Common pediatric ophthalmic

disorders
April 21,2015
Ayanaw Tsega
 Outline
• Infectious Diseases • Retina/uveitis
• Eyelid Disorders/Lacrimal
• Optic disc disorders
System

• Iris Abnormalities • Ocular tumors

• Cataracts • Ocular Trauma

• Glaucomas
 Common Infections
Ophthalmic disorders in Childhood
• Herpes simplex complex

• Ophthalmia neonatorum from Chlamydia

and Neisseria

• Bacterial conjunctivitis

• Viral conjunctivitis
 Herpes simplex complex
– Prior exposure to individual with cold sores, HSV-1 or
HSV-2 venereal or skin infection
• Unilateral blepharoconjunctivitis.
• Follicular conjunctivitis
• Herpes simplex keratitis
– Rarely bilateral.
– Conjunctival follicles

– Watery discharge
– +/- skin infection/vesicles
– Palpable preauricular lymphadenopathy
 Management
– Topical antivirals (1% trifluorothymidine eye
drop Q2hrs , 3% acyclovir eye ointment 5X/d )
• Oral acyclovir for recurrent infections with keratitis
• Cool compresses
• Topical antibiotics to skin lesions to prevent super-
infection
=> Complications
– Corneal involvement
– Uveitis
– Recurrence
 Ophthalmia neonatorum
• Direct contact with infecting agent Chlamydia trachomatis
during passage through birth canal
– Occurs around 5 - 12 days of age
– Earlier onset with premature rupture of membranes
– Mild swelling, hyperemia, and papillary reaction
– Minimal to moderate watery or filmy discharge
 Medical therapy
– Oral erythromycin
– Topical 0.5% erythromycin ointment
– Evaluation and treatment of parents and other
maternal contacts
 Bacterial conjunctivitis
– Rapidity of onset of signs and
symptoms
– Common cause of conjunctivitis in
children
– Hyperacute purulent conjunctivitis,
preauricular adenopathy, corneal
infiltrates or perforation (Neisseria)

• Gonococci type --- requires IV

antibiotics
 Bacterial conuncuitvitis
• Treatment
– Polymyxin B / Tri,methoprim >2moS
– Chloraphenicol gtt /ointment
– Ceftriaxone IV for gonnococal
– Ciprofloxacin eye drop
– Erythromycin ointment
• It depends on severity ,type and age of child
 Orbital cellulitis
• Most commonly a bacterial infection posterior to orbital septum
(Staphylococcus, Streptococcus, Haemophilus common)
– Periocular pain and/or headache
– Swollen, tender eyelid
– Fever
– Lethargy
– Decreased vision, or diplopia possible
– Eyelid edema, erythema, tenderness, warmth Proptosis
possible
– Restricted ocular motility possible
– Decreased acuity with RAPD possible
• Requires hospital admission
 Management
– Medical therapy
• Hospitalization with broad-spectrum intravenous
antibiotics ( cetraixone ,ceftazidime IV)
• Follow clinical signs and vision carefully
– Surgical therapy
• Drainage of subperiosteal abscess if patient not
responding to antibiotics and/or vision
compromised
• Debridement of sinuses if significant disease present
 Common inflammatory disorders
• Allergic conjunctivitis
– Seasonal
– Vernal KC
 Seasonal AC/ VKC
– Puffy eyes red, and irritated
– Rubs eyes frequently
– Intense itching, photophobia, lacrimation, and
discharge
– Seasonal exacerbations, especially spring and
summer
– Limbal: limbal papillae, especially superiorly,
micropannus, Horner-Trantas’ dots
– Palpebral: giant cobblestone papillae in superior
tarsal conjunctiva, pseudomembrane, mechanical
ptosis
 Management
– Systemic antihistamine if other symptoms
– Topical H1 blocking drops
– Mast cell stabilizer drops ( > 4years )
• Severe cases, mild topical corticosteroid drops
• List complications of  VKC
 Eyelid /lacrimal disorders
• Congenital ptosis
• Nasolacrimal duct obstruction
 Congenital ptosis
– Associated pupillary abnormalities
– Associated strabismus
– Decreased Levator function
– Poorly formed lid crease
– May have Lagoththalmos
– Amblyopia may be present
 Management of CP
– Describe medical therapy
• Quantification of ptosis/margin-reflex distance
• Measurement of levator function
• Evaluate corneal sensitivity
– Describe surgical therapy
• Surgical correction definitive treatment
• If no amblyopia, occlusion of visual axis, or ocular
torticollis, delay surgery till 4-5 years
• If amblyopia present, visual axis occluded, severe
chin-up position, prompt surgery needed
Congenital nasolacrimal duct OBs
• Epiphoria affects Aprox
20% neonates
• Spontaneous resolution
occurs in 96% of cases in
the first 12 months
• Most commonly caused by thin
mucosal membrane at lower
end of NLD (valve of Hasner)
 Pertinent features
– Epiphora and/or mucopurulent discharge with
or without an associated conjunctivitis
– Lower eyelid skin irritation/breakdown
– Reflux of mucoid material from the puncta with
digital pressure over the lacrimal sac
 Management
– Medical therapy
• Digital massage
• Topical antibiotics
• Observation
– Surgical therapy
• Nasolacrimal duct probing
• Balloon catheter dilation
• Silicone intubation of lacrimal system
• Dacryocystorhinostomy
 IRIS ABNORMALITIES
• Dyscoria
• Aniridia
• Iris coloboma
• Brushfield spots
• Heterochromia iridis
• Persistent pupillary membrane
• Microcoria /macrocoria
• Polycoria
 Aniridia

– Gene defect on chromosome 11

– Infant with nystagmus
– Photophobia
– Foveal hypoplasia
– Optic nerve hypoplasia
– Appears to have dilated pupils
– May have anterior polar cataracts
 Aniridia
– Have a rudimentary iris stump, so not true
aniridia
– Sensory nystagmus
– Poor visual acuity
– Small corneas
– Corneal panus
– Glaucoma
Medical therapy
- gonioscopy
– IOP measurement and treatment
 Congenital glaucoma
– Corneal edema
– Haab striae
– Corneal enlargement
(greater than 11.5 mm)
– Elevated intraocular pressure
– Epiphora
– Deep anterior chamber
– Buphthalmos
 Long axial length- common feature
• Corneal opacification – irreversible
• Myopic Fundus – irreversible
• Optic nerve cupping – reversible but high cupping ( CD ratio –high)
• Buphthalmos and pseudoproptosis–
“OX” eye appearance
 The hallmark of all forms of glaucoma in
infants and young children is ocular
enlargement
Treatment
Types of surgery :
 Goniotomy, , trabeculotomy,
trabeculoectomy , cycloablation
Thank you !
Cataract
– Epidemiology
– Etiology of pediatric
cataract
– Morphology of pediatric
cataract
– Options in management
of aphakia
– IOL power calculation in
children
 Epidemiology
• The major preventable cause of lifelong visual
impairment.
• 1.5 million blind child in the world of which
cataract contribute 10-20%
• All of them are not visually significant
• Prevalence of visually significant cataract is 1.2
to 6 in 10,000 live birth
• Bilateral cataract is more common than
unilateral
 Etiology
• Hereditary isolated • Bilateral : 45% idiopathic ,
cataract 50% hereditary , 5%
• Metabolic diseases infectious
• Intra uterine infections - • Unilateral : 85%
TORCHS idiopathic, 5% hereditary ,
• Trauma 1/3 of pediatric 2% infectious , 8% trauma
cataract
• Associated with systemic
• Syndromes and congenital disease : 25% in bilateral
cataract
,5% in unilateral
• Drug induced
• Idiopathic -50%
 Morphology and location

• Prediction of visual prognosis

• The more posterior and the more central the
cataract ,the greater the visual impact
• Morphological types:
1. Zonular cataract
2. Nuclear cataract
3. Sutural cataract
4. Sub capsular cataract 32
 Morphological types

5. Total cataract

6. Rosette cataract

7. Polar cataract

33
 Zonular cataract
• Is most common type of pediatric cataract
• Opacification of discrete region
• Developmental or congenital cataract
• Lens is relatively clear during critical period
• Amblyopia is not very dense and visual prognosis is
good
• It is progressive in nature eventually require
surgery
34
 Sutural cataract
• Involved Y sutures and fetal
nucleus
• non-Progressive or in some
case progressive
• Visually not significant
• In Bilateral , often AD and X-
linked inheritance

36
 Total or diffuse cataract
• All layers are involved
• Usually bilateral
• Often begins as lamellar or
nuclear cataract
• Visually significant
• Need early surgical intervention
• AD, Down’s syndrome
,Metabolic disease, Trauma
• Progression of other types of
cataract
37
 Other types

Anterior polar cataract

Rosette cataract
: blunt ocular trauma

Posterior Lenticonus
 Mx: Indication for surgery
• Morphology and location of cataract
• Size and density of the opacity
• Laterality
• Visual behavior of the infant
• Presence of associated ocular abnormalities
– strabismus, nystagmus, unsteady fixation after 8weeks
• Poor retinoscopy reflex
• When to operate?
– Very significant cataract before 6month
– Unilateral need early surgery. Why ?

39
 Management of Aphakia :
Spectacles Contact lenses
• Safest method b/c • Has several advantage
change in power is over aphakic glasses
possible for growing – Better field of view
eye – Less magnification
• Available – Better stereopsis
• Problems: • Problems:
– Cost for repeated change – Continuous change in
– Heavy corneal curvature
– Optical problems
• Good option for
bilateral aphakia than
unilateral

40
 IOL power calculation in children
• The IOL should aim for amount of residual hyperopia due to myopic
shift occurs in pseudoaphakia
• IOL power calculation has several problems
– Axial length increase by 2.4-3.3mm during 1st year and
1.2-2.2mm in 2nd year
– K-reading changes from +52.00D -/+ 4.00D to 42.00D -/+
4.00D 1st 6month
• K- reading by taking average adult’s 44.00D
– Capsule bag diameter 7-9mm -2year, 10-10.5mm
16years and 90% of lens growth occur in 1st year of life

41
 Study on IOL power determination
• 156 pseudoaphakia eye age 1month to 8yrs
• The younger the child the more the myopic shift
• Myopic shift is less in pseudoaphakia than aphakia and
• Also less in bilateral pseudoaphakia than unilateral
• In order to reduce this:
• 1 - 2 Years = IOL Formula - 20%
• 2 - 4 Years = IOL Formula - 15%
• 4 - 8 Years = IOL Formula - 10%
• > 8 Years = IOL Formula

42
Age in year Suggested post
operation goal
3 +5.00D
4 +4.00D
5 +3.00D
6 +2.25D
7 +1.50D
8 +1.00D
10 +0.50D
13 Plano 43
 Summary : pediatric cataract
• Congenital or acquired
• Visually significant or not
• Bilateral or unilateral
• Stable or progressive
• Partial or complete
 Summary
The successful Mx of Paediatric cataracts fall
under five headings
a. Cataract morphology and severity
b. Timing of surgical intervention
c. Optical correction
d. Acuity measurement and amblyopia
therapy
e. Management of complications
 Retinopathy of prematurity
• A proliferative retinopathy that develops in
premature infants due to incomplete
vasculogenesis of the retina at the time of
birth. Is a biphasic blinding disease

• Phase I - delayed retinal vascular growth

after premature birth
• Phase II - follows when phase I-induced
hypoxia releases factors to stimulate new
blood vessel growth
Retinopathy of Prematurity (ROP)
– Risk of visual loss increases as gestational age and birth
weight decrease

– Birth weight

– Gestational age at birth

– Current and postconceptional age

– Significant systemic illnesses

– Selection of patients for screening – all premature infants

with birth weight < 1500 grams, gestational age < 28 weeks
 Retinopathy of Prematurity (ROP)
– Stage – severity of disease
• Stage 1 = demarcation line
• Stage 2 = ridge
• Stage 3 = ridge with extraretinal fibrovascular
proliferation
• Stage 4 = subtotal retinal detachment
• Stage 5 = total retinal detachment

Stage 1 ROP. Note the demarcation line

between vascularized and avascular retina.
 Management

• Cryotherapy

• Laser photocoagulation
 • Cataract
• Retinoblastoma
• Toxocariasis
Luekocoria:
• Coat´s disease
Differential • ROP
diagnosis • PHPV
• Retinal detachment
 Optic nerve disorders
• Optic Nerve Hypoplasia
• Optic Atrophy
• Papilledema
• Pseudotumor Cerebri
• Pseudopapilledema
• Optic Nerve Drusen
 Retinoblastoma

A, Endophytic retinoblastoma with vitreous seeding. B, Exophytic retinoblastoma

with overlying detached retina.
 Etiology : RB
– Neuroblastic tumor arising form the retinal cells,
photoreceptors
– Sporadic incidence. About 50%
– Hereditary transmission, autosomal dominant,
the remaining 50%
– Lack of suppressor gene, or its deletion, will
permit germinal mutations to develop into
tumor
– Lack of suppressor will permit other tumors to
develop
 Retinoblastoma

• 25 % cases present with ET/ XT and less

common presenting ophthalmic features are;
vitreous Hge, ocular or periocular
inflammations ,glaucoma ,proptosis,

• Is a nueroblsatic tumor ,biologically similar to

neuroblastoma, and meduloblastoma
 Related complications
– Direct extension via optic nerve
– Orbital extension through sclera
– Chance of dying with retinoblastoma if not
treated approaches 100%, but if treated,
survival is 90% or better
– Chance of dying because of secondary tumor is
greater than death from retinoblastoma
– Osteosarcoma is common, especially if external
beam radiation has been used
– Long-term secondary tumor risk
 Nuerobastoma
• 20% show orbital involvement
• clinical manifestations :
- unilateral proptosis
- lid ecchymosis lid swelling, ocular
motility disorders ,
Other systemic signs: - abdomina fullness , pain ,
venous obstruction and edema ,hypertension ,
Mean age of diagnosis with orbital nueroblastoma =
2yrs
 Metastatic tumor of the eye

Nueroblastoma
 one of the most common childhood cancer . most common
source of metastasis : adrenal gland and sympathetic cervical
ganglion chain
 It develops from the tissues that form the sympathetic nervous
system (which controls body functions, such as heart rate and
blood pressure, digestion and levels of certain hormones
 Metastatic tumors
Rhabdomyosarcoma - the most common primary
malignant tumor of the orbit
- average age of onset 5-7yrs
- 5 % incidence
More aggressive ,carries poorer prognosis
Ophthalmic features = proptosis ( 80- 90%)
= globe displacement
= blepharoptosis
= conjunctiva and lid swelling, pain
(10%) palpable mass
 Any questions

• Thank you for listening