PEDS SELF-ASSESSMENT
BELOW ARE SOME TYPICAL QUESTIONS ONE MIGHT ASK ON A MIDTERM EXAMINATION IN PEDIATRIC OPTOMETRY. PLEASE ASSESS YOUR ABILITY TO ANSWER THE QUESTIONS TO FIND OUT IF YOU HAVE BEEN ATTENTIVE DURING CLASS AND DONE THE READINGS.
>>>>PLEASE NOTE<<<<
THESE QUESTIONS DO NOT INCLUDE THOSE THAT COULD BE TAKEN DIRECTLY FROM THE READINGS AS INDICATED ON THE COURSE HOMEPAGE.
1. LIST three signs of information overload when examining a young child.
a.___________________________________________________________
b.___________________________________________________________
c.___________________________________________________________
2. You perform a Hirschberg test on a two year old and you record OD +1.0 and OS -0.5. What is your diagnosis? Be specific.
3. The preferred method of testing visual acuity in a four year old child is which one of the following charts:
a. HOTV
b. Lighthouse
c. Allen
d. Tumbling E
4. You are performing a Mohindra dark room retinoscopy test on a young child. You record:
+2.75 - 1.50 x 180 for each eye. What is the predicted refractive error for this child?
5. A congenital esotropia frequently has associated with it one or more of the following motor anomalies:
a. overacting inferior obliques, dissociated horizontal deviation, latent nystagmus
b. dissociated vertical deviation, congenital nystagmus, superior oblique fibrosis
c. latent nystagmus, overacting superior obliques, dissociated vertical deviation
d. dissociated vertical deviation, overacting inferior obliques, latent nystagmus
6. Which one of the following is true about deprivation amblyopia?
a. accounts for 30% of all amblyopes
b. has a <0.4% prevalence rate in newborns
c. is almost always bilateral
d. can be successfully treated in adolescence
7. When using a two alternative forced choice paradigm to access some function in a young child, which one of the following accomplishes a clinically acceptable probability level of success?
a. six consecutive correct responses
b. four consecutive correct responses
c. four-out-of-six correct responses
d. two-out-of-three correct responses
8. You are testing a severely involved young child who cannot adequately respond to quantitative measures of visual acuity. LIST two methods of accessing qualitative or behaviorally relevant vision.
a.________________________________________
b.________________________________________
9. Which one of the following refractive errors measured in a one year old may be the most indicative of a child at risk for developing myopia in school?
a. minus spherical equivalent & x 180 cylinder
b. minus spherical equivalent & x 90 cylinder
c. less than +1.00 hyperopia
d. minus spherical equivalent & no cylinder
10. Select ALL that are typically true of congenital esotropia.
a. large angle of strabismus
b. unilateral
c. cross fixation
d. reduced adduction
e. amblyopia after surgery
f. greater hyperopia than age normal
g. motion processing anomaly
h. asymmetric OKN
i. significant accommodative component
11. Select ALL of the following that can be considered risk factors for myopia development.
a. heredity
b. ethnicity
c. educational level
d. athleticism
e. language development
f. nutrition / illness / privation
12. Bruckner's test is performed using which instrument?
13. Unilateral deprivation amblyopia is usually caused by which one of the following?
a. metabolic disorder
b. chromosomal disorder
c. local dysgenesis
d. craniofacial abnormality
14. When performing a Worth 4 Dot test with a four year old, the child reports 3 red dots and 1 green dot. This suggests:
a. a fusion response
b. green eye suppression
c. a diplopia response
d. an uninterpretable response
15. Which one of the following nearpoint test results would be indicative of myopia development or progression?
a. high PRA, esophoria, high fused cross cylinder
b. low PRA, esophoria, high fused cross cylinder
c. high NRA, esophoria, low fused cross cylinder
d. low NRA, esophoria, low fused cross cylinder
16. When performing the Krimsky test on a four year old, the corneal reflexes are centered (neutralized) with 25 pd BO. This suggests which one of the following?
a. 25 pd exotropia
b. 25 pd exophoria
c. 25 pd esotropia
d. 25 pd esophoria
17. You examine a young child and notice an esotropia with significant limitation in abduction of the right eye. You order a forced duction test. The result comes back negative. This suggests which one of the following?
a. probable MR restriction
b. VI nerve paresis
c. accommodative esotropia
d. probable congenital origin
18. Congenital esotropia is thought to be caused by:
a. abnormal EOM development
b. absence of sensory fusion
c. abnormal motor fusion processes
d. anomalous tonic convergence
e. all of the above
f. none of the above
g. b & c only
h. e & f only
i. a & b only
19. The monofixation syndrome is a frequent clinical outcome of congenital esotropia. This includes:
a. peripheral fusion,. global stereopsis, central suppression
b. ARC, central suppression, local stereopsis
c. central fusion, global (RDE) stereopsis, peripheral diplopia
d. peripheral fusion, local stereopsis, central suppression
20. When interpreting Bruckner's test:
a. the dimmer reflex is anomalous
b. the brighter reflex is anomalous
c. with motion indicates significant hyperopia
d. with motion indicates significant myopia
21. Which one of the following is not true concerning deprivation amblyopia?
a. 20/50-60 is possible with early intervention and aggressive treatment
b. intervention after 2-3 weeks of age reduces the prognosis
c. nystagmus improves the prognosis
d. fusion is difficult to obtain with monocular form deprivation
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Taz, a two year old mammalian infant cartoon character, spins into your examination room. His father, the REAL Tasmanian Devil, slobbers a lot and then reports his concerns that his son "looks cockeyed up at me from his crib...especially after spinning to the right. Bugs said I should get it checked out....then he pushed me off a cliff". You conduct an eye exam on Lil' Taz and find the following:
Retinoscopy (Mohindra): OD: +2.75-0.75 X 087 (20/30-2 D)
OS : -2.00 DS (20/20 D)
Cover test (w/ret. results) Distance: (primary gaze): 18Æ XT (left gaze): 35Æ XT
(right gaze):14Æ XT
EOM (versions): limited adduction O.D. with gaze to the left
globe retraction O.D. with gaze to the left
otherwise, smooth and full versions
Pupils: PERRLA (5.0 mm)
The following 7 questions deal with the case presented above. Choose the best answer BASED ON THE DATA PROVIDED! GOOD LUCK!
1. Since it is Taz's first visit to the eye doctor, it may be important to
A. immediately bring Taz back to your examination room and show him all your medical instruments
B. insist that his father remain in the waiting room during the exam
C. wear your white clinic jacket (to show Taz how clean you are)
D. to complete as many entrance tests as possible in the more friendly confines of the waiting area
2. When taking case histories for a child this age it probably would NOT be advantageous
A. to obtain a birth history
B. to ask about reading skills and grades in school
C. to ask about any perinatal trauma
D. to ask about the time of developmental milestones (i.e. walking, talking)
3. The oculomotor defect diagnosis is
A. CN III paresis
B. Duane's retraction syndrome Type I
C Duane's retraction syndrome Type II
D. CN VI paresis
4. T or F In this case, the dysfunction is most likely secondary to vascular occlusive disease
5. One clinical sign of this oculomotor defect not mentioned above is
A. decreased elevation O.D. on abduction
B. decreased palpebral fissure size on adduction
C esotropia at near
D. decreased palpebral fissure size on abduction
6. Based on what we talked about in class, what clinical feature of Taz's refractive condition is of most concern to us (i.e. amblyogenic). Remember his age!
A. astigmatism O.D.
B. hyperopia O.D.
C anisocoria
D. antimetropia
7. What prescription (if any) would you recommend in this case?
A. full antimetropic correction (if stable)
B. prescribe for the myopic eye only
C. monitor for 1-2 years before considering a Rx (wait till he is at school age)
8. A six month old child with a manifest refraction of -1.00 -1.50 X 090 O.U.
A. may well change over time and should only be monitored at this point.
B. is a significant myopic error and should be prescribed, if the refraction is stable
C. is a significant against the rule astigmatism finding and should be prescribed, if to avoid meridional amblyopia
D. is less problematic if there is an associated accommodative esotropia
9. Which of the following are considered to be refractive conditions that warrant correction (if stable) to a 7 year old?
A. hyperopic anisometropia of +2.00 D, O.D. and Plano, O.S.
B. 0.75 diopter of W/R cylinder
C. hyperopia of +3.00 D
D. A and C are correct
E. all are correct
10. A unilateral internuclear ophthalmoplegia has which of the following characteristics when the patient attempts conjugate gaze (assume the MLF lesion occurs AFTER crossing the midline)?
A. an inability for the eye ipsilateral to the lesion to adduct
B. an inability for the eye contralateral to the lesion to abduct past the midline
C. a nystagmus for the eye contralateral to the lesion on abduction
D. A and C are correct
11. An isolated, unilateral abducens nucleus lesion has which of the following characteristics when the patient attempts conjugate gaze?
A. an inability for the eye contralateral to the lesion to adduct past the midline
B. an inability for the eye contralateral to the lesion to abduct past the midline
C. an inability for the eye ipsilateral to the lesion to abduct past the midline
D. A and C are correct
12. T or F Infranuclear (sub-nuclear)lesions almost always involve the medial longitudinal fasciculus
Pepe' Lepeuw, an amorous male cartoon character finally won over the cat of his dreams (....he still insists that she is a skunk) and started a family of little Lepeuw's. Little Lillie, a eight year old girl, is your patient. She has an esotropia the appears to be constant. You complete a history and proceed with the exam. Excerpts are presented below.
Dry refraction: OD: +0.75-0.75 X 087 (20/20 Dist.)
OS : +1.00 DS (20/20 Dist.)
Cover test (w/ret. results) Distance: 35Æ ET (constant alternating) Near: 28Æ ET (constant alternating)
+ dissociated vertical deviation
EOM (ductions): full range with some difficulties with abduction O.U.
EOM (versions): bilateral overaction of the inferior oblique muscle
After-image test: left eye image (horizontal) displaced to the right of the right eye image (vertical)
The following 7 questions deal with the case presented above. Choose the best answer BASED ON THE DATA PROVIDED! GOOD LUCK!
13. In Lillie's case, the history should include
A. age of onset of esotropia
B. family history of esotropia
C. clinical course of esotropia
D. all of the above
14. After taking the history, you find out that Lilly's esotropia classification is just what you would expect from the above listed test results. What would be your prediction?
A. acquired esotropia
B. congenital esotropia
C. strabismic amblyopia
D. pseudoesotropia
15. After more testing, you find that Lilly has significant prism adaptation. What implications does this result have?
A. it indicates that relieving prisms are not viable at this point
B. it indicates that neutralizing prisms will effectively create sensory orthophoria and allow normal fusion to take place
C. it indicates that surgical intervention is less likely to be successful
D. all are correct
E. A and C are correct
16. When considering passive therapy for Lilly's ARC
A. never patch the patient as it would make the ARC more embedded
B. patching should be for 1-2 hours per day
C. prism should always be the neutralizing prismatic amount
D. none of the above are correct
17. When considering prescribing glasses for Lilly, a good doctor would
A. cycloplege Lilly to reveal full plus
B. prescribe 2/3 of the cycloplegic refraction values
C. determine if an add would effectively reduce the angle at near
D. A and C are correct
18. Once ARC has been successfully treated, and you are in the rehabilitation of a binocular pattern phase of therapy, it would be best to begin sensory fusion activities
A. with moderate sized stereo targets at 40 cm
B. with large, peripheral superimposition targets at the objective centration point
C. with moderate sized flat fusion targets with high contour at the objective centration point
D. with a couple of double martinis
19. After a wonderful job of therapy, Lilly has decent flat fusion skills as long as she wears a 10 prism diopter relieving prism. The orientation of this prism would be ______ and it ______ be ground into spectacle lenses
A. BO/could
B. BO/could not
C. BI/could
D. BI/could not
20. In the case of toddler (1-3 years old), occlusion therapy for an intermittent strabismus
A. should be constant and alternated (from left to right eye) daily
B. should be at least 12 hours/day
C. should not exceed 2-3 hours/day and should be monitored carefully
D. should be bitemporal occlusion only
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2. Describe the shape of the refractive error distribution curve in:
a. Newborns ---
b. 6-8 year olds ---
3. What name has been given to the physiological process that accounts for the changes in the distribution of refractive error described in #2?
4. The poor accommodative responses found in young infants can best be attributed to which one of the following factors:
a. Maldevelopment of the ciliary muscle
b. Relatively poor visual acuity creating a large depth of focus
c. Lack of experience in the control of accommodation
d. The relatively late onset of convergence-accommodation interaction
6. LIST the 3 accommodative-convergence findings that are predictive of the emergence of myopia or the progression of myopia.
a.
b.
c.
7. In the study reported by Monroe Hirsch, children with a retinoscopic refractive error of ³ _______________________ on school entry would be most likely to remain hyperopic throughout the school years.
8. Children in the first year of life have a high prevalence rate of significant ____________ -the-rule astigmatism.
9. Stereopsis and consistent disparity detection usually emerge at _____________ months of age.
10. The eye movements of newborns are characterized by which one of the following?
a. Hypometric saccades but accurate smooth pursuits
b. Accurate saccades and "tracking" type pursuit
c. Hypometric saccades and "tracking" type pursuits
d. Accurate saccades and accurate smooth pursuits
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A mother enters the clinic with her 3 year old son. The initial history form that she filled out indicated concern about the possibility of myopia because her child holds toys "extremely close" when playing with them. Myopia is present in both of the child’s parents. Answer the following questions concerning this case.
1. Please present two of the age appropriate tests/techniques that you can use to determine maximum distant acuity for this child.
2. If the child was 6 months old, would you have any reliable means to measure acuity? If so, what method(s) would be available to you? Please list two.
3. On extended Hx, you learned that the child was 4 weeks pre-mature. What follow-up questions come to mind. What other items of information may be important to gather in regards to this case? Please list three GOOD questions to ask.
4. This is the child’s first eye exam. Is it important to complete some tests in the waiting area. List three tests you would conduct and briefly describe how you would do them outside of the exam lane.
5. It turns out that the child’s APGAR scores were 5/6.
a. What implications does this score have for this little patient’s visual development?
b. List three (of the five) categories measured: _______________ , ______________ , _____________
6. If a six month old child presented with hyperopic anisometropia (O.D. +1.00 DS; O.S. +2.50 DS) and an intermittent left ET at near (strab. present 20% of the time).
a. What would be the best course of action for this patient as far as passive modes of vision therapy? Be specific as to type and timing of therapy.
b. What would be the best course of action for this patient’s refractive condition? Why?
c. What are your major concerns about patching in this case?
7. For a toddler, binasal occlusion has the potential to be quite helpful. List two visual skills that such an occlusion pattern could help.
8. Can you think of any reason to over plus a young patient at distance? Can you tell me about one such situation?
9. In class, the Rotating Hand Acuity Chart received less than rave reviews by your instructor. Why?
10. Which of the following acuity tests are NOT available in a near-point version?
A. Landolt C
B. Rotating Hand
C. Tumbling E
D. Broken Wheel
11. Briefly describe how you conduct a Broken Wheel Acuity Test. Include instructional set and ceiling criteria, please.
12. The following undergoes emmetropization (which is the complete answer):
A. hyperopia, myopia
B. hyperopia, myopia, astigmatism, amblyopia
C. hyperopia, myopia, astigmatism
D. hyperopia
13. Premature infants show a higher incidence of the following: (list four findings you might expect to see)
__________________, ________________, __________________, ________________
15. Optometric intervention for children and adults with a developmental disability may involve several things, name four:
________________, __________________, ___________________, _______________
16. A 10 year old female patient has an eso posture and has a dry refraction of +2.50 sph O.U. 20/20. Wet refraction revealed +4.00 D O.U. 20/50. With plus lenses, her eso posture is decreased at distance and near. Her parents report that her eye turns in when she is very tired. You would: (be specific and include your reasoning):
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1. What is the estimate of refractive error if you measure plano -1.00 x 90 performing Mohindra, or dark room retinoscopy?
2. With what lens powers would you neutralize the retinoscopic reflex when performing Mohindra, or dark room retinoscopy if the patient's actual refractive error was + 1.00 - 2.50 x 180?
3.(6) Please state 3 near point test findings that either together or individually indicate that a bifocal correction is required for a school aged child.
a .
b.
C.
4. What clinical test is of value in ruling out the presence of amblyopia or strabismus in a pre-school child?
5. You find a +1.0 mm <K in the right eye of a 1 year old infant. The left eye has a 0.5 mm <K. Based on this alone what are your impressions?
7. What are two major differences observed in refractive error distributions between newborns and 6-8 year old children?
a.
b.
8. What process is thought to account for this evolution of refractive error in children?
9. What level of hyperopia found in a child on entering school would suggest that this child has a significant probability of becoming myopic during the school age years (from Monroe Hirsch's data)?
10. Please describe the "passing" criteria in terms of probability theory when performing a 2 alternative forced choice testing paradigm.
11. List 3 non-optometric risk factors for the development or progression of myopia?
a.
b.
C.
12. List 2 preferred methods of assessing visual acuity in pre-school children (other than Snellen)?
a.
b.
13. Describe briefly the changes that occur in accommodative responses from birth to 3-4 months of age.
15. You are in a heated argument with a representative from the local school board who says that visual acuity testing is all that is required for a vision screening for the school district. What is your response (be succinct)?
16. You decide to measure vergence function in a clearly non-strabismic toddler. After placing an 8pd BO prism before the left eye, you perform a cover-uncover test to assess fusion. When the right eye is covered, the left eye doesn't move. When you remove the cover, the right eye moves in & the left eye still doesn't move? What is your impression?
17.You perform a Bruckner's test on a one year old and find that the left eye reflex is considerably dimmer than the right eye reflex. You explain the results to the child's mother and indicate that there's a problem that involves the right eye.
a. What could be wrong? b. The child's mother is a first year medical student who doesn't quite understand why the right eye is "wrong" and argues that the difficulty lies with the left eye, the "dimmer" eye. What is your response?