View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by KhartoumSpace UNIVERSITY OF KHARTOUM Graduate College Medical and Health Studies Board Common Eye Disorders in children attending Khartoum Eye Teaching Hospital By Maha Sirag Eldin Mustafa M.B.B.S (U of K) 1998 A thesis Submitted in partial fulfillment for the requirements of the Degree of Clinical MD in Paediatrics and Child Health Supervisor Prof. Salah Ahmed Ibrahim FRCPCH, MD Department of Paediatric & Child Health, Faculty of Medicine, U of K 2006 To: my parents, sisters and Brother. my husband my lovely daughter "Mai" Who lighten up my life I am indebted to Prof. Salah Ahamed Ibrahim for his keen interest, guidance and supervision throughout, the course of this study. My special gratitude to my co. supervisor Dr. Abdalla Elsiddig for his useful guidance and scientific direction. The help of Miss Hagir, the refracticnists, very much appreciated. I acknowledge very much the effort of Dr. Yaseen for his help on statistical analysis. I thank very much Miss Widad Abdel Magsood for her in typing this manuscript. I'm very grateful to the working group in ophthalmology clinic in Khartoum Eye Hospital, for their cooperation and assistance. Thanks to my husband, for his patience, understanding and continuous support. ABBREVIATIONS CO Corneal opacity CMV Cytomegalovirus ENT Ear Nose Throat O.R Ophthalmic artery O.V Ophthalmic vein WHO World Health Organization ABSTRACT This is a prospective hospital-based research aimed to study the clinical pattern of eye disorders in children, to identify the associated socio- demographic and medical factors for the common eye disorders, and to identify the causes of delayed or unnecessary referral. A total of 770 children (56.1% Males and 43.9% Females) aged one day to sixteen years, attending the out patient clinic of Khartoum Hospital for Eye Disease during the period from 1st June to 1st of December 2005, were studied. Apre-coded questionnaire was completed and physical examination with emphasis on eye findings was performed. The study showed that the predominant age group was 5-16 years, which represents 54.2% of the study population. The most common eye disorders observed in children were Conjunctivitis (36.7%), vernal catarrh (20%) and eye injuries (11.6%). Forty two percent of the eye disorders in children were contagious. It was found that; school age, low social class and poor housing conditions were significantly associated with contagious eye disorders. However, association of eye disorders with systemic illness was mostly observed in children with vernal catarrh and bronchial asthma. The mean age at presentation of congenital eye malformations (congenital cataract, congenital glaucoma and anophthalmous) was 2.5 years. It was found that, all cases of trachoma were active, i.e. preventable and treatable. The study showed lower prevalence of both refractive errors (5.9%) and squint (3.9%), compared to other community based studies. Vitamin A deficiency was reported in 3.9%, the majority of them had history of night blindness 60%; 30% had Bitot spots and 10% had corneal ulcer. This is an indicator to implement vitamin A supplementation program. Vernal catarrh was the commonest cause of patients' referral, representing 25.6%. Seventy two percent of appropriately referred patients were late referrals. Paternal unawareness was the most common (42.3%) cause of late referral. It is concluded that considerable number of eye disorders in children are contagious and readily preventable. Moreover, many cases of visual impairment could be eliminated by early diagnosis and treatment. The need for national program of visual screening at school entry and surveillances for early detection of childhood visual disorders should not be over looked. Further community based research is needed to evaluate the magnitude of vitamin A deficiency and squint. ﻤﺴﺘﺨﻠﺹ ﺍﻻﻁﺭﻭﺤﺔ ﺃﺠﺭﻴﺕ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺴﺔ ﺍﻟﻤﺴﺘﻘﺒﻠﻴﺔ ﻋﻠﻰ ﻤﺴﺘﻭﻯ ﺍﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﺒﻬﺩﻑ ﺩﺭﺍﺴﺔ ﺍﻟﻨﻤﻁ ﺍﻟﺴﺭﻴﺭﻯ ﻹﻤـﺭﺍﺽ ﺍﻟﻌﻴﻭﻥ ﻓﻰ ﺍﻷﻁﻔﺎل ﻓﻀﻼ ﻋﻥ ﺍﻟﺘﻌﺭﻑ ﻋﻠﻰ ﺍﻟﻌﻭﺍﻤل ﺍﻟﻁﺒﻴﺔ ﻭﺍﻻﺠﺘﻤﺎﻋﻴﺔ ﻭﺍﻟﺴـﻜﺎﻨﻴﺔ ﺍﻟﻤﺼـﺎﺤﺒﺔ ﻭﺭﺒﻤـﺎ ﺍﻟﻤﺅﻫﺒﺔ ﻹﻤﺭﺍﺽ ﺍﻟﻌﻴﻭﻥ ﻋﻨﺩ ﺍﻷﻁﻔﺎل ﺍﺠﺭﻴﺕ ﻫﺫﺓ ﺍﻟﺩﺭﺍﺴﺔ ﻓﻰ ﺍﻟﻌﻴـﺎﺩﺓ ﺍﻟﺨﺎﺭﺠﻴـﺔ ﺒﻤﺴﺘﺸـﻔﻰ ﺍﻟﻌﻴـﻭﻥ ﺒﺎﻟﺨﺭﻁﻭﻡ ﻓﻰ ﺍﻟﻔﺘﺭﺓ ﻤﺎﺒﻴﻥ ﺍﻷﻭل ﻤﻥ ﻴﻭﻨﻴﻭ ﻭﺍﻷﻭل ﻤﻥ ﺩﻴﺴﻤﺒﺭ ﻟﻌﺎﻡ 2005ﻡ. ﺍﻟﻌﺩﺩ ﺍﻟﻜﻠﻰ ﻟﻸﻁﻔﺎل ﺍﻟﺫﻴﻥ ﺸﻤﻠﺘﻬﻡ ﺍﻟﺩﺭﺍﺴﺔ 770ﻁﻔﻼ ﺤﻴﺙ ﺘﻡ ﺍﺨﺫ ﺍﻟﺘﺎﺭﻴﺦ ﺍﻟﻤﺭﻀـﻰ ﻟﻜـل ﻤـﻨﻬﻡ ﺒﻭﺍﺴﻁﺔ ﺍﺴﺘﺒﻴﺎﻥ ﺃﻋﺩ ﻟﻙ. ﻜﻤﺎ ﺨﻀﻊ ﺠﻤﻴﻊ ﺍﻟﻤﺭﻀﻰ ﻟﻔﺤﺹ ﺴﺭﻴﺭﻯ ﻋﺎﻡ ﻤﻊ ﺍﻟﺘﺭﻜﻴـﺯ ﻋﻠـﻰ ﺍﻟﻔﺤـﺹ ﺍﻟﺴﺭﻴﺭﻯ ﻟﻠﻌﻴﻭﻥ. ﺃﻅﻬﺭﺕ ﺍﻟﻨﺘﺎﺌﺞ ﺘﻔﻭﻗﺎ ﻋﺩﺩﻴﺎ ﻟﻸﻁﻔﺎل ﺍﻟﺫﻜﻭﺭ ﻋﻠﻰ ﺍﻹﻨﺎﺙ ﺒﻨﺴﺒﺔ ﺒﻠﻐﺕ 1:1.3 ﺒﻌﺩ ﺘﻘﺴﻴﻡ ﺍﻷﻁﻔﺎل ﺍﻟﻰ ﺃﺭﺒﻌﺔ ﻓﺌﺎﺕ ﻋﻤﺭﻴﺔ .ﻤﺜل ﺍﻷﻁﻔﺎل ﻓﻰ ﺴﻥ ﺍﻟﻤﺩﺭﺴﺔ ﺍﻟﻤﺠﻤﻭﻋﺔ ﺍﻷﻜﺒﺭ (54.2%) ﺒﻴﻨﻤﺎ ﻤﺜل ﺤﺩﻴﺜﻭ ﺍﻟـﻭﻻﺩﺓ ﺍﻟﻤﺠﻤﻭﻋﺔ ﺍﻷﺼﻐﺭ ( 1.3%) ﺘﻡ ﺘﺸﺨﻴﺹ 18ﻨﻤﻁﺎ ﻤﺨﺘﻠﻔﺎ ﻤﻥ ﺇﻤﺭﺍﺽ ﺍﻟﻌﻴﻭﻥ ﻋﻨﺩ ﺍﻷﻁﻔﺎل ﻗﻴﺩ ﺍﻟﺩﺭﺍﺴـﺔ ﺤﻴﺙ ﻜﺎﻥ ﺍﻟﺘﻬﺎﺏ ﺍﻟﻤﻠﺘﺤﻤﺔ ﺍﻟﺼﺩﻴﺩﻯ ﻫﻭ ﺍﻟﻤﺭﺽ ﺍﻻﻜﺜﺭ ﺸﻴﻭﻋﺎ ( 36.7%) ﻴﻠﻴﺔ ﺍﻟﻨﺯﻟﺔ ﺍﻟﺭﺒﻴﻌﻴـﺔ (%20) ﺜﻡ ﺇﺼﺎﺒﺎﺕ ﺍﻟﻌﻴﻥ (11.6%)، ﻭﺠﺩ ﺃﻥ 42% ﻤﻥ ﺇﻤﺭﺍﺽ ﺍﻟﻌﻴﻭﻥ ﻤﻌﺩﻴﺔ، ﺤﻴﺙ ﺃﻨﻬﺎ ﺍﻜﺜـﺭ ﺤـﺩﻭﺜﺎ ﻋﻨـﺩ ﺍﻻﻁﻔﺎل ﺍﻟﺫﻜﻭﺭ، ﺨﺎﺼﺔ ﻓﻰ ﺴﻥ ﺍﻟﻤﺩﺭﺴﺔ، ﺍﻷﻁﻔﺎل ﻤﻥ ﺍﻟﻁﺒﻘﺔ ﻤﻨﺨﻔﻀﺔ ﺍﻟﺩﺨل، ﻭﺍﻻﻁﻔﺎل ﺫﻭﻯ ﻅـﺭﻭﻑ ﺍﻟﺴﻜﻥ ﺍﻟﺴﻴﺌﺔ. ﺃﻤﺎ ﺒﻨﺴﺒﺔ ﻟﻠﻌﻭﺍﻤل ﺍﻟﻁﺒﻴﺔ ﻓﻘﺩ ﻭﺠﺩ ﺃﻥ ﻫﻨﺎﻟﻙ ﺍﺭﺘﺒﺎﻁ ﻫﺎﻡ ﺒﻴﻥ ﺍﻟﺭﻤﺩ ﺍﻟﺭﺒﻴﻌﻰ ﻭﻤﺭﺽ ﺍﻟﺭﺒﻭ ﺍﻟﺸﻌﺒﻲ. ﻭﺠﺩ ﺃﻥ ﻤﺘﻭﺴﻁ ﺃﻋﻤﺎﺭ ﺍﻷﻁﻔﺎل ﺫﻭﻯ ﺍﻟﻌﻴﻭﺏ ﺍﻟﺨﻠﻘﻴﺔ ﻟﻠﻌﻴﻥ (ﺍﻟﺴﺎﺩ ﺍﻟﺨﻠﻘﻲ، ﺍﻟﺯﺭﻕ ﺍﻟﺨﻠﻘﻲ ﻭﺍﻟـﻼ ﻋﻴﻨﻴﺔ) ﻴﺴﺎﻭﻯ 2.5 ﺴﻨﺔ. ﻜﻤﺎ ﺃﻥ ﻜل ﺤﺎﻻﺕ ﺍﻟﺘﺭﺍﻜﻭﻤﺎ ﻤﻥ ﺍﻟﻨﻭﻉ ﺍﻟﻨﺸﻁﺔ ﻭﺒﺎﻟﺘﺎﻟﻲ ﻤﻤﻜﻨﺔ ﺍﻟﻭﻗﺎﻴﺔ ﻭﺍﻟﻌﻼﺝ. ﻤﺜﻠﺕ ﺍﻷﺨﻁﺎﺀ ﺍﻹﻨﻜﺴﺎﺭﻴﺔ ﻭﺍﻟﺤﻭل ﻨﺴﺒﺔ ﻗﻠﻴﻠﺔ ﻤﻘﺎﺭﻨﺔ ﺒﺎﻟﺩﺭﺍﺴﺔ ﻋﻠﻰ ﻤﺴﺘﻭﻯ ﺍﻟﻤﺠﺘﻤﻊ. ﻜﻤـﺎ ﻤﺜـل ﻨﻘﺹ ﻓﻴﺘﺎﻤﻴﻥ (ﺃ) ﻨﺴﺒﺔ 3.9%، ﻤﻌﻅﻤﻬﻡ ﻴﻌﺎﻨﻭﻥ ﻤﻥ ﺍﻟﻌﻤﻰ ﺍﻟﻠﻴﻠﻲ ﺒﻨﺴـﺒﺔ 60%. ﻜﻤـﺎ ﻭﺠـﺩ ﺃﻥ ﺍﻟﻨﺯﻟـﺔ ﺍﻟﺭﺒﻴﻌﻴﺔ ﺘﻌﺘﺒﺭ ﻤﻥ ﺃﻫﻡ ﺃﺴﺒﺎﺏ ﺍﻟﺘﺤﻭﻴل ﺇﻟﻰ ﻤﺴﺘﺸﻔﻰ ﺍﻟﻌﻴﻭﻥ ﻭﻗﺩ ﻤﺜﻠﺕ 25.6%، ﻤﻌﻅﻡ ﺍﻟﺘﺤﻭﻴﻼ ﻤﺘـﺄﺨﺭﺓ (72%). ﻭﺠﺩ ﺃﻥ ﻋﺩﻡ ﺍﻟﻭﻋﻰ ﺍﻟﺼﺤﻲ ﻟﺩﻯ ﺍﻟﻭﺍﻟﺩﻴﻥ ﻴﺸﻜل ﺴﺒﺏ ﺭﺌﻴﺴﻰ ﻟﻠﺘﺤﻭﻴﻼﺕ ﺍﻟﻤﺘﺎﺨﺭﺓ. ﺨﻠﺼﺕ ﺍﻟﺩﺭﺍﺴﺔ ﺍﻟﻰ ﺍﻥ ﻋﺩﺩﺍ ﻤﻌﺘﺒﺭﺍ ﻤﻥ ﺃﻤﺭﺍﺽ ﺍﻟﻌﻴﻭﻥ ﻋﻨﺩ ﺍﻷﻁﻔﺎل ﻫﻰ ﺃﻤﺭﺍﺽ ﻤﻌﺩﻴﺔ ﻭﺒﺎﻟﺘﺎﻟﻰ ﻤﻤﻜﻨﺔ ﺍﻟﻭﻗﺎﻴﺔ. ﺒﺎﻹﻀﺎﻓﺔ ﺇﻟﻰ ﺃﻥ ﻤﻌﻅﻡ ﺤﺎﻻﺕ ﻀﻌﻑ ﺍﻟﻨﻅﺭ ﻴﻤﻜﻥ ﺍﻟﻘﻀﺎﺀ ﻋﻠﻴﻬـﺎ ﺒﺎﻟﺘﺸـﺨﻴﺹ ﺍﻟﻤﺒﻜـﺭ ﻭﺍﻟﻌﻼﺝ. ﻫﻨﺎﻙ ﺤﻭﺠﺔ ﻤﺎﺴﺔ ﻹﺠﺭﺍﺀ ﻤﺴﺢ ﻁﺒﻲ ﺸﺎﻤل ﻷﻤﺭﺍﺽ ﺍﻟﻌﻴﻭﻥ ﻟﺩﻯ ﺍﻷﻁﻔﺎل ﻭﻟﻜﻥ ﻟﺘﺤﺩﻴـﺩ ﻨﺴـﺒﺔ ﺍﻨﺘﺸﺎﺭ ﻫﺫﺓ ﺍﻷﻤﺭﺍﺽ ﺒﺼﻭﺭﺓ ﺃﻜﺜﺭ ﺩﻗﺔ ﻴﺠﺏ ﺃﺠﺭﺍﺀ ﺩﺭﺍﺴﺔ ﻋﻠﻰ ﻤﺴﺘﻭﻯ ﺍﻟﻤﺠﺘﻤﻊ. LIST OF TABLES Page No. Table 1: Age and sex distribution of the study group 72 Table 2: Mother's education and their awareness of aggravating factor 81 Table 3: Father's occupation among the study group 82 Table 4: Relation between family history of similar condition and consagous marriage 84 Table 5: Relation between diagnosis and presence of 86 known systemic illness Table 6: Frequency of eye disorders among the study group 90 Table 7: Distribution of eye disorders according to sex 95 Table 8: Distribution of eye disorders among different age group 97 Table 9: Distribution of eye disorders among different tribes 99 Table 10: Distribution of eye disorders according to Socioeconomic status 102 Table 11: Frequency of eye disorders in different housing condition 104 Table 12: Classification of the referred patients in the study group 109 Table 13: Causes of the late referral among the study 110 group LIST OF FIGURES Page No. Fig. 1: Age and sex distribution 73 Fig. 2: Distribution of the study group according to the social class 74 Fig. 3: Distribution of the study group by residence 76 Fig. 4: Distribution of the study group according to the tribe 77 Fig. 5: Distribution of the study group according to fathers' 78 education Fig. 6: Distribution of the study group according to the mothers' education 80 Fig. 7: Types of refractive errors seen among the study group 91 Fig. 8: Types of squint observed among the study group 93 Fig. 9: Stages of vitamin A deficiency among the study group 94 Fig. 10: Percentage of referred children 106 Fig. 11: Distribution of referred children according to the diagnosis 107 LIST OF CONTENTS Page Dedication I Acknowledgment II Abbreviations III English Abstract IV Arabic Abstract VI List of tables VIII List of figure IX CHAPTER ONE 1 1. Introduction and Literature Review 1 1.1. Background 1 1.2. Anatomy of the Eye 1 1.2.1. Development of the eye 2 1.2.2. Vascular supply and lymphatic drainage 3 1.2.3. Basic eye structure 8 1.3. Infectious and Inflammatory Eye Disorders 8 1.3.1. Conjunctivitis 11 1.3.1.1. Neonatal conjunctivitis (Ophthalmia neonatorum) 12 1.3.1.2. Other bacterial infections in infants and older children 13 1.3.1.3. Allergic conjunctivitis 13 1.3.1.4. Vernal conjunctivitis (vernal catarrh) 15 1.3.1.5. Chemical conjunctivitis 15 1.3.1.6. Viral conjunctivitis 15 1.3.2. Trachoma 18 1.3.3. Infections and Inflammations of The Lids 19 1.3.4. Orbital infections 20 1.3.5 Infection and inflammation of the Iris 49 1.4.1. Pre-septal cellulites 21 1.3.6 Infections and the retina 22 1.4. Eye movements disorders 30 1.5. Nystagmus 31 1.6. Childhood glaucoma 34 1.7. Cataract 37 1.8. Retinopathy of prematurity 39 1.9. Ocular Trauma 40 1.10. Optic nerve disorders 44 1.11. Ocular tumours 45 1.12. Acquired visual loss 46 1.13. Vitamin-A deficiency 47 1.14. Refractive errors 49 1.15 Vision screening 50 1.16. Global experience 60 1.17 Experience in Sudan Justifications 62 Objectives 63 Chapter Two 2- Patients and Methods 2.1 Study design 64 2.2 Study area 64 2.3 Duration of the Study 64 2.4 Study population 64 2.5 Sample size 65 2.6 Research Technique 66 2.7 Data analysis 69 2.8 Funds 70 2.9 Obstacles 70 CHAPTER THREE 3- RESULTS 3.1. Age and sex characteristic of the study population 71 3.2. Description of the social status of the study group 71 3.3. Distribution of the children according to their residence 75 3.4. Distribution of the children according to their tribes 75 3.5. Parental level of education 75 3.6.