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Kid Eye examination :tokyo_tower::recycle: (:three: Refraction วัดค่าสายตา…
Kid Eye examination
:tokyo_tower::recycle:
:one:
Slit lamp
for 6 mo.- 2 y/o: on family lap
for 2 y/o up: stand up or kneeing
if child is
scared
➭ Loupe with ไฟฉาย
or
Portable slit lamp (20D lens with Direct ophthalmoscope)
if child is
ดิ้น + scared af
➭ Restrain & Lamp magnifier (by personal experience depend of CC & priority) may make worse eye experience (WT)
:two:
Intraocular pressure
:!: no need to measure in every kid
Measure in kid with
Established glaucoma
Large optic nerve cups
Cup-to-disc asymmetry
Ocular risk factors including Aphakia, Pseudophakia, Uveitis
Systemic risk factors including Chronic systemic steroid use
How
:question:
มีไรบ้าง?
Applanation test (Goldmann tonometer, Tonopen, Perkin's tonometer)
Indentation test (Schiozt tonometer)
:!: ยาก & วัดได้ต่ำกว่าค.จริง low scleral rigidity
With or Without topical anesthetic
With
topical anes
Goldmann applanation :star2:
gold standard
Perkins tonometry
Tonopen
Without
topical anes
Non-contact tonometry
Rebound tonometry
ICare™
:warning:
not approved by US FDA
:baby:
Age group
4-6mo. + กินนมอิ่ม ➭ ใช้ยาชาหยอด then
tonopen
Or
Icare (w/o sedate)
6mo. up ➭ sedate with
Choral hydrate
:green_apple: + ยาชา
Choral hydrate
:green_apple:
Dose
Neonatal: 25 mg/kg
Infant & children: 25-75 mg/kg
may repeated within 30 min after 1st dose
Max dose: 100mg/kg or
1 gm in <1y/o
or
2 gm in >1y/o & adult
Onset: 30-60 min
Duration: 4-6 hr
Careful in Liver & Kidney เสื่อม
NPO time for choral hydrate :grapes:
:!: monitor V/S during using it, prep all emer kits or inform ped (just in case), before D/C recheck V/S again
Toxicity
CNS suppression, CV suppression
No specific antidote
Supportive Rx
give
Activated charcoal
to :arrow_down: absorption
give
Flumazenil
to fix ภาวะ CNS
give
Lidocaine or Propanolol
to fix Ventricular arrhythmia
4 yr up + good co-operation ➭ uses Goldman tono like adult
:three:
Refraction วัดค่าสายตา
Aim: refraction without accommodation
:baby: Age group
เด็กโต
Watch cartoon pic fr TV at 3-6 m from เก้าอี้ตรวจ (mayb not control accomodation)
เด็กเล็ก
can't control accommodation
or
needed thorough VA
or
เด็กตาเหล่
➭ gives
Cycloplegic drug
:cherry_blossom:: for
คลาย ciliary ms
(use in การเพ่ง) and makes
eye not in accommodation status
:cherry_blossom:
Cycloplegic agent
purpose:
main
- to วัดค่าสายตา
to relax ciliary ms eg. ม่านตาอักเสบเจ็บตา, traumatic injury
2 types
that available in Thailand
1% Cyclogyl eye drop (cyclopentolate)
เหมาะสมใช้ในห้องตรวจ
หยอด 1 drop q 5-10 mins x 3 times then wait at least 30-45 min after last drop
Duration: 12-24 hrs (mayb up to 72 hrs)
SEs: ท้องอืด,
Behavioral changeถ้าได้มากไป
0.5%(out of stock), 1% Atropine eye drop
:check:
best cycloplegic agent
Onset: 12 hr (late onset)
Duration: 2 wk (long duration)
SEs: flushing face, lethargy, fever
Dose: bid for 3 days before clinic
เหมาะกับ Refractive accommodative esotropia
Combine
drug:
Dark iris
Combo of 1% cyclopentolate 10 ml + 1% tropicamide 2.5 ml + 10% phenylephrine 2.5 ml
Stand auto-refraction
- Not suitable for children
Hand held autorefractor [Retinomax]
prefer
:check: - very quick fixation time
:four:
Fundus examination
More invasive exam
for premature baby (suitable time after half way feeding)
Dilating drop: 0.75% mydriacyl + 2.5% phenylephrine
:warning:Relative
small risk for apena
but still worrisome
Last process in exam
:five:
Motility & Sensory examination
Principle: start with calm & comfortable
การตรวจที่ต้องจับเด็ก ➭ Last process
eg. doll's head maneuver
:six:
Corneal light reflex test
ตรวจตาเข
Hirschberg's method
จุดเงาสะท้อน at ห่างจาก pupil ไป 1 mm ~7 degree or 15 prism diopter
จุดเงาสะท้อน at between pupil & limbus ➭
15 degree or 30 prism diopter
จุดเงาสะท้อน at limbus ➭
45 prism diopter
Modified Krimsky's method
Bruckner's test
Cover test
:balloon:
3 types
:stars::stars:
Cover-Uncover test
:stars::stars:
Alternate cover test
Simultaneous prism-cover test
1.EOM movement 2. Sensory (vision & Pt co-op) 3.Fovea fixation
If one of these พัง ➭ can't neutralize!
:seven:
Pupil examination
Pupillary reaction in GA > 30wk
If small pupil ➭ can uses lens 20D มาช่วยดูได้
Check what?
Contour
Size & relative size
Light reaction
Consensual reflex
Color
:eight:
Red reflex
:tada:
Popular วิธี in Kid
can check tho kid not co-op
regardless of kid age
!Comparing both eyes
Reflex ที่ต่างกัน may indicate
Ocular media opacity
Cornea ➭ Corneal scar
Lens ➭ Cataract
Vitreous ➭ Vitreous hemorrhage
Refractive error
Strabismus
Bruckner's test
uses
direct ophthalmoscope
for red reflex of both eyes at the same time
Stands 30-50 cm in front of child eye
Setting: Dark room
ให้เด็กมองไกล
ส่องไปที่ดั้งจมูก ➭ เห็นแสงสีแดงสะท้อนออกมา
Reflex
Brighter ➭ Strabismus
Dimmer ➭ Ocular media
:nine:
Visual field
Child can look at object & be still ➭ can test VF คร่าวๆได้
Child ไม่ยอมปิดตาทีละข้าง ➭ test พร้อมกันสองตา
Binocular VF
Age group :baby:
3 y/o up ➭ check VF by นับนิ้วในทิศต่างๆ
6 y/o up ➭ check VF by Goldman perimeter โดยใช้ target ใหญ่ที่สุดและสว่างสุด
Recommended Eye Examination Frequency for Pediatric Pt
:grapes: