V OLUME 1, I SSUE 1
P AGE 5
A SK D R . W ONG ! Strabismus Surgery or Not A 2½ year old girl presents for a 4th opinion for Strabismus Surgery. The pregnancy, birth and developmental milestones were all normal. There is no family history of any strabismus or amblyopia. The parents report that the eye turn is more noticeable when she is tired or sick. Both eyes turn out, however, the left eye seems to turn out more. This was first notice approximately 8 months ago. This was the first visit to the ophthalmologist and a report was written. It was noted that she had a 40-50 pd exophoria and she has “good control”. In addition, her vision was 20/25 for both the right and left eyes with Allen Picture Cards. The parents then brought her to see a pediatric ophthalmologist who recommended strabismus surgery. The parent wants to avoid surgery and went to see a Developmental Optometrist who was very noncommittal. What is your opinion? Should they have surgery or not? (cont. pg 8)
Dr. Lyndon Wong is the chief of primary care services at SUNY college of optometry. Being on the west coast, most of you may not know of him, but he is best known for his bubbly personality and unfathomable patience with 3rd year students. Nonetheless, his expertise and knowledge leave him second to none. He has decided to share some of his experience with us and is open to any questions you may have regarding this case or any other situations.
The Infant Vision Exam I know, you are all wondering, how do I examine an infant. Well, it doesn’t require much. What do you really need to know? The first thing is the refractive error, afterall, this will give you an idea of what the visual acuity should be. Secondly, is there a strabismus present and lastly is there any obvious ocular pathology. All of these can be done in your office. You don’t need any special equipment or training. Everyone was trained to do this throughout your career. Refractive error, there is something called Retinoscopy. I am sure you have all done this and by now should be pretty accurate with this technique. How do I perform retinoscopy on an infant? Well, Mohindra Retinoscopy, of course. Remember this is done at 50 cm in complete darkness and the patient fixates the light on the retinoscope. It would help if you had a lens rack but loose lenses will work just as well. Don’t forget to take out your working distance +1.25. How do I do a cover test? Hirshberg test, you shine a transilluminator at the patient and look at the corneal reflexes (purkinje images) to make sure they are symmetrical. In a dark room, the infant will fixate the light and allow you to do an alternating cover test. Remember, if the parents tell you there is a strabismus present then there probably isn’t one. However, if the grandparents tell you an eye turns then you better find one. Pathology, do I dilate? Case history is very important to determine if there is any family history of pathology. In most cases, the pediatrician and obstetrician will know if there are any high risks pathology and will be treated right away. There is that rare occasion you may need to rule out any pathology. So, you dilate and try your best. If you have any concerns then you can always refer to a pediatric ophthalmologist. Remember, one of the key things to look for is leucocoria.
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