TASHA TAN MDMBA 070011

Patients Datay A. G. y 4 months old y Female y Filipino y Resides in Marikina y Roman Catholic y Mother:

60% Reliable

Chief Complaint:

Opacity in the middle of both eyes

Subjective Findings: HPIy 2 months y PTA y Leukocoria, OU y Child did not follow

objects or respond to visual stimuli y Consult at the QMMC Ophtha OPD

s/p Lensectomy of OD

ADMISSION

Birth Historyy Born Full Term to a G3P3 (3003) mother y Delivered via NSD in a lying in and assissted by a

midwife and OB-Gyne y Birthweight = 7.2 lbs y Mother had a total of 12 prenatal check-ups in a private clinic y Mother had an asthma attack on her 8th month of pregnancy

Past Medical Historyy s/p Lesectomy OD y No other previous surgeries or hospitalizations y Currently taking Iron supplements Vitamin C supplements Multivitamins y No known food or drug allergies y Newborn Screening was normal

Family Historyy Cataract Maternal Grandfather Senile mature cataract Paternal Uncle

Personal and Social Historyy Both parents are college graduates and work as

supervisors y Is usually left at home with aunt when parents are at work

Immunization History

y 1 BCG y 3 Hepatitis B y 2 DPT y 2 OPV

Physical ExaminationAT THE OPD JULY 28, 2010

Vital Signsy Heart Rate y Respiratory Rate y Temperature

102 bpm 24 rpm 36.9

Physical Examination: HEENTy HEENT Intact tympanic membrane Nose midline, symmetrical, with no discharge No Tonsilopharyngeal congestion No palpable cervical lymph nodes, flat neck veins

Physical Examination: Eyes; VAy OD: Able to follow bright colored objects and light beyond midline y OS: No regard for bright colored objects or light

Eye Examinationy Gross Examination Eye position symmetric. Lids OU

- No hyperpigmentaion, contusions, erythema, tenderness, palpable masses. - No matting.

Lashes OU

Eye Examinationy Gross Examination

Conjunctiva. OU - No swollen glands. Bulbar conjunctiva clear. Palpebral conjunctiva pink. Scleara OU Unicteric Cornea. OU - Cornea clear with no lesions, opacities, mass. Anterior chamber. OU - formed and clear. Pupils OU - Pupils are symmetric and round, measure 3 mm, equally brisk and reactive to light.

Eye Examinationy Extra Ocular Muscles

Eye Examinationy Tonometry

Unremarkable

y Ophthalmoscopy.

ODdull red orange reflex. Clear media with peripheral opacity Slightly

OS Very

dull red orange reflex. Hazy media.

Cup disk ratio and macula were not appreciated because of the dull red orange reflexes and cloudy media.

Cranial Nerves: Optic Groupy II

(Ophthalmic)Difficulty to assess optic disc, retina on fundoscopy Sensitive to light source in a dark room With visual fixation Pupils equal, 2-3mm, EBRTL | partial ROR, OU

y III

(Oculomotor)

No ptosis, outward, downward, adduction or elevation displacements of both eyes Intact EOMs

Cranial Nerves: Brachiomotor Group and Tonguey IV (Trochlear) No appreciated upward and outward eye deviation y VI (Abducens) No medial deviation of the eyes No nystagmus yV

(Trigeminal)Corneal response in both eyes

y VII (Facial) Corneal / Blink reflex present

Salient FeaturesHistory Physical Exam

y Age (4 months) y Leukocoria y Does not seem to

y Lens Opacity y Visualization of fundus

difficult

notice or fixate on objects

Differentialsy Retinoblastoma y Congenital Cataract

Admitting DiagnosisSENILE MATURE CATARACT, OS

Course in the Wards

Day 1

y Assessment Congenital Cataract, OS y Plan Moxifloxacin eye drops

1 drop Q4

DAT, NPO past midnight Lensectomy with partial anterior vitrectomy, OS

Day 2

y Subjective Irritable when wearing the eye patch y Objective Unremarkable findings on general physical examination

Day 2 July 29, 2010

y Assessment Congenital Cataract, OS s/p Lensectomy with partial vitrectomy OU y Plan Moxifloxacin eye drops

1 drop Q4 1 drop Q1 1 drop Q8

Prednisone eye drops

Atropine eyed drops

Day 3 July 29, 2010

y Subjective Better activity Left eye now able to see light and follow objects y Objective Otherwise unremarkable findings

Operative techniquey Patient Supine y Anesthesia inducted y Asepsis and antisepsis y Sterile drapes placed y Lid retractors placed y Stab incision at 2 o clock position y Intracaneral tryphan blue y Irrigation of tryphan blue

Operative techniquey Intracaneral OVD y Main port incision at 10 o clock position y Anterior capsulotomy y I and A of lens material y Part anterior chamber vitrectomy y Final I and A y Suturing with nylon 10-0 (corneal suture) y Eye patching

Intra Operative Findingsy OD Distinct disc border Slightly dull/hazy media No detachment (+) ROR CDR 0.3, AVR 2:3 Refraction:05:21 5s +3.00s

Intra Operative Findingsy OS White cortical material not seen anymore No detachment (+) ROR CDR 0.3, AVR 2:3 Refraction:19.5s c 2.00 cyl x 150 +3.00 sph

Intra Operative Findingsy Cornea OD: y IOP OD:

V 11 H 11 8.5 10.0

OS:

V: 11.5 H: 11.5 10.2 10.9

OS:

Day 3

y Assessment Congenital Cataract, OS s/p Lensectomy with partial vitrectomy OU y Plan Moxifloxacin eye drops

1 drop Q4 1 drop Q1 1 drop Q8

Prednisone eye drops

Atropine eyed drops

Advisedy Follow-up y Wearing of protective eye patch y Compliance to medications y Watch out for postoperative complications, consult

should be done

Congenital Cataracty Congenital (infantile) cataracts Present at birth or appear shortly thereafter May be unilateral or bilateral y About one-third of cataracts are hereditary y Another third are secondary to metabolic or

infectious diseases or associated with a variety of syndromes. y The final one-third result from undetermined causes.

Congenital Cataracty Congenital lens opacities are common and often

visually insignificant. y A partial opacification or one out of the visual axisor not dense enough to interfere significantly with light transmissionrequires no treatment. y Dense central congenital cataracts require surgery.

Congenital Cataracty Congenital cataracts that cause significant visual loss y y

y y

must be detected early Large, dense white cataracts may present as leukocoria (white pupil), noticeable by the parents, Unilateral infantile cataracts that are dense, central, and larger than 2 mm,will cause permanent amblyopia if not treated within the first 2 months of life. Symmetric (equally dense) bilateral cataracts may require less urgent management. When surgery is undertaken, there must be as short an interval as is reasonably possible between surgery on the two eyes.

Congenital Cataracty Lens extraction through a small limbal incision

utilizing a mechanical irrigation aspiration handpiece. y Phacoemulsification is rarely required. y The posterior capsule and anterior vitreous are removed using a mechanical vitreous suction-cutting instrument.

Prevents formation of secondary capsular opacification or after-cataract Avoids the necessity for secondary surgery and enhances early optical correction.

Congenital Cataracty Complications are similar to those reported with

adult cataract procedures. y Optical correction can consist of spectacles in older bilaterally aphakic children y Most childhood cataract operations are followed by contact lens correction y Use of intraocular lenses in early childhood is becoming increasingly frequent. I

Lessens the difficulty of optical rehabilitation associated with contact lenses in children May need to be changed as the eye develops.

Congenital Cataracty The visual prognosis for childhood cataract patients

requiring surgery is not as good as age-related cataract. y Amblyopia and occasional anomalies of the optic nerve or retina limit the degree of useful vision that can be achieved. y The prognosis for improvement of visual acuity is worst following surgery for unilateral congenital cataracts and best for incomplete bilateral congenital cataracts that are slowly progressive.