Baylor College of Medicine and Texas Childrens Hospital Common Ophthalmic Findings in Children Objectives Be able to identify common ophthalmic findings in children Be able to perform a basic eye exam ID: 913925
Download Presentation The PPT/PDF document "Honey Herce, MD Department of Ophthalmol..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Honey Herce, MD
Department of Ophthalmology,
Baylor College of Medicine and Texas Children's Hospital
Common Ophthalmic Findings in Children
Slide2Objectives
Be able to identify common ophthalmic findings in children.Be able to perform a basic eye exam.Be able to manage common ophthalmic findings in children.
Common Ophthalmic Findings in Children
Slide3Slide4Slide5Slide6Pediatric eye examVision PupilsOcular alignment and motilityGross observationPediatric Ophthalmologist will do a full exam (8-point eye exam) consisting of the following:Tonometry (checking eye pressure)
Slit lamp examinationRefraction (Checking for glasses prescription).Dilated fundus exam.
Slide7Vision In ChildrenBlinks to light/Reacts to light: develops by GA 31 weeksFix and follow: develops by 2-3 mos gestational age.Pictures: Allen chartLetters: HOTV chart/matching, Snellen Chart, crowding bars
* With all of these, you want to look for symmetry*
Slide8Fix and FollowDistraction is keyObserve if they watch you and if they can follow you.Check monocularly and see if they have a preference for an eye.
Slide9Allen Chart
Tumbling E’s
Slide10Inaccurate visual acuity tests!!!
Vision Tests for Verbal children
Slide11Accurate visual acuity tests!!!!
Slide12Ocular Alignment and motilityGross ObservationCorneal light reflex testingHirschberg testingKrimsky testingCover/Alternate cover testing:
Slide13Slide14Bruckner testSimple test for amblyopia risk factorsUse your direct ophthalmoscopeShine the light on each eye alone (red reflex test) Then both eyes togetherLook thru view finder
Slide15Amblyopia risk factorsStrabismusHigh or asymmetric refractive errorsDeprivation: i.e. cataract
Slide16Abnormal red reflexCorneal opacitiesCataractVitreous hemorrhageRetinal detachmentRetinoblastomaStrabismusRefractive errors
Slide17Ocular Motility Document each function of each extraocular muscle
Slide18Right Eye Left Eye
SR IO IO SR
LR MR MR LR IR SO
SO IR
Slide19Ocular Anatomy
Slide20Slide21Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide22Strabismus* *G.
strabismos, squinting
= any Misalignment of the eyes~2-4% of all people
Slide23Slide24Strabismus Which direction in the misalignment?
Control of the deviation?
ESO – turning inwardEsophoria (tendency to turn in, usually controlled)
Esotropia
(constant misalignment)
Intermittent
esotropia
(intermittent misalignment)
EXO – turning outward
Exo
phoria
(tendency to turn out, usually controlled)
Exotropia
(constant misalignment)
Intermittent
exotropia
(intermittent misalignment)
Measurements are done at Distance (20 feet) and near (1/6 m)
Slide256 extra-ocular muscles (EOMs) per eye
Medial/
nose
Slide26How do we assess Strabismus? Assess Alignment
Assess Movement of the eyes
Slide27How do we assess Strabismus? Assess Alignment
Make assessments when they walk into the room and as you are examining them.Are the eyes straight looking straight head?If not
Describe the deviation/s
Slide28Alignment Assessment
Gross observationObvious misalignment
Corneal light reflex centration In same place on eye? Eyes are straightMight look crossed but really is straightIn different positions on eyes? An eye is misaligned
Left eye is subtly
esotropic
Slide29Alignment Assessment
Cover testing
Cover fixing eye and crossed eye shifts to pick up fixation
Gold standard test
Slide30Congenital Esotropia a.k.a. Infantile EsotropiaPresentation before 6 mos.They usually will have a large deviation.Crossing in a baby that does not go away and as they get older gets more constant.
May run in families.Surgery is indicated.Increased frequency in Cerebral Palsy and hydrocephalus
Slide31Accomodative EsotropiaCharacterized by:Onset after age 18 mos. Usu intermittent at onset but then becomes constant. when tired or sick, can appear acutely
They can develop amblyopia on the eye that turns in more.Glasses keep the eyes straight.Associated findings:+3.00D to +10.00D- High refractive error.Often hereditaryAmblyopia frequent- 2/3
Slide32TreatmentTreat Amblyopia (patching therapy).Correct refractive error with glasses.Surgery for residual eye crossing with the glasses.
Slide33Intermittent ExotropiaIntermittent misalignment, however if long standing can turn into a constant deviation. Eyes usually are straight then becomes exotropic and the patient blinks and they go back to straight. Onset varies from 6
mos – 6 yrsCan be progressive 75%TreatmentGlasses if high refractive error.Alternate occlusion therapyPrism therapy (base-in prisms)Over-minus glasses: this induces an accomodative convergence.
Surgery
Slide34Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide35“Lazy Eye”
Not a medical termUsed by patients, relatives to describe: - Strabismus - Amblyopia
- A blind eye (any cause) - Ptosis - Almost anything
Slide36Amblyopia*
*G. amblyopia, dimness of vision
Definition: poor vision in an eye (or both eyes) even though the retina and optic nerve are normal and even though the correct glasses are in placeSo why can’t the eye see?
Usually unilateral
~2-5% of the population
Slide37The eye can’t see because it has been “turned off”
or suppressed by the brainso that even with the right
glasses correction - the vision isn't right3 Causes of suppression
are the causes of amblyopiaStrabismus
(misaligned eyes) – brain suppresses the deviated eye
Refractive errors
(high degrees of nearsightedness, farsightedness, or astigmatism, especially if the refractive errors are asymmetric) – brain suppress the eye/s w blurrier vision
Deprivation
(lack of form vision due to blockage of light getting to retina – cataract, ptosis, vitreous hemorrhage) – brain suppress the eye/s
Slide38How do we test for amblyopia?Check vision! Check for the risk factors that may lead to amblyopia
What are the THREE risk factors for amblyopia??
Slide393 Amblyopia Risk FactorsStrabismusHigh or asymmetric refractive errors (uncorrected)
DeprivationCataract Ptosis
Slide40Amblyopia TreatmentClear the ocular media (
ie cataract extraction, ptosis surgery, etc.) - if needed
Provide glasses - if neededPatch the better eye or Blur the better eye with atropine drops
Atropine 1 drop, to the good eye, 2d a week
Patch good eye 2h/d
Slide41FollowupCheck vision every 2-3 months while undergoing patching or atropine Stop treatment whenVision is equal/normal in each eye
ORVision improvement in amblyopic eye stalls in spite of therapy (cant cure all amblyopia)Continue follow up to ensure amblyopia doesn’t recur (won’t after age 7)
Slide42Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide43Leukocoria* Means “white pupil”This occurs when the pupil is white rather than black or when there is an abnormal red reflex.The red reflex appears red because when light enters the eye, the retina reflects a small amount of light. The reddish-orange color is the normal color of the retina. Anything obscuring it will change the red reflex.
Slide44LeukocoriaThis can be due to many causes.CataractRetinoblastomaVitreous hemorrhageRetinal detachmentRetinopathy of prematurity
Intraocular infectionHigh refractive error or Asymmetric refractive error
Slide45Slide46Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide47Nasolacrimal duct obstructionObstruction at distal end of duct: Valve of Hasner6% of newborns90% resolve by 6 months95% resolve by 9 monthsTearing, mucous dischargeWHITE eye
Slide48NLDO TreatmentMassage sac with each feed Topical antibiotic drops after massagewhen infectedProbe in office age 9-12 monthsProbe in OR anytime after 6-9 months– can stent with tubes or do balloon dilation.
Slide49Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide50ChalazionA localized bump on the eyelid due to blockage of one or more meibomian glands. (oil glands) This is different from a stye or a hordeolum which is a small abscess due to the glands getting infected.
Slide51Slide52TreatmentFrequent warm compresses and lid scrubs help unclog the oil glands. Anti-inflammatory eye drops and ointments sometimes are needed.For long-standing chalazia, surgical drainage may be necessary.
Slide53Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide54PtosisPtosis is a drooping of the upper eyelid.Can cause amblyopiaObstruction of the visual axisCan cause anisometropic astigmatismWatch the patient when they walk in
Chin up head posture is good: means they are using the eye.
Slide55Causes of ptosisCongenital ptosis: frequently hereditary3rd nerve palsyHorner’s syndrome1-2 mm ptosis
of upper and lower lidsAnisocoria worse in the darkMyasthenia gravisMarcus Gunn jaw wink
Slide56Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide57ConjunctivitisIt is an inflammation or infection of the conjunctiva. The conjunctiva is the loose connective tissue that covers the surface of the eyeball. It is one of the most common complaints that present to the emergency room department. 30%There are many causes of a conjunctivitis ranging from allergic to viral to bacterial to chemical.
Slide58Pediatric red eye
Slide59ConjunctivitisAge and presentation will dictate managementNeonatal: gonorrhea, chlamydia, HSV
URI Symptoms: adenovirusPurulent: bacterialAllergic
Slide60ConjunctivitisViralAcute or subacute onset with usually an exposure history.Minimal pain level .Clear watery discharge, photophobia and itching*
Very contagiousTreatment: Self limited, supportive care with artificial tears and cool compresses.BacterialAcute onset, with minimal pain. Chemotic conjunctiva, copious thich and purulent dischargeTreat with antibiotic eye drops. i.e.
PolytrimAllergicAcute ro subacute onset. May be seasonalHallmark of symptom is itching and a clear watery discharge. Treat with antihistamine drops and mast cell stabilizers. I.e. Zaditor, Pataday
Slide61Neonatal ConjunctivitisThree etiologies: Chemical, Bacterial, Viral.Chemical conjunctivitis: within the first 24 hours of life.Neisseria Gonorrhea: 3-5 days after birth.Present with acute conjunctivitis with severe lid edema and
mucopurulent discharge.C. Trachomatis: 5-14 days after birth.Mild swelling and mucopurulent discharge. Important to also treat systemically to prevent PneumoniaHSV: 1-2 weeks.
Slide62Strabismus
AmblyopiaLeukocoriaCongenital CataractRetinoblastomaROPOthers: vitreous hemorrhage, high refractive errorNLDOChalazionPtosis
ConjunctivitisCellulitisCommon Ophthalmic Findings in Children
Slide63Preseptal CellulitisInflammation and infection of the tissues anterior to the orbital septum.Swollen and erythematous lid, but the eye is white and motility is full. Three main routesDirect inoculation with eyelid trauma i.e. insect bites.Spread from contiguous structures
Paranasal sinuses i.e. ethmoid diseaseChalazia/HordeoleumDacryocystitisImpetigoHSVHematogenous
Slide64Preseptal CellulitisTreatment: Oral antibioticsIf the patient does not respond to oral antibiotics in 48 hours or if suspecting orbital disease- IV antibiotics needed.CT scan if suspecting orbital cellulitis.
Slide65Orbital CellulitisInfection of orbital contents posterior to the orbital septumEtiology:SinusitisDacryocystitis
DacryoadenitisDental infectionsIntracranial infectionsTraumaPostorbital surgery
Slide66Orbital CellulitisSymptoms:Decreased visionPain with eye movements
DiplopiaSigns:FeverLid erythema and edemaProptosis
Motility restrictionsRelative afferent pupillary defectConjunctival injectionOptic nerve swelling
Slide67Orbital CellulitisCT to further assess extent and presence of orbital abscessBlood culturesBroad spectrum antibiotics
Special considerations if immunocompromisedConcern for fungal (Mucormycosis)Consultations
OphthalmologyENTInfectious Disease
Slide68Questions?
Slide69