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Optha: Pediatric Ophthalmology (Sala)

Terms in this set (69)

Where the cornea and sclera meet.

This is a weak spot in the eye that is susceptible to trauma
What is the Limbus of the Eye?
6-8 years of age.

Normal visual acuity (20/20) is achieved around 3 years of age.

Obtaining full 20/20 vision requires stimulation of the visual cortex, and not just physical development of anatomical structures.
Visual development is usually complete around what age?
Strabismus
Misalighnment of the eyes. Both eyes do not look at the same place at the same time. Problem with eye teaming. Brain has a hard time putting together 3D images. Can be fixed with glasses.

Amblyopia
Problem with visual acuity., usually in one eye.
Visual development did not occur properly due to improper signaling in one eye to the brain. Did not receive proper input
Define:

Stabismus

Amblyopia
Forced Preferential Looking
gray and checkered board with distance, look where their eyes go

Fixation preference
which eye do you wanna fixate with?
induce double vision, put prism in eye, induce vertical strabismus
see which eye they wanna use! only quantitative though, can see which eye is better

Fighting Occlusion
Vision Testing in Children

Birth to 3 years of age
Subjective Tests

Allen Pictures
Tumbling E's
HOTV
Vision Testing in Children

3 to 5 years of age
Snellen Acuity
Vision Testing in Children

5 years of age and up
Definition - Diminished visual acuity (usually by 2 lines) not due to any organic pathological condition.

Etiology - Lack of neuro-sensory stimulation due to conflicting images (strabismus) or blurred retinal image.
Amblyopia

Definition

Etiology
Amblyopia

Usually unilateral.
Treatable if detected at an early age.
Otherwise known as "lazy eye".

Note: being cross-eyed does not mean you have a "lazy eye." The physical appearance of the eyes does not correlate with the phrase "lazy eye"
Lazy eye refers to lack of visual acuity!
What is the leading cause of visual impairment in childhood?
This is the most common cause of amblyopia.

Child's brain is still adaptive - there will be a suppression of the image from the deviated eye.

Results from constant eye turn in one eye
Strabismic Amblyopia
Amblyopia that results from a difference in the refractive errors between the eyes (Anisometropia).

The eye with the lesser refractive error provides the brain the clearer image, the other eye is susceptible to the development of amblyopia.

Will usually be detected during visual acuity testing.
Refractive Amblyopia
Also known as amblyopia ex anopsia.

Results from inadequate sensory input due to an opacity in the ocular media or occlusion of the eye.
·Cataract
·Corneal Scar
·Ptosis
Form Deprivation Amblyopia
Occlusion Therapy - Occlude (patch) the better seeing eye - patching schedule is titrated to depth of amblyopia and age of the patient.

Pharmacological Penalization - Usually consist of blurring the good eye with a cycloplegic eye drop (e.g.. Atropine).
Treatment of Amblyopia
PHORIA only presents when binocular vision is eliminated and eyes aren't focusing together on an object. A latent deviation can come out as soon as you cover one eye! Eye slightly drifts in when one eye covered. ONLY DEVIATED SOMETIMES, cross cover test

TROPIA phoria can turn to tropia, manifest deviation, bigger misalignment when the patient is using both eyes to look at an object. ALWAYS DEVIATED, cover uncover test eye corrects when you do cover uncover test

Phori: Presents when you cover one eye.
Tropia: Goes away when you cover one eye
Strabismus

Difference between:
phoria and tropia
Inward - Eso-
Outward - Exo-
Upward - Hyper-
Downward - Hypo-
Strabismus is named for the direction of the deviation or misalignment
Esotropia! Eyes not covered, note the light reflex and how one is turned inward
Naming of the pathology?
Eyes are not crossed

Patient might have flat broad nose, or broad epicampal folds
If patient looks cross-eyed but the light reflex is identical in both eyes... What is going on?
Corneal Light Reflex

Misalignment of light reflected from cornea
What is the Hirshberg Reflex?
Corneal Light Reflex - Hirshberg Reflex

Cover test

Alternate prism cover test
prism is added to cover test to quantitate the misalignment
Testing options for Strabismus?
Normalize the visual acuity - treat amblyopia if present.

Equalize the vision - treat anisometropia if present, treat hyperopia if patient is esotropic.

Surgery is indicated if misalignment persists especially if patient is in spectacles

Vision therapy usually not efficacious.
Treatment of Strabismus
children are normally hyperopic because eye are smaller farsighted so if kid cross eyed, just give em glasses to correct hyperopia!

adults are normally myopic because eyes are larger! nearsighted
children are naturally...

adults are naturally...
-Inward turning of eyes most often in children 2-3 years old EYES CROSSING WITHOUT GLASSES!

--Related to optical focusing (accommodation), frontal headaches when reading

--common in kids w/ hyperopia (far-sightedness)

--can lead to development of esotropia
Accommodative Esotropia
Recession -- weakening eye muscle, medial rectus

Resection -- tightening eye muscle lateral rectus
Recession vs Resection procedure if patient esotropic
Otherwise known as Ophthalmia Neonatorum.

Any conjunctivitis occurring within the first month of life, including:
mild chemical conjunctivitis
severe bacterial conjunctivitis

Considered an Ophthalmic emergency.
Begin presumptive therapy immediately.
Cultures and scrapings mandatory to rule out gonococcal conjunctivitis
Neonatal Conjunctivitis
Neisseria gonorrhoeae
Neisseria meningitidis
Chlamydia trachomatis
Staphylococcus aureus
Streptococcus pyogenes
Streptococcus pneumoniae
Neonatal Conjunctivitis:
Etiology (6)
Most common infectious type of neonatal conjunctivitis.

Onset 5 to 14 days after birth or exposure.
Presents as an acute purulent conjunctivitis

Hyperemia and edema of eyelids
Papillary response of palpebral conjunctiva
Hyperemia and injection of bulbar conjunctiva
Preauricular lymphadenopathy
Chlamydial Conjunctivitis

S/S?
Giemsa stain of conjunctival scrapings
(basophilic inclusion bodies)

Direct immunofluorescence studies of the conjunctiva
Chlamydial Conjunctivitis

Diagnosis?
Prophylaxis - topical erythromycin (IlotycinR) ophthalmic ointment at time of birth

Infants - oral erythromycin or sulfa agents, adjunctive topical erythromycin

Parents - oral tetracycline or erythromycin
Chlamydial Conjunctivitis

Treatment?
Onset 2 to 6 days after birth

Rapidly progressing infection

Copious purulent drainage, chemosis, lid edema

Complications include corneal perforation with endophthalmitis
Neisserial Conjunctivitis

Clinical Presentation
Edema of the Conjunctiva
chemosis
Displacement of the eye from the orbit
Proptosis
Inflammation within the eye
Endophthalmitis
Begin presumptive therapy immediately usually administered parenterally

Ocular irrigation and fortified ophthalmic solutions (antibiotic solutions)

Parents require treatment
Neisserial Conjunctivitis

Treatment?
Laboratory work-up mandatory:

Gram stain of conjunctiva revealing gram negative diplococci

Gonococcal cultures and sensitivities
Neisserial Conjunctivitis

Diagnosis
Infection or inflammation confined to eyelids and periorbital structures anterior to the orbital septum.
Pre-Septal Cellulitis
Active infection or inflammation of the orbital soft tissues posterior to the orbital septum
Orbital Cellulitis
Fever
Proptosis
Chemosis
Restriction of ocular motility
Pain with movement of the eye
Decreased vision
Pupil abnormality - afferent pupillary defect
Orbital Cellulitis

Clinical Findings?
Restrict Ocular Motility!
Orbital Cellulitis

What must you make sure you do?
Extension from periorbital structures
-Paranasal sinuses
-Face and eyelids

Exogenous causes
-Trauma

Endogenous causes
-Bacteremia with septic emboli

Intraorbital
-Endophthalmitis
Panophthalmitis
Causes of Orbital Cellulitis?
Staph species
Strep Species
H. Influenzae - more common in children
Anaerobes
Polymicrobial infections related to sinus infections
Microbiology of Orbital Cellulitis
fibrotic levator muscle, most common cause, concern is that this is amblyogenic

she will compensate to have her eyes work, chin will be high, head high!
Congenital Ptosis
--distance from upper lid to light reflex!

--this girl is -2
Margin to Reflex Distance-1
(MRD1)

Describe
--Frontalis Suspension
--mechanically lift the lid!
--so now frontalis muscle lifts eyelid
--goal is to eliminate head posturing!
Treatment of Ptosis
ANISOMOTROPIA high difference in refractive power!
Mild ptosis in a child can lead to....
Most common abnormality of the nasolacrimal system.

Signs and symptoms include:
mucopurulent drainage (chronic dacryocystitis).
Secondary blepharitis.
Epiphora (excessive tearing).

Spontaneous resolution in 85% of patients by 6 months of age.
Dacryostenosis
Broad-spectrum antibiotics to control the chronic dacryocystitis

Creiger maneuver - nasolacrimal sac massage

Probing and irrigation of nasolacrimal system
Dacryostenosis: Treatment
nasolacrimal sac massage
Creiger Maneuver
Epiphora

Excessive tearing
Key sign for Dacrostenosis
Involuntary, rhythmic, pendular or jerky oscillation of the eye(s).

May be manifest or latent

Can be associated with:
-Optic nerve hypoplasia
-Oculocutaneous albinism
-Neurologic disorders
Congenital Nystagmus
Work-up usually involves neuro-imaging.
Visual electro physiologic test may aid in diagnosis
VEP Visual Evoked Potential
ERG Electroretinography
VA's are diminished - usually within 20/40 to 20/200 range

Sometimes have null point away from primary gaze

Compensatory head posture may become apparent as the child's visual demands increase
Congenital Nystagmus

Workup
lack pigment behind the iris, its normally black and gathers light energy, but here its white, put baby to microscope to see the transillimunation. can lead to congenital nystagmus!
Oculocutaneous albinism
a position of gaze where nystagmus dampens, diminshes!
What is a null point?
Most common intra-ocular malignancy in childhood

Average age at time of diagnosis usually 18 months of age
Usually fatal if metastatic at time of diagnosis
Retinoblastoma

Basics
Presenting Signs and Symptoms
-Leukocoria 56%
-Strabismus 20%
-Glaucoma 7%
-Poor Vision 5%
-Routine Exam 3%
-Orbital Cellulitis 3%
Retinoblastoma

S/S?
Treatment usually consists of enucleation

Over 90% survival rate if tumor confined to the eye at time of enucleation

Spreads by local invasion via optic nerve
Retinoblastoma

Treatment?
put chemotherapy directly to opthalmic artery, hit the retinoblastoma! super good treatment
What is intra-arterial chemotherapy?
A leading cause of childhood blindness

1/3 inherited, 1/3 associated with other conditions or syndromes, 1/3 unknown cause

Early diagnosis and treatment extremely important
Infantile Cataract

Etiology/SS
Treatment:
Cataract extraction
Optical correction of aphakia
Occlusion therapy for amblyopia
Infantile Cataract

Treatment?
Bilateral in 2/3rds of patients

Signs and Symptoms
•Corneal edema (corneal clouding)
•Eye enlargement (buphthalmos)
•Epiphora (excessive tearing)
•Photophobia
Infantile Glaucoma
Treatment is surgical, also need to treat subsequent refractive errors and amblyopia
Infantile Glaucoma

Treatment?
Buphthalmos

Eye enlargement, seen with infantile glaucoma
What is observed?
Cloudy cornea, seen with infantile glaucoma

Recall: Hurler syndrome also has corneal clouding!
What is observed?
notice change in shape
--notice cup/disc ratio
--notice vessels!
--GLAUCOMA can be a cause
--glaucomatous optic atrophy bc pressure
--asymmetry or disc//cup ratio > .3!! is concerning
Diagnosis?
1: measures distance from corneal light reflex to upper lid

2: measures distance from corneal light reflex to lower lid
MRD-1, MRD-2 values
Hyperthyroidism and the eye

most common cause of bilateral/uni proptosis + exopthalmos
--MRD-1, lids are riding up a little high! +6
--eyelid protraction, thick hard eye muscles, orbital swelling, weight loss
--proptoptic, eyes bulging out a bit
Diagnosis?
Retinal Artery Occlusion/Emboli

notice the decrease in transparancy, edema can cause this too!
Diagnosis?
Laceration, affecting sclera, iris
Diagnosis?
Ectropion

--lower eyelid margin is rolled outward
--not touching eyeball!
--corneal breakdown if eye isn't lubed
Diagnosis?
Persistent myelination
--retinal nerves+brain nerves should not have myelin
--myelin in the retina!
--enlarged blind spot, cant stimulate retina under myelin, energy cant get beneath! feathery!
--MYOPIC excessively near sighted
Dermatochalasis

excess skin on eyelids! not ptosis!
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