International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students: Chapter VIII. Pediatric Ophthalmology and Strabismus

Educational Goal:

Students should understand the normal anatomy of the extraocular muscles and normal ocular alignment. Students should understand the principles of abnormal ocular alignment, such as exotropia and esotropia, and the risk of amblyopia in children. They should understand that infants and children with loss of red reflex require immediate ophthalmologic evaluation.

A. Anatomy of the extraocular muscles and their fascia.*

(REF. 22 Fig. G13)

1. Origin, course, insertion, innervations, and action of the extraocular muscles.*

a. Horizontal rectus muscles.*

b. Vertical rectus muscles.*

c. Oblique muscles.*

d. Levator palpebrae superioris muscle.*

e. Insertion relationships of the rectus muscles.*

2. Blood supply of the extraocular muscles.***

a. Arterial.***

b. Venous.***

3. Fine structure of the extraocular muscles.**

a. Fiber types.**

B. Amblyopia.*

(REF. 2G Slide 10-15) (REF. 3 Case 22, Esotropia and amblyopia, p. 44)

1. Strabismic amblyopia major cause of unilateral decreased visual acuity in children.** (REF. 2G Slide 14, 17)

2. Refractive amblyopia.** (REF. 2G Slide 12, 13)

3. Form deprivation and occlusion amblyopia.** (REF. 2G Slide 11)

C. Strabismus.*

1. Concomitant strabismus.** (REF. 4 Fig. 6.3)

2. Incomitant strabismus.** (REF. 4 Fig. 6.4)

3. Heterotropia.* (REF. 4 Table 6.1 and Figure 6.5)

a. Esophoria: inward deviation - not manifest.***

b. Esotropia: inward deviation - manifest.* (REF. 2G Slide 17, 37) (REF. 22 Fig. H07, H08)

c. Exophoria: outward deviation - not manifest.***

d. Exotropia: outward deviation - manifest.* (REF. 2G Slide 37) (REF. 22 Fig. H09, H10, H11, H12)

e. Hyperphoria: upward deviation - not manifest.***

f. Hypertropia: upward deviation - manifest.* (REF. 9 IV Nerve Palsy, Fig. 8-14)

g. Hypophoria: downward deviation - not manifest.***

h. Hypotropia: downward deviation - manifest.* (REF. 2C Slide 29)

D. Examination of the eyes.*

1. Visual acuity and amblyopia.*

a. Newborns.***

b. Infants to two years old.** (REF. 2G Slide 29, 30)

c. Two to four years old.** (REF. 2G Slide 32, 33) (REF. 4 Fig. 6.6)

d. Four to five years old and up.** (REF. 2G Slide 34)

E. Strabismus testing.*

1. General inspection.*

2. Corneal light reflex – Hirschberg test (REF. 2G Slide 36-38) (REF. 4 Fig. 6.11) (REF. 22 Fig. H06).**

3. Cover test (REF. 4 FIG 6.12)

4. Other tests.**

a. Red reflex.** (REF. 2G Slide 19, 23)

b. Ophthalmoscopy (REF. 2G Slide 24 – 27)

c. Pupillary testing.**

F. Leukocoria.*

1. Retinoblastoma.* (REF. 4 Fig. 6.14) (REF. 22 Fig. H27, H28, H29)

2. Persistent Hyperplastic Primary Vitreous (PHPV).*** (REF. 22 Fig. H39, H40)

3. Retinopathy of Prematurity (ROP).** (REF. 10 Stages of retinopathy of prematurity, Fig. XXIV-2-XXIV-6 p. 304) (REF. 22 Fig. H32, H33, H34, H35, H36)

4. Cataract.** (REF. 2G Slide 42)

G. Management or referral.*

1. Amblyopia.* (REF. 2G Slide 39)

2. Strabismus.*

3. Leukocoria - cause for urgent referral.*

Clinical Competencies

Students should:

Perform visual acuity testing in each eye in preverbal children by fixation and recognizing fixation preference, if present.**
Understand the importance of measuring visual acuity in children two to five years old with Allen cards, HOTV test, or tumbling E card with each eye.***
Recognize and characterize ocular misalignment (strabismus) by performing Hirschberg testing.*
Recognize leukocoria and importance.*
Understand the importance for urgent referral for leukocoria, amblyopia, and strabismus in a child.*

* Basic Level: Necessary in the education of medical students worldwide.

** Standard Level: A higher level of ophthalmic understanding than the basic curriculum of most international medical students.

*** Advanced Level: Advanced cognitive and clinical skills more appropriate for students who seek further training in ophthalmology, which may be covered in an ophthalmology elective in medical school.

(Also see: More on Educational Priorities)

Next: IX. Diseases of Eyelid, Lacrimal System, and Orbit

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