the worst-case scenario survival...
TRANSCRIPT
Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016
The
WORST-CASE SCENARIO
Survival Handbook
By Raymond Chu, OD MS
I certify:
• I have no proprietary interest in the tested
product
• I have no equity interest or significant payments
by the sponsor of a covered study
• Lecture content and
format is free from
commercial bias
• Lecture content was
independently
prepared by myself
Fix Follow Maintain
• Monocular
• Fixate on an object
• Follow the object into
various gaze positions
• Maintain fixation
Binocul Vis Strabismus Q. 2001;16(2):85-90.
The use of the FFM is so insensitive, and so
unspecific, that it’s virtually useless.
Fixation Preference
• Screening test for
strab & amb
• Sensitive to > 3 line
difference
• Dissociate: 10 BU
Sensitivity (specificity):
• aniso 20% (94%)
• strab 69% (79%)
Cotter et al. Ophthalmology 2009
Teller Acuity Cards (TAC)
• Designed for 6 months to 3 yrs
• Median time: 3.2 - 8.4 min
• Repeatable ± 0.5 octave
• 1 octave IOD is significant
• 30 cpd ≈ 20/20 Snellen equiv.
Precision-Vision
Full set: $3929
½ set: $2131
Keeler Acuity Cards
Richmond Products: Set of 18 cards $1,800.00
Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016
LEA Grating Test
• Same principle as TAC
• Designed for 12 months to 2 yrs
Good-Lite: $250
Cardiff Acuity Test
• Vanishing optotype
• Avg admin: 3-5 min.
• Designed for 6 months
to 3year olds
• 3 cards per acuity level
• Threshold: 2/3 correct or 3/4
• Can be used in cases of
suspected malingering
Richmond Products: $1800
LEA
• Matching / ID
• Well standardized for 2+ year
old children
• VIP study: Superior to HOTV
test in 3 y.o.
• Crowding ↑ sensitivity for
amblyopia
• IOD >1 line may be significant
LEA
• Matching / ID
• Well standardized for 2+ year
old children
• VIP study: Superior to HOTV
test in 3 y.o.
• Crowding ↑ sensitivity for
amblyopia
• IOD >1 line may be significant
Picture Chart
Patti Pics
Wright figures
Visual acuity for preschoolers
• Isolated single optotype
• High-contrast optotype
• Without directional
component
• A matching response
• Presented at 3m
Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016
HOTV
• Letters do not blur out equally
• 3-5 yr olds
• VIP study: 4 y.o. HOTV or LEA
• Test @ 10 ft.
• ATS study: ± 1 line
Dry Retinoscopy• Need to control accom and on-axis
• Phoropter vs lens bars
• Refracting glasses
• Don’t forget to subtract WD
Richmond Products: $115-120
Trial Frames
Richmond Products
Set of 5: $100
$27 each
Mohindra/ Near Retinoscopy
• 50 cm working distance
• Dark room illumination
• Ret beam: minimal intensity
• Occlude non-tested eye
• Correcting factor -1.25 D
• Borghi and Rouse (1985): Cycloplegia
revealed +0.50 to +0.75 D more plus than
near retinoscopy
Cycloplegic Agents
Infant (<1 yr):
2 drops, 0.5% cyclopentolate
spaced 5 min apart
Child (≥ 1 yr):
2 drops, 1.0% cyclopentolate
spaced 5 min apart
Gulden Ophthalmic: $22.00 / dozen
Wet Retinoscopy
• For Strab: occlude non-
tested eye
• Increase in aberrant
reflection
Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016
Autorefraction
• Non-cyclo = not reliable
• Diagnostic only when
cyclopleged
EOM
Doll’s Head Reflex
(oculocephalic reflex)
Brückner
• WD: 1 meter
• Room illumination:
Dark
• Brighter reflex =
suspected eye
Hirschberg
• Corneal reflex
displacement
• Nasal = (+)
• Temporal = (-)
(+)
(-)
12 mm
4 mm
Kappa Test
1 mm displacement = 22D
Cover Test
Ensure fixation and
accommodation on target
Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016
Pediatric Flashlight Stereopsis
RDS E
Lang II
Testability
86% for 3 yo,
89% for 4 yo,
93% for 5 yo
No polaroid
glasses needed
Preschool
Assessment of
Stereopsis with a
Smile (PASS)
Richmond
Products:
$158
Bernell
Good-
Lite:
$178-
389
StereopsisAmong children aged 3 yrs 0 months
through 3 years 6 months
Stereopsis
Preschool Randot Test
Stereo Fly
Randot Stereo Test
Good-Lite:
$189Good-Lite:
$189
Latham and Phillips Ophthalmics: $365
Randot Preschool Stereoacuity
Test
J AAPOS 2008;12:23-26
Binocular & Accommodative testing
Subjective
• Phorometry
• Risley prism
vergence ranges
• Accom Amps &
Facility
• NRA / PRA
Objective
• NPC
• Cover Test
• Prism bar vergence
ranges
• MEM
Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016
Confrontation VF
• @ 6-7 months, ~93% of an adult
Color Vision
Cotter et al (1999): 100%
sensitivity and 90.5%
specificity in screening of
kindergartners (5-7 yrs)
X-link recessive:
1:12 boys and 1:200 girls
have color deficiency
Bernell: $99.95
Richmond
products:
$279
IOP
Standard of care in school age
children
Veatch Ophthalmic:
$3990
IOP
Icare
$3750
Tonopen vs GATBaseline Characteristic N (%)
Average Tonopen IOP (OD, mmHg)
≤11 58 (12)
11 to 16 313 (66)
16 to 21 146 (31)
>21 22 (5)
Mean (range) 15.4 (6 to 25)
Average GAT IOP (OD, mmHg)
≤11 68 (14)
11 to 16 313 (66)
16 to 21 90 (19)
>21 2 (0.4)
Mean (range) 14.2 (8 to 23)
Dilating Agents
• Phenylephrine 2.5%
– Don’t use in <3 yo
or hx of
cardiovascular
problems
– No effect on accom
• Tropicamide 1%
– Safest dilating agent
Presented by Dr. Raymond Chu at Idaho Optometric Physicians Annual Congress 2016
Anterior Segment Evaluation
$2980-4260
EIDOLON Hand
Held Slit Lamps
5x magnification
Eidolon: $595
Bluminator / 20 + transilluminator
7x image
Eidolon
Set of 10: $675
$75/each
Poterior Segment Evaluation
• MIO: 5x, ~45o
• BIO: ~2.5x, ~35o
• DO: ~15X, ~6.5-10o
Optos
• ~ 200o view without
dilation
• The younger the child,
the more difficult the
setup
Examination of the infant/toddler
1. Hx
2. Teller / LEA
grating / Cardiff/
Fixation
preference
3. EOM, NPC
4. Hirschberg &
Kappa &
Brückner
5. MEM
6. Ant seg eval,
pupils
7. Cyclo ret
(0.5% for <1 yr)
8. Post seg eval
Examination of the preschooler
1. Hx
2. LEA (3 or 4) or
HOTV (4) VA’s
3. EOM, NPC,
Cover Test, Stereo
4. Dry ret
5. MEM
6. Ant seg, pupils
7. Color vision OU
8. Cyclo ret
9. Post seg