paediatric ophthalmology community to the hospital siobhan wren consultant ophthalmologist

Paediatric OphthalmologyCommunity to the hospital

Siobhan WrenConsultant Ophthalmologist

Hospital ServiceWorkloadAmblyopia

Visual development/assessment

Evaluation of the paediatric patientRed reflex

Detecting squints

Red eyes

Diagnosis of Paediatric Referrals (March 09)

Data available for 319/337

68%

Other includes ptosis/NF/retinal abN

Possible Amblyopia present in 124

Amblyopia

• Strabismus• Refractive• Occurrence

– 1-3% population– up to 5% pre-school

Visual development

• 1 month– pupils react to light– defensive blink present by 6-8 weeks– 3 weeks onwards watches familiar nearby face

when being fed– gaze caught and held by dangling bright toy gently

moved in line of vision at 15- 25 cm

• 3 months– very alert– fixes and follows toy at 15-25cm– converges eyes if toy brought toward eyes

• 6 months– any squint now is abnormal– reaches out for objects– searches for toy once it leaves visual regard

• 9 months– very alert to people– immediately grasps for toys– watches activities of people or animals within 3-4

metres with sustained interest for several minutes

• 12 months– interest in pictures– points to objects of interest

Health Visitor Questionnaire at 8 months and 2½yr contact

1. Do the parents suspect a squint?

2. Are there any concerns about vision, eye lids, eye movements, pupil size or shape?

3. Is there any family history of squint, amblyopia, glasses in early childhood, or wearing a patch.

4. Are there any risk factors of squint combined with family concerns i.e. prematurity or developmental delay

Fast track clinic run by a highly specialised orthoptist and paediatric optometrist can successfully assess large numbers of amblyopia &/or strabismus suspects.

A 74% discharge rate of 1st referrals, following the protocol, has a significant impact on paediatric outpatient clinic.

Surgical rates within this group of patients is in line with the national surgical rates .

Conclusions of Study into Fast track appointments

Making a diagnosisHISTORY

• Family history• Identify risk factors

– Prematurity– Developmental delay– Juvenile Rh Arthritis

• Family album• Photophobia• Redness• Discharge

– Purulent, watery

EXAMINATION

• External inspection• Red reflex• Corneal light reflex• Cover test

– Squinting– Head tilt– Eyelid closure

• Visual acuity >3 yrs– Defective ocular fixation/

interactions

Red reflex technique Sit in front of the child

and parent at about arm’s length. Set the ophthalmoscope to around +2 (green or black)

Focus on the parent’s eyes to show that the test is non-invasive and recognition of the normal red reflex in that particular ethnic group.

Then focus on the child’s face

and encourage the child to look at the light. Focus on the red reflex within the pupil.

The Childhood Eye Cancer Trust

Head postures • Check motility

Conjunctivitis

• Close contacts affected• Unilateral bilateral• Sticky discharge• Diffuse redness• Cornea and pupil normal• Chloramphenicol

• Cellulitis- Refer urgently

• Neonatal conjunctivitis: refer urgently– Risk of corneal perforation from n.

gonorrhoea

Allergic conjunctivitis

• Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC)

• Vernal keratoconjunctivitis (VKC) Atopic keratoconjunctivitis (AKC)

• Giant papillary conjunctivitis (GPC)

Symptoms

ItchingItching TearingTearing Rubbing Rubbing eyeseyes

00 AbsentAbsent AbsentAbsent No desireNo desire

11 TraceTrace TransientTransient RareRare

22 MildMild MildMild OccasionalOccasional

33 ModerateModerate ModerateModerate FrequentFrequent

44 SevereSevere SevereSevere ConstantConstant

Signs

RednessRedness Eyelid/Eyelid/Conjunctiva Conjunctiva swellingswelling

Sub-tarsalSub-tarsal

00 AbsentAbsent AbsentAbsent NormalNormal

11 MildMild Mild Mild Uniform Uniform ‘velvety’ ‘velvety’ papillae papillae appearanceappearance

22 ModerateModerate ModerateModerate Non uniform Non uniform with papillaewith papillae

33 SevereSevere SevereSevere Giant papillaeGiant papillae

Management• Allergy testing• Cool compress

• Artificial tear substitutes • Systemic and/or topical

antihistamines• Vasoconstrictors

• Mast cell stabilizers • Nonsteroidal anti-

inflammatory drugs (NSAIDs)

• Corticosteroids• Immunotherapy

Otrivine-antistin BD/TDS £2.35Otrivine-antistin BD/TDS £2.35 antazoline & xyometazoline antazoline & xyometazoline antihistamine and vasoconstrictor (weak) antihistamine and vasoconstrictor (weak) >5yrs NB sympathomimetic>5yrs NB sympathomimetic

Optilast QDS £6.40Optilast QDS £6.40 azelastine azelastine Antihistamine >4yrs 6 weeksAntihistamine >4yrs 6 weeks

Emadine BD £7.49Emadine BD £7.49

Relestat BD £14.00Relestat BD £14.00

emadastine emadastine

EpinastineEpinastine

Antihistamine >3 yrsAntihistamine >3 yrs

Antihistamine >12 yrs 8 weeks Antihistamine >12 yrs 8 weeks

Sodium chromoglycate QDSSodium chromoglycate QDS£3.08 (many other names eg £3.08 (many other names eg Optichrom) Optichrom)

sodium chromoglycatesodium chromoglycate mast sell stabilisermast sell stabiliser (weak); (weak);very safe very safe

Rapitil BD/QDS £5.12Rapitil BD/QDS £5.12 nedocromil sodium nedocromil sodium mast sell stabiliser >6yrs 12 weeksmast sell stabiliser >6yrs 12 weeks

Alomide QDS £5.48Alomide QDS £5.48 lodoxamidelodoxamide mast sell stabiliser >4 yrsmast sell stabiliser >4 yrs

Zaditen BD £9.75Zaditen BD £9.75 ketotifenketotifen mast sell stabiliser >3 yrsmast sell stabiliser >3 yrs

Opatanol BD £4.11Opatanol BD £4.11 olopatidine olopatidine mast sell stabiliser >3 yrs 16 weeksmast sell stabiliser >3 yrs 16 weeks

Acular £5.00Acular £5.00 ketorolacketorolac prostoglandin inhibitor prostoglandin inhibitor

Ocufen £37.15Ocufen £37.15 fluriprofenfluriprofen prostoglandin inhibitor prostoglandin inhibitor

Voltarol £6.68Voltarol £6.68 diclofenacdiclofenac prostoglandin inhibitor prostoglandin inhibitor