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“The Institute of Optometry is unique in being an independent self-financing charity dedicated to

the promotion of clinical excellence, research, and education in optometry.”

Roberson (1989)

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OPTOMETRY FOR CHILDREN:

SAFE PRACTICE

Prof Bruce EvansBSc (Hons) PhD FCOptom FAAO FEAOO FBCLA DipCLP DipOrth

Director of Research Institute of Optometry

Visiting Professor City University

Visiting Professor London South Bank University

Private practice Brentwood, Essex

References

Pickwell’s Binocular Vision Anomalies, 5th Edition, Elsevier, 2007

Best practice or safe practice?

Average can be defined as a point

or as a rangeIf a point, then 50% of

practitioners are below average

Easiest to consider ranges

C.Optom guidelines described as

“good practice”

Presentation today describes

average (typical) range & unsafeaverage

expert

best practice

average

range

unsafe

just reasonably

competent

good

below average

but OK

unusual, may

be unsafe

best

C.Optom

guidelines

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Thoughts on “below” or “seriously below” the standard required

Typical \ Reasonable Safe Maybe unsafe Definitely unsafe

Performed by large body of optometrists Meets standard Meets standard Below standard

Unusual, but not exceptional Meets standard Depends on details Below standard

Exceptional: will not be found in everyday

practice

Meets standard Below standard Seriously below

standard

PLAN

AVAILABILITY OF OPTOMETRIC EYECARE

OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE

SOME COMMENTS ON OPTOMETRIC RECORDS

CONCLUSIONS

Full handout from: www.bruce-evans.co.uk

Research on quality of care in

optometric eyecare

Rakhee ShahResearch Fellow Institute of Optometry

Post-graduate student City University

Bruce EvansDirector of Research Institute of Optometry




David EdgarProfessor of Clinical Optometry City University

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Plan

Study 1

A telephone survey to assess the availability of

state-funded eye care in the UK

Study 2

The use of standardised patients to assess the

content of optometric eye examinations in the

UK

Study 3

The use of computerised clinical vignettes to

assess the content of optometric eye

examinations in the UK

Child scenario: questions

1. At what age do you start testing kids? My son is one year old.

2. We have a family history of "lazy eye"/"squint". Should he have an

eye test?

If answer to question 2 is YES, then proceed to 3; if no to 4,5,6.

3. Can it be done at your “opticians”?

If answer to question 3 is NO, then proceed to 4, 5, and 6.

4. At what age should he have an eye test?

5. What should I do if I see his eye turning?

6. Is there anybody you can recommend I may able to contact/visit?

If answer to question 3 is YES, then proceed to question 7.

7. Will I be paying for the consultation? How much?

Child scenario: results

At what age do you start testing kids?

Mean 3.1 years (Shah, Evans, Edgar; 2007)

[c.f., C.Optom survey (2008): 76% of optoms test younger than 3y]

We have a family history of turn. Should he have an eye

test & can it be done there?

Proportion Examine

there

Exam.

elsewhere

No exam.

Total

sample

46% 30% 24%

Non-

London

48% 31% 21%

London 36% 21% 43%

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General discussion: ethics

NHS GOS regulations:

DoH argue that optoms cannot exclude a category of px

GOC standards of practice:

“Recognise and work within the limits of your scope of

practice, taking into account your knowledge, skills, and

experience”

Joint document on children’s eyecare by

C.Optom, R.C.Ophthalmol., BIOS:

Appropriate skills & expertise before managing any child

Those who do not spend a significant proportion of their

time in management of children discouraged from

participation in children’s eyecare

General discussion: ethics

Only 7% of children aged 0-5y visit optoms

Guggenheim & Farbrother (2005)

Many optoms may lack experience

Situation even more serious for people with

intellectual disabilities

PLAN


OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE


CONCLUSIONS


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Ocular health

Ocular pathology very rare in

children

With pre-school, optometrist

unlikely to get more than a

glimpse

Pupil reactions possibly, usually

not recorded

May see more with dilation

Limited view of retina not justification by

itself for dilation

Visual fields rarely tested in

children

Intraocular pressure almost never

tested in children

PLAN


OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE


CONCLUSIONS


Visual acuity: overview

Macula is poorly developed at birth

Large variation in rate of development

Results vary with different test methods

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Visual acuity: grating preferential looking

Teller or Keeler or Lea

Suitable from birth

Not good at detecting strabismic amblyopia

Visual acuity: Cardiff cards

Vanishing optotypes suitable from 6 months

Binocular readings possible for 96% aged 12-36 months

Adoh and Woodhouse (1994)

A “game” that children enjoy

Poor at detecting strabismic amblyopia

In 1998, only c. 12% had this test

In 2008, 29% said used always or sometimes with pre-school children

Visual acuity: letter matching

Most common in 1998: Sheridan Gardiner

Good practice

Glasgow Acuity Test

Sonksen Silver or revised Sheridan Gardiner

Cambridge cards

Best: crowded singles with Test Chart 2000

Possible from c. 2.5 years

2014: 75% optoms using computerised chart

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Visual acuity: near charts

Thomas the tank engine

Institute of Optometry near test chart

Many others

?child-friendly charts rarely used

Visual acuity: “better than nothing”

Reaction to occlusion

10∆ up one eye

Should alternate freely

Norms vary with test type

(Evans, 2007, Pickwell’s Binocular Vision Anomalies, Elsevier)

minimum normal acuity for age (months)

method 1 3 6 12 24 36 48

vertical prism test with 10 ∆ up one eye, should alternate freely

grating preferential looking (Teller, 1990) 6/180 6/90 6/30 6/24 6/12 6/6 6/5

Cardiff cards (binoc.; Adoh & Woodhouse, 1994) 6/48 6/15 6/12 6/6

Cardiff cards (monoc.; Adoh & Woodhouse, 1994) 6/38 6/19 6/12

Tumbling E 6/42 6/15 6/15 6/12

Snellen chart letter matching 6/12 6/9

PLAN


OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE


CONCLUSIONS


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Refraction: Basic minimum

Are the retinoscopy reflexes

symmetrical and no large refractive

errors?

Be adaptable about working distance

Hold trial lenses with infants

Fixation target is anything that will

attract their attention, ideally Test

Chart 2000

Refraction: cycloplegic

Textbook indications for cycloplegic:

Symptom of intermittent esotropia (SOT)

Sign of esophoria or esotropia

Unexplained poor visual acuity

Unexplained symptoms

Variable or suspicious Rx

When should a reasonably competent optometrist carry out a cycloplegic?

In pre-school child when esotropia or significant hypermetropia

Refer if under 3 months and needs cycloplegia

Most optometrists would probably refer if under 1 year

Refractive error: normal development

At birth +2.00 DS (SD = 2.00 DS)

very variable in first year

On average, hypermetropia decreases rapidly during the first year to a mean level of about +1.50 D at age one year

High astigmatism in first year often reduces

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Refraction: norms

Nearly 75% of children with esotropia &/or amblyopia have a significant Rx

myopia, hypermetropia (2.00), anisometropia (1.00), astigmatism (1.50)

North American guidelines (Leat, 2011), in UK suggestions from Evans (2007, Pickwell’s Binocular Vision Anomalies, 5th edition)

age

(months)

refractive errors probably require correction if stable and:

N.B.., better prognosis if Rx is reducing and non-cyclo ret<< cyclo ret. If Rx more than half the values below then monitor

1-6 (refer) > +6.00 DS > -5.00 DS > 6.00 DC hypermetropic anisometropia > 2.50 DS/DC

6-9 > +4.00 DS > -5.00 DS > 4.50 DC hypermetropic anisometropia > 2.00 DS/DC




PLAN


OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE


CONCLUSIONS


Orthoptics: tests of alignment

Cover test: the gold standard

Should be at least attempted & recorded

Others:

Hirschberg: inaccurate 1mm = 15-20∆

Krimsky: ±14∆

Bruckner

Symmetry of red reflexes, direct ophthalmoscope at 80-100cm, dial in

correction for clear view. Darker reflex in strabismic eye

Detects strabismus, anisometropia, anisocoria or pathology

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Orthoptics: motility

Infants don’t like having head held

Practitioner should move around

Or parent can rotate the child

Should be at least attempted in every child

Often carried out but only recorded if abnormal

Orthoptics: motor fusion

Base out prism test

Have child fixate a detailed picture

Can measure in older children with prism

bar

Motor fusion assessment in young children

is good practice/best practice

age (months) test response

0-3 20 ∆ out unlikely to make any response

by 6 20 ∆ out should be overcome

Evans (2007) Pickwell’s Binocular Vision Anomalies, 5th edition

Orthoptics: sensory fusion & stereo

Good practice is to test stereo-acuity in pre-school children

It is questionable whether a failure to do so falls below the standard

of a reasonably competent optometrist

More likely to do so if child has other risk factors for strabismus

70% of optoms say they always test in pre-school children

(C.Optom, 2008)

The test used is

matter of personal

preference

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Orthoptics: stereotest norms

Generally, different tests give different results

So, test should be named or obvious (e.g., only test)

age test response

0-3 mo. any unlikely to make any response

6-18 mo. Lang 1 observe patient’s eyes: may see fixations indicating sees pictures

18-24 mo. Lang 1 or 2 should fixate and may point at pictures

> 24 mo. Lang 1 or 2 should be able to point and name pictures

≥ 24 mo. Randot (shapes) if sees shapes on random dot background indicates no strabismus

≥ 24 mo. Randot (animals) should be able to see all animals

3-5 yrs. Randot (circles) 70"

> 5 yrs. Randot (circles) 40" or better

3.5 yrs. Titmus 3000” (Romano et al., 1975)

5 yrs. Titmus 140” (Romano et al., 1975)




3-5 yrs. Frisby 250"

3-5 yrs. TNO 120"

Orthoptics: treating amblyopia

Main causes of amblyopia are strabismus

(squint) and/or anisometropia (one eye

more long-sighted than other)

Treated by (a) glasses and usually (80%)

also (b) patch

Treatment widely believed to be less

effective over 7y

Actually, only applies to strabismic amblyopia

C. Optom survey (1998):

75% of optoms treat anisometropic amblyopia

25% treat strabismic amblyopia (75% refer)

Unclear if just spectacles or patch too

PLAN


OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE


CONCLUSIONS


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Paediatrics: routine for 0-1.5 yr

attempt ophthalmoscopy

attempt visual acuity

reaction to occlusion, vertical prism, PL

test binocularity

corneal reflexes, cover test, motility, (Lang, 10∆ out)

retinoscopy

Paediatrics: routine for 1.5-4 yrs

ophthalmoscopy

visual acuity

reaction to occlusion, vertical prism, Cardiff cards, letter or picture matching

cover test, motility, stereo-test

maybe 20∆ out

retinoscopy

Re-exam intervalsDocument below from Optical Confederation is often taken literally

BUT: “each patient should be considered individually and a recall interval

recommended - which may be longer or shorter than the intervals in the

Memorandum - depending on the patient’s clinical needs”

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PLAN


OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE


CONCLUSIONS


Clinical records are an imperfect description

of the content of eye examinations

Rakhee ShahResearch Fellow Institute of Optometry

Post-graduate student City University

Bruce EvansDirector of Research Institute of Optometry




David EdgarProfessor of Clinical Optometry City University

Record abstraction: examples

46-65% of optometrists don’t record retinoscopy

Up to 18% of optometrists under-record motility,

but up to 16% can over-record this!

3-10% under-record visual fields

18-27% under-record biomicroscopy

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What should you expect from the profession?

what a typical optometrist says they do

expert

average

range

unsafeGOC standards

good

below average

but OK

unusual, may

be unsafe

best

what a typical optometrist does

what a typical optometrist writes in their records

PLAN


OCULAR HEALTH

VISUAL ACUITY

REFRACTION

ORTHOPTIC FUNCTION

SUMMARY OF ROUTINE


CONCLUSIONS


Conclusions

Please note that the lecture applies to typical

optometrists

Some optoms have specialised in paediatrics and/or

orthoptics

� Less likely to refer but expected to practise to

higher standard

There is no such thing as a standard sight test

Wide range of degree of co-operation to be

expected from typical pre-school child

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GOC standards of practice

8.2.6 must record “Consent obtained for any examination”

Is all the profession guilty of misconduct?

“We find comfort

among those who

agree with us –

growth among those

who don’t.”

Frank A. Clark

Full handout of slides from www.bruce-evans.co.uk