International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist: Chapter 11. Pediatric Ophthalmology and Strabismus

Basic Level Goals: PGY-2

A. Cognitive Skills

Describe basic examination techniques for strabismus (e.g., ductions and versions, cover and uncover testing, alternate cover testing, prism cover testing).
Describe basic visual development and visual assessment of the pediatric ophthalmology patient (e.g., central, steady, maintained fixation; illiterate E, Allen cards, Landolt C rings).
Describe basic anatomy and physiology of strabismus (e.g., innervation of extraocular muscles, primary actions, comitant and incomitant deviations, overaction and underaction, restrictive and paretic saccades and pursuit movements).
Describe basic sensory adaptations for binocular vision (e.g., normal and anomalous retinal correspondence, suppression, horopter, Panum's area, fusion, stereopsis).
Describe and recognize pseudostrabismus.
Describe different etiologies of amblyopia (e.g., deprivation, ametropic, strabismic, anisometropic, organic).
Describe etiologies of esotropia (e.g., congenital, comitant and incomitant, accommodative and non-accommodative, decompensated, sensory, neurogenic, myogenic, neuromuscular junction, restrictive, nystagmus blockage syndrome, spasm of the near, monofixation syndrome, consecutive).
Describe etiologies of exotropia (e.g., congenital, comitant and incomitant, decompensated, sensory, neurogenic, myogenic, neuromuscular junction, restrictive, basic, divergence excess, exophoria, convergence insufficiency).
Describe various strabismus patterns (e.g., A or V pattern).
Describe etiologies, evaluation, and management of vertical strabismus (e.g., neurogenic, myogenic, neuromuscular junction, oblique overaction or underaction, dissociated vertical deviation, restrictive).
Describe non-surgical treatment of strabismus.
Describe different forms of childhood nystagmus.
Describe features, classification, and treatment indications for retinopathy of prematurity.
Describe etiologies and types of pediatric cataract.
Describe and recognize ocular findings in child abuse (e.g., retinal hemorrhages) and appropriately refer to child protective services or other authorities.
Describe common hereditary or congenital ocular motility or lid syndromes (e.g., Duane's syndrome, Marcus Gunn jaw-winking, Brown syndrome).
Describe typical features of retinoblastoma.
Describe basic features of dyslexia.
Describe basic evaluation of decreased vision in infants and children (e.g., retinopathy of prematurity, hereditary retinal disorders, congenital glaucoma, measles, vitamin A deficiency).
Describe identifiable congenital ocular anomalies (e.g., microphthalmia, persistent fetal vasculature).
Describe ocular findings in inherited, metabolic disorders
1. Mucopolysaccharidoses (e.g., Hurler syndrome, Scheie syndrome, Hunter syndrome, Sanfilippo syndrome, Morquio syndrome, Sly syndrome).
2. Lipidoses (e.g., Tay-Sachs disease, Sandhoff, Niemann-Pick, Krabbe's, Gaucher's, Fabry's disease, metachromatic leukodystrophy).
3. Aminoacidurias (e.g., homocystinuria, cystinosis, Lowe and Zellweger syndromes).
Describe ocular findings in chromosomal abnormalities (e.g., trisomy 21; trisomy 13; trisomy 18; deletion of the short arm of chromosome 11; deletion of the long arm of chromosome 13; Cri du Chat syndrome, Turner’s syndrome).

B. Technical/Surgical Skills

Perform an extraocular muscle examination based on knowledge of the anatomy and physiology of ocular motility.
Assess ocular motility using testing of ductions and versions .
Apply Hering's and Sherrington's laws.
Perform basic measurement of strabismus (e.g., Hirschberg test, Krimsky method, cover testing, prism cover testing, simultaneous prism cover testing, alternate cover testing, Parks-Bielschowsky three-step test, Lancaster red-green test, Maddox rod testing, double Maddox rod testing).
Perform assessment of vision in the neonate, infant, and child.
Recognize and apply in a clinical setting the following skills in the ocular motility examination:
1. Stereoacuity testing
2. Accommodative convergence/accommodation ratio (e.g., heterophoria method, gradient method)
3. Tests of binocularity and retinal correspondence
4. Cycloplegic refraction (retinoscopy)
5. Anterior and posterior segment examination
6. Basic and advanced measurement of strabismus
7. Cover test measurement
8. Assessment of vision
  
  i. Teller acuity cards
  
  ii. Fixation preference test
  
  iii. Standard subjective visual acuity tests
  
  iv. Induced tropia test

Assist a primary surgeon in performing extraocular muscle surgery including:
1. Recession
2. Resection
3. Muscle weakening (e.g., tenotomy) and strengthening (e.g., tuck) procedures
4. Transposition
5. Use of adjustable sutures

Standard Level Goals: PGY-3

A. Cognitive Skills

Describe basic and more advanced strabismus examination techniques (e.g., combined vertical and horizontal prism cover testing, double Maddox rod testing).
Describe basic and more advanced visual development and visual assessment of the pediatric ophthalmology patient (e.g., blink to light or threat, measures of fixation and following behavior, objective measures of visual acuity).
Describe more advanced anatomy and physiology of strabismus (e.g., torsion, tertiary actions, consecutive deviations).
Describe more advanced sensory adaptations (e.g., anomalous head position).
Describe basics of binocular sensory testing (e.g., Titmus stereo testing, Randot stereo testing, Worth four-dot, Bagolini lenses, afterimage testing).
Describe and recognize different etiologies of amblyopia.
Describe and recognize etiologies of esotropia.
Describe and recognize etiologies of exotropia.
Describe and recognize various strabismus patterns (e.g., A or V pattern).
Describe and recognize the etiologies of vertical strabismus.
Describe and utilize the non-surgical treatment of strabismus and amblyopia (e.g., patching, atropine penalization, Fresnel and grind-in prism therapy).
Describe and recognize the different forms of childhood nystagmus (e.g., sensory, motor, congenital, acquired).
Describe and recognize retinopathy of prematurity (e.g., stages, treatment indications).
Describe and recognize etiologies and types of pediatric cataract (e.g., congenital, traumatic, hereditary, idiopathic).
Describe and recognize less common hereditary or malformative ocular anomalies and syndromes (e.g., Mobius, Goldenhar syndrome).
Describe and recognize typical features of retinoblastoma (e.g., differential diagnosis, evaluation, treatment indications and types).
Describe the main features of dyslexia and its relationship to vision.
Describe basic evaluation and differential diagnosis of decreased vision in infants and children (e.g., retinal and optic nerve etiologies, amblyopia).
Describe recognizable causes of blindness in infants (e.g., albinism, optic nerve hypoplasia, achromatopsia, Leber's congenital amaurosis, retinal dystrophy, congenital optic atrophy).
Describe etiology, evaluation, and management of congenital infections (e.g., toxoplasmosis, rubella, cytomegalovirus, syphilis, herpes).
Describe and recognize the common causes of pediatric uveitis.

B. Technical Skills

Perform a more advanced extraocular muscle examination based on knowledge of the anatomy and physiology of ocular motility
Assess more advanced ocular motility problems (e.g., bilateral or multiple cranial neuropathy, myasthenia gravis, thyroid eye disease).
Apply Hering's and Sherrington's laws in more advanced cases (e.g., pseudoparesis of the contralateral antagonist, enhancement of ptosis in myasthenia gravis)
Perform more advanced measurements of strabismus (e.g., double Maddox rod testing, Lancaster red green testing, use of synoptophore or amblyoscope).
Perform assessment of vision in more difficult strabismus patients (e.g, uncooperative child, mentally impaired, nonverbal or preverbal).
Perform basic extraocular muscle surgery:
1. Exercise surgical judgement for the indications and contraindications for strabismus surgery
2. Perform preoperative assessment, intraoperative techniques, and describe intraoperative and postoperative complications of strabismus surgery
3. Perform the following strabismus surgeries:
  1. Recession
  2. Resection
  3. Muscle weakening (e.g., tenotomy) and strengthening (e.g., tuck) procedures
  4. Transposition
  5. Use of adjustable sutures
4. Manage the complications of strabismus surgery (e.g., slipped muscle, anterior segment ischemia)

Advanced Level Goals: PGY-4

A. Cognitive Skills

Describe and perform the most advanced strabismus examination techniques (e.g., complicated prism cover testing in multiple cranial neuropathies, patients with nystagmus, dissociated vertical deviation, double Maddox rod testing).
Perform the most advanced techniques for assessment of visual development in complicated or non-cooperative pediatric ophthalmology patients (e.g., less common objective measures of visual acuity, electrophysiologic testing).
Apply the most advanced knowledge of strabismus anatomy and physiology (e.g., spiral of Tillaux, secondary and tertiary actions, spread of comitance) in evaluation of patients.
Describe clinical application of the most advanced sensory adaptations (e.g., anomalous head position, anomalous retinal correspondence).
Recognize and treat the most complicated etiologies of amblyopia (e.g., refraction non-compliance, patching failures, pharmacologic penalization).
Recognize and treat the most complex etiologies of esotropia (e.g., optical, prism-induced, postsurgical/consecutive).
Recognize and treat the most complex etiologies of exotropia (e.g., supranuclear, paralytic pontine exotropia, consecutive).
Recognize and treat the most complex strabismus patterns (e.g., aberrant regeneration, postsurgical, thyroid ophthalmopathy and myasthenia gravis).
Recognize and treat the most complex etiologies of vertical strabismus (e.g, skew deviation, postsurgical, restrictive).
Apply non-surgical treatment (e.g., patching, atropine penalization) of more complicated forms of amblyopia (e.g., non-compliant, patching failures).
Recognize, evaluate, and treat the most complex forms of childhood nystagmus (e.g., sensory, spasmus nutans, associated with neurologic or systemic diseases).
Recognize and treat (or refer for treatment) complex retinopathy of prematurity (e.g., stages, treatment indications, retinal detachment).
Recognize and treat (or refer for treatment) uncommon etiologies and types of pediatric cataracts (e.g., congenital, traumatic, metabolic, inherited).
Recognize and appropriately evaluate the more complex hereditary ocular syndromes (e.g., bilateral Duane syndrome, Mobius syndrome).
Recognize and treat (or refer for treatment) patients with complicated retinoblastoma (e.g., bilateral cases, monocular patient, treatment failure, pineal involvement).
Recognize and evaluate the less common congenital ocular anomalies (e.g., unusual genetic syndromes).
Apply the most advanced principles of binocular vision and amblyopia (e.g., physiology of binocular vision, diplopia, confusion and suppression, normal and abnormal retinal correspondence, classification and characteristics of amblyopia).
Recognize and treat complex pediatric retinal disease (e.g., inherited retinopathies).
Recognize and treat complex pediatric glaucoma.
Recognize and treat complex pediatric cataract and anterior segment abnormalities (including surgical implications, techniques, and complications).
Recognize and treat complex pediatric eyelid disorders (e.g., congenital deformities, lid lacerations, lid tumors).
Recognize and treat (or refer) pediatric orbital disease (e.g., orbital tumors, orbital fractures, rhabdomyosarcoma, severe congenital orbital malformations).

B. Technical/Surgical Skills

Perform more complex extraocular muscle surgery (e.g., vertical and horizontal muscle surgery; reoperations).
Describe indications and contraindications for more complex strabismus surgery.
Describe and perform the preoperative assessment, intraoperative techniques and to describe postoperative complications for more complicated strabismus surgery (e.g., reoperations, slipped muscle).
Describe indications for and to perform adjustable sutures in more complicated cases (e.g., thyroid ophthalmopathy).
Describe and manage more complex complications of strabismus surgery (e.g., globe perforation, endophthalmitis, overcorrection).