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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?
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.
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
Forced Preferential Looking
gray and checkered board with distance, look where their eyes go
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
Vision Testing in Children
Birth to 3 years of age
Vision Testing in Children
3 to 5 years of age
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.
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
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.
Also known as amblyopia ex anopsia.
Results from inadequate sensory input due to an opacity in the ocular media or occlusion of the eye.
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
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
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
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
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
Giemsa stain of conjunctival scrapings
(basophilic inclusion bodies)
Direct immunofluorescence studies of the conjunctiva
Prophylaxis - topical erythromycin (IlotycinR) ophthalmic ointment at time of birth
Infants - oral erythromycin or sulfa agents, adjunctive topical erythromycin
Parents - oral tetracycline or erythromycin
Onset 2 to 6 days after birth
Rapidly progressing infection
Copious purulent drainage, chemosis, lid edema
Complications include corneal perforation with endophthalmitis
Edema of the Conjunctiva
Displacement of the eye from the orbit
Inflammation within the eye
Begin presumptive therapy immediately usually administered parenterally
Ocular irrigation and fortified ophthalmic solutions (antibiotic solutions)
Parents require treatment
Laboratory work-up mandatory:
Gram stain of conjunctiva revealing gram negative diplococci
Gonococcal cultures and sensitivities
Infection or inflammation confined to eyelids and periorbital structures anterior to the orbital septum.
Active infection or inflammation of the orbital soft tissues posterior to the orbital septum
Restriction of ocular motility
Pain with movement of the eye
Pupil abnormality - afferent pupillary defect
Restrict Ocular Motility!
What must you make sure you do?
Extension from periorbital structures
-Face and eyelids
-Bacteremia with septic emboli
Causes of Orbital Cellulitis?
H. Influenzae - more common in children
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!
--distance from upper lid to light reflex!
--this girl is -2
Margin to Reflex Distance-1
--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).
Epiphora (excessive tearing).
Spontaneous resolution in 85% of patients by 6 months of age.
Broad-spectrum antibiotics to control the chronic dacryocystitis
Creiger maneuver - nasolacrimal sac massage
Probing and irrigation of nasolacrimal system
nasolacrimal sac massage
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
Work-up usually involves neuro-imaging.
Visual electro physiologic test may aid in diagnosis
VEP Visual Evoked Potential
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
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!
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
Presenting Signs and Symptoms
-Poor Vision 5%
-Routine Exam 3%
-Orbital Cellulitis 3%
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
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
Optical correction of aphakia
Occlusion therapy for amblyopia
Bilateral in 2/3rds of patients
Signs and Symptoms
•Corneal edema (corneal clouding)
•Eye enlargement (buphthalmos)
•Epiphora (excessive tearing)
Treatment is surgical, also need to treat subsequent refractive errors and amblyopia
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
--GLAUCOMA can be a cause
--glaucomatous optic atrophy bc pressure
--asymmetry or disc//cup ratio > .3!! is concerning
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
Retinal Artery Occlusion/Emboli
notice the decrease in transparancy, edema can cause this too!
Laceration, affecting sclera, iris
--lower eyelid margin is rolled outward
--not touching eyeball!
--corneal breakdown if eye isn't lubed
--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
excess skin on eyelids! not ptosis!
THIS SET IS OFTEN IN FOLDERS WITH...
ENT: Lectures 4-6 (Steehler)
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