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Tales from the Crib; 7 Infant Case Reports

Optometry’s Meeting 2016, Boston

NOTHING TO DISCLOSE

John ‘JT’ Tassinari OD FCOVD

Diplomate Binocular Vision Perception Pediatric Optometry Section Amer Acad Optometry

Assoc. prof Western Univ Health Sciences College of Optometry, Pomona CA

jtod@sbcglobal.net

1. CR age 13 months

Original chief concern (age 11 mos): Crossed LE

Pediatrician referred to P-OMD: no esotropia (ET) needs SRx

Parents seek 2nd opinion from JT

Presenting Concerns:• Why glasses? “He sees fine”• Why no ET “look, his LE is crossed, isn’t it?”

Additional HX• Bad experience with OMD • Records request failed. SRx not filled• Healthy. Normal pregnancy, birth, delivery, development

CR age 13 mos Exam Results

VA: Fix & Follow & Resistance to Occlusion UTT

Kappa/Hirschberg: normal, no strabismus

Unilateral Cover Test (UCT): no strabismus

Dry Retinoscopy plo -100 090

+300 -100 090

Bruckner Test - unsure

Posterior Seg eval and cycloplegia - impossible

Fix and Follow Visual Acuity Test. A monocular pursuit test. Examiner judges quality of pursuit

• Monocular

• Test Target: small and silent

• Test Distance: 15cm - 25cm

• Show target to baby & cover 1 eye

Does she fixate (“fix) it? Then move it.

Does she follow it?

• If yes to both questions, baby passes test.

• This test is also a unilateral cover test and motility test

CR age 13 mos. Assessment

• PSUEDO ET

• 3D Hyperopic Anisometropia – amblyiogenic

• Sub-optimal refractive measurement

• Inconsequential astig(-1.00 @ 90 e.e.)

• Incomplete exam

Psuedo Esotropia

• An illusion that esotropia is present. Common

• Etiology: < normal and/or ≠ visible white sclera

• Anatomical features that cause

Prominent epicanthal folds

wide flat bridge

narrow IPD

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CR age 13 mos. PLAN

• Parent Ed re Psuedo ET

• Recommend cycloplegic / DFE with ointment

• Explain necessity of SRx

• Explain why patching will not cure hyperopia LE

Parents forbid cycloplegiaProceed with SRx ft wearOD Plano DSOS +3.00 DSRTO 1 month

CR age 18 mos.

Hx: SRx (& patching) failed “he just takes ‘em off”

Fix & Resistance to Strab

Follow Occlusion R’Scopy tests

OD pass ‘fail’ -.25 Plo neg

OS fail FAIL +275 +3.25

A: Aniso Hyperopia Amblyopia OS

P: 1. atropine penalization of OD – rejected by parents

2. Try SRx again. Put glasses on while CR is sleeping

HRx plano DS+3.00 DS

• Dr. sits near child. Become boring

• Assistant gains child’s visual interest and attention in a small toy, preferably 2 – 4 meters away

• Surreptitiously cover 1 eye

• Does baby resist the cover or lose interest?

• If yes, baby may have poor vision with eye that is uncovered. Test is a fail for the uncovered eye.

Resistance to Occlusion VA Test(Unilateral cover test at far with judgement of monocular fixation)

CR age 22 month cling to Dad refuse to leave waiting room R

Hx: 5-15 hours of SRx per week Occlusion impossible

HRx Over-Ret MEMOD PLODS -0.25DS -.25DSOS +3.00DS plo +.50 plo +.75

Fix/Follow Test Resistance to Occlusion VAOD normal OD normalOS fail OS fail

A

• Hyperopic Aniso, probably > 3.00 D, SRx sub-optimal

• Amblyopia LE

P

• Reccomm cyclo refraction. Atropine ung each eye the night before exam. Parents agree. 1 week later….

Cyclo +1.50DS Upgrade SRx to Plano DS

Ret +5.50DS +4.00DS

C R. Age 22 mos. A & PCooperative CR. Age 3; 1

• Past 3 mos, SRx 1 – 30 hours/week, no occl

• Best VA (Broken wheel test) OD 20/25

OS 20/80

• Stereo: maybe Color V: normal each eye

• Over scope & MEM: HRx Good

• Plan: Aim for ≥ 30 hours every week of SRx ON

Occlusion 15 hours / week

HRxPlano DS+4.00 DS

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Follow-ups: Good Compliance w FT SRxno occlusion

AGE VA LEFT EYE

3; 7 20/ 60 Broken Wheel

4;4 20/40 “ “

5;0 20/40 H O T V Definite random dot stereo

5;6 20/30 H O T V 5 point (RS25) Near Numbers

• Wears SRx just about full time indoors. 100% for school. Never did occlusion

• 20/25+ 2/6 Full Chart BCVA Left Eye. Near VA Left Eye: RS20

• Normal Stereo, no suppression. Normal vergence skills. SR stable

Mature, advanced reader, well coordinated, friendly CR. Age 6 years, First Grade

Reflections /Qs/ Lessons

• If no pseudo ET, CR probably not diagnosed until age 4 - 5

• Cycloplegia important

• Part time wear of (incorrect) SRx from age 1-2 then FT age 3-5 years, w/o occlusion, sufficient

• Variables: aniso onset & his neuroplasticity

• Brief Case Hx at age 18 – still aniso and still 20/20

2. JH, 6 weeks Recalcitrant NEONATAL

CONJUNCTIVITIS

• Red RE Onset: birth Today: Red “way worse”

• 1. Erythro ung TID 2. Gentamicin drops TID

• +mucous +mattering• DDx:

1. Resistant ordinary Bacterial Conjunctivitis

Gram Neg: Erythro ineffective / Gent resistance common

2. Toxic conjunctivitis due to gentamicin

3. NOT ordinary Bacterial (uh-oh)

Neonatal Infectious Conjunctivitis

Conjitis acquired during birth Neonate with Conjitis

Ordinary

Pathogen is from Sexually Transmitted Disease Nosocomial

(Neonate = age 0 – 1 month)

Hospitalization, swab, culture, probably needs oral antibiotics

Should respond to additional application of the prophylactic antibiotic (erythro ung) or polytrimdrops

Ordinary bacterial neonatal conjunctivitis

• mild visible inflamm +mucopurelence

• Classic crusting/mattering upon awakening

• G+: Staph , Strep

G-: E Coli, Haemophilus, moraxella

pseudomonas (rare)

• Readily respond to antibiotics

erythromycin ointment G +

polytrim drops G+ G-

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Neonatal Conjunctivitis, timing

Onset Likely etiology

Birth - 12h Toxic

Birth + 2-3 days n gonorrhoeae bacterial

> 3 days non-gonococcal bacterial

6 – 14 Days Chlamydial Herpes Simplex

non-gonocc bacterial

Neonatal Conjunctivitis Clinical presentation

Etiology Presentation .

Toxic early, mild, minor discharge, serous <> thick

Ordinary Bacter mild thick white discharge minor redness.

classic mattering after nap/sleep

Gonococcal hyperacute, bilateral re chemotic conj. copious

discharge. Lid edema

Chlamydial serous progressing to mucopurulent discharge

eyelid edema, red tarsal conj (no follicles),

pseudomembranes may form, uni or bilateral

H Simplex serous discharge, mild conj redness, + dendrites

Unresponsive to ordinary antibiotics. Mother has the STD

JH, 6 weeks Recalcitrant Conjitis

• Red RE Onset: birth Today: Red “way worse”

no photophobia

• Erythro ung TID Gentamicin drops TID

• +mucous +mattering eyelid red, swollen

• Tx: 1. D/C Gent.

2. Cont Erythro ung

3. Add Polytrim drops

4. Add Ocusoft pads

Complete cure 4

days later

3. KG, small baby w small optic nerves

• Well V Exam, InfantSEE. No concerns

• 3 older siblings

• Age 7 mos, KG looks small, age 4-5 mos

• “All my babies start out small”

• BIO and direct oscope views, optic discs look small

• Exam o/w normal, incl visual function

Bilateral Optic Nerve Hypoplasia

• Due to reduced number of retinal ganglion cells / optic nerve fibers

• Wide range of severity

Mild Severe

Normal Visual function Blindness

• Bilateral: abnormally low growth hormone

3. KG, small baby w small optic nerves

A: Mild bilateral optic nerve

hypoplasia

P: Refer to pediatrician, advise r/o of

low growth hormone

Outcome: Pediatric endocrinologist, HGH Rx

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4. AT, age 6 mos. High Refr

Infant Ametropia Algorithm

No Concern Concern Problem

Hyperopia < 3.25 3.50 – 5.00 > 5.00

Myopia < 1.00 >1.00 ---

Astigm <2.00 2.00-3.00 >3.00

Aniso <1.00 1.00-2.00 >2.00

No Concern Concern Problem

Hyperopia < 3.25 3.50 – 5.00 > 5.00

Myopia < 1.00 >1.00 ---

Astigm <2.00 2.00-3.00 >3.00

Aniso <1.00 1.00-2.00 >2.00

Repeatable: Rule of 3s. 3x 3 mos apart. Months apart can vary based on case. High hyperopia, shorter. Aniso and astig - longer

See at age 3 years

Follow every3 – 6 months

If repeatable, prescribe

4. AT, age 6 mos. F (Mom is patient x 20 years)

• Presents with 0 concerns. Well V Exam, InfantSEE.

• Healthy Normal Pregn & Birth

• Eye Contact, Visually Guided Reaching, Motor NL

• No strabismus per Kappa/Hirschb & Cover Test

• Versions full Pupils Normal

• Fix and Follow ok, but not great each eye

• Resistance to occl: OD = OS

Cornea ReflectionFact: The dot of light reflected by the cornea from a point light source is usually not in the exact center of the pupil.

Why? The pupillary axis and visual axis are usually not coincident

Pupillary axis = an imaginary line that is perpendicular to plane of iris.

Testing for Strabismus withAngle Kappa and Hirschberg Tests

Angle KappaThe angle subtended by the intersectionof the visual axis and pupillary axis.

Kappa TestA monocular test. Patient looks at light.Method – Determine location of CR in the pupil zone.Is it in the exact center? Is it 1mm nasal from center? Temporal?

Angle Kappa & Kappa Test Kappa, a monocular observation

Typical Result

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Hirschberg Test for Strabismus

• Room lights dim, both eyes open

• Shine a point light source at baby

• Compare dots of light that are seen against dark background of pupils.

• Are they in the same place?

Yes: no strab,

No: strabismus

Nearpoint Retinoscopy, Baby

High Hyperopia (≥ 350)per Cyclo

Lag at near

High, more concern

Low, (<1.25D) less concern

AT, age 6 mos Retinoscopies

Distance (dry) Near

OD +2.00DS +1.00 ↔ +2.00

OS +2.50DS +1.00 ↔ +1.50

Cycloplegic Retinoscopy w 1.0% cyclopentalate

OD +7.00DS

OS +7.00DSNo Concern Concern Problem

Hyperopia < 3.25 3.50 – 5.00 > 5.00

AT, Age 6 Months

• Hyperopia each eye (7.00D) well outside of normal range. “Problem” No Strab at this time

• + Risk for Strab Ambly Delayed Developm

• Plan:

No Concern Concern Problem

Hyperopia < 3.25 3.50 – 5.00 > 5.00

Problem: If repeatable, prescribe. Cut full by 2.50DRepeatable = “rule of 3s”

AT, Age 6 Months

• Hyperopia each eye (7.00D) well outside of normal range. No Strab at this time

• + Risk for Strab Ambly Delayed Developm

• Plan:

1. Re-examination 1 month to for repeat finding.

2. Parent Education, emphasize esotropia

3. Home guidance, heavy visually guided motor

4. Answer multiple intense Qs from parents

Hyperopia Future

AT,

age 6 mos 7mos 9mos 12mos

+7.00DS +7.00DS +7.00DS

+7.00DS +700DS +7.00DS

+6.00DS +5.00DS +4.00DS+6.00DS +5.00DS +4.00DS

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(AT, age 7 ½ mos)

• Pediatrician refers to Ped OMD

• Ped OMD prescribes +7.00 -.50 180 each eye

• Ped OMD disagrees with my plan to refrain from SRx, cut plus, and Home VT

• Parents do not fill SRx, return to my office

AT Age 9 months

• “We want you to know we didn’t come last month because we had to get a 2nd opinion”

• Near Retinoscopy 1.00, 1.50 lag each eye

• Hyperopia Unchanged (7.00D each eye)

• SRx prescribed +4.50DS OU

• 2 months later: good compliance. “she is more active”

5. BB, 6mos F

Dry +350 -325 010Ret +350 -325 170

Cyclo+450 -300 010+450 -300 170

“Ametropia outside normal range”“Near VA per fix and follow a bit weak”Plan: Refrain from SRx. Emmetropization possibleRTO 3 mos. Home guidance

No concerns. Mom following advice for well vision exam at age 6 months.

Emmetropization

An active process whereby the axial length of the eye, Lens, and Cornea grow/change by a marked degree toward emmetropia.

5.BB age 6mos F+450 -300 010+450 -300 170

3. AT age 6mos F+700DS+700DS

6. LF age 6 mos M+5.50 -1.50 180+2.50 -.50 180

Emmetropic Adult Eye (60D, 23mm)

43D

23 mm

17D

Emmetropic Adult Eye (57D, 24mm)

43D

23 24mm

17D14D

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Emmetropic Adult Eye (61D, 22.7mm)

43 44D

23 22.7mm

17D48D 43D

43

17mm 85D 23 mm 60D

17D

Newborn vs Adult Eye85D 60D

37D

-.75 +2.00D +4.75

normal bell curve peaked bell curve

48D 43D

43

17mm 85D 23 mm 60D

17D

Newborn vs adult Refractive status

37D

Emmetropization

Lens: Thins & flattens by amount X

Cornea: Flattens by amount Y

(and spherocizes by amount ‘K’)

Axial length: grows by amount Z

to match X + Y

Emmetropization Science

• Animals wear minus lenses inducing hyperopia..

axial elongation ramps up, increases.

• Animals wear plus lenses axial elongation slows/halts

• Humans: Neonates with high hyperopia emmetropize (grow) more than neonates close to emmetropia*

• Neonates with high astig have more astig decrease than Neonates with low or no astig* (!)

* Saunders KJ et al. V Res 1995 N=22Erlich et al Optom V Sci 1997 N=254

Emmetropization Science, Human eyes w compromised input

Disease Condition Eye response

Congenital cataract

Corneal opacification

Ptosis axial elongation

Vitreous Hemorrhage

ROP

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Emmetropization Science, myopic babies*

3,166 infants > 47 myopes

Age 8 mos (n=47) Age 3 years

mean: -.53D +.61D

range: -2.25 -.50 -.75 +1.62

Greatest change: age 2 – 3 years

7 (15%) remained myopic (.25 - .75)

(No biometry)* Erlich DL. V Res 1995

Emmetropization, future science

Diagnose high hyperopia or aniso early in life

Plan: Prod axial elongation with xyz

Diagnose progressive myopia 2/2 axial elongation

Plan: Shut down elongation with the reverse of xyz

BB, age 3 years. Feb 2016 Frequent blinking

Unaided V AcuityOD: 20/20OS: 20/20Method: Lea symbols at 10 feet

Cyclo Ret+1.00 - .50 180+1.00 - .50 180

(Cyclo Ret at age 6 mos)+4.50 – 3.00 010+4.50 -3.00 170

A: Normal vision

Blepharitis

P: Lid scrubs ocusoft baby

Phone call 1 week later – blinking gone

6. LF age 6 mos, F

• No concerns Healthy Normal Devel

• FEH: Dad anisomyopia

• Fix & Follow

OD – Fail

OS - Pass

• Resistance to occlusion: Fail RE

• Bruckner Test: OD whiter/brighter - Fail

Bruckner Test

Qualitative judgement regarding eye alignment and anisometropia

Method:

Room lights dim. Pre-Dilation

Direct ophthalmoscope 50 cm away. +1.00 in o’scope –large spot size- encompass and look at both eyes.

Interpretation: Whiter brighter eye = abnormal

could be strab or aniso

LF Age 6 months F

Fix & Follow OD – Fail OS - Pass

Resistance to occlusion: Fail OD

Bruckner Test: OD whiter/brighter – Fail

CYCLOPLEGIC RETINOSCOPY

OD +5.50 -1.50 180

OS +2.50 -.50 180

Sph EquivOD +4.75OS +2.25Aniso = 2.50D = Problem

(>2.00D)

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LF, Age 6 mos A & P

A: Amblyogenic Anisometropia 2.50D, “problem”

Amblyopia OD per F&F and R to Occl tests

P: Refrain from SRx

1. Repeatable?

2. Emmetropization possible

Recommend re-eval in 6 weeks

Visually guided activities, including monocular (cover LE)

LF Age 9 months

Age 6 mos Age 9 mos

Fix & Follow: OD – Fail

R to occlusion: OD-Fail

Bruckner:

Cyclo

Ret

+5.50 -1.50 180

+2.50 -.50 180

OD - Pass

OD - Pass

OD brighter OD=OS

+3.00 – 1.00 180

+2.00 - .50 180

LF: Optical change OD in 3 mos

Age 6 mos Age 9 mos

Hyperopia 4.75 D 2.50D

(sph equiv) (2.25D reduction ! Wow!)

Axial Length: increased .75mm wow

7. JP Marked Esotropia. Age 5 mos

• “We don’t want our baby to have the surgery.

Will vision therapy help?”

• Onset: age 3 mos.

• 2 exams with Ped OMD

- No glasses needed

- Eye muscle surgery planned at age 6-12 mos

• Tobacco use for first 1-3 weeks of pregnancy. All else normal (birthweight etc)

Magnitude Variable?Mom: No Dad: YesPedOMD: (no records)

JP, age 5 mos exam

• Obvious constant esotropia

• Unilateral Cover test: reluctant/unable to abduct uncovered eye

• Magnitude per krimsky method: 30-40^BO

• Centration point: 4-7 cm

JP, age 5 mos exam (cont)

• Vision: fix & follow pass each eye but abduction very difficult.

• Normal abduct: yes (r/o Duanes, 6th nerve)

• Resistance to occlusion: Pass each eye

• Cyclo Ret: +150 – 75 180 each eye

• DFE: neg (r/o sensory strabismus)

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JP, age 5 mos A & P

A: Infantile constant 30 – 40^ esotropia with:

1. cross fixation

2. minor, non-contributory accomm/hyperopia

component

3. magnitude slightly variable today

P: Home VT, parent education about possibility of no benefit. RTO 1 month

Esotropia early in life (first 6 months)

Smaller angle (<20), variable, intermittent. Gone by age 2 months. common

Accommodative Esotropia: rare. SRx for hyperopia cures it.

Neurodevelopmental or disease based ET

Infantile Esotropia: 1%

Infantile Esotropia

Onset first 6 months of life

Non-accommodative

Usually Large angle 40 – 50 diopters

Associated findings: DVD, OAIO, Latent Nystagmus

Current standard of care:

Follow until deviation is stable or spontaneous

resolution. If no resolution, eye muscle surgery (EMS).

EMS usually at age 6 – 12 months

Majority need EMS

Infantile Esotropia: longitudinal course and outcome

Rate of spontaneous resolution

Intermittent: 50 - 70%

Constant w variable magnitude: 30 - 40%

Constant w unchanging magnitude 10%

Constant + unchanging + large (>40) 1-2%

+ unchanging across 2 visits

Will JP need EMS? Probably

Likelihood of spontaneous resolution

Good Bad

Intermittent Constant

Small (<30) Large (>40)

Variable at exam Unchanging

Variable across exams Unchanging

JP, Home VT

• Alternate almost full-time occlusion. While occluded:

Saccade, pursuit, accomm activities. Emphasize temporal periphery and temporal gaze (abduction)

• With both eyes open:

Repetitive pattern blanket on the floor and/or

over the crib (binocular stimulation)

Binocular pursuits and reaching at centration range

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JP, follow-up

• Phone Call 1 week later: “it seems better. we are doing the home VT and patching”

• Age 6 ½ months: Esotropia gone.

References for treating infantile esotropia with methods mentioned in lectureChristenson GN, Rouse MW, Adkins DA Management of Infantile Esotropia. J Amer Optom Assoc 1990;61 (7): 559-72

Forrest EB. Treating Infant Esotropia: A Case Report. Amer J Optom & Physio Optics 1978; 55 (7) 463-465

Reading References

Visual Development, Diagnosis, and Treatment of the Pediatric Patient. RH Duckman

Principles and Practice of Pediatric Optometry

AA Rosenbloom & MW Morgan

Your Child’s Vision. A Parents Guide to Seeing, Growing, and Developing. RS Kavner

Yackle K, Fitzgerald DE. Emmetropization: An Overview

J Beh Optom 1999; Vol 10 (2): 38-43