Dr Casey UngOphthalmologist

Dunedin Hospital Eye Clinic

Marinoto Clinic & Specialists

Dunedin

8:30 - 9:25 WS #140: Paediatric Ophthalmology

9:35 - 10:30 WS #150: Paediatric Ophthalmology (Repeated)

Paediatric

OphthalmologyCasey Ung

GPCME Conference 2017

Horncastle Arena Christchurch

Examination in paediatrics

The examination has to be tailored for the development

of the child

Cooperation and understanding of the

parents/caregivers is essential

Sometimes a repeat appointment has to be made

should an examination be unable to be completed

Equipment that I use

Equipment that I use (cont.)

Equipment that I use (cont.)

Preferential looking

Equipment that I use (cont.)

The direct ophthalmoscope

The direct ophthalmoscope

An extremely versatile and essential item of ophthalmic equipment;

Checking the pupil reflexes

Detect ocular misalignment (observing the corneal light reflexes)

Media opacities and leukocoria

A preliminary assessment of the angle

Blue light filter for checking fluorescein uptake

Fundoscopy

The reflex

Examination in paediatrics (continued)

Paediatric ophthalmology has its challenges and

rewards

During my training and fellowship, it was always stressed

that one had to engage the child’s attention:

1 toy, 1 look

Also; NEVER SHOW FEAR!

Corneal light

reflections

(reflexes)

BRÜCKNER REFLEX

Comparison of fundus red reflexes when viewed

simultaneously (at arms length) through direct

ophthalmoscope

Good for detecting small angle squints and

amblyopia

Sensitivity 86% and specificity 68% for detecting

amblyopia risk factors

In children with amblyopia, 95% sensitive

Cover testing

A selection of

Paediatric Ophthalmology…

Amblyopia

Strabismus/Squint

Visual Development

Requires clear images and aligned eyes during

early childhood

The two eyes compete with one another from

birth to make connections to the visual cortex

Vision at birth 6/480, 6/36 at 6 mos, 6/9 at age 3

Fusion and stereopsis develop at about 4 mos

of age (coincident with foveal maturation)

Can occur only up to age 8 years

Amblyopia

Amblyopia: Poor vision due to abnormal visual experience in early life

Prevalence is about 3%

Prevalence is decreased when screening and early intervention are instituted (supported by RCTs)

Prevalence is higher in medically underserved populations

Amblyopia

The management consists of trying to give the

amblyopic eye more use, “exercising it”.

Can be done through patching the good eye or

penalising it with Atropine eye drops (both work equally

as well according to the PEDIG studies)

Amblyopia treatment continues until age 7-9yo, but be

aware of reverse amblyopia

STRABISMUS (SQUINT)

DEFINITION: Misalignment of the Eyes

TERMINOLOGY:

Eso- Convergent

Exo- Divergent

-Phoria: a Latent Squint

(held in place by fusion)

-Tropia: a Constant Squint

SQUINT

AMBLYOPIA REFRACTIVE

ERRORS

SQUINT TYPESEsotropia: A constant

convergent squint (crossed eyes)

Infantile Esotropia

Acquired Esotropia

Exotropia: A constant divergent squint

Intermittent

Constant

Others

IV N palsy

III N palsy

Vertical squints

Infantile Esotropia

Not truly congenital

Onset usually between four

and six months of age

Typically have moderate to

large angle of squint

Treatment is surgical, anytime

after six months

Early surgery = better chance

for binocularity

Accommodative Esotropia

Exotropias

DETECTION OF SQUINT

• External Appearance

• Asymmetry of Corneal

Light Reflexes

(Hirschberg Test)

• Cover Test

• Bruckner Test

• Amblyopia

Corneal light reflexes

Epiphora

A common scenario where there is congenital

NasoLacrimal Duct Obstruction (NLDO)

Critical Features:

Watery eyes, since birth

Can intermittently be mucopurulent, although no

conjunctivitis (more colonisation rather than infection)

Can spontaneously resolve (80-90% in 1st year) hence

normally do Probe and Syringe after 1 year old

Blockage of the Nasolacrimal Duct

Dangerous epiphora

Dacryocoele:

Congenital blockage

whereby there is no

drainage and develops

a collection which can

become infected

Needs urgent Probe +

Syringe

Dangerous epiphora (cont.)

Congenital glaucoma:

Epiphora

Photophobia

Blepharospasm

Corneal clouding

Buphthalmos

Infantile Glaucoma

Affects 1/8-10,000

children (M East 1/2,500)

Primary congenital

glaucoma usually

sporadic,

80%>recessive, rarely

dominant

60% present by 6/12,

80% by 1

2/3 male, 2/3 bilateral

GLC3 gene-2p21, 1p36

Blepharitis, Styes and Chalazia

Quite a common condition and blepharitis is much more

common in Trisomy 21

Ophthalmia neonatorum

Any severe conjunctivitis in the newborn

period

Bacterial - N Gonorrhoeae

- Ps aeruginosa

- Staph aureus

- Strep pneumoniae

- H influenzae

Chlamydia

Viral - HSV type II (and I)

Chemical

Investigation

Conjunctival swabs

(culture/Gram stain

Conjunctival scrapings

(Chlamydia PCR)

Immunofluorescent

studies (HSV/Chlamydia)

Infected or Not?

Potentially life-threatening infection of the tissues behind

the orbital septum

More common in children but any age may be affected

Critical features:

Unilateral, tender, red periorbital and lid oedema

Proptosis

Painful ophthalmoplegia

Optic nerve dysfunction (RAPD, decreased vision)

Child is sick!

Orbital cellulitis

Orbital cellulitis

Typically associated with sinus disease however may be

due to extension of preseptal cellulitis, local spread

(dacryocystitis, dental abscess), haematogenous or

post-traumatic/surgical

Complications:

Ocular: endophthalmitis, CRA/V occlusion, optic

neuropathy

Intracranial (rare): meningitis, abscess, cavernous

sinus thrombosis

Subperiosteal/Orbital abscess

Orbital cellulitis

Orbital cellulitis

Before and After ☺

LEUKOCORIA

(WHITE PUPIL)

• Commonest cause - Congenital cataract

• Must always exclude Retinoblastoma

CONGENITAL CATARACTS

• Hereditary

• Metabolic

• Infectious

• Systemic Disease

Paediatric Cataract (cont.)

Estimates of 130,000 to 200,000 with cataract

Can be a huge economic impact, because they require

extra care and attention

At present, there is no medical/non-surgical treatment

for cataract…

Principles of Treatment

Clearing the visual axis to allow visual

development

In the 1970’s, treatment delayed until (at least)

6 months of age.

More surgeries are now being performed at

earlier and earlier ages (some within the first 2

weeks of life)

Visual rehabilitation included:

Aphakic spectacles

Aphakic C/Ls, and more recently

Secondary IOLs

Primary IOLs

Principles of Treatment (cont.)

Anaesthetic risks have to be balanced against the

impact on child’s visual development

Bilateral cataracts (especially if symmetrical) typically

operated on within a week or two of each other.

Unilateral cataracts bear discussion…

Aetiology of Paediatric Cataract

Younger children

Genetic aberrations

Metabolic disorders

Prematurity

Intrauterine infections

Older children

Trauma

Drug-induced

Radiotherapy

Laser therapy (ROP)

Unilateral or Bilateral

Bilateral cataracts more likely to suggest systemic

/ hereditary / infective cause:

Down Syndrome, Trisomy 13 or 15, Alport Sd, Lowe Sd

TORCH, Varicella, Rubella

Ocular abnormalities: Aniridia, AntSeg dysgenesis Sd

Toxic: Steroids, radiotherapy

Unilateral cataracts tend to be sporadic or

“traumatic”:

PHPV, AntSeg dysgenesis

Traumatic

Possibly Rubella or masked bilateral cataract

Retinoblastoma

Malignant eye cancer

≈1/18,000 live births

Often results in loss of eye if tumour growth can not be controlled

Many tumours now treatable with laser

Retinoblastoma (cont.)

Recessive Gene

“Two Hit” Hypothesis

“Dominant” Inheritance

RETINOBLASTOMA

• Multiple tumours in 1 eye

• Bilateral involvement

• One tumour in 1 eye

Germinal

Mutation

Somatic

Mutation

Nystagmus and wobbly

eyes

Used to be categorised as Congenital

Motor or Congenital Sensory Nystagmus

However, now simply called Infantile

Nystagmus syndrome

Nystagmus (cont.)

The nystagmus syndromes that we see can be associated with

ocular or systemic causes.

Ocular causes: typically associated with poor vision, with VA less

than 4/24 or 6/36; e.g. Ocular/Oculocutaneous Albinism, untreated

congenital cataracts, optic nerve hypoplasia

Isolated Idiopathic Nystagmus Syndrome (“Congenital Motor

Nystagmus”) is a nystagmus syndrome not associated with systemic or ocular abnormalities. In contrast to above may have reasonable

vision

Child with Poor

Vision

• Acute intervention (PLVC)

• Mobility

• Low Vision Aids

• Counselling for Parents

• Medicolegal issues

• Whole of life cost $1m

Thank you for your attention!

Any questions?