B B Eye Foundation
Sukhsagar, 2/5 Sarat Bose Road, Kolkata - 700020

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Pediatric Ophthalmology & Strabismus

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There is a need of spreading more awareness among pediatricians and primary care physicians to recognise the common peditric eye diseases. They are the primary doctors of the child and anything missed at that level may present to the pediatric ophthalmologist very late, by which time the chances visual recovery may not be very good.

We bring to you the very best in Pediatric Ophthalmology & Strabismus

    Consultants:
    Dr Prachi Subhedar Ghosh
    Dr Santanu Mitra

Parents walking into the clinic often ask:

  • Power is increasing rapidly!
  • Can increase in glass power be stopped?
  • Is myopia hereditary?
  • Is squint only a cosmetic problem which can be ignored till the child grows up?
  • Is Pediatric Cataract same as adult cataract?
  • Is Pediatric Cataract Surgery an elective surgery?
  • Is Surgery alone enough for the child to gain maximum visual potential?
  • Do premature children need routine eye check-up?
  • If yes, when and why?
  • What is ROP?
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    If we are able to answer these questions correctly, then we will be in better equipped to realize the seriousness of some of the pediatric eye problems. With majority of the ophthalmologists too being very busy with their adult patients, the children were often deprived of proper attention. But then the realization came that if we compare the life expectancy of our pediatric patients, one blind child will be equivalent to 5 blind adults. This led to the evolution of Pediatric Ophthalmology as a separate sub-speciality.

    With history, we could get some clues to suspect eye diseases in children. Some of the important points to be noted are:

  • Antenatal Infection – TORCH
  • Consanguinity
  • Birth Trauma and Anoxia
  • Family History – Down Syndrome, Myopia, Squint, Retinal Detachment
  • Premature Delivery with Oxygen Therapy
  • Delayed Milestones
  • Sibling involvement
  • Abnormal Eye Movements
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    Pediatric Ophthalmology & Strabismus



    Vision Assessment in Children:
    One major hurdle in detecting eye problems in children is that we are not able to record vision of infants and pre-school going children as easily as we could do in school going children and adults. There are various indirect hints which can help us to roughly assess the vision in pre-school children.
    Fixation pattern

    This gives a gross idea of the visual status of infants.

  • Fixation and Following of light
    1. Binocular
      Uniocular
  • Fixation Pattern on Accommodative Target
    1. Central
      Steady
      Maintained
  • Resistance to Occlusion of One Eye
  • Proper fixation reflex develops around 2-3 months of age
  • If a normal torch light is shown to the child from different directions and the child is following the light, it is a positive sign. It can be checked uniocularly as well by covering one of the eyes of the child.

    More technically if the child’s fixation pattern recorded in terms of central/uncentral, steady/unsteady and maintained/unmaintained.

  • Central/Uncentral – By this term we determine that while the child is fixing on the torch light, whether the light reflex is falling or the centre of the pupil or not. If it is eccentric, that is a sign of subnormal vision in the child.
  • Steady/Unsteady – If the fixation is steady the child will not be having any involuntary movements of the eye while fixing on the target object or light. If the child has nstagmus, then it is an unsteady fixation and is indicative of poor vision.
  • Maintained/Unmaintained – This term is always used in relation to the other eye. It is more important in the presence of squint in the child. During this test, one of the eyes of the child is occluded and is shown a torch light or target. Once the child is fixing with the uncovered eye, the the occluder from the other eye is removed. Now we determine whether the child is maintaining fixation with the same eye, or the other eye takes over the fixation. If the second eye takes fixation on being uncovered, it gives an indication that the first eye may be amblyopic.
  • Optokinetic reflex with Catford Drum

  • Nystagmus can be elicited by passing a succession of white and black stripes through the patient’s field of vision.
  • The visual angle subtended by the smallest stripe width is determined.
  • If a positive response is elicited - Acuity at least 6/120 in the newborn.
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    Visual Evoked Potential (VEP)

  • Cortical potential have been used to assess visual acuity in children.
  • VEP latency rather than amplitude is used to measure visual acuity.
  • It has been extremely helpful for collecting information on maturation of visual functions.
  • Whether the responses from the two eyes differ is recorded.
  • Is used to chart progression of the condition in case of bilateral reduced visual acuity.
  • Lea’s Symbol

  • Parents are given a sample of different symbols to train the child to identify them.
  • During the next visit, child’s visual acuity can be determined by asking him to identify those symbols of different sizes.
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    Pediatric Ophthalmology & Strabismus



    Common Pediatric Eye Diseases
    The most common pediatric eye diseases we come across in routine practise are as follows:
     
    Amblyopia (Lazy Eye)

    Types

  • Strabismic
  • Anisometropic (Best Prognosis)
  • Sensory Deprivation (Worst Prognosis)
  • Treatment done by proper optical correction and patching of the better eye.
  • Treatment of Amblyopia is possible only till a certain age.
  • Strabismus and sensory deprivation amblyopia (caused by media opacities like pediatric cataract, ptosis, lid hemangiomas etc) are easy to detect. It is important to recognise these conditions as serious enough to cause permanent visual impairment in children. Children with sensory deprivation amblyopia may require urgent surgical intervention before amblyopia therapy by glasses and patching is initiated.

    Strabismus

  • Infantile Esotropia
  • Accomodative Esotropia
  • Intermittent Divergent Exotropia
  • Paralytic Strabismuss Syndromes
  • The first three are the most common and important in children. It is important to understand that squint is not just a cosmetic problem. It can lead to amblyopia of one of the eyes. Satisfactory treatment for amblyopia caused by strabismus is available only upto 9-10 years of age.

    Infantile esotropia

  • Age of onset: Infancy.
  • Large angle esotropia without high refractory error.
  • May be associated with dissociated vertical deviation.
  • Early surgery important to maintain binocular vision and stereopsis.
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      Infantile Esotropia
     

    Pediatric Ophthalmology & Strabismus



    Accomodative Esotropia

  • Age of onset – Around 3 years.
  • May/may not be associated with high hypermetropia.
  • Generally gets corrected by optical correction.
  • Bifocals to be given for high AC/A ratio.
  • Early treatment important to prevent amblyopia.
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    Intermittent Divergent Squint

  • Onset – infancy to early childhood.
  • Generally preserves fusion and stereopsis.
  • Surgical results good.
  • Early detection of amblyopia if any, important.
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    Squint in children can be detected by simple hirschberg test in which a torch light is shown to the child’s eye and the posittion of the corneal light reflex determined. Normally it should fall on the centre of the pupil in both eyes. If one of the reflex is on the centre of pupil and other peripherally, it indicates that the child is having squint.

    Squint – Take home message

  • Not a cosmetic problem in children.
  • Needs immediate attention.
  • Can cause permanent visual impairment in one or both the eyes.
  • Early surgery may be necessary to maintain binocular vision and stereopsis.
  • Can appear in adulthood as well – Mostly paralytic.
  • May need more than one surgery for full correction.
  • Has to be combined with amblyopia therapy to achieve best results.
  • Routine follow up important.
  • Squint may be the only clinical manifestation of Retinoblastoma.

     

    Pediatric Ophthalmology & Strabismus



    Common Pediatric Eye Diseases
    Nystagmus

    It is almost anivariably associated with subnormal vision. Could be either sensory or congenital motor nystagmus. Any abnormality in the anterior visual pathway right from the cornea to optic tract can lead to nystagmus. But if such a pathology is not detected and nystagmus is present along with abnormal head posture, it is more likely to be a case of congenital motor nystagmus. In congenital motor nystagmus the binocular vision is generally good, and such children should not be encouraged to correct their head posture. It is an attempt to improve their vision by adopting a posture at which the nystagmus is least. The head posture alternatively can be corrected by surgery on the extraocular muscles. Latent nystagmus may be associated with infantile esotropia.

    White Pupillary Reflex requires immediate attention because it could be both life threatening and cause permanent visual loss. The common causes of leucocoria are Congenital cataract, Retinoblastoma, Retinopathy of prematurity, Coats disease, Toxocariasis, Primary hyperplastic persistent vitreous etc.

    Congenital Cataract

  • Dense unilateral cataract in children is considered an emergency and should be operated immediately.
  • Even bilateral cataract should be operated as early as possible.
  • Sensory deprivation amblyopia caused by congenital cataract has worst prognosis if left unattended.
  • Rubella in 1st trimester may lead to total cataract.
  • Amblyopia therapy following cataract surgery is as imporatant as the surgery itself.
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      Congenital Cataract
     

    Pediatric Ophthalmology & Strabismus



    Common Pediatric Eye Diseases
     
    Retinopathy of Prematurity (ROP)
  • It is a bilateral disease that affects the vitreous and peripheral retina.
  • It is caused by a combination of factors, of which the most important is prematurity.
  • Increase in incidence is due to better neonatal care available in present hospitals resulting in better survival rate of premature children.
  • Timely treatment in early stage with laser may prevent irreversible visual loss.
  • Risk Factors for ROP are:

  • Prematurity
  • Low birth weight
  • Complex neonatal hospital course
  • Prolonged supplimental oxygen
  • Screening Protocol

  • Children born at less than 32 weeks of gestation or weighing less than 1500 gm, when they have reached age of 5 wks from birth or 32 weeks postconception (whichever is later).
  • If no ROP is found, then one more check after one month is required.
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    Retinoblastoma
  • It is the most common intraocular malignancy of childhood.
  • More than 90% of children can be cured of retinoblastoma by early detection and treatment of the affected eye.
  • The average age of children with retinoblastoma is 18 months.
  • Most common presentation is white pupillary reflex.
  • Treatment options available are:

  • Laser therapy
  • Cryotherapy
  • Brachytherapy
  • Chemotherapy
  • Enucleation
  • Examination of siblings is important

     
    Buphthalmos

    Salient features are:

  • Large eyeball.
  • Bluish sclera.
  • Child Photophobic.
  • Sturge Weber Syndrome.
  • Early treatment necessary to preserve vision

  • One should rule out infantile glaucoma if any child with large eyeballs and bluish tinge on the sclera is not able to tolerate light.
  • Infantile Nasolacrimal Duct Block

    It is a common problem in infants which leads to mucoid discharge and watering from one or both the eyes. In most of the cases it can be treated by simple massage in the lacrimal sac area. Proper technique of massage is important. Most of the times patients don’t respond to treatment due to improper massage technique. It may lead to unnecessary syringing and probing under general anesthesia later on.