Dr.

Safinaz Mohd Khialdin

INTRODUCTION
Early detection & treatment of paediatric
ocular disease is critical

Delay in diagnosis results in irreversible

vision loss

Assessment should begin at birth

A childs eye is not a small adult
eye
Nothing beats.
Good history

Maternal
Obstetric
Peripartum
Milestones
Nothing beats.
Thorough examination

Observation/ inspection
VA
Red reflex & RAPD
Extra-ocular motility
Dilated fundal examination
VISUAL ACUITY MILESTONE

Age Normal acuity

0-2 months Pupillary response, sporadic fix and

follow,jerky eye movements
2-6 months Central fix and follow, smooth eye movements

6 months 2 Grabs for toys, central fixation, accurate &

years smooth pursuit eye movements
3-5 years 6/12 and not more than 2 lines difference
between eyes
>5 years 6/9 and not more than 2 lines difference
LECTURE CONTENTS
1. Common ophthalmic problems in
children

2. Leucocoria

3. Other common ocular childhood

problems
CONTENTS
1. Common ophthalmic problems in
children

2. Leucocoria

3. Other common ocular childhood

problems
 COMMON OPHTHALMIC PROBLEMS IN
CHILDREN
1. Cataract

2. Refractive error

3. Amblyopia

4. Strabismus

5. Cloudy cornea
 COMMON OPHTHALMIC PROBLEMS IN
CHILDREN
1. Cataract (section on Leucocoria)

2. Refractive error

3. Amblyopia

4. Strabismus

5. Cloudy cornea
 COMMON OPHTHALMIC PROBLEMS IN
CHILDREN
1. Cataract

2. Refractive error

3. Amblyopia

4. Strabismus

5. Cloudy cornea
REFRACTIVE ERROR : DEFINITION
Physiological condition whereby the
refracting system of the eye does not
focus objects on the retina

and a corrective lens has to be placed in

front of the eye to enable a sharp image
to be seen.
REFRACTIVE ERROR : EXAMPLES
Examples:

1. Myopia

2. Hyperopia

3. Astigmatism
MYOPIA (SHORT SIGHTED)

Refractive error
image in front of retina (long eye ball)
Correction: Concave lens (minus lens)
HYPEROPIA / HYPERMETROPIA
(LONG SIGHTED)

Refractive error
image behind retina (short eyeball)
Correction: Convex lens (plus lens)
ASTIGMATISM

Refractive error
image cannot be focused sharply at a point
because either the cornea or the lens is not
spherical
has different powers on different meridians
Correction: cylindrical lens
REFRACTIVE ERROR : PRESENTATION
Various presentations:

Squeezing eyes
Squint
Headache ocular/ frontal/ diffuse
Tearing
Complains of tired eyes
Child is slow at school
Has problems with attentiveness
Strong family history of myopia or other refractive
error
REFRACTIVE ERROR
Untreated or under treated will cause
AMBLYOPIA
 COMMON OPHTHALMIC PROBLEMS
IN CHILDREN
1. Cataract

2. Refractive error

3. Amblyopia

4. Strabismus

5. Cloudy cornea
AMBLYOPIA
Lazy eye (laymans term)

Definition:

Unilateral/ bilateral decrease of best corrected

visual acuity

caused by form vision deprivation and/ or

abnormal binocular interaction

for which there is no obvious cause found by

physical examination of the eye

Is potentially reversible during the critical period

CRITICAL PERIOD
Why is visual development important?

Sensory function continues to develop after

birth

Requires proper visual stimulation

Normal vision receptive cells, clear media and
normal retina
Normal alignment
Normal CNS development
How does amblyopia
develop?
Brain receives 2 stimuli

Brain will select the better image and

suppress the blur or conflicting image

Abnormal eyes detrimental to visual

development
CAUSES OF AMBLYOPIA

Ammetropia (bilateral high refractive error)

Anisometropia (large/ asymmetrical

refractive error difference between eyes)

Strabismic (squint)

Occlusional / form deprivation (media

problem)
ACTION

Suspect if best corrected visual acuity of one

eye is consistently poor despite normal eye
examination / correction of refractive error

Refer quickly

Can be treated or reversed if detected earlier

(critical period)
 COMMON OPHTHALMIC PROBLEMS
IN CHILDREN
1. Cataract

2. Refractive error

3. Amblyopia

4. Strabismus

5. Cloudy cornea
STRABISMUS

Definition
Deviation of the eyes so that their visual axes are
no longer parallel
Causes of squint
Muscle imbalance
Refractive errors
Ocular abnormalities cataract, macular
scar, optic disc pathology
Special syndromes Duanes, Brown
Associated disease hydrocephalus,
cerebral palsy, meningitis
Concomitant squint
Angle of squint is the same in all
directions of gaze

Muscle imbalance
Refractive errors
Ocular abnormalities
Incomitant squint
Due to lesions anywhere along
neurological pathway and in orbit

Eg cranial nerve lesions or orbital

musculofacial syndrome (Duanes,
Browns)
Other presenting features
Symptoms
None
Noted by parents
Poor vision
Funny eye movements

Signs
Poor vision
Abnormal head posture
Tests (torch)
Corneal light reflex not symmetrical/ central (Hirschberg test)
Cover test
Extraocular movements
 Examples
Horizontal

Esotropia Convergent squint

Es In

Exotropia Divergent squint

Ex out

Vertical
ACTION
Refer to ophthalmologist (urgent)
Treatment of refractive errors
Treatment of amblyopia
Ocular exercise
Surgery

Why?
Amblyopia
Loss of binocular single vision
Cosmetic blemish
PSEUDOSQUINT

Note corneal light reflexes are central and

symmetrical
If not sure, refer
 COMMON OPHTHALMIC PROBLEMS
IN CHILDREN
1. Cataract

2. Refractive error

3. Amblyopia

4. Strabismus

5. Cloudy cornea
CLOUDY CORNEA

External exam (+10-20 Direct oph)

Poor vision
Reduced red reflex

Causes
Congenital glaucoma
Mucopolysaccharidoses (Hurlers etc)
Hurlers syndrome
Corneal dystrophy
Birth trauma
Chemical injury
Keratoconus - hydrops
CONGENITAL GLAUCOMA

Rare (1:10000)
65% males
10% AR
Isolated trabeculodysgenesis
Other features:
Tearing (important cause of this)
Buphthalmos (ox eye)
Photophobia
Optic disc cupping

Haab striae
Associations
Ocular - Aniridia, anterior segment dysgenesis,
ectopia lentis

Systemic Sturge Weber, neurofibromatosis,

rubella
CONGENITAL GLAUCOMA
If left untreated, can result in:

Raised IOP that damages optic disc

-> glaucomatous cupping -> optic
atrophy

Early diagnosis will prevent blindness

CONTENTS
1. Common ophthalmic problems in
children

2. Leucocoria

3. Other common ocular childhood

problems
LEUCOCORIA
White pupillary reflex
Most obvious when dilated pupil seen in
dim light
LEUCOCORIA

Differential diagnoses
Retinoblastoma
Congenital cataract
Coats disease
Persistent Hyperplastic Primary Vitreous
(PHPV)
Retinopathy of Prematurity
LEUCOCORIA

Differential diagnoses
Retinoblastoma
Congenital cataract
Coats disease
Persistent Hyperplastic Primary Vitreous
(PHPV)
Retinopathy of Prematurity
RETINOBLASTOMA
Most common intraocular malignancy of
childhood
Rare (1 in 14000-20000)
3% of all childhood cancers
Bilateral in 30-35%
Age at diagnosis (18 months (90% < 3y))
May be inherited (6% AD, 94% sporadic)
RETINOBLASTOMA

Presentation
Leucocoria (white reflex)
Strabismus
Poor vision
Incidental ocular exam
Orbital inflammation: Redness, pain
Retinal detachment (exudative)
Proptosis
Systemic metastases
RETINOBLASTOMA
Sight threatening
Life threatening
Refer urgently
LEUCOCORIA
Differential diagnosis
Retinoblastoma
Congenital cataract
Coats disease
Persistent Hyperplastic Primary Vitreous
(PHPV)
Retinopathy of Prematurity
 CONGENITAL CATARACT

Definition of cataract : Opacity involving the lens

 Leading cause of
blindness
Interferes with normal
visual development

Inherited 1/3
Associated with other
diseases 1/3
Idiopathic 1/3
CATARACT : AETIOLOGY
Idiopathic
Traumatic
Ocular Aniridia, PHPV, ROP
Systemic disease
Infective -TORCHES
Metabolic galactosaemia, hypocalcaemia,
hyper/hypoglycaemia
Chromosomal Downs
Other syndromic - Marfans, Alpert
Drug related steroids, sulphonamides
Inherited AD, AR, X linked
 CONGENITAL

Nuclear cataract Cortical cataract

Lamellar cataract
 SECONDARY
Ocular - Anterior subcapsular
Atopic dermatitis

Systemic oil droplet cataract

Galactossaemia

Vossius ring in traumatic cataract

Other presentations of
childhood cataract
Lack of visual interest
Strabismus
Nystagmus
Developmental delay
Associated with systemic/ ocular
abnormalities
ACTION
Prompt detection & dedicated screening

Referral to Ophthalmologist (urgent)

Why?
Monocular/ binocular cataract in infants
results in significant visual deprivation
Early visual rehab can prevent amblyopia
(form deprivation)
LEUCOCORIA
Differential diagnosis
Retinoblastoma
Congenital cataract
Coats disease
Persistent Hyperplastic Primary Vitreous
(PHPV)
Retinopathy of Prematurity
COATS DISEASE

Vascular exudation
Leaky telangiectatic
vessels
Exudative RD with cholesterol
crystals
PERSISTENT HYPERPLASTIC PRIMARY
VITREOUS
 RETINOPATHY OF PREMATURITY
Stage 1 Stage 2 Stage 3 Plus disease

Leucocoria occurs
in Stage 5 ROP
(retinal detachment)
Cicatricial ROP
LEUCOCORIA
TAKE HOME MESSAGE
A child with white pupil should be
urgently referred to an ophthalmologist
to establish the cause

Detailed evaluation of the normally

symmetrical red reflex is easily
accomplished in a darkened room by
using a bright direct ophthalmoscope
CONTENTS
1. Common ophthalmic problems in
children

2. Leucocoria

3. Other common ocular childhood

problems
Other common problems
encountered with children
Tearing
Discharge
Itchiness
Redness
Swelling
TEARING
Babies:

Blocked nasolacrimal duct

Congenital glaucoma
Blepharitis
Corneal abrasion
Nasolacrimal duct
obstruction
Caused by
Late canalisation
Block by debris

Spontaneous canalisation occurs in 90%

(12-18 months)

Refer TRO other nasty conditions

Other manifestations
Sticky eye discharge
Reflux of purulent material
Acute dacryocystitis
Management
Digital massage
Probing
Surgery
 DISCHARGE

Ophthalmia neonatorum
- Neisseria gonorrhoea

Acute dacryocystitis
 ITCHINESS

Giant papillae in VKC

Shield ulcer in VKC

REDNESS
Infection
Diffuse conjunctivitis, corneal ulcer/ abrasion

Inflammation
Ciliary uveitis

Tumour

Trauma
Focal foreign body
SWELLING
Note location of swelling
Chalazion
Preseptal cellulitis
Viral conjunctivitis
Orbital cellulitis
Orbital cellulitis
Decreased vision
RAPD
Impaired ocular motility
Chemosis/ injection (not always)
Sick (not always)

Urgent referral & admission for IV

antibiotics, may need surgical drainage
Orbital cellulitis
RECAP..
1. Common ophthalmic problems in children**
Refractive error and amblyopia
Strabismus
Cloudy cornea

2. Leucocoria**
Retinoblastoma
Cataract
Coats disease
PHPV
ROP

3. Orbital cellulitis**
Thank you for your
attention.