Common Pediatric Ophthalmology Problems Janine E. Collinge, MD • I have no conflicts to disclose Objectives

• To understand mechanisms and screening strategies for and

• To employ appropriate first-line treatment for red eyes, ocular trauma, and adnexal disorders in children

• To explain to current concepts in ROP and normal vision milestones Common Disorders

• Nasolacrimal duct obstruction

•

• Trauma

• Strabismus

• Amblyopia

• disorders

• of prematurity

• Vision Screening Eye Exam

• Common tools available in the office for eye exam.

• Direct ophthalmoscope • Penlight • Eye chart • Toys • Eye patches or occluder Case 1

• 6 mo with chronic, bilateral tearing and discharge since birth. No injection or swelling of the eye itself, occasional eyelid erythema. Nasolacrimal Duct Obstruction

• 3-5% of full-term newborns

• Manifest in first 1-2 months

• Unilateral or bilateral

• Chronic tearing

• Mucoid/mucopurulent discharge

• Crusting of Anatomy NLDO Evaluation NLDO Treatment

• Nonsurgical

• NLD massage

• Topical medication:

• Antibiotic

• antibiotic/corticosteroid combination

• 95% resolve with conservative management by age 1 year. Surgical NLDO Treatment

• NLD probing and irrigation

• NLD probing with silicone tube intubation

• Lacricath balloon catheter

• DCR (dacryocytorhinostomy)

• Timing: usually deferred until age 12 mo NLD Probing Complicated NLDO

•

• Dacryocystocele

• * management may be more complex: oral antibiotics, hospitalization, urgent probing Mimickers of NLDO

• Childhood

• Conjunctivitis

• **Refer Case 2

• 12 yo with 4 day history of redness involving both eyes. Associated watery discharge with foreign body sensation. Conjunctivitis

• Allergic

• Viral

• Bacterial

• Neonatal

• Watery discharge, itching, bilateral

• Association with systemic allergy symptoms

• Treatment: • Topical • Antihistamines • MC stabilizers • Steroids if severe • Oral drugs little effect Viral Conjunctivitis

• Diagnosis: • Viral culture

• Adenovirus • Treatment: • Supportive

• HSV-1 • Treatment: • Oral acyclovir • Topical ganciclovir • Bacterial prophylaxis • REFER

• NO STEROIDS Bacterial Conjunctivitis

• Diagnosis: • Conjunctival culture • Gram stain

• Common bugs: • Staph • Strep • H flu

• Treatment: • Sulfa • Polytrim • Fluoroquinolones • (but consider resistance)

Neonatal Conjunctivitis

• Chemical • Rare now that AgNO3 not used.

• N. • Severe, hyperpurulent • 1-3 days post partum (up to 1 week) • Need IV rx to prevent meningitis

• Chlamydia • Most common, less purulent • 3-5 days (up to two weeks) • Topical and PO to prevent pneumonia.

• Gram stain and Culture discharge early! • *** consider GC/Chlamydia in at risk populations. N. Gonorrhea Conjunctivitis Chlamydia Conjunctivitis Case 3

• 12 yo hit in left eye with baseball yesterday. C/O blurry vision and headache. Trauma

• One of most common causes of vision loss in childhood.

• Baseball, fireworks, fishing, foreign objects, cigarettes, etc. Trauma Trauma

• Tape shield over eye.

• Prompt referral to ER/ophthalmologist Shaken Baby Syndrome Abusive Head Trauma

• Ocular, intracranial, and musculoskeletal injuries that result from severe shaking.

• Strongly suspected when extensive retinal hemorrhage is found in association with brain injury.

• Eye findings are all internal, and external exam almost always normal.

• *****Severe accidental head trauma and CPR rarely associated with retinal hemorrhage, and not extensive. Retinal Hemorrhages: Abusive Head Trauma Case 4

• 9 mo with eyes crossing inward. Parents have noticed crossing since birth and there has not been any improvement. Infantile (congenital) • Most common

• Onset before 6 months of age

• Moderate to large deviation

• Low hyperopia (don’t need glasses) Infantile Esotropia

• Glasses do not correct alignment

• Treatment is surgical

• May need patching or other treatment for amblyopia Pseudoesotropia

• Broad, flat nasal bridge causing appearance of esotropia, but without deviation. Case 5

• 3 yo with intermittent inward deviation of eyes several times a day. Seems worse at near than distance. Accommodative Esotropia

• Onset 2-4 years of age

• Due to significant hyperopia ( causes convergence)

• Moderate deviation

• Often amblyopia Accommodative Esotropia

• Treatment: • Full correction of hyperopia with glasses or contacts • Amblyopia treatment

• Surgery: • Only if glasses do not fully correct deviation

• Increases in frequency with increasing age

• Can be seen in young children

• More associated with CNS abnormalities

• Treatment: • Can involve glasses • Can involve patching • Often surgical

• Congenital 4th nerve palsy

• Brown’s Syndrome Case 6

• 4 yo with decreased vision in one eye on routine vision screening/office exam. Child has no complaints and parents never notice a problem with eyes. Amblyopia (Lazy Eye)

• Decreased vision in one or both eyes that cannot be improved with proper optical correction due to a failure of normal binocular development Amblyopia (Lazy Eye)

• Children are susceptible from birth to visual maturity • Treatment can be successful until at least age 13 (17 in some cases)

• Present in 2-4% of population

• Commonest cause of visual loss from 0-50 years of age Amblyopia Forms

• Refractive • Large uncorrected errors in one or both eyes

• Strabismus • One eye suppressed by brain to avoid

• Visual Deprivation/Occlusive • , , scar Refractive Amblyopia

• Hyperopia (farsighted) • (nearsighted) • (Ametropia) Anisometropic Amblyopia

• Significant difference in (hyperopia/myopia/) between the eyes.

• Results in blurred image in one eye which impairs visual development. Strabismic Amblyopia Occlusive Amblyopia

• Impairment of visual axis

• Ptosis • Capillary hemangioma • Media opacity: cataract, corneal scar, hemorrhage • Occlusion Amblyopia Treatment

• Clear the visual axis • Often requires surgery

• Correct refractive errors • Glasses, contacts

• Stimulate use of amblyopic eye • Patching– of the better seeing eye • Topical – of the better seeing eye

• ** must occur during early period of visual plasticity Amblyopia Case 7

• 1 yo with unilateral droopy eyelid noted since birth. Parents deny ocular misalignment, / abnormalities, or variability throughout the day. Ptosis

• Congenital

• Horner’s Syndrome

• Cranial Nerve III palsy

• Marcus-Gunn jaw wink

• Myasthenia gravis Congenital Ptosis

• Developmental dystrophy of levator muscle.

• May be associated with , strabismus, and amblyopia.

• Complete eye exam. Ptosis Surgery

Surgical correction Case 8 • 6 yo with new onset of “bump” on right upper eyelid, just above the lash line. Has increased in size over last 1-2 weeks with mild overlying erythema. Eye is not red and is without discharge.

• Chronic inflammatory granuloma of a meibomian gland.

• Caused by retention of secretory material due to obstruction of duct. Chalazion Treatment

• Non-surgical • Warm compresses 4 times per day for 2-3 weeks • (+/- topical antibiotic/steroid)

• Surgical • If no resolution • Incision and drainage • Intralesional steroid injection

• Most improve with conservative management Case 9

• 34 week premature born at 29 weeks gestation weighing 1,000 grams at birth receiving routine eye exams since 32 weeks of age. What is Retinopathy of Prematurity?

• Retinal development is incomplete

• Imbalance of growth factors can cause abnormal development of blood vessels

Retinal ROP ROP ROP Treatments

• Cryotherapy

• Laser

• Anti-VEGF injection

• Investigational studies

• Vitrectomy +/- repair ROP Screening Protocol

• All birth weight <1,500 g.

• All infants born gestation age < 31 weeks.

• All infants 1,501 - 2,000 g with unstable course or oxygen supplementation.

• First exam 30 to 32 weeks gestational age.

• Subsequent exams at 3-14 day intervals, dictated by disease staging and severity. ROP

• Occurs in 60% of infants <1,250 g, of these, 12% will require treatment (1,300/yr).

• 500-600 new cases of blindness annually in US due to complications of ROP.

• Risk factors: low birth weight (<1 Kg), <28 wks, oxygen, IVH, multiple transfusions, and multiple gestation .

• Associated: high myopia, strabismus, amblyopia, , retinal detachment, and cataract. Case 10

• 4 yo healthy child presenting for routine well child check. Parents deny any visual issues. Childs visual acuity measures 20/60 in each eye by LEA symbols.

Pediatric Investigator Group (PEDIG) • NIH funded

• Multi-center studies, coordinated by Jaeb center

• Focus on common pediatric eye diseases (amblyopia, strabismus, NLDO)

• Dean McGee Eye Institute is the only PEDIG site in Oklahoma THANK YOU!

FOR YOUR ATTENTION

Any questions?