I.
5 Anterior segment pediatric cases presented in the following format
A. Case history
B. Entrance Testing
C. Anterior segment and posterior segment findings
D. Differential Diagnosis
E.
Assessment
F.
Plan
G. Additional treatment options
H. Unique aspects of treating disease in pediatric and disease background
II. Case 1
A. Case historyB. Entrance Testing
1. Visual acuities, EOM’s, pupils, and cover test
2. Methods to evaluate vision on a nonverbal or uncooperative child
a) Teller acuity
b) Face plates
c)
Fixation preference (central, steady, maintained)
C. Anterior segment examination –including options other than slit lamp in
uncooperative child
D. Slit lamp examination in Children
1. Evaluation by Burton lamp
2. External illumination (transilluminator or BIO with 20D)
3. Portable slit lamp
4. Flipping lids in Children
5. Pro’s and con’s of topical anesthetic in Children
a) If apprehensive may make exam much more difficult, more
beneficial in older children
E.
Posterior segment of examination
1. When to dilate a pediatric patient with an anterior segment injury
2. What drops to use
a) Benefits of Cyclopentolate
b) Tips on instillation
F.
Retinoscopy findings
G. Differential diagnosis
1. Corneal Abrasion
2. HSV
3. Uveitis
4. Corneal Ulcer
5. Foreign body
6. Conjunctivitis
H. Assessment
1. Corneal abrasion right eye
I.
Plan
1. Ciloxan Ointment 4 times a day right eye
2. Other options for medications in corneal abrasions in kids
3. Follow-up 3 days
J.
Pain management in children
1. OTC Tylenol or Ibuprofen, prescription pain medications typically not
indicated
2. Why pressure patching is typically not indicated
a) One study did not show any difference in pain management or
healing time with pressure patch
III.CASE2- Vernal Conjunctivitis
A. Case history
B. Entrance testing
C. Anterior segment findings with photo
D. Posterior segment findings
E.
Refraction
F.
Differential Diagnosis
1. Bacterial Keratoconjunctivis
2. Viral Conjunctivitis
3. Chlamydia
4. Staph Hypersensitivity Keratitis
5. Allergic Conjunctivitis
6. Vernal Conjunctivitis
G. Assessment
H. Plan
I.
Options for treatment of vernal conjunctivitis
J.
When and how to evaluate IOP in children
1. Goldmann, Tonopen, Icare, digital palpation
K. Demographics for Vernal conjunctivitis
IV. Case 3- Idiopathic Uveitis with emphasis on JIA association
A. Case history
B. Entrance testing
C. Anterior segment findings with A/C photo
D. Posterior segment findings
E.
Diagnosis
F.
Additional case history questions pertinent to children with uveitis
1. History of previous red eye
2. History of joint pain
3. Patient or family history of autoimmune disease
4. History of trauma
G. When to have a systemic evaluation in pediatric patients with uveitis and timing
H. Importance of referral to pediatric rheumatologist
I.
Plan and options for treatment
1. 1 week Followup
2. What to do if patient is not responding to treatment
3. IOP
J.
Rheumatological findings of patient
K. Common causes of uveitis in Children
L.
Things specific to uveitis in children
1. JIA
a) Types of JIA
2. Importance of FU/schedule of FU for JIA patients without history of uveitis
3. Uveitis risk to vision in Children
4. Ocular complications
5. Importance of referral if not responding to treatment
V. CASE 4 PEDIATRIC CATARACTS and APHAKIA
A. Differential diagnosis of absent red reflex
1. Anisometropia
2. Cataract
3. Retinoblastoma
4. Coats disease
5. PHPV
6. Coloboma
7. Retinal detachment
8. Myelinated nerve fiber layer
B. Is it visually significant opacity?
a) Opacities of 3mm or greater are usually considered visually
significant
C. Referral to pediatric ophthalmologist
D. Management of Aphakia in pediatrics
1. Types of contact lenses
2. Table of common lenses and parameters
3. Initial Fitting aphakic Contact lenses
4. Evaluating anterior segment in an infant
5. Over-plus based on age
E.
Example 2 month old unilateral cataract s/p lensectomy
1. Infant Aphakia study
F.
Evaluating Fit
G. Wear time
H. Amblyopia treatment
VI. Case 5- HSV dermatitis/Keratitis
A. Case History
B. Entrance Testing
C. Anterior segment evaluation- with cornea and lid photo
D. Posterior segment evaluation
E.
Differential Diagnosis
1. Corneal Abrasion
2. Corneal Ulcer
3. Bacterial conjunctivitis
4. Preceptal cellulitis
5. Hordeolum
F.
Assessment
G. Plan
H. Options for treatment (specific to pediatrics)
1. Orals only
2. Zirgan- studies and individual experience
3. Viroptic
I.
J.
VII.
Risks to vision in patients with HSV keratitis
1.
Corneal scarring
2.
Anisometropia secondary to induced astigmatism
3.
Amblyopia as a secondary complication
Dosing of common oral medications for Children
References
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9. Tyler’s Quarterly Soft Contact Lens Parameter Guide June 2010