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271 Cards in this Set
- Front
- Back
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About _% of school age children ave a learning disability
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5-15%
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Three definitions that define "good vision"
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1 VA
2.Visual Efficiency (accom, binocularity, etc) 3. Visual Information processing |
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_________________________ is the ability of brain to extract and organize visual information from the environment and to coordinate t his information wit other sensory modalities in higher cognitive functions
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Visual Information Processing
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T/F Optometrists do not diagnose, evaluate or treat learning disabilities
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T
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When there are uneven abilities between Perceptual and Verbal IQ scores, you should do what kind of evaluation
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Visual Processing
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Visual information processing begins with
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perception
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____ is an active process of extracting info from the environment and integrating it to make it meaningful
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perception
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T/F Learning disabilities are assumed to be homogeneous
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FALSE
LDs are HETEROGENOUS in nature and can be a mix of lanuage, vision, speech, auditory, etc that results in the LD |
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Mattis Learning Disabilitiy Classificaition found that the #1 cause of LD is
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Language- 47%!
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Boder LD Classification found that ____ was the cause of 63% of learning disabilities
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Dysphonetic (language)
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Conclusion for the Kavale Study
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Visual Prossessing skills account for moderate proportions of variance in reading. Premise thqt reading disability solely a language problem.
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Solan, Mozlin, Rumpf study found that childdren from K to grade 2 showed
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a very strong relationship between visual perception and reading readiness
Also showed relationship etween visual perception and readng readiness but not as strong |
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Solan study on perceptual norms and relationsips to Math concluded that
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there is arelationship between visual perception and math skills, at least in older cdrein grade 4-5
40% of those with RD or LED also present with a visual component |
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____% of those with RD or LED also present with a visual component
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40
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Kavale Study Conclusion
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1. VP important correlate with reading achievement
2. VP skills a factor in predicting reading achievement |
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T/F Solan Mozlin Rumf study found that children of all grades had a strong relationshi between visual perception and reading readiness
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FALSE ONLY up until Grade 2
Beyond Grade 2…. – not dominant Skills in K predict reading proficiency @ end of grade 1 VP skills play a significant role in reading in the primary grades |
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Solan's Study on PErceptual Norms and Relationships to Math found that ___% of math disabilite are due to perceptual problems and ____% are due to a mixed disorder
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20%
20% 40% of those with a RD or LD present with a visual component |
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T/F As many as 1 out of every 5 people in the US have an LD
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T
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LD risk factors include
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1. CNS dysfunction
2. Genetics cause “at risk” genotype 3.Psychosocial & biological factors contribute 4.Maternal nutrition 5.Premature birth Low birth weight (<2500 grams) For given SES, lower birthweight = lower IQ For given birthweight, lower SES = lower IQ |
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T/F A low birth weight baby is MORE suspectible to ADD
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T
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Dyslexia is a LD that is _______ in origin
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neurobiological
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T/F Dyslexia is a phonological system problem
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T
They are usually NOT phonoloigcally normal phonological=connection btwn sounds and symbols |
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A child with dsylexia may have difficulty with accurate and or fluent word recognition, poor spelling, and ____ abilities
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decoding
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Definition of phonologic
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connection between sounds and symbols
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With pts with dyslexia the disurption is uaully located where in the brain
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left posterior areas
parieto-temporal and occipiro temporal They have a greater reliance on Broca's area, frontal regions, and right hemisphere |
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Dyslexics have a greater reliance on ___ area, frontal regions, and right hemisphere
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Broca's
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________ - a reading disorder
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Dyslexia
Neurobiological & genetic - 10 regions of different chromosomes, known as DYX loci, in genetic linkage with dyslexia….often inherited. |
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____– writing disorder
Difficulty transferring language into written output |
Dysgraphia
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_____________ math disorder
Difficulty in understanding numbers and number concepts (more, less, larger, smaller, etc.) |
Dyscalculia
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_________ is the most common childhood learning disorder
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Dyslexia
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_________________ involves
ID, discrimination, spatial awareness, integration Ability to analyze, interpret & act upon |
Visual Information Processing
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What are the 4 skills tested with WISC-IV?
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Verbal
Perceptual Reasoning Working Memory Processing Speed FSIQ (Full Scale IQ) |
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Boder 3 subytypes of Dyselxics
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A. Dyphonetic (67%)
B. Dyseidetic (10%)- problems with whole word gestalts, visual, reversals C.Mixed |
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What is Dyseidetic dyslexia?
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The dyseidetic child, on the other hand, generally has a good grasp of phonetic concepts. The prominent characteristic of the dyseidetic is the inability to revisualize the gestalt of the word. Usually, the child has little difficulty spelling words which may be long but are phonetically regular. It is the small but irregular nonphonetic words, such as what, the, talk, does, that create the greatest difficulty for this child.
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Coltheart Dual Route Model
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2 interacive yet distinct pathways for word recognition
i. Indirect- sublexial phonological decoding route for pronunciation of unfamiliar words ii. Direct- lexical route for automatic recognition of high frequency words. Weakness in either pathway could result in 2 different subtypes of dyslexia: 1. Phonological dyslexia (difficulty with nonword reading) 2. Surface dyslexia- difficulty with irregular word reading |
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Phonological dyslexia definition
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(difficulty with nonword reading)
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Surface dyslexia definition
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difficulty with irregular word reading
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Pirozzola 2 subtypes
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a. Auditory-Linguistic
- Low Verbal IQ, Reading errors and spelling errors b. Visual-spatial - right%left disorientation, spatialk dysgrapia, reading errors and spelling |
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Nonverbal Learning Disorders
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pt's are often very talkative but not conveying a message, typically pt has a lot of emotional distress. They are often not detected until 3-4th grade because they are good decodes.
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Nonverbal LEarning Disorders
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Signifcant primary deficits (tactile, visual perception), secondary deficits (tactile attention, visaul attention), Tertiary Deficits (Tactile memory, visual memory)
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Mathematics Disorders
Culbertson Study definitons |
developmental disorder involving deficits in counting computational skills, ability to solve word prolems and understanding numbers
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Magnocellular Vision Deficit Two Processing Systems
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1.Transient
Magnocellular motion sensitive Low Resolution Processes overall stimulus organization 2.Sustained Parvocellular pattern sensitive High Resolution Object ID; stimulus configuration |
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Magnocellular Vision Deficit transient system digests information regarding
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– WHERE??
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Vision Deficit SUSTAINED system digests information regarding
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– WHAT??
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Major function in reading
Reading involves: |
1.Fixations – sustained – extracts details
2.Saccades - transient Reading involves integration of information between eye movements 3.Role of Transient System – diminishes persistence effect of sustained channels by erasing pattern information from previous fixation |
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Role of Transient System
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– diminishes persistence effect of sustained channels by erasing pattern information from previous fixation
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Alterations in the order & timing or processing speed of the two systems can result in a ______ deficit.
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visual processing
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What is RAN?
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RAN
Rapid Automatized Naming Ability to name visual stimuli quickly Highly predictive of dyslexia Involves many visual, cognitive and linguistic processes. Responsive to VT |
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What are Integrative Factors?
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The Ability to integrate information from various sensory modalities
Intramodal i.e.Visual-visual pattern matching Intermodal i.e. Auditory - Visual How do we learn best?? |
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What is an example of InTRAmodal integration?
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i.e.Visual-visual pattern matching
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What is an example of InTERmodal integration?
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i.e. Auditory - Visual
How do we learn best?? Match a Picture (visual-visual) Spell or Say the word orally (auditory-visual) Write the Word (visual-motor) |
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3 Components to ADHD
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Hyeractivity
Impulsivity Inattention Problems must have started efore age 7!! |
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In order to be classified as ADHD, problems must have started before pt is ___ years old
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7
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What Meds are given to pts with ADHD?
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Pyscho-stimulants:
Ritalin Adderall Dexedrine Focalin Nonstimulant: Strattera |
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T/F Strattera is a psycho0stimulant medication given to treat ADHD
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FALSE
non-stimulant! |
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Concerta is the long lasting formula of ___ given to ADHD pts
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Ritalin
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Increased chances of kids with dyslexia also have ___. Some studies estimate a 40% relationship
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ADHD
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WHat Intelligence test is given to 2-7 yr olds?
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Wechsler Preschool and Primary Scale of Intelligence
WPpSI |
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WHat Intelligence test is given to 6-16 yr olds?
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Wechler Intelligence Scall for Children
WISCH |
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While the Standford-Binet Test of Intelligence is not commonly given, what ages it is appropriate for?
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2-21 yrs
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What are the 4 Indices of WISC?
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Verbal Comprehension
Perceptual Organization Working Memory Processing Speed |
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Block design, picutre concepts and maxtrix reasoning are all part of what WISC index?
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Perceptual Organization
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Difital Span, letter-number sequencings and arithmetic are part of what WISC index?
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Working memory
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Coding is part of what WISC index?
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Processing Speed
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Boder found that ___% of LD pts have a perception and a mixed perception/language deficit
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31% have visual processing deficits
Dyseidetic – 9 % (visual processing) Mixed – 22% |
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___ speed are slowerin children with LD; these kids have to think through every single step and reading becomes teadious
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perceptual
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The Beery test tests what part of Visual Processing?
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Simultaneous learning
- how quickly a child can process info |
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___ extracts details and tests the paroveculalr system while reading
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Fixation
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During reading, saccaes uses the ___ system
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magnoceullar system
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Boder found that ___% of LD pts have a perception and a mixed perception/language deficit
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31% have visual processing deficits
Dyseidetic – 9 % (visual processing) Mixed – 22% |
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___ speed are slowerin children with LD; these kids have to think through every single step and reading becomes teadious
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perceptual
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The Beery test tests what part of Visual Processing?
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Simultaneous learning
- how quickly a child can process info |
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___ extracts details and tests the paroveculalr system while reading
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Fixation
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During reading, saccaes uses the ___ system
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magnoceullar system
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If transient system is defective, one can get _____, where wors will overlap and reader will get confused
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masking
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T/F A problem with the transient system is a vision=based problem
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T
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What is the best method of learning?
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Intermodal; it intergrates all the senses together
sight, seeing, motor |
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____________Skills
The ability to understand directional concepts that organize external visual space. |
Visual Spatial
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Visual Sptatial skills include
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laterality (knowing right to left)
Directionaltiy |
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2 Most important Visual Spatial Skills tests
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Southern California Right/Left Test
Gardner test of reveral frequency |
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By what age should a child know right to left on themselves?
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6 years – left vs. right on self
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By what age should a child know right to left for objects in space?
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7 – 12 years – left vs. right for objects in space
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The Gardner test of reversal frequency tests matching, execution and _______
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Recognition
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What are 2 subsets of Visual Anaylsis skills?
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Form Constancy
Simulatenous memory/visualization |
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________ constancy: tell a child to look at a pic above and find it below
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Form
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T/F The Beery test is a test of Visual anaylsis skills
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T
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What is the TVPS form perception test?
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Ability to recognize your backpack along the side of the room after a test
Feature analysis Comparison Memory |
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T/F Children under age 5 have incomplete, unsystematic search patterns, making form constancy difficult
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T
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What is TAAS?
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Test of Auditory Analysis Skills – TAAS
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PCO Primary Care Battery of Tests includes:
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Gardner Recognition Subtest
Ayres R/L TVPS Form Constancy TVPS Visual Memory Beery - VMI |
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The WAIS IQ test is appropriate for what ages?
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16 to 89 years
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T/F The Perceptual Reasoning Index of the WISC test is a NONnverbal administration and response
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T
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1 Standard Deviation away on the WISC IQ score is how many points?
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1 SD = 15 point difference--> is significant
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at Birth the average RE is
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2 D Hyper
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99% of cHildren are between what RE at birth?
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-6 to +10D
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The distribution of RE begin to narrow at what age?
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5 yrs of age
few cases of sifnificant RE |
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T/F You shouldn't Rx every RE just because its there
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T
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At birth what % of child are anisometropic?
in school? |
11-22%
1% |
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At birth what % of children are hyperopic?
in school? |
30%
30% |
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At birth what % of children are astigmatic?
in school? |
20-60%
10% |
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At birth what % of children are Myopic?
in school? |
25%
1-->2-->12-->25% |
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Rate of change for myopies
____ per year |
.25-.50D
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Rate of changes for hyperopes
.25-.50D every ___ years |
6
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Example:
5 yrs old RE +2 what will they be at age 17? |
.25-.50D change every 6 years
+1.50 to +1 D |
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15 year old with a +.25D, what will they be at age 18?
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.25-.50 D every 6 years
plano to a +.12D |
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Consider Rxing cyl for a child if it is over ____D
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1.25D
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*AMBLYIOGENIC ANISOMETROPIA?
1. How much of a difference in myopic refractive error will cause it 100% of the time? 50% of the time? |
>6.5D
>5D |
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*AMBLYIOGENIC ANISOMETROPIA?
1. How much of a difference in astigmatism refractive error will cause it 100% of the time? 50% of the time? |
>3.5D
>2 D |
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*AMBLYIOGENIC ANISOMETROPIA?
1. How much hyper refractive error will cause it 100% of the time? 50% of the time? |
>3.5 D
> 2D |
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AMBLYIOGENIC ISOMETROPIA
1. How much myopic refractive error will cause it 100% of the time? 50% of the time? |
>8 D
> 6D |
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AMBLYIOGENIC ISOMETROPIA
1. How much hyperopic refractive error will cause it 100% of the time? 50%? |
>6D
> 4D |
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AMBLYIOGENIC ISOMETROPIA
1. How much astigmatic refractive error will cause it 100% of the time? 50%? |
>3D
> 2D |
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H. Example:
1. 15 month old 2. routine exam 3. VA OD, OS 20/80 FPL 4. orthophoria @ near 5. Stereo – none 6. Refractive error i. OD +1.00 = -3.00 x 120 ii. OS +1.50 = -4.00 x 30 7. Refractive error not within normal range for age 8. VA Subnormal level 9. Amblyopia possible 10. RX? |
See px every 3 months to monitor for change. If RE is staying the same for ~6 months, then Rx. Rx close to the whole RE.
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G. Example:
1. 8 month old 2. routine exam 3. VA OD, OS 20/400 FPL 4. CT: orthophoria @ near 5. Stereo – none 6. Refractive error +8.00 OD, +9.00 OS Do we Rx? |
7. Refractive error not within normal range for age
8. VA subnormal level 9. Amblyopia is possible 10. RX? Yes |
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F. Example
1. 30 month old 2. routine exam 3. VA OD, OS 20/100 FPL, not cooperative @ distance 4. CT: orthophoria @ near i. poor fixation @ distance 5. Stereo – none 6. Refractive error -7.00 OD, -6.50 OS Do we Rx? |
7. Refractive error not within normal range for age
8. No VA may indicate subnormal level at distance 9. Amblyopia possible 10. RX? Yes, full amount if possible |
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I. Example
1. 6 year old 2. trouble seeing “stuff” far away 3. short attention span 4. doesn’t copy well from board 5. VA OD 20/30 OS 20/40; OU 20/25 6. CT: Ortho @ D; 2 XP @ N 7. +GF / 100 sec arc 8. Refractive error i. OD +4.00 = -1.00 x 180 ii. OS +3.75 = -0.50 x 180 12. RX? |
Yes, but less than full RE. Maybe half of both the sphere and cyl. You don’t want to affect the XP too much with the rx.
9. Refractive error in not within normal range for age. There is a lot of hyperopia and cyl OD 10. VA is subnormal 11. Amblyopia is possible |
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1. 7 year old
2. trouble seeing far 3. VA OD, OS 20/40+; OU 20/30 i. .4/.3 M @ near 4. CT : ortho D; 4 XP N 5. Stereo - +GF; 25 sec arc 6. Refractive error i. OD -1.00 = -2.00 x 180 ii. OS -1.00 = -2.00 x 180 do you rx? |
7. Refractive error not within normal range
8. VA is not normal 9. Amblyopia possible due to high cyl 10. RX? Yes, the entire RE |
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L. Example:
1. 9 month old 2. Routine Exam 3. VA - OD, OS 20/100 4. CT - ortho @ distance & Near 5. 480 sec arc 6. Refractive Error: i. OD Pl = -2.25 x 90 ii. OS Pl = - 2.00 x 90 7. RX? |
NO!! The cyl will go away as the child grows.
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1. 3 year old
2. No complaints – i. doing well in preschool ii. able to read letters 3. VA OD 20/50; OS 20/25 4. CT - ortho @ D & N 5. Refractive Error: i. OD pl = -2.50 x 180 ii. OS pl = - 0.75 x 180 6. RX: |
pl -1.75 x180 up to pl -2.50 x180 OD and possibly pl -0.75x180OS
i. You want to at least Rx -1.75 cyl OD |
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1. 3 year old
2. No complaints – 3. VA OD 20/60; OS 20/60 4. CT - ortho @ D & N 5. Refractive Error: i. OD Pl = -3.00 x 160 ii. OS Pl = - 3.00 x 50 6. RX: |
Up to the full Rx because oblique axis and therefore will NOT go away. May cut a little to smooth adaptation.
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O. Example
1. 12 month old 2. VA 20/100 OD, OS 3. Cover Test - 10 XP 4. Stereopsis – none 5. Refractive Error: i. -6.50 = -0.75 x 090 ii. -5.50 = -1.00 x 090 6. RX? |
Rx the entire sphere. We don’t care about the cyl because it will go away.
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1. 5 year old
2. VA i. OD 20/20 ii. OS 20/100 3. Cover Test: ortho at distance & near 4. Stereopsis: none 5. Refractive Error: i. OD +1.00 sphere ii. OS +4.00 = -2.00 x 180 6. RX? |
OD plano (so that child does not experience blur and not wear the glasses) OS +3.00-2.00x180
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J. Example
1. 18 month old 2. Eye drifts inward 3. VA: 20/50 OD, OS 4. CT: i. 15 EP @ near; ii. 10 EP @ distance 5. No stereo 6. Refractive Error: i. Dry: +2.50 sph OU ii. Wet: +3.50 sph OU 7. AC/A = (15+5)/2.5 = 8/1 8. RX? |
Yes, rx ~ +2.00 OU. Don’t give the full rx. ½ of rx isn’t enough because the px will still be eso.
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K. Example
1. 8 year old 2. CC: eye drifting in 3. VA: 20/20 OD, OS 4. Cover Test: i. 5 PD EP @ distance ii. 10 EP @ near 5. Stereo: 20 sec arc 6. Refraction: i. +1.00 sphere OD, OS 7. AC/A = 8/1 8. RX? |
Yes; give rx even though VA is 20/20 because px is EP at near.
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White bumps along the corneal limbus are known as
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(Tranta’s dots)
Treatment: Patanol, 1 gtt, BID, 3 mos |
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__________conjunctivitis – A common conjunctivitis; a chronic, year round allergic reaction that affects millions of people. It is often related to substances that we come in contact with at anytime of the year such as animal dander, chemicals and dust.
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Atopic
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Differential Diagnosis of Itching
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A. Seasonal/hay fever allergic conjunctivitis
B. Vernal conjunctivitis C. Contact dermatitis D. Atopic conjunctivitis E. Lash infestation F. Blepharoconjunctivitis |
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T/F Corneal involvement is uncommon in Seasonal Conjunctivitis
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T
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Signs of Vernal Conjunctivitis include
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A. Cobblestone papillae
B. Limbal papillae with whitish chalky dots (Tranta’s dots) – accumulation of eosinophils C. Superior keratitis or pannus of cornea D. Intense itching during warm months but may present year round |
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Superior keratitis or pannus of cornea, along with cobblestone papillae are present in pts with
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Vernal Conjunctivitis
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Contact Dermatitis can be due to
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Cosmetics, nail polish, eyeglass frames, soaps, shampoos, perfume, laundry agents
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T/F Atopic Conjunctivitis is
typically an ADULT disease |
T
Signs: 1. Smaller papillae & more prominent in lower fornix 2. Conjunctival scarring is more common 3. Associated staph, bleph & eczema |
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___ Conjunctivitis is typically an adult disease
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Atopic
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What are signs of Atopic Conjunctivitis?
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1. Smaller papillae & more prominent in lower fornix
2. Conjunctival scarring is more common 3. Associated staph, bleph & eczema |
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The tx goal for kids with allergies is
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to stop the itching and rubbing
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______________drops
are very short acting – after 1.5 hours redness returns 2. Should not be used chronically in children since long-term use may be associated with a. Drowsiness b. Bradycardia Good 1st treatment! |
Decongestant-antihistamine
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T/F Naphcon-A & Vasocon-A are first line drugs used to treat kids with allergies
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FALSE
Naphcon-A & Vasocon-A are not good choices because they are vasoconstrictors b. Oral ingestion can induce coma and marked reduction in body temperature approved for ages 6 and up |
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Naphazoline is contraindicated in
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low birth weight and premature infants
t is a sympathomimetic agent with marked alpha adrenergic activity. It is a vasoconstrictor with a rapid action in reducing swelling when applied to mucous membrane. |
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Pure antihistamine drops
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1.Livostin
a.No longer available 2. Emadine a. H1 receptor antagonist b. Indications: allergic conjunctivitis c. Pediatric: age 3 or older d. Sig: 1 gtt up to QID e. Disp: 5 ml f. Alcon |
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_________ are excellent for children with extended seasonal allergies or predictable onset each year
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Topical mast cell membrane stabilizers
examples: 2. Alomide 0.1% 3. Crolom |
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An example of an Eosinophil Chemotaxis Inhibitors
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1. ALAMAST
a. Mast cell membrane stabilizer-eosinophil chemotaxis inhibitor b. Decreased itching may occur after a few days but may take up to 4 weeks c. For children ages 3 & up d. QID |
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What is Optivar?
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a. Antihistamine-mast cell membrane stabilizer and eosinophil chemotaxis inhibitor
b. Itch relief within 3 minutes! c. For children 3 & older d. Sig: BID |
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________ are only use in most severe cases of pediatric allergies
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Corticosteroids
(FML is the only steroid approved for kids 2 years or older) |
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Best therapy for children with allergies: .
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start with PataDay and then switch to Alocril for maintenance because you can use a mast cell stabilizer for 3 months and PataDay can get expensive
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How long should your pt stay home after being diagnosed with Viral conjunctivitis
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7-12 days
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__________ are contraindicated in Down’s – use 1% tropicamide, 2.5% phenyl, separated by minutes to dilate
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Atropine and cyclogel
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Atropine: side effects
A. Early stages of poisoning: |
1. Blind as a bat: Blocks ciliary muscle
2. Dry as a bone: Inhibition of sweat & salivary glands (dry mouth) 3. Red as a beet: Inhibition of sweat glands- to compensate there is dilation of skin blood vessels to try to lose heat 4. Hot as a hare: Inhibition of sweat glands & lack of heat dissipation as well as the parasympatholytic action on the anterior hypothalamus, the body heat control center of the brain, ie, temperature elevation |
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B. Advanced stages of Atropine poisoning:
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1. Mad as a wet hen: CNS effects
2. Hallucinations 3. Ataxia 4. Confusion 5. Restlessness 6. Death! |
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No atropine refractions until after _________ due to the sensitive period of vision development!
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3 months of age
May induce amblyopia in a very young child. |
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Atropine and cyclogyl contraindicated in:
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a. Down’s children (trisomy 21)
b. Children with neurologic disorders: spastic paralysis, brain damage, seizures c. Albinism |
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A. 6 year child with Down’s syndrome presents to your office for a routine examination. Upon examination, you notice a right, intermittent ET. You find moderate hyperopic astigmatism OU and a high AC/A. You decide to perform a cycloplegic refraction. What dilating agents would be most appropriate to use in this case?
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3. Use 1% tropicamide and 2.5% phenylephrine.
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Case: A conscientious mother brings her newborn in for a routine eye examination. The baby is 1 mo. old. The mother had esotropia and wants her baby to have frequent routine check-ups.
1. Birth Wt: 5 lbs. 1 oz. 2. Baby was 3 wks early 3. Normal pregnancy and delivery 6. Examination is normal. You decide to perform a routine dilated fundus examination. What diagnostic drugs would be appropriate for this baby? Choose the best dilating agent below. a. 1% cyclopentolate, OU 2 gtts, separated by 5 minutes, would be required due to immaturity of the iris muscles. b. 0.5% atropine, ung, OU: required due to immaturity of the iris muscles. c. 1% cyclopentolate, 1 gtt OU d. 1% tropicamide 1 gtt OU and 2.5% phenylephrine 1 gtt OU, separated by a few minutes e. 0.5% tropicamide 1 gtt OU and 2.5% phenylephrine 1 gtt OU, separated by a few minutes |
E
c. Use punctal occlusion, hold lids apart for 30 sec, then wipe excess after lids are closed |
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Dilating agents 1 to 5 years of age
1. Light irides |
a. 0.5% Tropicamide, 1gtt
b. 2.5% Phenylephrine, 1 gtt c. 20min later add 0.5% Tropicamide if needed d. Each drop is separated by several minutes |
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Dilating agents 1 to 5 years of age
2. Dark irides |
a. 1.0% Tropicamide, 1 gtt
b. 2.5% Phenylephrine, 1 gtt c. Use punctal occlusion, hold lids apart for 30 sec, then wipe excess after lids are closed in all cases if possible |
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A. A 3 yo blonde, energetic child failed a screening indicating a “possible problem” indicating that he may need glasses. Your examination reveals a low amount of myopic astigmatism OU, although fixation during retinoscopy was extremely variable. You decide to do a cycloplegic refraction. What cycloplegic would you employ for this child?
A. 1% cyclopentolate, 2 gtts, OU, separated by 5 minutes. Two drops would be required since administration would be difficult in this child. B. 0.5% atropine, ung, OU. An ung would be best since administration would be difficult in this child C. 1.0% cyclopentolate, 1gtt, OU; 2.5% phenylephrine, OU. D. 1% tropicamide, OU and 2.5% phenylephrine, OU, separated by a few minutes. Add 1% tropicamide, 1gtt, OU, after a few minutes. E. 0.5% tropicamide, 1gtt, OU, and 2.5% phenylephrine, 1 gtt, OU, separated by a few minutes. |
C
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To cycloplegia a dark irides 3 yr old pt you would use what?
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c. 1.0% cyclopentolate, 1gtt, OU; 1% tropicamide, 1gtt, OU; 2.5% phenylephrine, OU – cyclo is not a great dilator in dark eyes so need tropicamide too
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__________remains cycloplegic refraction standard of care for accommodative esotropia in ages 0-4 years.
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Atropine
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Modified traditional atropine regimen (this is recommended).
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The day before the examination:
1 gtt, 1% atropine solution, TID or 0.5% atropine UNG, BID – parents can administer easily |
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TEARING – differential diagnosis
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A. Congenital glaucoma
B. Non-patent nasolacrimal system C. “Crocodile” tears – mis-wiring of CN VII – eyes tear when child salivates D. Entropion/ trichiasis E. Keratitis and/or conjunctivitis F. Foreign body |
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NON-PATENT NASOLACRIMAL SYSTEM
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A. Etiology: imperforate membrane at the end of the N-L duct
B. R/O congenital abnormalities of upper & lower puncta C. Associated lash crusting or secondary bacterial infection with purulent discharge D. This “pink eye” comes & goes; recurrent E. Palpation of sac w/ reflux confirms diagnosis F. Treatment: 1. Antibiotics if infected, massage, probing of the nasolacrimal system 13 mo of age 2. 95% resolve by age one; spontaneously |
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Crocodile tears is usually assoicated with what syndrome?
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Duane’s
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Congential glaucoma management plan? Pick the best answer.
a. Reschedule patient to return when ready for a feeding & repeat IOP reading in your office in 24 hours? b. Refer patient to an ophthalmologist within 1 week? c. Refer patient to an ophthalmologist to be seen within 24 hours? d. Refer patient to a pediatric ophthalmologist experienced in glaucoma surgery & management within 24 hours? |
D
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History of forceps delivery or difficult delivery usually cause what to appear?
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Descemet’s White Lines
1. Forceps injury- Ruptures in Descemet’s membrane & endothelium a. Vertical or oblique tears b. Corneal edema may be now or later c. Normal corneal diameter d. Usually unilateral |
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What will the cornea look like in a pt with congenital gluacoma?
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2. Congenital Glaucoma
a. Central splits in Descemet’s usually have parallel “rail track” pattern b. Corneal edema c. Increased corneal diameter d. Common bilateral or asymmetric |
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T/F Increased cupping in congenital glaucoma is reversible
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T
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Tearing in infants and toddlers assume __________ until proven otherwise.
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congenital glaucoma
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Differential diagnosis of Corneal Edema
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A.Forcep’s injury- Ruptures in Descemet’s
B.Congenital glaucoma C. Congenital hereditary endothelial dystrophy (CHED) – bilateral, and normal corneal diameter |
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___________- A white pupil, the presenting sign in many of the childhood diseases seen in private practice
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Leukocoria
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Differential diagnosis of leukocoria
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a. Lenticular: Cataract
b. Media: vitreous i. Retinal detachment iii. Retinoblastoma—assume until proven otherwise!!! iv. Coat’s Disease v. Toxocara Canis Granuloma vi. PHPV vii. Retinal astrocytoma—doesn’t usually cause RD viii. Retinopathy of Prematurity ix. Coloboma x. Morning Glory (1) *iv, v, and vi are the most common |
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If pt has leukocoria you must assume its ______ until proven otherwise
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retinoblastoma
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Which is the correct Management of Retinoplastoma
1. Refer to general ophthalmologist within 2 weeks? 2. Refer to general ophthalmologist within 24 hours? 3. Refer to retinal specialist within 1 week? 4. Refer to ocular oncologist within 24 hours? 5. Refer to general ophthalmologist next available appointment? |
4
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___________ is the #1 childhood malignancy, present in 1/20,000 births. Itis #1 because it is the most serious and metastasizes
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retinoblastoma
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Retinoblastoma never arises in a pt age:
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3 years 9 months
it CAN be dx after this though |
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I. Individuals at high risk for RB:
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1. Individuals with a sibling who has RB and a positive family history
2. A patient with a parent who has unilateral RB and a positive family history 3. A patient with a parent who has bilateral RB and a positive family hx |
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RB may be unilateral (__%) or bilateral (__%)
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70
30 |
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Top 2 signs of RB
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L. Signs and Symptoms of retinoblastoma
1. Leukocoria 60-70% 2. Strabismus 20% |
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Prevalence of Orbital cellulitis in pts with RB?
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0.2- 0.5%
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Shields study:
81% of children with unilateral sporadic RB require _____ if they present with obvious external findings of leukocoria, strabismus, or red eye and are detected by their family or pediatrician |
enucleation
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What causes RB?
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Disease arises from loss or mutation to the RB tumor suppressor gene (chromosome 13)
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Heredity of RB
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a. AD w/ 80-90% penetrance
b. Bilateral are usually inherited |
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________is currently the leading conservative treatment modality for RB.
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Chemoreduction
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What is Corneal Staphyloma like?
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Descemet’s membrane is missing
Cornea is enlarged, ectatic & opaque Most cases are unilateral |
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What is Sclerocornea?
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Bilateral
Asymmetrical Predominantly peripheral corneal opacification with vascularization R/O glaucoma with EUA Congenital 50% are sporadic |
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How would you explain to the parents the hereditary nature of Congential Glaucoma?
It is not always hereditary It can be AR or sporadic It can be associated with rubella It can be associated with fetal alcohol syndrome All of the above It is not always hereditary It can be AR or sporadic It can be associated with rubella It can be associated with fetal alcohol syndrome All of the above |
All of the above
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___________--> Hurler’s-like phenotype
Corneal clouding (CC) Retinal degeneration Optic atrophy 2.mild facial changes and CC |
Mucopolysaccaridosis
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C. Work –up for Unilateral congenital cataract (UCC)
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1. Prenatal hx
2. Dilated SLE 3. DFE 4. Lab studies include TORCH titers and VDRL test |
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a. Fix & follow – if child can fix and follow with one eye but not with the other than you should look to see if there is ________
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a cataract
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you can usually refract a pt with cataract to
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20/60 or better
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G. Work Up for BCC/bilateral congenital cataract
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1. Prenatal hx
2. Dilated SLE 3. DFE 4. Genetics evaluation 5. Lab studies a. Urine: i. + reducing substance: galactokinase deficiency ii. Aminoaciduria: Lowe’s iii. Hematuria, proteinuria: Alport’s iv. “maltese cross” figures: Fabry’s b. Blood i. CBC ii. Erythrocyte enzymes: galactokinase deficiency iii. Glucose: hyper/hypoglycemia iv. TORCH titers, VDRL test v. Calcium, phophorus: hypoparathyroidism or pseudo vi. Serum ceruloplasmin vii. Cholesterol pathway enzymes |
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Good postoperative VA was achieved in most healthy children with dense bilateral congenital cataracts when surgery was
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performed early(before 6-8 weeks of age)
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T/F Chronic glaucoma developed predominantly when cataract extraction was performed during the first week of life.
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T
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In children who's cataract were operated on early, by 1 month of age, VA was ____ in the better eye
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0.4-0.8
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Prognosis for UCC is most dependent of
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the compliance of post-treatment
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__________appears to be most prevalent in children undergoing cataract surgery the 14 -34th day of life.
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Aphakic glaucoma
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It would appear that the optimal time to remove dense congenital cataracts in an infant and to initiate optical treatment is when the child is ___________ of age
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4-6 weeks
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Most life threatening risk to an infant is postoperative ___ which is higher in preterm infants less than 44 post-conception weeks of age
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apnea
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What does a Lamellar cataract look like?
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3. Lamellar: Shell of an opacity sandwiched between the clear nucleus and cortex
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______ cataract
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1. Opacity of more or less the entire embryonic or fetal nucleus similar to lamellar cataract and are often not highly visually significant
Density varies from fine dots to a dense white and chalk-like, central cataract |
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Cerulean Cataract Characteristics:
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1. Blue-dot
2. Sky-blue or sea green (cerulean) hue and can be beautiful 3. Situated in the peripheral cortex a. They are often concentrated in the equatorial region of the lens 4. Variably sized dot-like shape but sometimes are elongated 5. Early onset 6. Largely stationary 7. A.D. 8. Visually insignificant, don’t cause much degradation |
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____________: Asymmetrical thinning and posterior bowing of the posterior lens capsule centrally or peripherally
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L. Posterior lenticonus
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The ___, the ___and the ____ of cataract are the most important factors
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type
location density |
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T/F Nuclear cataracts are often associated with microphthalmos
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T
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Wedge-shaped cataracts as part of a lamellar cataract; this may occur with
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a. Stickler’s syndrome
b. Conradi’s syndrome c. Neurofibromatosis type 2 d. Fabry’s disease |
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________ aka oil droplet: faint irregularity in the central aspect of the posterior cortex - difficult to see except with retro; with dietary restriction lens opacity is reversible
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Galactosemia: oil droplet
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____ cataract : green, red, blue flecks scattered diffusely through out the lens and are not visually significant
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Hypoparathyroidism, myotonic dystrophy: christmas tree
a. Xmas tree |
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Definition: benign congenital overgrowth of abnormal located tissue
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Dermoid
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Where are Dermoids usually located
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Location: usually in corneoscleral junction, IT (inferior-temporal) quadrant and may be multiple
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T/F Dermoids CAN distort contour of cornea giving astigmatism and amblyopia
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T
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Presence of a bulging, opaque cornea that protrudes through the aperture
Differentials: |
a. Congenital glaucoma
b. Peter’s anomaly c. Sclerocornea d. Corneal dermoid e. Corneal staphyloma |
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Peter’s Anomaly
Hallmark is |
absence of the central corneal endothelium & Descemet’s membrane
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N. Peters’ plus syndrome
1. Ocular anomaly plus: |
a. Short stature
b. Cleft lip and/or palate c. Abnormal ears d. Developmental delay |
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XI. Metabolic Disease
A. Types: |
1. Mucopolysaccaridosis
2. Cystinosis 3. Wilson’s Disease |
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T/F All corneal layers are symmetrically infiltrated with acid mucopolysaccharide
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T
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Work-up of MPS would include all of the following except?
Torch blood studies Radiological studies Analysis of urinary MPS and leucocyte enzymes Full systemic work-up Genetic evaluation |
Torch Blood studies
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____________:
1. Abnormal protein metabolism 2. Infantile form a. Growth retardation b. Renal failure c. Decreased skin and hair pigmentation 3. Eye findings: a. Corneal crystals may begin at 2 months of age b. Start anterior and move posteriorly c. Pigmentary retinopathy d. Photophobia e. SPK & recurrent erosion f. Seldom decreased VA g. Defect in lysosomal transport h. Accumulation of cystine in lysosomes i. Glaucoma may occur due to crystal accumulation |
Cystinosis
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___________ dystrophy
A. AD B. Evident at a few years of age C. Progresses to stromal haze in twenties with possible decrease VA |
Central crystalline Schnyder’s
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__________ bilateral GOLD COPPER (can be greenish-brown) peripheral band 1-3mm in width at the level of Descemet’s membrane. The band extends to the limbus and is most prominent in the vertical meridian.
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D. Diagnosis: Kayser-Fleisher ring
E. Causes: 1. Wilson disease and other liver disorders 2. Multple myeloma 3. Carotenemia |
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7. Wilson’s disease may be associated with?
a. Sunflower subcapsular cataract b. Recurrent corneal erosions c. Increased lipid levels d. Corneal clouding e. Mucopolysaccaridosis |
A
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T/F With Wilson's Disease, if not treated leads to permanent brain damage
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T
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T/F congenital hereditary endothelial dystrophy is usually unilateral
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FALSE
Bilateral |
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If child has Arcus workup for ?
1. Monitor in one year- this is a normal variaition 2. Chech urine levels for copper 3. Check urine levels for diabetes 4. Check plasma lipid levels 5. Check calcium levels |
Check plasma lipid levels
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In what layer does arcus occur?
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the Stroma
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2. Retinopathy: OD had no retinoscopic reflex while OS was +2.50-1.25x090.
3. SLE revealed total cataract OD and shallow anterior chamber, normal OS 4. DFE revealed brownish ciliary processes. (brown little bumps) 5. Externals: palpebral aperture is smaller, OD smaller than OS. OD appears microphthalmic 9. A scan: OD: short anterior-posterior diameter OS: normal 10. B scan: OD: retrolental mass and persistent hyaloid remnants. OS: WNL H. Diagnosis: |
Persistent Hyperplastic Primary Vitreous
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T/F Persistent Hyperplastic Primary Vitreous is usually unilateral and the affected eye is usually microphthalmic
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T
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Leukocoria that occurs when pt has Persistent Hyperplastic Primary Vitreous is due to
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the retinal detachment
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Toxocara canis is a parasitic infection transmitted
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through dog feces and sometimes from undercooked meat (non-genetic basis for the disease)
2. The parasite is generally obtained through eating dirt |
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T/F Toxocara canis is a bilateral disease
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F
Toxocara is usually unilateral in its presentation, even though it is a systemic disease! |
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A. Toxocara endophthalmitis is most often confused with RB because
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1. Complete RD
2. Absent red reflex B. TOXOCARA 1. Severe cellular reaction 2. Synechiae & cataract common C. RB 1. No severe cellular reaction 2. Synechiae & cataract rare in RB |
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How is Toxocara endophthalmitis different from RB?
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B.TOXOCARA
Severe cellular reaction Synechiae & cataract common C. RB No severe cellular reaction Synechiae & cataract rare in RB |
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____________________ is a benign, congenital tumor with stable or slow growth, usually on or near the optic nerve head.
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astrocytic hamartoma (AH)
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____________may be associated with the following:
a. Café au lait spots b. Ash leaf spots c. Shagreen patches d. Butterfly pattern nodular/papular lesions/rash On the nose and cheeks (adenoma sebaceum) e. Tuberous sclerosis |
Astrocytoma
(50% of patients with TS have AH) |
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____ is one of the most common causes of severe visual impairment in childhood
1. In the US, ___is the second most common cause of childhood blindness |
ROP
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Birth weight – this is the #1 risk factor: the lower the birth weight, the higher the risk for ___ - TEST QUESTION!
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ROP
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The classic lesion of acute ROP:
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an arteriovenous (AV) shunt clinically seen as a gray, white, pink or red demarcation line between vascular and avascular tissue
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Pathognomonic lesion of acute ROP:
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; Demarcation line between vascularized & avascular retina. The more posterior & more circumference the worse the prognosis
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Types of Nystagmus
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A. Congenital Nystagmus
1. Pendular 2. Jerky 3. Mixed |
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XII. SLO FUN (KNOW for test!)
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A. S = Symptomless
B. L = Latent component C. O = OKN inversion- drum dampens nystagmus 1. If you have a right-jerk nystagmus, movement will decrease if the drum rotates to the left. D. F = Fixation: fixation exaggerates the oscillation – when they fixate a distance target E. U = Up gaze: up gaze never converts to vertical nystagmus – should not convert from horizontal to vertical – sign of a neurological problem F. N = Null point: point where movement is minimized |
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antiepileptics are known to cause
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nystagmus
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3 types of nystagmus
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pendular, jerk, combination
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Jerk NYstagmus characteristics
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2. Jerky
a. Fast & slow phase b. Slow = pathologic drift c. Fast = corrective saccade d. Named after fast phase |
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Latent nystagmus is usually associated with what kind of stabismus?
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ET
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T/F congenital nystagmus can present both unilaterally and bilateraly
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FALSE
always bilateral |
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T/F Congenital nystagmus is always better at near vision and is always symmetrical
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T
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CONGENITAL ______nystagmus is equal in velocity in both directions
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PENDULAR
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T/F Congential Jerk Nystagmus tends to have a better VA and prognosis than pendular
|
T
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Acquired jerky is almost always associated with ________ lesions
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neurological
ASSUME …Posterior fossa lesion |
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_____________ syndrome features nystagmus dampened by convergence, leading to esotropia.
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Nystagmus-blockage
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NEUROLOGIC PRESENTATION of NYstagmus
VCR |
1. V - vertical conversion
2. C – chiasmal signs 3. R – lack of reversal in latent nystagmus |
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____________can slow down nystagmus, has allowed some patients the ability to drive. It only lasts a few months, so pts need repeat injections
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Botulism
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XXI. ACQUIRED NYSTAGMUS IN INFANCY
A. 2 Types in children: |
1. Spasmus nutans
2. SEE-SAW |
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Spasmus nutans Triad
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i. Aquired Nystagmus
ii. Head nodding iii. Anomalous head position |
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Patients presenting with ________ should undergo MRI to rule out glioma if evidence suggests an anterior visual pathway or hypothalamic disease.
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spasmus nutans
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In aquired see-saw nystagmus we see
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2. SEE-SAW
a. One eye elevates and intorts b. Other eye depresses and extorts |
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Typical onset of spasmus nutans
|
The age range for spasmus nutans is 6 months to approximately 3 years old
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ACQUIRED JERKY NYSTAGMUS IN INFANCY is known as
|
Periodic alternating nystagmus (PAN)
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|
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Oculomotor dysmetria
is the inability to |
fixate a target
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Parinaud’s Retraction Nystagmus is a paralysis of
|
up gaze
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Gliomas-- #1 cause of
|
optic atrophy
|
|
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b. DM (center of disc to center of macula) / DD (disc diameter)
i. Greater than 3 mm suggests ___________ |
ONH hypoplasia
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2. Sensory lesions associated with congenital pendular nystagmus include all EXCEPT:
A. Lebers Congenital Amourosis B. Achromatopsia C. Glioma D. X-linked Congenital Stationary Night Blindness |
c
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7. Irlen lenses appear to:
a. Change a person’s ability to accommodate b. Change how long a person could read c. Make individuals read better d. Improve color vision |
B
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8. A 10 year old child has been diagnosed with a non-verbal learning disability. You would anticipate she would have difficulties in:
a. Word decoding and spelling b. Verbatim memory and mathematics c. Mechanical arithmetic and spelling d. Reading comprehension and Science |
d
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9. A 7 year old boy was found to have an auditory processing deficit. You would most likely anticipate problems in what aspect of his WISC-IV IQ Test?
a. Working memory Index b. Processing Speed Index c. Verbal Comprehension Index d. Perceptual Organization Index |
c
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12. You receive a psychoeducational report on an 11 year old child with the following subtest scores:
• Similarities = 8 • Word reasoning = 7 • Block design = 11 • Digit Span = 8 • Coding = 10 Based upon this information you can deduce that: a. there is probably a visual organizational problem b. there is a probable problem in processing speed c. you should perform a developmental eye movement test based upon these results d. there is unlikely to be a visual processing problem |
d
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13. Good socialization skills, a flat occiput, soft straight hair and iris hypoplasia are seen in which of the following:
a. Trisomy 21 b. Trisomy 18 c. Cerebral Palsy d. Fetal Alcohol Syndrome |
a
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14. PEA stands for:
a. Perennial epicanthal agenisi b. Prenatal Exposure to Alcohol c. Peripheral Exposure to Alcohol d. Persons Exposed to Alcohol |
b
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15. Individuals with which 2 conditions would be “friendlier” than normal to strangers:
a. Cerebral Palsy and Fragile X Syndrome b. Fragile Y Syndrome and Trisomy 21 c. FAS and Cerebral Palsy d. FAS and Trisomy 21 |
d
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17. An example of a Visual Perceptual Test that has strong input from the Transient Visual Processing System is:
a. Beery Test of Visual Motor Integration b. Wold Sentence Copy Test c. TVPS Test of Visual Discrimination d. Ayres Southern California Right/Left Discrimination Test (or Piaget Test of Right/Left Concepts) e. A test of Auditory Analysis Skills |
d
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A 4 year old child presents with the following:
20/70 VA at distance OD 20/60 VA at distance OS 20/20 VA at near OD, OS Cover Test: (without correction) ortho at distance, 10 EP at near Refraction: OD -3.00 = -.50 x 180 OS -2.50 = -.25 x 170 You should: A. Not prescribe at this time as the visual acuity is still within a normal level and the refractive error is not significant for this age. B. Prescribe –2.50 OD and –2.00 OS without the cylinder C. prescribe ½ of the RX & ask the child to remove the glasses for close work D. Prescribe the full distance RX along with a bifocal |
d
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19. A 5 year old child presents with a chief complaint of letter and word reversals. You test the child and find that they are making reversals and don’t even know their left from their right hands!! This indicates:
a. The child has delays in laterality and directionality b. The child has delays in directionality only c. The child has delays in laterality only d. These observations may be normal |
a
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19. A 5 year old child presents with a chief complaint of letter and word reversals. You test the child and find that they are making reversals and don’t even know their left from their right hands!! This indicates:
a. The child has delays in laterality and directionality b. The child has delays in directionality only c. The child has delays in laterality only d. These observations may be normal |
a
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