Paediatric Ophthalmology Community to the hospital

1. Paediatric OphthalmologyCommunity to the hospital Siobhan Wren Consultant Ophthalmologist

2. Hospital Service Workload Amblyopia Visual development/assessment Evaluation of the paediatric patient Red reflex Detecting squints Red eyes

3. Diagnosis of Paediatric Referrals (March 09) 68% Possible Amblyopia present in 124 Data available for 319/337

4. Amblyopia • Strabismus • Refractive • Occurrence • 1-3% population • up to 5% pre-school

5. Visual development • 1 month • pupils react to light • defensive blink present by 6-8 weeks • 3 weeks onwards watches familiar nearby face when being fed • gaze caught and held by dangling bright toy gently moved in line of vision at 15- 25 cm

6. 3 months • very alert • fixes and follows toy at 15-25cm • converges eyes if toy brought toward eyes • 6 months • any squint now is abnormal • reaches out for objects • searches for toy once it leaves visual regard

7. 9 months • very alert to people • immediately grasps for toys • watches activities of people or animals within 3-4 metres with sustained interest for several minutes • 12 months • interest in pictures • points to objects of interest

8. Health Visitor Questionnaire at 8 months and 2½yr contact • Do the parents suspect a squint? • Are there any concerns about vision, eye lids, eye movements, pupil size or shape? • Is there any family history of squint, amblyopia, glasses in early childhood, or wearing a patch. • Are there any risk factors of squint combined with family concerns i.e. prematurity or developmental delay

9. Conclusions of Study into Fast track appointments • Fast track clinic run by a highly specialised orthoptist and paediatric optometrist can successfully assess large numbers of amblyopia &/or strabismus suspects. • A 74% discharge rate of 1st referrals, following the protocol, has a significant impact on paediatric outpatient clinic. • Surgical rates within this group of patients is in line with the national surgical rates .

10. HISTORY Family history Identify risk factors Prematurity Developmental delay Juvenile Rh Arthritis Family album Photophobia Redness Discharge Purulent, watery EXAMINATION External inspection Red reflex Corneal light reflex Cover test Squinting Head tilt Eyelid closure Visual acuity >3 yrs Defective ocular fixation/ interactions Making a diagnosis

11. Red reflex technique • Sit in front of the child and parent at about arm’s length.  Set the ophthalmoscope to around +2 (green or black)  • Focus on the parent’s eyes to show that the test is non-invasive and recognition of the normal red reflex in that particular ethnic group. • Then focus on the child’s face and encourage the child to look at the light. Focus on the red reflex within the pupil.

12. The Childhood Eye Cancer Trust

15. Head postures Check motility

17. Conjunctivitis Close contacts affected Unilateral  bilateral Sticky discharge Diffuse redness Cornea and pupil normal Chloramphenicol Cellulitis- Refer urgently Neonatal conjunctivitis: refer urgently Risk of corneal perforation from n. gonorrhoea

18. Allergic conjunctivitis • Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC) • Vernal keratoconjunctivitis (VKC) Atopic keratoconjunctivitis (AKC) • Giant papillary conjunctivitis (GPC)

19. Symptoms

20. Signs

21. Management • Allergy testing • Cool compress • Artificial tear substitutes • Systemic and/or topical antihistamines • Vasoconstrictors • Mast cell stabilizers • Nonsteroidal anti-inflammatory drugs (NSAIDs) • Corticosteroids • Immunotherapy