With age-appropriate tests and tools, primary care providers can identify vision concerns in very young patients before there are lasting effects. In this video, UCSF specialists discuss screening methods and offer a case-based look at the diagnostic process for issues ranging from amblyopia to ocular tumors. Also included: criteria for urgent referrals.
Uh I'm Talita Queen angle is the new pediatric ophthalmologist at Students Hospital. And I'm looking forward to working with our view. So today we'd like to talk about when to call your neighborhood pediatric ophthalmologist. Uh so pediatricians should always include pediatric vision screening in their routine care of Children. The American Association for Pediatric Ophthalmology Industry Business has published the guidelines to promote early um detection and treatment of vision treating conditions. So I will be talking more about vision is screening and as you've been showing interesting cases later. So our learning objects today is to appreciate the importance of vision screening during childhood. Also understand methods of visual acuity screening and appreciate the new technologies that can identifying signs of potential vision loss is problems. So why to perform vision screening? So primary care providers are the first line of defense to avoid vision laws in Children and why do Children lose vision in Ethiopia is the most common cause of vision loss. And Children in Ethiopia is a decrease in vision development that happens when the brain doesn't not get normal stimulation from the eyes. And this abnormal development of vision results uh when one or both eyes and an unclear image to the brain and the brain is unable to learn to see clearly with that. I even when glasses are used so only Children can get amblyopia and it's not treated in childhood, it results in permanent loss of vision in blue Europa, It's most commonly caused by untreated reflective eros, extra business and other vision with others such cataract glaucoma. Fortunately pediatric vision screening can reduce the incidence of vision loss related to Ethiopia and the area that Ethiopia is attacked. The better the visual recovery and the long term prognosis Permanent vision loss occurs by seven years of age. Amblyopia affects 2 to 3% of Children in the United States. In Children who can collaborate direct measurements of visual acuity using charts, remains the gold standard for vision screening. So for newborn and kids below three years old, it's important to take a half history, including eye problems in close relatives. We have to check if the kid has the ability to look and follow a moving object from side to side up and down corner light reflects. Our over testing are really important to the texture business and we also have to check the eyelids and pupils and red reflexes. So the red reflects test is no events of task that can show early warning signs of serious eye conditions. In Children, we usually perform a red reflects tests amusing and of thomas cope absent, red reflects or a white. I grow maybe signs of serious eye disease. In Children including rich noble stone in a corner light reflects tests. The child's intention is attract to a target while the light is pointing at the child's eyes. In kids with destroy business, the light reflects will not be in the center of each people. So here is a video to demonstrate the alternate covert tests and how to detect this. Your business. In Ortho foria. There is no movement of either I when the cover is moved back and forth from one eye to the other. If re fixation is seen each time the cover is moved. This may indicate a hetero trow pia. Re fixation movements each time the cover is moved are also seen in Hetero Foria. In Hetero foria fusion. A liver jin's restores normal ocular alignment. As soon as binocular viewing is allowed. Uh so soon mr. Business is a condition that you see very often in our clinic and it's when the child appears to have a real estate business because of the enlarged epic canto folds. But look at this picture in the bottle and the note that the light reflects this metric in each eye and the status of your business go away as the baby's face begins to grow. So Children aged 3-4 years old must be able to see 2050 with each eye. And the testing should be done at 10th it. So we recommend uh leah symbols, H. O. T. V. Letters for visual acuity measurement Uh dumbly in charge. It's not recommended for Children aged 3-4 years old as it requires a spatial orientation skills. And young Children may not yet have the ability to express the orientation of those opta types. Children aged between four and five years old must be able to see 2040 with each eye And above five years old. They must be able to see 2032 or 2030 with each eye depending on the charge used. And it's important to repeat the task everyone to two years. So let's talk about 40 screening. So those devices are often very useful in Children between one and five years old. But they do not replace visual security screening with eye charts in older Children. So what is the difference between vision screening with my charts and instrument based in screening device? So visual screening with eye charts test the actual visual clarity like 2030 2020 2040. And the visual screening device typically do not test visual acuity directly. Uh screening device test for one point I conditions or risk factors that can cause decreased vision or in Ethiopia. So those devices take a photographic image of the eyes, red reflects or some other measurements to estimate the prescription of the eye. They also may detect ocular alignment and other conditions such as cataracts. So here we have some common instrument based device. My favorite is the the plus opticals from Germany. So I just wanted to emphasize that direct measurement of visual acuity using vision charts is the current gold standard for vision screening unless the child is not able to perform such a test. So far, the screeners are more generous for young Children. There is a higher detection and referral rates and fewer false positive but higher chance of missing at risk Children. And it's not recommended for Children older than six years of age. Uh huh. Uh So when the child fails vision screening, it's important to check if the kid was having a bad day was distract. And also check the numbers on the device. We are not going to prescribe glasses for kids with astigmatism less than 1.52 dieters or myopia less than three for kids below one year old. So those kids are not going to wear those glasses and uh these astigmatism around one point 1.5 or two will not cause amblyopia unless the kid has this difference refractive power between the two eyes above two diabetes or more. So checking the numbers on the device are really important before making a referral to us. So when you need to refer a patient to us. So below one year old refer Children who do not track well after three months of age and Children with an abnormal red reflects or history of Richmond bus toma in a parent or sibling between one year and three years old refer Children with an extra business connick clearing and discharged Children who fail for screening between three and four years old refer Children with vision, less than 2050 in between 54 and five years old, refer Children with vision less than 2040. And of course have Children who fail 40 screening and with Mr business so five years old or older refer Children who cannot read At least 2032 with either I or Children who are not reading at a great level. And and of course it's the business cases and uh we have to repeat division screening every 12 years after age of five. So uh so we can find those vision screening kit on on april's website. That's easy and thank you. So now as in is going to show us some interesting cases, so thank you. Um So we'll get started. Okay? So what we're gonna do in my president, my portion is um we're going to kind of go over some chief complaints that might present in your clinic and uh I want to walk you through what you know we hope you guys can do and then what you guys definitely need to send to us for. I tried to choose five of the most common um presentations so that would that would kind of apply to what you've seen your clinic that you would need to send us. Um So I think it will be very useful to take a look at these and we can talk about how to manage them. And I'm looking forward to the questions at the end. Um And yeah and then we are definitely gonna mention where we intervene and how we intervene in those specific cases. And I'm also gonna gonna take a second to go through the differential diagnoses of each of these and kind of talk a little bit about each of them and like what like what this case is and what it could potentially be and why we need to see it or why we don't need to see it in in those circumstances. All right. So case one um mother has noticed that are otherwise healthy. Six month old baby. Uh Baby's eyes have been crossing significantly since birth. Um The icy it seems to alternate which I was crossing. Okay. So it's a very common presentation in our clinic. Not probably not super common in yours but does come up. Um So the differential diagnosis for this patient is pseudo East utopia can generally Zootopia accommodated the Zootopia. Non accommodative acquire dystopia in the six storm poles. So um we're going to go through the first one differential. So the first differential studio East Metro P. A. And so in some ways a trophy a, you know, there's a prominent epic Cantel folds and the flat nasal bridge. You look over here, you see how this is kind of moving in. The eyes actually pseudo means the eyes are not actually crossing. It just appears that they're crossing it. When the kid looks, the mom and dad will start when the kid looks left, it looks like they're crossing. When the kid looks right, it looks like when they look straight, look straight in the eyes look straight. But for some reason it looks like this. And so you know what I do in my clinic is often times, I'll pinch the skin right here. And also this is what will look like when they're, when they're knows develops fully and you'll see that the eyes look very straight. Um, and and the way we kind of know that these kids don't actually a Visa trophy is, you can look at these corneal reflexes, it's all the little white little dot you're seeing here when you shine a pin light on these kids and you can see that they center right in the center of the pupil, even though the appearance looks like the eyes might be crossing. So if they're actually crossing with these, these little lights will be on the, on the color part of the iris, not in the center. Um also, there is no, there is like typically these kids will dilate them when they come in our clinic and they don't have a refractive error. And so typically these are just no intervention. But these kids are always welcome at a clinic if you're unsure, you feel free to send it to us because this is something that shouldn't be missed if it is another diagnosis. So that moves into can generally see Tropea A. So this typically presents by six months of age. Um, and uh, you know, these kids sometimes have a refractive error, but as I told you to mention, it's normal for kids to have a small amount of high propia when they're young. Um that's not concerning. And actually the glasses typically won't help these kids for the amount of crossing they have. Um what you'll notice is they do something called cross fixating. And so when they're looking to the left there using the right eye, and when they're looking to the right there using their left eye. And that way they don't have to ever move the either. And what you'll notice is if you patch one of the two eyes, you'll see that oh, all of a sudden that the other is moving around all over the place. And and typically like if a, if a kid has a specific type, I'll actually do prescribe alternate patching until I do surgery just to make sure that I've treated all the amblyopia before I do my surgery. And sometimes like in in in rare occasions you'll see that just doing the patching. Actually, sometimes the kids don't even need the surgery. So you know, if you see a kid and you're 100% sure that their eyes cross then feel free to start doing alternate patching before they see us. But this is something that you know, if you're sure they're crossing, they have s a trophy. There's six months of age. We like to get them into our clinic relatively fast because these kids need surgery and the reason they need surgery fastest, it will preserve their ability. If we do surgery soon, it has a higher likelihood of preserving their ability to use both of their eyes together and to have good three D. Vision. And so here's kind of a little slide and it shows that if you do the surgery um in the 7 to 12 month phase after they've seen the crossing your likelihood of getting good three D. Vision After surgery is significantly higher than if you wait to like you know two years of age or even a year and a month. So while to Lina mentioned it is important the kid has amblyopia if a kid has like a refractive error plus 1.5 on the field of vision screen because one doctor of astigmatism and maybe that's something you know we don't need to see right away because we're probably going to get glasses. But this is something that if you see an eye crossing and you're concerned this something where we do tend to intervene pretty fast and and you got you guys can definitely call our clinic and we try to get them in uh streamline their visit appointment. And so you know, the question comes up, is that a lot of this? Because why their eyes crossing, why don't they see double? So kids brains are very flexible as I'm sure you guys are aware is pediatrician them. So what they tend to do is kids actually can can block one of the eyes. And so what they're doing is the eye that's crossed. They basically turning the eye that's crossed off and then they're only using the other eye. And then right when they close the other eye, the the eye that they turned off turns on so they only turn the eye off when they only turn the eye off when both eyes are open. And so this is called this Katima and suppressions Katima and and it's the way kids still see single despite the eyes being crossed. And if an adult has uh you know, and I crossed them like that, they tend to see double if they haven't had in their whole life and and this guy Tony can stay and that's why I like a lot of these kids here and they end up not like the kids that don't get perfect stereo vision. They still don't see double upwards because their brain kept this Katima. And so our mission is trying to decrease the scrotum is present to as low as possible, too small of an area as possible. So the kid sees a single and three D. As much as possible. So now we're gonna move into accommodating vis a trophy a so this is different. So this is going to present after the age of one and the eyes aren't going to be dramatically crossed. And what the main thing is that you're gonna see on exam. When we examine that, we see that they have a large refractive area. They're typically hyper optic to the ranges of plus three, two plus seven. Um and sometimes you know, you give them most of times you give these kids the glasses and the results are dramatic. So the size cross you can see here it's crossed, you put the glasses on them and then all of a sudden it's fixed but sometimes it's accommodated and has a non accommodated components. So sometimes you put the glasses it fixes a little bit but it doesn't fix all the way. And so those kids typically look where a a surgery on top of one of the glasses. But when we do the surgery, we typically do it so that they'll still wear the glasses afterwards. And the extra amount is just for the same thing to kind of get rid of this suppressions Katima, it's the same thing that happens and can generate the trouble. We're trying to get that down to nothing. And and like they need the glasses because they're actually typically hyper opic and that's far sighted. So these are a little bit more uncommon in pediatric populations. And we kind of look out for these cranial nerves six pauses. And you know, you can kind of see that in your in your clinic. Uh it's very dramatic if they have a cranial nerves six. Because what you'll notice is uh for some reason, one I can't go out uh and the other eye goes in dramatically. And even then it might not be a creative six falls. It can also be something called Duane syndrome. Um but you know, if you have any concern about that using that dark clinic and and we'll we'll work on figuring out Another thing is sensory strop in and you know, typically kids under one if one of their eyes doesn't work like um like a very common diagnosis I've seen that's been sent to my clinic is optic nerve hyperplasia. And these kids come to my clinic and um every trying to rule out the Mercy syndrome and and they have a mildest Agnes and but for some reason one of the eyes isn't working super well. And so if you're under the age of one, what happens if that is not working well? It goes in, the brain turns it off and it tends to go in. And if after the age of 1 to 2, if you know, you get an injury to an eye or something and if you weren't born with the typically that I will go out. So centuries a trophy is typically something occurs in younger populations. And finally, there's another thing and I have had two or three these bases in my clinic is called my stagnant blockage syndrome. Uh, and this is basically kids, you know, Nystagmus is when the eyes are wiggling right? And so away, that away that a patient can stop my stagnant is by convergence. So convergence is bringing the two eyes together. So you'll see a lot of patients, they actually don't, they're not crossing. What they're doing is they're dampening their next Agnes. Uh, and that's by doing this thing. And so typically if it's really dramatic, you can, you can do surgery for them and help them fix it. So that kind of goes through I crossing and and the main, the main, the main ones, I didn't cover Duane syndrome, which is a little, you know, a little bit more advanced. But I'm sure we would see those basically saw them in your clinic anyways. Um, so, so for this patient mother's nose otherwise help the six month old babies I who's been crosses significantly since birth seems to alternate. So this one was can generally see trophy because of the age. The age is very important for the presenting less than six months, less than a year of age is usually going to be generally so trophy and it's usually pretty dramatic presentation. These will require surgery. And as I mentioned, if we do the surgery promptly, oftentimes, the results are better than if you wait. All right now we're going to look at case to constant tearing out of left eye. Mothers noticed that are otherwise healthy. Three year old son has been tearing since birth and it sometimes appeared to have Carolyn discharge. Mother notes that the eye has never been read. So this is a picture of this presentation. Okay, So, so this is, you know, there's not much tricks to this. What this is, this is a congenital nasal lockable duct duct obstruction. Um, uh, there isn't typically, you know, A lot of kids have this, but it resolves on their own by the age of one. And um what you'll see is the reason they have it is there's an imperfect valve the valve has and I'll show you the anomaly of that in a, in a second slide. And most of the times these resolve on their own, by the age of 1, 90% of cases resolved. I've actually had one resolved in the middle of my clinic, like I'm just pressing on and I just resolved. And so it's great if that happens. But if it doesn't happen after the age of one, that's kind of when we tend to do an intervention here is kind of a little bit of the anatomy. Um your here's your punch. Um and you can see it. If you flip your eyelids open, you can see a little hole that's where the tears drain. This is your calculus right here, upper and lower calculus. And then when you close your eyes, it squeezes these and it pushes things into your Lakmal sack. And this is called your Lakmal sack. And then from your lack of Mossack things going to your Lakmal duct and that this empties out below the inferior status and into your like nose. And so, you know, your nose runs up to you cry basically. Right. And so that's kind of the same. This kind of it's an example of this anatomy and configuration. Um Typically what happens in these kids is they have an imperfect vala Hasner which is over here. And so they are unable to get the tears, the tears get blocked up. And so, you know, the treatment for these kids is is you know, we If it's not resolved after the age of one will recommend the Crigler massage and then after the Kremlin massage, we can do a probing of this system and we do the probing under general anesthesia. Typically some pediatric pediatrics, most we'll do it in the clinic. But uh, we don't do that here. Um It's kind of controversial to do that. Um This is a more severe version of the same thing. So this is called a decree assistance. I wanted to share this with you guys. So if this presents you know if you're seeing babies in the hospital and you see this is kind of something a little bit more urgent slash emergent. And so this has an island a third day of life and the same thing um The sack is distended. The lockable sack is distended. And there what can happen here is because it's distended and stuff staying inside of there it can become infected, anything cause something called doctor of cystitis and then the overlying skin king of precept of cellulitis. So typically if you see these we I've had two of these over the course of the year here and we like to give antibiotics, calm down the skin infection and calm down. The doctor societies watch and get some labs they admit get amid for observation. Then within a day or two I'll do the probing irrigation. Um. Yeah, so this is typically below the nasal, immediately below a nasal to the medial cancer. As you can see in the photo. A dermal insists will typically be a lateral campus and above and it won't be read. And then encephalitis it will be above the medial campus. Okay. And GMOs are just going to be bright red and they're gonna be wherever they're not gonna look infectious, there's going to be no discharge. And so like I said, we want to do digital massage and probing and clinic will probe the doctor system seals and try to you know, take out as much violence as possible because it helps them kind of relax a little bit before we do the program irrigation. Okay. So our patient was mothers noticed her otherwise helping three year old son. So this is three and as I said 90% resolved by the age one. And so for this case it's like well you have a general video that didn't resolve probably enough to do you under anesthesia and you can attempt the curriculum massage in the meantime. And so if you see a kid like this in your clinic and there's a great recommendation for you guys are selling do the massage and then get them referral to us um after the age of wanda. Unless it's obviously a directory assistance here which we need to see commercials. All right. So white in the center of I so this mother is noticed that are otherwise healthy. Four week old baby born full term has a white cloud in her left eye. So this is called Luca Korea differential diagnosis luke Korea's congenital cataract retinoblastoma. Which is kind of like the first thing you see right now. So if you see this you have to rule this out immediately. That's like your first thing I got to roll this out for. I worry about anything else because as we know that uh it's a tumor suppressor gene and there can be other tumors and they can be other things going on and you have to really kind of take care of that aggressively. Um and obviously we don't do that here. We would get ocular oncologists involved in the management of that. Um and then talk so cmv retinitis. Rop these other clauses and P HPV primary hyper plastic primary vitreous persisted high plastic primary victories. And that's gonna be another cause of this. So as I mentioned I always so I had one of these this morning and I'm going to show you the video from this morning. I did a congenital cataract this morning on a three month old and I always do an examiner anesthesia before I removed the cataract to make sure that the patient doesn't retinoblastoma. And so I'll do a B scan and and when I do the B skin, I'm looking to make sure there's no hyper calcification along the posterior pole and make sure nothing happened in my patient today. There was none of that. Um so what's the instance of these cataracts and kids? So this is probably gonna be a cataract right? Um about 150. But like man, that's that sounds like a lot right? But the reality is there's a lot of cataracts but they're usually typically really small and most of them are not getting surgery. Sutra lens capacities are really small. They're not businesses, these kids are going to develop normal vision if I don't do surgery. So I'm just watching their interior cataracts and And um the nuclear cataracts. I'm just watching most of them. Unless the vision drops around 2080 then I start to consider to do something but most of the time it doesn't um Now when do I do surgery when I do surgery is if I see dense bilateral cataracts and and you know if I can't see pass it into the sea, the retina then I know they're not seeing out to see into the world. So then I'm I'm thinking in my mind like ok this is time to do surgery. Um and typically if it's bilateral, I do surgeries a few days apart. We recently just got o. R. Time allocated to us. Kind of like I have now a day every like one week and a half and I keep sometime open in case one of these come in like this one that I did today was given to us what we saw in clinic last week. So we could get them in this week and we could keep it within the recommended period of 61st six to eight weeks of life. And so um uh and then finally density lateral cataract. You would think a dense bilateral cataracts worse than a density in a lot of cataract. But the reality is a density lateral cataracts actually more concerning. Um in a sense because what's happening is the brain is as until he was mentioning, you know one eye is basically being favored over the other I because of the cataract. And so what's happening is once if you have to remove that kind of very fast because if not the brain will block out that I completely and it will only use the other eye. And so surgery as soon as possible and you know, because we don't want that other favorite. And right after surgery, you will be patching the good eye to you. Start using the cataract guy. Um uh, so that it can catch up basically. And even if it catches up those first six weeks of life or so important that it might not even be enough. So after we do them, I typically leave them a fake uh, if their infantile, if they're above the age of one or two, I will start putting lenses in. But today, for instance, I didn't put a lens in. Um because there's like a study that's been done by uh, optimal said stanford, the Infinite Faith Treatment studies, a nationwide study and it showed putting in secondary putting in aisles too early had a little bit higher negative outcomes. And so I kind of pulled off unless there's a reason for me to put it in. Like the families unreliable and I don't know if they're going to be doing the patching and stuff. I know it's going to be cooperative. Then I'll put the lens in just because I don't want to take any chances. And that is probably better outcomes. So there is a clinical Indication to put the lenses in under 12 months of age, after 12 months of age and almost uniformly put the lenses in. Um So what was this baby? So this baby, you know, infantile cataract, um possibly left persistent hyper plastic, primary vitreous, but that would not change the management. Um And then urgent surgery followed by contact once from prevent amblyopia. I can just walk you through this brief. This is from this morning actually. I did this surgery two hours ago and you can just see here's a dense cataract right there and then here you know I'm going in I'm making two incisions on the outside, getting in there getting the cataract uh and you stay in the outer shell of the cataract. Yeah. You know and then you start to remove it and so we use this thing called a tractor and we will for congenital cataracts at least. And you typically go and you just kind of remove out the substance the material. This patient had a cataract. I was on the back portion of the lens. So what I do now is it's just me removing it and then I make a little scene that this little this little hole right here is the opening I make. So that later when the kids older after they've done their lens, they've done their contact lens for several years. I can put an implantable lenses an older age and predicted in such a way that they don't need glasses. And so I I try to do it and be really exact on it. Um and typically if you wait till the age of seven and they do contact lenses, you can get. Exactly, that's why I don't do it before the age of two because it's unpredictable your outcome. What is going to be even if you follow the best tables and so there's still that posterior cataract and right there that still there and moving I around a lot. Sorry, as I did this this morning, I uh it's the video editing wasn't great. Um but you can see right here now I start to go for the posterior portion and this is the most, mostly a posterior. So these cataracts can be anywhere, they can be anterior posterior. So this was a posterior one. And you can see here now, I'm starting to pull this guy out and tried to increase the strength of the pool on it to get this guy out, take you a little bit more. And so there's a so every one of these kids, if you don't remove the back layer of the cataract, they will come back and they'll have something called the secondary cataract. So on on infants, I always remove the secondary cataract. So this is the secondary cataracts already kind of there. And so there's no question on this when you remove it in the surgery, as opposed to leaving both actually intact. So right now, that's what I'm doing. I'm first I'm removing that air bubble and then I'm removing this posterior, this posterior opacity. And uh you'll see, I'm just cutting around it slowly and it's gonna slowly start to disappear. Yeah, yeah, that's my hand, because you don't want to like exposed too much light to the kid while you're not doing anything. And then here I go. See now I've removed that posterior pole and now the central portions open and this is considered a surgical success. Um, and so now, but the surgical success is not really surgery. It's now how you manage the kid after surgery. And how much patch did you do? Because this kid only had a unilateral cataract. And um, and, and so that's kind of how we judge how, how good you did. All right. So case four I wandering mothers noticed that her otherwise healthy six year olds, I wanders outward throughout the day. Reports that mostly happens while the patient is tired or has just awoken sometimes while daydreaming even it can be either I mom reports. So this is, this is different than the eye going in. That's easy trophy. This is Sophia and in some cases it's the same thing. There's an exit, there's a pseudo exit trophies, something it looks like the eyes are wondering, but they're actually not. There's also congenital extra fee. It's when the eyes have been wandering since birth and it's always president and in this X parentheses, t is intermittent extra trivia and that is for when the X. Utopia is sometimes there and, but most of the time is not finally the century extrovert, as I mentioned earlier in the presentation, it's when as opposed to the kids, I going in when they hadn't been using it early in life. If something happens to kids, I later in life, uh, they have a trauma or something that I will tend to go out if they're not using it. So this is pseudo XT. Um this is the one where it looks like the eyes going out but that is actually not going out because you can see the lights are pretty well lined up. It just looks like the eyes going out. But typically these are actually uh it's weird the history actually tells you most of these patients you ask them like I always ask anyone with extra fee like were you born full term or were you born preterm and if you were born Mhm Preterm you could have had ROP and that can drag your immaculate outward. If you drag your immaculate outward. What that happens is to fixate the I. U. Turn your eye outward so that the images are fixating on your retina but you're not your eyes actually not wandering. It's actually just being in the right place for you to see appropriately and to not see double. So here's what I was mentioning about the pen light and this is kind of, you see how the pen lights on the outside and you can do this in your clinic when you see a face you're and you're thinking, hey this I might go out the side, might go in, let me see what's going on. And so you can see here if the, if the lights on the outer portion, it has to be centered on one, if it's centered on both amazon straight, if it's centered and it's on the outer rim of the people, that means this size in if it's centered on one and then the i it's on the inner part of the iris. Then um yeah, that I was going out and so that's like in these patients, these are extra traffic, but in the studio, extra traffic patients actually normal. Finally, there's also hypertrophy, hypertrophy that just needs to hide up in the eyes down. And that can be seen in Fortner policies, among other things. So for our patient, intermittent extra topia variable onset, six months to six years of age, the eye goes out. Sometimes it's probably very common thing you guys hear about any clinic. These should be seen by us. Um You know what we do? Often time depends on how well they how well did they fixate? And so if they if they like this kid, she's seeing straight here and then she squinting along sunlight. But then sometimes eyes out if she's seeing straight the majority of the time and then she the eye wanders and she blinks and she brings it in. We classify that as uh classified, that is fair. Um If she can do it without blinking, just you snap your fingers. She pulls i in. That's good. And we don't actually do sir, I don't do surgery for that. And even for fair I typically won't do surgery. Um And but for poor and or a progressive kind I will consider doing surgery. And so here's kind of the way like and even before surgery we consider different things like over minus glasses. And it's basically what that does is that pushes the kids I to focus even in the distance. So they have to focus a lot to focus in the distance. And that makes them to always kind of be on guard. And it sometimes works really well for internet Zootopia and getting them to where they have at least good control. Um And finally if I consider served as I mentioned if um if they're constantly extra tropical or if they're like 90% of the time exit topic because like I said, I want to preserve their ability to see three D. Vision. And um And and yeah and and in some cases the way to go. Um So here are some of the surgical methods that we use. The most common is bilateral lateral rectus recession. Um And then um and then you just uh you know you just follow them afterwards and you still, a lot of times these kids have amblyopia. You have got to treat amblyopia while you're doing while you're after. You do the surgery because these kids have a tendency to regress. And even if you do the surgery can start wandering and if you're not treating the underlying amblyopia. So this kid was, as I mentioned internet. Next Topia good control because the moms that only happens in their tired. So I'll probably try over minus classes for them uh and then see them in three months. And if it worsens in the future, you can consider surgery, but definitely not right now. All right. There's the last one patients, a five year old male of the island bump for four months. But the ice also read. And so my mom was like, I wasn't red originally, but now it's red and her son is now reporting pain. So on exam you see a white dot and that actually is concerning. So you know, typically you see a sky. I'm happy for you guys to treat the sky. And uh you know, do warm compresses do good lid hygiene. But if you ever see any white on the, I have three kids from Oakland who now have these types of white stars. They had a side and it scratched the eye in the center. And now they have a scar along the uh like right on the visual access and it affects their vision. And there really is no treatment for that. You have to a corneal transplant. And uh, so it's like Basically I'm stuck because the vision is 2040. I don't want to do a corneal transplant on them. And but you know, if this had been caught earlier and this has been treated more aggressively at the beginning, it would have turned into this and it's not just a sty oftentimes it's the kids who have more than one size and the crust along their eyelashes and they're not doing appropriate hygiene. If you ever see that the warm compresses are good. A lot of time to see. Kids aren't agreeing. But if you see crusting along the lash base, it's really important for you guys to recommended hygiene. There's a key soft at CVS or Walgreens. Get that, rub the lash bases aggressively and show them in the clinic how to do it. I show them in the clinic how to do it and you'll be surprised at like the outcomes are like dramatic. You'll see a kid whose eyes I was a complete mess up. You do that for like two weeks. They look like like nothing ever happened. But if you leave it then this will happen and this will happen. It can happen along with visual access and it can it can cause some severe damage. Um so this is something if you the eye turns red on the sky and it wasn't it wasn't ready to begin with. Just get them to us relatively soon. Right? And uh here's some information about some of the West 18 and uh and who you can contact over there um as well. And there's some more members of the East Bay team dr cox was in clinic today. If we have like toasters patients, he sees them. And dr Sue is Alexandra moen and she does a great job out there as well. And then pediatric glaucoma, Doctor Oates will accident dr Rhodes and then Doctor D'Alba she'll do a lot of theatrical nature business. And and uh there's a neuro there's two neuro pediatric neuro models out there who do a great job as well. And we send patients out there to them if it's very complicated and we're concerned about different things that we don't treat on a regular basis. Mm.