Term
| Six to Eight Weeks vision |
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| Two to Three Months vision |
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| Three to Four Months vision |
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| F/F; central, steady, maintained (CSM) |
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| LEA pictures, HOTV (20/40-20/20) |
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| round, reactive and equal with direct ophthalmoscope over both pupils |
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Definition
binocular
• Check for equal or unequal amounts of light
• Check for how light fills the pupil: • Is it bright light or is it dim light? |
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Definition
normal bruckner red reflex
So we'll give some examples here of what's normal. So here I call your attention to the fact that the pupils are dilated in this external photograph. But you can see how they're very symmetric, meaning that they're equal, and they're round. Also you'll notice that the red reflex is similar. And also, the last thing I want to call your attention to is you see this corneal light reflex, a little white dot, it's in the center of the pupil. So that is also going to be helpful in our assessment of the pupil of how the light is filling up in that space. So this is a representation of normal. |
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Definition
| This next one here, this is a representation of an abnormal red reflex or an abnormal Bruckner red reflex. You can see I call your attention to the left pupil. That you see half of it appears to be whiter as compared to the right pupil. The right pupil, again, it's round. It has the corneal light red reflex in the center. And it is a red reflex that is all diffuse. It's all the same color, whereas that's not the case for the left eye. So this is very important because it leads us to an assessment of something that could be wrong with the child's vision. |
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Definition
This is a second example of a Bruckner red reflex that's abnormal. Again, it's in the left eye here. And in comparison to the earlier photo I just showed you, this little boy-- the red reflex for the right eye isn't as light. And so it's a darker red reflex. So it's hard for us to see the difference between pupil and iris. But what we do see is the fact that this corneal light reflex is centered in the right pupil.
And what I'll call your attention to to the left eye is that we don't see the corneal light reflex in the left eye there, because of how abnormal the light is being processed to the pupil. So again, this is a very gross way to initially evaluate a child and their potential vision terms of the Bruckner red / |
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Definition
Here's a third example of the abnormal red reflex being indicated here. And here, it is also in the left eye that is representing something that is abnormal. While you do see the corneal light reflex in the left eye and the right eye, you'll notice that you can hardly see a definition of the pupil in the left eye, whereas, that isn't the case in the right eye. You see a round pupil. And you see the redness of the red reflex of that pupil in the right eye. And so, again, this is a third example of an abnormal red reflex, what we call an abnormal Bruckner red reflex, in the left eye.
And this is important, as we'll be talking about shortly, is because even though these children are not able to tell us what they can see, that we're able to make an assessment that there is something wrong. There's something wrong with how light is being processed in this left eye, not only here of this baby, but of this little boy for the left eye, and this little boy also. So all three examples happen to be of the left eye and now we have a clue as we're doing our exam that we're going to be concerned about the vision being abnormal and there being pathology for the left eye in comparison to the right eye. |
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Term
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Definition
• Evaluation of how the light is reflected on the cornea, relative to the pupil
• Is it centered?
• Is it nasal?
• Is it temporal?
• Is it superior?
• Is it inferior?
And when I am talking about ocular alignment, I'm talking about how the eyes work together-- if they are straight, or if they are crossed, or if they're wandering outward. So Dr. Hirschberg was one of the first to describe it, so it's called the Hirschberg test. And here-- we touched on it a little bit just a moment ago-- here we talk about how light looks on the cornea, how it's reflected. Is it in the middle or centered? Is it nasal, meaning toward the nose? Is it temporal, meaning toward the ear? Is it superior, meaning toward the upper lid? Or is it inferior, meaning toward the lower lid? |
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Definition
Hirschberg Test: Normal
And here, this next example is about how a child is-- yes, they're staring at us. And it is quite extreme-- but this is supposed to represent a normal Hirschberg test. Meaning that the light, the dots of light, or the corneal light reflex you see it's right in the center of the pupils. And they're not off to the side either nasal, temporal, inferior, or superior. And it's similar in both the right and the left eye. |
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Definition
Here, this is also you can see a toddler. We're trying to assess about the Hirschberg test. And I am asking is it abnormal because of the very fact that you can see that this right eye appears to be closer to the eyelid here, or what's called the epicanthal fold, or this flat nasal bridge, the right eye appears closer than the left eye.
However, if you focus on the corneal light reflex alone, meaning this white dot of how it reflexes off of the cornea, you can see it's centered for the right and it's centered for the left. And the child is actually looking off to the left gaze for the camera. And there is this appearance that the right eye may be turning inward, because of this flat nasal bridge. So this is supposed to represent a normal test, not an abnormal test in terms of the Hirschberg evaluation. |
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Definition
And here, I'll call your attention to something that is abnormal for the Hirschberg test in terms of where this corneal light reflexes. So if we look at the right eye, clearly that eye isn't looking at us. And you can see the corneal light reflex is nasal, meaning it's toward the nose. And as we compare it to the left eye, that corneal light reflex is centered.
So here, we know by the Hirschberg test that this child has an ocular misalignment, meaning the eyes are not straight. And this right eye is turning outward, or what we call exotropia because of the simplicity of this Hirschberg test about seeing where the corneal light reflex is. |
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Term
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Definition
• Versions: Evaluation of both eyes together
• Ductions: Evaluation of each eye Individually
• Often Doll’s Head Maneuvers helps to assess the eye movement in abduction
A third aspect of our pediatric eye exam is being able to determine the eye movement assessment. So when we talk about eye movements, we can talk about it in two different ways-- whether the eyes are evaluated together or separately. So when we're looking at both eyes together-- and this is usually the case for children, because of the very fact it's difficult if they're crying, or if they're fussy, or if they are having an eye exam for the first time, then it's difficult to evaluate the eyes individually. Versions is what is the definition of our evaluation of both eyes together.
Ductions is the definition of evaluation of each eye individually. And this is much easier to do on a school age child. But it can be attempted on a toddler or an infant. But it's much more challenging to do.
And one way that we work around the challenges of fully assessing a child's eye movements is something called Doll's Head Maneuvers. And Doll's Head Maneuvers Is where you as the examiner hold the head to one side and then the child looks off to the other. And then you hold the head to the other side and the child looks off to the other side. Sometimes you can put your hands right on their forehead. Or other times, you can use a toy as a fixation device off to this side or, likewise, off to that side.
And so it's important for us to do something like this if we're worried that the eyes are turning inward. And we don't know how much can they turn outward. We may not be able to fully assess unless we force the eyes to move in that direction. So that's why we have to physically move the head. |
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Definition
So a review here of the extraocular movements. And this here is a picture of the extraocular muscles right on a child's face. And when we look at a child, the eyes that the right eye and the left eye, they work together-- it's important to remember-- like a pulley system. And so one eye isn't acting in isolation from the other. So there are antagonist and agonist muscles.
So just to review here, the muscles on the outside part here, right here, are called the lateral rectus muscle. So I'll bring it to your attention on the baby here in the slide. And the lateral rectus muscle is only controlled by one cranial nerve. And it's cranial nerve 6th. Cranial nerve six, that's its only job in the whole world, is to take care of the lateral rectus muscle. So that's the muscle on the outside that controls-- its chief action is called abduction, moving the eye outward.
Now moving to the inside muscle here called the medial rectus muscle, the medial rectus muscle, its job is to move the eye inward or in adduction. And it is controlled by cranial nerve three. Now, cranial nerve three is a very important cranial nerve in the eye. And it controls most of the eye muscles, except for the ones that out I'll mention. So it is controlled by the superior division of the cranial nerve three.
Next, we have the inferior oblique. And the inferior oblique, even though it's in name called inferior, what it does, it elevates. It brings the eye up. When the child looks up and off to the inside, called elevation and adduction. And it is also the inferior oblique also controlled by cranial nerve three.
Also, bringing the eye in elevation or having the eye go up is the superior rectus muscle. And the superior rectus muscle is just where you may imagine it to live in the eye anatomically superiorly. And it is controlled by cranial nerve three also, the superior division of cranial nerve three.
Now, we go about moving the eye inferiorally, the inferior rectus, is very important for its action to move the eye downward or in infraduction. And the cranial nerve three also controls inferior rectus muscle. And it's the inferior division of the third nerve.
And lastly, the superior oblique. Even though superior oblique is called superior, it moves the eye downward and in adduction. And it is controlled by cranial nerve four. So cranial nerve four just also has one job in the eye and it's to control the superior oblique. And the superior oblique muscle and then is important for torgan. And it's also important for downward and inward movement. |
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Term
| nystagmus up to 3 mo of age |
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Definition
when a child is very young, the hardwiring, so to speak, of the eye movement is being made. And so nystagmus and nystagmus-like movements, it's not an unusual thing to see in a child that's very young and even up to three months of age. So between six weeks-- so when they're coming home from the NICU-- when they are a couple of weeks old or even if they stay in the NICU longer, between six weeks and three months old, it's not unusual to see that.
And even depending on if a child is born prematurely, we may see nystagmus or nystagmus-like movements at around age three months old. |
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Term
| nystagmus between 4 mo and6 mo |
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Definition
| we become very concerned if we're seeing nystagmus between four months to six months, and certainly six months and older. |
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Term
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Definition
• Involuntary shaking, to-and-fro movement of
the eyes, together or individually.
• Jiggling or jerking movements: horizontal, vertical, rotary.
• Both eyes? Asymmetric: one eye?
• Directionality? Frequency and Amplitude? |
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Term
| Pediatric Vision Assessment components |
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Definition
• Bruckner test for red reflex: √
• Hirschberg test for ocular alignment: √
• EOM assessment: full or limited: √
• Vision: fixation? Central, steady, maintained? √ |
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Term
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Definition
• A reduction in vision during the time of visual development
• Monocular or Binocular
• The input from an amblyopic eye causes shrinkage in the neurons of the lateral geniculate body
• Prevalence in North America and Europe: 1-5% |
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Definition
| So here, I'll call your attention to a little toddler who you can see here, the left eye is turning inward. And how we know that is that that corneal light reflex, that Hirschberg test, you see the temporal aspect of the corneal light reflex. It is on the temporal side, or the lateral side, of the pupil as the eye is turning inward in the left eye. And you see this is in contrast to the centered, or in the middle of the pupil for that right eye. And so there is no misalignment, or no strabismus, of that right eye |
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Term
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Definition
Strabismus and Corneal Light Reflex
And let's just review the light reflex-- the corneal light reflex, that is-- in strabismus, and how important that is. And so if we just have a pen light, a pen light that we can hold in front of a toddler's face, an infant's face, even a school-aged child's face, it's very important. So this top panel A represents alignment, something that we call normal alignment orthotropia. Here, we see the corneal light reflex is centered in the pupil.
B panel represents the eye turning inward. And you can see that the corneal light reflex is even off the pupil. It's in the center of the iris. And so the B panel represents a left eye of having an inward turning eye, or esotropia.
The C panel represents the left eye turning outward. And here, again, you don't see the corneal light reflex on the pupil, but the corneal light reflex is on the nasal aspect of the iris. And so this eye alignment is called exotropia-- and again, representing abnormal corneal like reflex.
And lastly, the D panel is representing the eye in looking upward, or what we call hypertropia. So the left eye is hypertropic. And you'll notice here that the corneal light reflex is inferior. It's not in the center of the pupil, and it's at 6 o'clock here. It's in the inferior aspect. So this is a nice review of B, C, and D representing abnormalities in the corneal light reflex for this left eye. |
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Definition
A second type of amblyopia it's called anisometropia. So anisometropia is talking about the optics of the eye being different in either eye, meaning the left eye having one optics, and the right eye having another optics, in terms of it being either nearsighted, farsighted, or having astigmatism. So this next picture is just to give you an idea of what the eye sees as a process. So this is supposed to represent the left eye seeing everything nice and crisp and clear. And this is supposed to represent the right eye seeing it blurred.
And so this is another type of amblyopia. And actually, this type of amblyopia is very important in vision screenings today with children, because we know, as children, we don't walk around patching or closing one eye versus the other. So a child may not know that they're seeing blurry out of one eye. And in this example here, it's the right eye versus the other eye, the left eye. |
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Definition
A third example of amblyopia is called deprivation. And deprivation, in this context, meaning blocking light being processed for the vision to get processed. So there's a blockage of light. This is an up close and personal view of a cataract in a child. So here, this white opacity is a lens opacity. And you can see that it's a dilated pupil.
So you can see a nice red reflex that looks normal around the cataract. However, the size of this cataract is important, and its location is important. While it's a little bit off to the side, it's definitely still involving the center of where light gets processed. And of note, it's over 3 millimeters. And so, what we do know in deprivational amblyopia, if there is something blocking more than 3 millimeters of light, as this cataract is doing, then it's going to be causing vision damage and harm to visual development, and hence, amblyopia. |
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Term
| Chief Complaint and History for ambylyopia |
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Definition
• Description of Visual Response • Description of Eye Alignment
So now, moving forward in terms of how we would know whether or not our patient-- or our child that we're seeing, or talking to the parent or caregiver-- has amblyopia, getting a chief complaint and history is very important. And in my book, Mom and Dad or the caregiver are always right. So even if you're seeing one thing in your exam, what they're describing is really critical. Because they're seeing this child day in, and day out.
So the description of the visual response, especially as their favorite faces in the world typically are their mom and dad. Also, the description of the eye alignment. Is the eye turning inward toward the nose, outward toward the ears? Or is it happening every day? Are they noticing it once a week? Do they notice it when the child is tired? These are important clues for us to know how big an impact it's making on a child's vision. |
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Term
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Definition
• • • •
Ocular Alignment Assessment
Visual Response: each eye; both eyes Motility: versions versus ductions
Stereopsis: if possible (checking for depth perception) |
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Definition
So here, we're going to review some external photographs of a child having an ocular misalignment. So I'll call your attention to this top panel here. In neither panel the child is really looking straight ahead at the photographer. But what's important for us is to compare the corneal light reflexes. So while the top photograph, the child is looking downward at the photographer, you'll notice that the corneal light reflex is off temporally, meaning off to around 10 o'clock and it's not centered for that right eye, whereas it is at around 12 o'clock for that left eye. And so here, we're seeing the asymmetry, meaning that the eyes do not look like they are aligned based on our Hirschberg our or corneal light reflex test. And so our diagnosis for this top panel would be a right esotropia.
The left lower panel for the external photograph, I'll bring your attention to the left eye. You see the corneal light reflex. Again, it looks like it's around 2 o'clock. It's not centered. And it's up and off temporally. And while the child isn't looking straight at the camera, it's looking after the right again, you'll see that the right eye, the corneal light reflex is around 12 o'clock. So the lower panel is supposed to represent an esotropia, an inward turning eye of the left eye. |
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Term
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Definition
• First6months
• Large angle
• Cross-fixation possible
• Yet:Usually eye dominance
• Amblyopia35-40%
• Neuro:Normal
• Stereopsis:Reduced
• LatentNystagmus
• Intermittent
• Alternating
• Neuro: normal
• Stereopsis: normal • Amblyopia: rare
• Treatment
• Spectacles if needed
• Surgery at 4-5 years old |
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Term
| Strabismus Surgery: Example for Exotropia |
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Definition
-Surgery to weaken or recess both lateral rectus muscles
-Bilateral medial rectus muscle recession before and after (Subconjuctival Heme): |
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Term
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Definition
High Hyperopia: Bilateral Isometropia
Now switching gears to refractive causes of amblyopia, we had talked about anisometropia, where I showed you the photograph of a blurred picture for the right eye, and a sharp picture for the left eye, for aniso-- meaning a difference. Now I'm going to talk about when there is a similarity between the optics of the eye's isometropia, meaning the same. Here, this is representing bilateral-- both eyes-- isometropia of high hyperopia, meaning in this case, the child is hyperopic-- or farsighted-- at a far greater rate that's normal. So he needs glasses to help not only for vision, but likely even alignment. And so here, you can see the thickness of the glasses, but certainly, the eyes are straight. And we would expect to see good vision with him with this treatment scenario. |
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Term
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Definition
High Myopia: Bilateral Isometropia
Next, I'll bring your attention to, again, isometropia that's bilateral. But instead of being for hyperopia or farsightedness, it's for myopia, or nearsightedness. And this is representing in a child that is very nearsighted. You can see, the glasses almost look like they have a prismatic effect in them. But it's very important for this child to be in glasses because of the very fact that he will develop amblyopia and have a severe decrease in vision without treatment, even though it is isometropic, meaning it's similar or symmetric in both eyes. |
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Term
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Definition
Leukocoria:
Amblyopia and Underlying Etiology
Next, we're going to talk about some of the pearls that we had talked about, the importance of the red reflex and why it's important about an abnormal Bruckner red reflex, is to discover pathology-- whether it's threatening to a child's life or threatening to the well-being of the eye. And here, when we have a white pupil, it's called leukocoria. And so it's very important for us to know the underlying diagnosis, or our differential diagnosis.
So here, I'll bring your attention to this little boy. You can see that there's an abnormal red reflex on the right eye, leukocoria. You can see there is a whitish pupil. Here at the top panel, it's much more severe. You see a child looking off in right gaze, so he's not looking at the photographer. But when you compare the two pupils, the pupil is solid white on the right eye, and it is darker on the left eye.
Again, for this lower panel for this child looking at you, the right pupil is normal, if you see the centered corneal light reflex. But you can see that the left pupil is solid white for the leukocoria. So that's very concerning.
So a child that has leukocoria, such as in this little boy here, we're going to have a very high suspicion of a retinoblastoma-- and also in this photograph at the top here, as well as in this lower photograph. So all three are supposed to represent a very high suspicion for retinoblastoma. |
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Term
| Leukocoria Differential Diagnosis |
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Definition
• Retinoblastoma
• Cataract
• Retinopathy of Prematurity (ROP)
• PersistentFetal Vasculature (PFV)
• Infection: Toxocara
• Retinal Detachment
• Coats Disease |
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Definition
| And this is also a photograph of the retina, the fundus photograph of what a retinoblastoma looks like in a very calcified form. That's what we would see from an ophthalmologic point of view. |
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Term
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Definition
| Cataract, as you can see here in this lower panel, of an opacity that is causing the pupil to be gray or hazy. It is not red. It's not completely white, but it's certainly abnormal. And so this little boy here has bilateral cataracts. So that's also important on our differential for leukocoria. |
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Term
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Definition
• Early evaluation important: 1 to 3 years old • Early diagnosis is critical
• Long-term impact of visual development |
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Term
| retinopathy of prematurity. |
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Definition
| You're going to have a higher suspicion in a child that is premature. And so they can have an abnormal retina. And they can even have a retinal detachment. So, retinopathy prematurity is important. And that goes also with the history of what's going on with our patient. |
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Term
| PFV, persistent fetal vasculature |
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Definition
| And this is a unilateral process. And it is a smaller eye that develops with an abnormal cataract that has a stalk that is attached to the optic nerve. So this child would also have an abnormal red reflex, but our suspicion should be for persistent fetal vasculature if it's unilateral-- meaning in only one eye-- and if it's a small eye. And so that is very important one. Our next step for that patient would be doing a Vscan ultrasound. |
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Term
| infection and inflammation and autoimmune disease i |
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Definition
| infection such as toxocara, if a child has that, that presents from in utero, and then we would see this in a toddler, or even a child who develops it later on. If we see some inactive scarring in the retina, that it would present as an abnormal red reflex. |
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Term
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Definition
| Retinal detachment, which would be unusual, but typically, you would see it with a tumor such as retinoblastoma, or in the context of retinopathy prematurity. And lastly, something very rare, known as Coats disease. But it's always important on the differential diagnosis. But there's a reason why it's listed last, is that usually, it's unilateral. It's in boys. And it is an abnormal development of the retinal vasculature. And so the retinal vasculature in these boys typically look like light bulbs on a Christmas tree. And they can also leak and cause retinal detachments and swelling in the retina. And so this also is brought to our attention by the abnormal red reflex. |
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