Visual difficulties

Referrals pathways for Regional Paediatric model

Index:

Diagnosis

Practice points

Management

Referral pathways

Visual difficulties can manifest in different ways in children, with screening in children generally being quite easy and readily accessible.

See also the Royal Children's Hospital pre-referral guidelines.

Diagnosis

Vision difficulties can manifest in different ways in children and should be considered in the following circumstances:

• poor fixing and following at 6-8 weeks of age
• roving eye movements
• poor fine motor development in infants
• learning difficulties, poor school performance or school related behavioural problems
• persistent headaches

Visual disturbance can also be the presenting sign of or an association with various medical problems:

• neurological problems including seizures
• benign intracranial hypertension
• increased intracranial pressure
• migraine
• neurological disorders/syndromes and global developmental delay
• cerebral palsy

Practice points

• Visual difficulties should be suspected in children with poor fine motor development, learning difficulties, school related behavioural problems or persistent headaches.
• Visual disturbance can also be the presenting sign of various medical problems.
• Red flags in children presenting with visual disturbance that warrant urgent referral include sudden onset visual changes, 6th cranial nerve palsy (limited abduction of affected eye), nystagmus and/or diplopia, morning vomiting and/or headache.

Management

Referral for visual assessment is important in the evaluation in any child presenting with symptoms above (see Diagnosis).

Initial medical assessment (prior to formal visual assessment) of a child with visual difficulties should include a neurological and developmental history and examination.

Reg flags in children presenting with visual disturbance that warrant urgent referral include:

• sudden onset of persisting visual difficulty
• new onset 6th cranial nerve palsy (limited abduction of affected eye)
• nystagmus and/or diplopia
• morning vomiting and/or headache

Referral pathways

• Optometrist or ophthalmologist
  • Community based optometry services are appropriate for initial assessment of vision in most children
  • Referral to an ophthalmologist should be considered first if the child is particularly young (< 12 months) or there are associated neurological concerns.
    • Ballarat Health Services - public ophthalmology clinic
    • Ballarat Eye Clinic - private opthalmology clinic
• Paediatrician
  • Referral to emergency services or early discussion with paediatric services is advisable when any red flags are present (see above).
  • Referral to paediatric outpatient services is not appropriate for the assessment of the majority of isolated visual disturbances in children.
  • Referral to paediatric outpatient services is advisable when there are concerns suggesting an underlying medical diagnosis in the setting of visual disturbance.