Other

Planning screening in pediatric ophthalmology. Medical examination of children by an ophthalmologist

Did your baby flinch from loud noises in the first 2-3 weeks? life?
Does the child freeze at the sound of someone else's voice? at the age of 2-3 weeks?
Does a baby turn around at the age of 1 month? at the sound of a voice behind him?
Does a 4 month old baby turn his head? towards a sounding toy or voice?
Is a 4 month old baby alive? at the sound of your mother's voice?
Does a child aged 1.5-6 months react? screaming or opening your eyes wide to sharp sounds?
Does a child aged 2-4 months hum?
Does babbling turn into babbling in a child aged 4-5 months?
Do you notice the appearance of new (emotional) babble in your child as a reaction to the appearance of his parents?
Does a sleeping child become disturbed by loud noises and voices?
Do you notice in a child aged 8-10 months. the emergence of new sounds, and what?

The use of such questionnaires makes it possible to more accurately determine hearing pathology in early childhood or even during the neonatal period, and therefore to outline preventive measures.

Hearing Screening

Timely identification of audiological problems allows early initiation of interventions aimed at increasing communication, social and educational skills in these children. There has been debate for many years about the value of selective hearing screening and universal audiological screening in the newborn period.

Unfortunately, only half of newborns with significant hearing loss are identified using a selective screening strategy based on the presence or absence of risk factors for hearing loss: family history of hearing loss in childhood, history of congenital infections, anatomical malformations of the head, neck or ears, weight at birth less than 1500 g, a history of hyperbilirubinemia exceeding a critical level, severe asphyxia at birth, bacterial meningitis; history of ototoxic drug use; long-term mechanical ventilation; the presence of a congenital/hereditary syndrome or its stigmata associated with sensorineural hearing loss.

The average age at which a child with significant hearing impairment is identified, for example in the United States, is 14 months. Limitations in screening technologies, leading to inconsistencies in test interpretation and high rates of false-positive results, logistical problems associated with availability and implementation, resulted in the US in 1999 with the reaffirmation of a policy of universal hearing screening in the newborn period to identify newborns with significant hearing loss by three months of age so that intervention can begin by six months of age. Ideally, the first screening should be carried out before discharge from the hospital. Newborns up to 6 months. traditionally studied using brainstem response testing.

A newer physiological technique, otoacoustic emissions or evoked brain potential testing, shows promise as a simple screening technique. However, specificity issues and logistical problems with consistent use and interpretation of this test raise questions regarding its introduction for universal screening.

Some pediatricians advocate a two-step screening strategy whereby children who are deficient on otoacoustic emissions testing are referred for screening with brainstem response testing. Until an optimal screening method becomes available, specific methodology for newborn hearing screening is limited to these tests.

Children over 6 months. can be examined using behavioral, auditory brainstem, or otoacoustic emissions testing. Regardless of the technique used, screening programs should be able to detect hearing loss of 30 decibels or more in the 500-4000 Hz region (speech frequency), a level of deficit at which normal speech development may be impaired. If a hearing deficit is identified, the child should be promptly referred for further evaluation and early intervention in the form of targeted education and socialization.

In addition to performing a rough hearing assessment and interviewing parents regarding hearing problems, a formal hearing screening should be performed on all children at each wellness visit. Risk factors that may necessitate formal screening outside the neonatal period include: parental concerns about hearing loss and/or language delay; a history of bacterial meningitis; neonatal risk factors associated with hearing loss; history of head trauma, especially involving temporal bone fractures; the presence of syndromes associated with sensorineural hearing loss; frequent use of ototoxic drugs; neurodegenerative diseases and infectious diseases such as mumps and measles, which are associated with hearing loss.

Visual impairment

The most common type of vision disorder in children is refractive error. Through a thorough history, examination, and visual function testing, visual impairments can be detected early and their symptoms reduced or eliminated.

Risk factors for developing eye pathology include:

prematurity, low birth weight, hereditary diseases in the family;
BHV infection, rubella, herpes and sexually transmitted diseases in the mother during pregnancy;
diathesis, rickets, diabetes, kidney disease, tuberculosis in a child; ophthalmological diseases in a family history (amblyopia, hypermetropia, strabismus, myopia, cataracts, glaucoma, retinal dystrophy);
diseases in the family history that can affect vision (diabetes, multiple sclerosis, collagenosis);
the use of medications that can affect vision or cause a delay in vision development (steroid therapy, streptomycin, ethambutol, etc.);
viral infections, rubella, herpes in a child.

Vision Screening

Routine vision screening is an effective way to identify otherwise undetected problems that need to be corrected. Since normal visual development depends on the brain receiving clear binocular visual stimulation, and the plasticity of the developing visual system is limited in time (the first 6 years of life), early identification and treatment of various problems affecting vision is necessary to prevent permanent and irreversible visual deficits.

Routine age-related vision assessment should be performed at every primary care pediatrician's office visit, beginning with newborn examinations, and at any age include a review of adequate anamnestic information regarding visual problems and family history, a gross examination of the eyes and surrounding structures, and observation of pupillary symmetry and reactivity. , assessment of eye movements, identification of the “red reflex” (to detect clouding and asymmetry of the visual axis) and age-specific methods for assessing eye preference, adjustment and visual acuity. Special ophthalmoscopic examinations are carried out at 1, 3, 5, 6, 7, 10, 12 and 14 years, then annually until the age of 18 as part of the annual medical examination of children or as directed by a pediatrician.

In newborns, eye condition, adjustment, and visual acuity can be roughly assessed by observing the child's ability to visually follow an object. This involves noticing any behavioral evidence of eye preference by alternately closing each eye when presented with an object of interest and observing the position of symmetry of light reflected from the corneas when the light source is held a few centimeters in front of the eyes (corneal light reflex). Visual adjustment (looking with both eyes) should be constantly present by 4 months. life. It is especially important to evaluate the “red reflex” during the neonatal period. Identifying the absence of red reflex defects or asymmetries is key to prompt identification and treatment of visual axis opacities and many posterior ocular abnormalities.

In infants and preschoolers, visual preference and regulation can also be assessed by performing a more complex single eye closure test. It involves closing and opening each eye while the child looks straight ahead at an object approximately three meters away. Observation of any movement of the uncovered eye when the opposite eye is closed, or the closed eye when the occlusion is removed, indicates a potential eye misalignment (strabismus) and requires discussion with the ophthalmologist about a plan for further examination. Regardless of etiology, strabismus that remains untreated ultimately results in cortical suppression of visual input from the nondominant eye and absence of spatial vision, making early diagnosis and treatment critical.

By 3-5 years of age, stereoscopic vision can be assessed using a stereotest or stereoscopic screening devices. Formal visual acuity testing should begin at age three years with age-appropriate techniques. Approximately 20-25% of children have an identifiable refractive error, usually premyopia or myopia (nearsightedness), by the time they reach adulthood. The use of picture tests, such as the LH test, and Allen picture cards are most effective in screening preschoolers. By age 5, most children can be successfully screened using standard alphabet cards and the flip test.

Schoolchildren, including adolescents, should have annual visual acuity tests. Examination of preschoolers should continue if visual acuity in either eye is reduced. In children 5-6 years old, if it is impossible to read most of the lines, further examination is necessary. At any age, differences in visual acuity measurements between the eyes of more than one line require further evaluation.

Periodic examinations of the organ of vision and testing of visual functions should be carried out by family doctors at certain intervals: upon discharge from the maternity hospital; at the age of 2-4 months; at the age of 1 year; at the age of 3-4 years; at the age of 7 years; at school - once every 2 years. Children at risk of developing eye pathology should be examined annually. Newborns and infants at risk are examined quarterly during the first two years of life.

IN Within the walls of our clinic, we often encounter situations when, having heard one or another ophthalmological diagnosis, parents ask the question: “ How long have we had this problem??”, and are very surprised when they hear in response: “This problem is not three weeks old, or even several months old, this is a congenital pathology" And often we see the amazed and confused look of moms and dads. And when we start asking when they visited an ophthalmologist, we get many answer options, such as:

- “Why do this before school?”
- “We were - we were told that everything will pass with age.”
- “We were assured that it is impossible to examine a child under 3 years old,” and so on.

U us in the center Children are examined by an ophthalmologist at any age. Already at the age of up to 1 year, our specialist can confidently say: the child has or does not have a congenital pathology, whether his visual system is delayed in development, whether there is a threat of strabismus, etc.

How do we quickly and easily check the vision of babies under 1 year old?

T now in our center in Kharkov, thanks to the device “Plusoptix, Gemany” we can with high precision scan the child’s visual system as early as 3 months.
The verification procedure is very simple and does not require any effort from the child.

IN The doctor takes measurements with the Plusoptix device within 15-30 seconds. At this time, the child is in the arms of his parents, we attract his attention with a special sound. Depending on the screening result, the doctor gives further recommendations and gives the patient the examination result.

Why is ophthalmological screening in infancy so important?

ABOUT The peculiarity of eye diseases is that they are not accompanied by painful sensations (except for injuries) , so the child is not able to realize that he sees poorly and cannot tell her parents about it.

P The first visit to an ophthalmologist should be planned at 3-4 months. It is at this age that the correct position of the eyes is established and possible pathologies are already visible. The doctor evaluates the condition of the optic nerve and retinal vessels, which are an indicator of cerebral vascular tone. At this age signs of such serious diseases are visible How:

V congenital glaucoma (increased intraocular pressure),

To ataract (clouding of the lens),

n toses (drooping of the upper eyelid),

h malignant neoplasms requiring urgent surgical intervention.

E If we also add paralytic strabismus and some developmental anomalies of refraction, which can already be not only diagnose, but also successfully correct before the age of one year, it becomes obvious how Early ophthalmological screening is important.

Relevance
The lack of optimal dispensary monitoring of vision in children entails untimely prescription of therapeutic and preventive measures, which leads to an increase in morbidity. A remote vision screening program for schoolchildren, developed and implemented in practice, makes it possible to effectively identify pathology at an early stage. The wide interest shown in the implementation of this program at the regional and federal levels requires further programmatic and methodological improvement.

Target
To analyze the effectiveness of remote vision screening examinations in schoolchildren, to outline ways for its effective implementation in practice at the regional and federal levels.

Materials and methods
A computer program has been created: Program for remote vision screening examination (DVS). The program allows you to interactively conduct four types of examinations:
1. Study of visual acuity. An analogue of the Landolt optometric optotype test table is used. It is generally accepted that these optotypes are the most reliable in the study of visual acuity. The angular size of the optotypes is set during quantitative verification of the test strip before the study by the school employee responsible for the screening. The number of optotypes presented to the patient and the number of permissible errors strictly corresponds to the world standard when studying visual acuity in an ophthalmology office.
2. Determination of the state of the student’s refraction at the time of the examination, its shift towards hypermetropia or myopia. This is a duochrome test: let us recall that a nearsighted person sees more clearly those optotypes that are located on a red background, and a farsighted person sees those on a green background. The test is very significant given the fact that monitoring refraction against the background of school visual load makes it possible to judge the child’s functional readiness for it. A complete control ophthalmological examination in some cases does not confirm the presence of myopia, but visual overstrain detected during screening allows us to judge a high risk of myopia.
3. Detection of astigmatism by assessing the clarity of vision of multidirectional segments of the radiant figure. If the optics are physiologically relatively symmetrical, then the subject will not indicate these differences.
4. The Amsler test allows you to indirectly exclude or identify pathology of the macular zone - the area of the retina responsible for the condition of central vision.
The survey results are automatically entered into the database and stored there. The peculiarities of entering the passport data of the subjects make it possible to control the screening results, regardless of whether the child continues to study in this school or another after a change of place of residence.
The screening regulations involve the use of a program posted on the website of our clinic using the Internet.
The examination is carried out in a computer class simultaneously to a group of 5 schoolchildren. Depending on the number of tests performed, the examination takes from 4 to 8 minutes. Thus, in one academic lesson, it is possible to conduct a vision screening examination for all students in one class of a general education school (30–40 people).
The screening examination of schoolchildren has been coordinated with the main departments of health, education, communications and information technology of the Novosibirsk mayor's office, and parent committees of schools.
The following organizational activities are being carried out:
1. Management and district departments of education:
— coordination of organizational events;
— agreement on the timing of screening;
— information letters to school principals.
2. Directors, head teachers, computer science teachers:
— instructions on how to use the program;
— screening regulations;
— harmonization of material, technical and software.
3. Class teachers:
— informational consent of parents to conduct a screening examination;
— bringing screening results and recommendations to their attention.

Results
Participated in the pilot project
8. secondary schools in Novosibirsk. Over three weeks, vision examinations were carried out on 3,017 students. 870 schoolchildren had their vision tested twice (at the beginning and at the end of the school year, as planned with the widespread introduction of technology).
For comparison, over the course of 8 years, our branch’s visiting teams carried out ophthalmological examinations on 26,829 school and college students. Thus, the proposed method made it possible to increase the efficiency of screening examinations of schoolchildren’s vision by more than 9 times. Theoretically, with an organized examination, it is possible to conduct vision screening of all schoolchildren in Novosibirsk (about 1.0 thousand people) in one month.
Visual impairment was detected in 1,497 schoolchildren (49.6%, including 7% of primary school children). The screening reliability was
9.% of those with visual impairment and 100% without impairment. This was confirmed by random examination of visual acuity and refraction by the medical team on site.
When analyzing the causes of these artifacts, several causes were identified:
— deviation from the developed screening regulations, which, although it takes place in a playful way, still requires clear actions from students and proper control from the person in charge;
— low technical level of equipment in computer classes, primarily the use of 13-inch diagonal monitors based on ray tubes that have exhausted their service life;
— problems with Internet connections that are not provided by Internet providers at the required level as stated.
Technical problems can be eliminated at the stage of testing the capabilities of computer classes.
The regulations are clearly developed and stated in the instructions, and must be strictly observed when conducting the examination.
A targeted full ophthalmological examination was carried out on 614 students with identified visual impairments. This is the second stage in our planned system of medical examinations for schoolchildren.
It was found that 450 of them require surgical or conservative treatment. In fact, treatment was provided to 125 schoolchildren free of charge for parents.
In the process of work and analysis of the screening results, promising developments of the program we proposed were outlined and already partially implemented:
1. Screening study of binocular vision functions.
Relevance: high probability of binocular vision impairment with high visual acuity.
Funds raised:
— Lancaster glasses (departmental target state program (TsGP), LLC Center for Children's Vision "Ilaria" (CDZ));
— software development (Novosibirsk branch of the Federal State Institution “MNTK “Eye Microsurgery” named after Academician S.N. Fedorov of the Russian Medical Technology”).
2. Screening study of anomalies of the anterior segment and adnexa of the eyes.
Relevance: pathology imaging (leukoma, ptosis, strabismus, etc.).
Funds raised:
— webcam (CHP);
— creation of a specialized program block with a video database (NF FGU MNTK);
— analysis of the video database by ophthalmologists (NF FGU MNTK - telemedicine).
3. Monitoring compliance with the distance to the monitor from which the screening examination takes place.
Relevance: Improving the quality of screening examinations.
Funds raised:
— webcam (CHP);
— frame with a test strip (TsGP, NF FGU MNTK, TsDZ);
— software development (NF FGU MNTK).
4. Entering the address of the subject.
Relevance: the opportunity to inform parents directly about the need for a full examination of their children, explanatory and coordination work.
Funds raised:
- expansion of the scope of the passport part of the program (NF FGU MNTK - registration, completed).
5. Expansion of the database on secondary educational institutions of the Russian Federation.
Relevance: high interest in the implementation of the program of the subjects of the federation.
Funds raised:
— expansion of the scope of the passport part of the program (NF FGU MNTK, completed);
— personal access via login and password for each school (NF FGU MNTK, completed).
6. Screening study of vision of preschool children.
Relevance: high level of myopia in primary school children.
Funds raised: development of the test part of the program for preschool children (NF FGU MNTK).
7. Combination of the basic program with additional screening diagnostic equipment.
Relevance: objective detection of ametropia even with high visual acuity.
Funds raised:
— Plusoptix binocular refractometer (TsGP, TsDZ);
— development of software combining 2 databases (NF FGU MNTK).

Conclusions
The proposed comprehensive target program allows:
— identify schoolchildren with reduced vision in a timely manner and in greater numbers;
— targeted, effective provision of the necessary specialized ophthalmological care;
- monitor the state of vision of schoolchildren throughout the entire period of study;
— identify institutions in violation of SanPiN standards.

Price"Plusoptix screening test"- 150 UAH - without doctor’s examination

Cost of "Plusoptix Screening Test"- 175 UAH with professional examination by a doctor

All parents wish their children health. As you know, preventing the development of a disease is much easier than treating it. rid kids and their parents out of trouble A comprehensive preventive examination will help with your health. It is for this purpose, for first year of a child's life, once a month you need to visit certain specialists. And it is no coincidence, because the first year is a very important period in the life of a baby, since it is at this time that the formation of all organs and systems of the body occurs. In our state healthcare system, a pediatrician examines the child monthly and only if any pathology is suspected, sends him for consultation to specialized specialists. But is it always possible to see a problem with the “naked eye”?

As it turned out, not always! We are talking about the development and formation of the child’s visual system. Within the walls of our clinic, we often encounter situations when, having heard one or another ophthalmological diagnosis, parents ask the question: “How long ago did we have this problem?”, and are very surprised when they hear in response: “This problem is not three weeks old, and not even a few months, this is a congenital pathology.” And often we see the amazed and confused look of moms and dads. And when we start asking When did they visit the ophthalmologist?, we get many answer options, such as:

- “Why do this before school?”
- “We were - we were told that everything would pass with age.”
- “We were assured that it is impossible to examine a child under 3 years of age,” and so on.

How to check the vision of a child of the first year of life?

Now in our center in Kharkov, thanks to the “Plusoptix, Gemany” device, we can accurately check the vision (visual acuity) of a child up to one year old.

This is how the visual acuity test procedure works:

Doctor within 15-30 seconds the device takes measurements "Plusoptix"
Further, depending on the result of the examination, the doctor gives further recommendations and gives it to the patient examination result.

Why is it so important to consult a pediatric ophthalmologist in infancy?

The peculiarity of eye diseases is that they are not accompanied by painful sensations (except for injuries), so the child is not able to realize that he sees poorly and cannot tell his parents about it.

First visit to the ophthalmologist need to plan at 3-4 months. It is at this age that the correct position of the eyes is established and possible pathologies are already visible. The doctor evaluates the condition of the optic nerve and retinal vessels, which are an indicator of cerebral vascular tone. At this age visible signs of such serious diseases How:

congenital glaucoma(increased intraocular pressure),
cataract(cataract),
ptosis(drooping of the upper eyelid),
malignant neoplasms requiring urgent surgical intervention.

If we add paralytic strabismus and some refractive errors, which can not only be diagnosed, but also quite successfully corrected before the age of one year, it becomes obvious how important is an early examination by a pediatric ophthalmologist?.

There's no doubt The fact is that preventive examination is necessary for all children. But there is a certain risk group that needs to visit an ophthalmologist almost as an emergency.
In what cases visit to the ophthalmologist so necessary:

pregnancy took place against the background of gestosis of any severity (preeclampsia, eclampsia)
case of intrauterine chronic hypoxia
during rapid or, on the contrary, protracted labor with a long anhydrous period
C-section
umbilical cord entanglement
birth injuries
premature birth before 38 weeks of gestation
premature placental abruption
Apgar score less than 7-8 points
IUGR (intrauterine growth retardation)
TORCH – infection (congenital rubella, chlamydia, mycoplasmosis, herpetic infection)
burdened family history according to ophthalmologists: - myopia (myopia) - hypermetropia (farsightedness) - astigmatism - strabismus - cases of congenital cataracts, glaucoma, optic nerve atrophy.

Let's summarize:
1) When is the first visit to an ophthalmologist necessary? - At 3-4 months
2) What is needed for this? - The child should be full and not want to sleep
3) How complex is this examination? - In the absence of pathology, it does not require either expensive equipment or a lot of time
4) What information content? - 100%, since at 3 months the child is not yet afraid of the doctor, takes good care of the toy and is calm during the entire examination
5) What will this give us if pathology is detected? - Timely identification of the problem opens up the possibility of early conservative treatment.
6) How can an infant wear glasses? - We assure you that children even at this age will be able to wear glasses, and the sooner we begin to solve this problem, the greater the chance that the child will go to school with a completely healthy visual system prepared for the load.

Ophthalmology uses instrumental research methods based on the achievements of modern science, allowing for early diagnosis of many acute and chronic diseases of the organ of vision. Leading research institutes and eye clinics are equipped with such equipment. However, an ophthalmologist of various qualifications, as well as a general practitioner, can, using a non-instrumental research method (external (external examination) of the organ of vision and its adnexal apparatus), conduct express diagnostics and make a preliminary diagnosis for many urgent ophthalmological conditions.

Diagnosis of any eye pathology begins with knowledge of the normal anatomy of ocular tissues. First you need to learn how to examine the organ of vision in a healthy person. Based on this knowledge, the most common eye diseases can be recognized.

The purpose of an ophthalmological examination is to assess the functional state and anatomical structure of both eyes. Ophthalmological problems are divided into three areas according to the place of occurrence: the adnexa of the eye (eyelids and periocular tissues), the eyeball itself and the orbit. A complete baseline survey includes all of these areas except the orbit. For its detailed examination, special equipment is required.

General examination procedure:

visual acuity test - determination of visual acuity for distance, for near with glasses, if the patient uses them, or without them, as well as through a small hole if visual acuity is less than 0.6;
autorefractometry and/or skiascopy - determination of clinical refraction;
intraocular pressure (IOP) study; when it increases, electrotonometry is performed;
study of the visual field using the kinetic method, and according to indications - static;
determination of color perception;
determination of the function of extraocular muscles (range of action in all fields of vision and screening for strabismus and diplopia);
examination of the eyelids, conjunctiva and anterior segment of the eye under magnification (using loupes or a slit lamp). The examination is carried out using dyes (sodium fluorescein or rose bengal) or without them;
examination in transmitted light - the transparency of the cornea, chambers of the eye, lens and vitreous body is determined;
fundus ophthalmoscopy.

Additional tests are used based on the results of anamnesis or initial examination.

These include:

gonioscopy - examination of the angle of the anterior chamber of the eye;
ultrasound examination of the posterior pole of the eye;
ultrasound biomicroscopy of the anterior segment of the eyeball (UBM);
corneal keratometry - determination of the refractive power of the cornea and the radius of its curvature;
study of corneal sensitivity;
examination of fundus parts with a fundus lens;
fluorescent or indocyanine green fundus angiography (FAG) (ICZA);
electroretinography (ERG) and electrooculography (EOG);
radiological studies (x-ray, computed tomography, magnetic resonance imaging) of the structures of the eyeball and orbits;
diaphanoscopy (transillumination) of the eyeball;
exophthalmometry - determination of the protrusion of the eyeball from the orbit;
pachymetry of the cornea - determination of its thickness in various areas;
determining the condition of the tear film;
mirror microscopy of the cornea - examination of the endothelial layer of the cornea.

T. Birich, L. Marchenko, A. Chekina