentexotropia

Ø Age2

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:about-3.0OD,-3.5OS

Ø CycloplegicrefracTonØ OD-1.50D OS-2.00D

1B:WHATWILLYOUDO?

Ø ChildhasX(T)

Ø Age2:potenTalforamblyopiaØ Strabismic

Ø Ametropic:Myopic

Ø Myopia<-2.0Dmaybeasensorydestabilizingfactor

LOGICALMANAGEMENT:1B

Ø Givemyopic(full)cycloplegicrefracTonØ Startwithlowestminus

Ø ImprovedVAmaybeenoughtocontrolX(T)

Ø GivemanifestrefracTonbecauseofroleofoverminuslensesinX(T)

Ø Mayevengivehigherminus(upto-3.0D)ifdeviaTonsmall(<20D)–Jampolskyetal

Ø Childrentolerate“overminus”well

CASE1B

Ø IntermiZentexotropia

Ø Age2

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:-3.00OD,-3.50OS

Ø CycloplegicrefracTonOD-1.50D OS-2.00D

Ø Whatwillyoudo?

1.  PrescribemanifestrefracTon

2.   PrescribecycloplegicrefracRon

3.  Observefornowbecauseachild’sworldisatnear

4.  PrescribecycloplegicrefracTonascontactlenses

5.  Giveatropinetohaltprogressionofmyopia

C

CASE1C

Ø Esotropic,intermiZent

Ø Age2yr

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:about-3.0OD,-3.5OS

Ø CycloplegicrefracTonØ OD-1.50D OS-2.00D

1C:WHATWILLYOUDO?

Ø ChildhasE(T)

Ø Age2:potenTalforamblyopiaØ Strabismic

Ø Ametropic:Myopic

Ø Myopia<-2.0DmaybesTmulaTngexcessaccommodaTon&convergence

LOGICALMANAGEMENT:1C

Ø Givemyopic(full)cycloplegicrefracTon

Ø NoroleforgivingmanifestrefracTonoroverminuslenses

Ø MonitoreffectofRxonalignment

Ø Monitorfordevelopmentofamblyopia

CASE1C

Ø Esotropic,intermiZent

Ø Age2yr

Ø VA:OUfixes,follows,canCSM,nopreference

Ø Manifestdifficult:-3.00OD,-3.50OS

Ø CycloplegicrefracTonOD-1.50D OS-2.00D

Ø Whatwillyoudo?

1.  PrescribemanifestrefracTon

2.   PrescribecycloplegicrefracRon

3.  Observefornowbecauseachild’sworldisatnear?

4.  PrescribecycloplegicrefracTonascontactlenses?

5.  Giveatropinetohaltprogressionofmyopia?

C

CASE2A

Ø 3/Ffailedapreschoolvisionscreening

Ø VA:OD20/50linearAllen,20/30singly

OS20/30linearandsingly

Ø Orthotropic

Ø ManifestrefracTon

Ø OD:-3.00D OS:-1.00D

Ø CycloplegicrefracTonØ OD:-2.50D OS:-1.00D

CASE2A:WHATWILLYOUDO?

Ø 3y:visualsystemimmature

Ø AlreadyamblyopicØ Linearacuityshowsatleast2linedifference

2A:LOGICALMANAGEMENT

Ø GivecycloplegicrefracTon(lowestminus)

Ø MonitorVAimprovement(usuallyamonth)

Ø Startamblyopiatreatmentifnecessary

CASE2A

Ø 3/Ffailedapreschoolvisionscreening

Ø VA:OD20/50linearAllen,

20/30singlefigures

OS20/30linearandsinglefigures

Ø Orthotropic

Ø ManifestrefracTonØ OD:-3.00D

Ø OS:-1.00D

Ø CycloplegicrefracTonØ OD:-2.50D

Ø OS:-1.00D

Ø Whatwillyoudo?

1.  Observefornow,child’sworldatnear.

2.  PrescribemanifestrefracTon,childisstarTngschool.

3.  PrescribecycloplegicrefracTon

4.   PrescribecycloplegicrefracRonandstartamblyopiatherapy.

5.  RepeatrefracTonin3months.

C

CASE2B

Ø 3yrsold,recentonset30PDE(T)’

Ø Neurologically,systemicallynormal

Ø VA:OU,fixes,follows,canCSM

Ø OnlyleaeyealwaysturnsinintermiZently

Ø Manifest:+0.50-1.00x90OU

Ø CycloplegicrefracTon:(cyclopentolate1%)Ø +3.00-1.00x90OU

2B:WHATWILLYOUDO?

1.  CyclopentolaterefracTonalready>+2.00,higherlikelihoodthatatropinerefracTonwilluncovermoreplus

2.  LikelytobearefracTveaccommodaTveintermiZentET

3.  Righteyepreference(onlyleaeyeintermiZentlyturnsin)suggesTveofamblyopiathoughmild

2B:LOGICALMANAGEMENT

Ø Atropinecycloplegia

Ø GivefullcycloplegicrefracTon

Ø DetermineeffectonalignmentandcontrolofintermiZentesodeviaTon

Ø Bifocalsiff:Ø RepeatatropinesamerefracTonasprevious

Ø ETcontrolledatdistance,residualET’atnear

CASE2B

Ø 3yrsold,recentonset30PDE(T)’

Ø Neurologically,systemicallynormal

Ø VA:OU,fixes,follows,canCSM

Ø OnlyleaeyealwaysturnsinintermiZently

Ø Manifest:+0.50-1.00x90OU

Ø CycloplegicrefracTon:(cyclopentolate1%)

Ø +3.00-1.00x90OU

Ø Whatwillyoudo?

1.  PrescribemanifestrefracTon

2.  Cutplusby1.0DfromcycloplegicrefracTon:+2.00-1.00x090OU

3.  GivecyclopentolatecycloplegicrefracTon

4.   DoatropinerefracRonandprescribethis

5.  PrescribecycloplegicrefracTonwithbifocals.

6.  PaTent’scaserequiressurgery.

C

CASE2CØ 3/Fwith25PDofX(T)

Ø VAOU:20/20eithereyeoccluded,unaided

Ø Eithereyedeviatesoutwardwithnoobviouseyepreference

Ø DryManifestRefracTon:+2.00-1.00x180

Ø UnabletocooperateforsubjecTverefracTon

Ø CycloplegicrefracTon+3.00-1.00x180

CASE2C:LOGICALMANAGEMENT

1.  Trytoimprovecontrol:Ø  DetermineiftheEORadestabilizingfactor?

Ø  withholdingglassessimilartogiving“overminus”?

Ø  TrialwithEOR,mayneedtoTtratehyperopiccomponent

Ø  RoleoforthopTcs,convergenceandanTsuppressionexercises

CASE2C:LOGICALMANAGEMENT

2.Ifforsurgery:Ø  Needtouncoverfullplus(atropine)refracTon,givemaximumplus

toasclosetocycloplegicaspossible

Ø  RemeasurewithRxfortargetangleforsurgery

CASE2CØ 3/Fwith25PDofX(T)

Ø VAOU:20/20eithereyeoccluded,unaided

Ø Eithereyedeviatesoutwardwithnoobviouseyepreference

Ø DryManifestRefracTon:+2.00-1.00x180

Ø UnabletocooperateforsubjecTverefracTon

Ø CycloplegicrefracTon+3.00-1.00x180

Ø Whatwillyoudo?

1.  NoprescripTonifpaTentdoesnotwantsurgery.

2.  PrescribeRxevenifpaTentdoesnotwantsurgery.

3.  Dosurgeryfor25PDXTandprescribeRxaaersurgeryforunder-orovercorrecTon

4.   DoatropinerefracRonandprescribethisifpaRentwantssurgery.

C

2C:3Y,HYPEROPICX(T)

1.  NoprescripTonifpaTentdoesnotwantsurgery.Ø  (significantEOR)

2.  PrescribeRxevenifpaTentdoesnotwantsurgeryØ  (doesnottellyouifdryorwet)

3.  Dosurgeryfor25PDofexotropiaandprescribeRxaaersurgeryforunder-orovercorrecTon

Ø  (TargetanglesTlluncertainwithouttryingmaxplus)

4.   DoatropinerefracRonandprescribethisifpaRentwantssurgery.

ENDOFDISCUSSIONOFANSWERS