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Ped Ophtho for The Common Pediatric Ophthalmology Problems Janine E. Collinge, MD • I have no conflicts to disclose Objectives • To understand mechanisms and screening strategies for amblyopia and strabismus • 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 • Conjunctivitis • Trauma • Strabismus • Amblyopia • Eyelid disorders • Retinopathy 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 eyelashes 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 • Dacryocystitis • Dacryocystocele • * management may be more complex: oral antibiotics, hospitalization, urgent probing Mimickers of NLDO • Childhood Glaucoma • 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 Allergic Conjunctivitis • 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. gonorrhea • 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 erythromycin 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) Esotropia • 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 (accommodation 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 Exotropia • 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 Hypertropia • 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 diplopia • Visual Deprivation/Occlusive • Cataract, ptosis, cornea scar Refractive Amblyopia • Hyperopia (farsighted) • Myopia (nearsighted) • (Ametropia) Anisometropic Amblyopia • Significant difference in refractive error (hyperopia/myopia/astigmatism) 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 atropine – 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, pupil/ iris 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 anisometropia, 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. Chalazion • 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 infant 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 +/- retinal detachment repair ROP Screening Protocol • All infants 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 pregnancies. • Associated: high myopia, strabismus, amblyopia, nystagmus, 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 Eye Disease 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?.
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