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Pediatric Ophthalmology

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Paediatric Ocular Safety

Vision is arguably the most important of the five senses.
It plays a crucial role throughout childhood and beyond.

Vision : Infant’s perception

Vision contributes a great deal to an infant’s perception of the world.
Many parents naturally are concerned about their child’s vision.

Children's Eyes : Facts

Babies are born with an underdeveloped visual system.
Throughout the first year of life, the child's vision grows and develops with him.
As children grow and mature, over 80% of what they learn is processed through their eyes .
Good vision involves much more than just seeing clearly without glasses.

Blindness in Children : Challenge for Eye Care

Out of total blindness in the world, 5 percent is childhood blindness.
In India, prevalence of childhood blindness averages around 1.0 per 1000.
In India, 400,000 children are blind from conditions, which could have been either prevented or cured.
This is the challenge faced by everyone dealing with eye care for children.

Eye Defects

Major Causes of Blindness and Vision Problems

Strabismus (Squint or cross eyes)
Amblyopia ( Lazy Eye)
Ptosis (Drooping upper eyelid)
Refractive Errors
Retinopathy of Prematurity
Cataract
Congenital Glaucoma
Ocular Injuries

Strabismus

Exotropia Left Eye

Accommodative Esotropia

Cross Eyes/Squint	Eye defect in which one eye cannot focus with the other.
Strabismus	5% of the children suffer from squint. With early detection, accurate diagnosis and proper treatment, squint can be cured. Treatment before age 8-9 years. Before 6 years of age gives the best results.
Signs to watch out for	Child’s eyes do not appear straight. Child’s eyes wander from time to time during the first few months of birth Abnormal head tilting or turning when focusing on objects Squinting the eyes when trying to see normally Double vision Poor vision in one or both eyes

Amblyopia

Lazy Eye Amblyopia	Amblyopia is loss of normal vision in an eye that looks healthy. Caused by lesser use of that eye in early childhood as compared to the other eye.
Prevalence	Affects 1.6-3.6 % percent of children It is four times common in infants who are premature .
Signs to look out for	Child using one eye more often Tilting the head constantly An eye drifting when the child is tired, sick or in bright light Child tends to close one eye when in sunlight Rubbing the eyes Abnormally high blink rates Child examines objects by drawing them close to the eye
Recommended Eye Check up Schedule	By birth Between the age of 6 months to 1 year At about 3 years of age / before school admission at about 5 years of age

Ptosis

Drooping Of Upper Eye Lid	The muscle that raises the upper eyelid fails to develop properly in one or both eyes, in some children. This muscle weakness, which causes the upper eyelid to droop, is called ptosis
Signs to Look Out for	Abnormal eye movement, Muscular or nerve diseases, Extra growth observed in eyelid tumors Affected eye looking smaller than the normal healthy eye Irritation of the eye Difficulty in closing the eye completely Eye tiredness, strain due to keeping the eyes open Children tend to lift their head up and bend back or raise their eyebrow in order to see under the eyelid

Refractive Errors

Refractive errors are eye disorders in which the shape of the eye does not allow the proper bending of the light that enters the eye, resulting in blurred vision.
Refractive errors are seen in 20% of children.

Refractive Errors

Myopia ( Near Sightedness )
Hyperopia (Far Sightedness )
Astigmatism ( General Blurred Vision )

Myopia

Shortsightedness	Most common refractive error A child can see close objects, but has problems with seeing things far away. Can be corrected by using concave lens
Symptoms	Inability to read properly from the black board, but no problems during reading or writing from a book. Suffers from headache Squeeze their eyes while trying to see Nausea after reading, Holds books close to one's face, or Writing with one's head very close to the table.

Hyperopia

Long-sightedness	Children cannot see things close to them, but have no problem for distant object. As compared to myopia, hyperopia is uncommon in children. Can be corrected using convex lens
Symptoms	Difficulty in reading, writing and looking at nearby objects Eyestrain while trying to read for long hours May have squint (crossed eyes).

Fatigue

Common signs and Symptoms

Pain
Watery Eyes
Burning sensation in eyes
Children rub their eyes constantly
Blink frequently
Headache in the forehead region intensified in the evening
Recurrent swelling of eyelids

Correction

Corrective spectacle is the best option available. An eye check-up and change of glasses if necessary, has to be done once in 6 months for children under 5 years of age and once a year thereafter.
Children older than 15 years can use contact lenses if they don’t want spectacles.
Those over 18 to 20 years of age with stable power also have the option of LASIK, a laser refractive surgery apart from contact lenses.

Retinopathy of Prematurity

ROP

Retinopathy Of Prematurity is a disorder of retinal blood vessel development in the premature infant.
The severe form is characterized by retinal vascular proliferation, scarring, retinal detachment, and blindness.

Causes

Prematurity: It affects prematurely born babies.
All babies less than 1500 g birth weight or younger than 32 weeks' Gestational Age (GA) at birth are at risk of developing ROP.

Development: In premature babies

In premature infants, the normal growth of blood vessels stops.
The area without adequate blood supply emits a chemical trigger to stimulate growth of the abnormal vessels.
These vessels lead to a formation of scar tissue attached to both the retina and the vitreous gel.
As the scar contracts, it may pull on the retina creating a retinal detachment.

Symptoms

White pupils (Leukocoria)
Abnormal eye movements (Nystagmus)
Crossed eyes (Strabismus)
Severe nearsightedness (Myopia)

Diagnosis

The only way to diagnose that baby has ROP is an eye examination by an ophthalmologist at 4 weeks of age.

Cataract

Clouding of the lens (lens becoming opaque) leading to blurred vision or blindness is called Cataract.

Congenital Cataract

When a child suffers from cataract right from birth it is called congenital cataract

Cataract & Childhood Blindness

An estimated 200,000 children are blind from cataract in the world.
The childhood cataract prevalence is reported to be 1 to 15 per 10,000 children.
In India about 15 percent of children in schools for the blind have cataract.
In India 60,000 children are blind because of bilateral cataract.

Congenital Cataract : Major Causes

Major causes of bilateral cataract in India are:
- Rubella Infections
- Heredity
- Intrauterine infections,
- Metabolic disorders
- Genetically transmitted syndromes

Symptoms

White pupil upon flashlight examination
Misaligned eyes
Involuntary rhythmic movements of the eyes back and forth, up and down, around, or mixed (nystagmus)
Cloudy or blurred vision
Decreased vision
Lights appear too bright and/or present a glare or a surrounding halo

Glaucoma

Glaucoma is a condition in which the normal fluid pressure inside the eyes (Intraocular pressure, or IOP) slowly rises as a result of the fluid aqueous humor which normally flows in and out of the eye not being able to drain properly.

Congenital Glaucoma

Occurs in one out of 10,000 infants.
The younger the age at which the glaucoma appears, the more difficult to treat successfully.

Symptoms

Eye affected with glaucoma enlarge in size
Cornea swells up and becomes hazy
Clouding and whitening of cornea
Eye becomes painful and tearing
Excessive sensitivity to light, hence the baby tries to cover the eyes

A Simple way : To Check For Unusual Signs and Symptoms Which Indicate Abnormality

Check list of Common Symptoms

Teary red eyes
Drifting of the eyes
Frown or rub their eyes
Squint their eyes , squeeze their eyes to read
Trouble in reading the blackboard
Lack eye-hand co-ordination
Short attention span
Covering one of the eye while reading
Complain of double, blurred objects
Complain of Headache

Ocular Injuries

Leading cause of monocular visual problems & blindness in children.
Accounts for approximately 8-14% of total injuries in children.

Ocular trauma in children is mainly accidental and has an agespecific pattern

Causes

In the Indian context main causes are

Wooden stick injuries & iron rods
Pencils, Pens, scales
Broken glass bangles, & tea cup
Toys like tops , bat, ball , bows and arrows etc.
Sports
Sharp edged objects and furniture at home

Symptoms looks for

Visual loss
Bleeding on the surface or inside the eye
Cut or tear in eye lid
Swelling
Foreign body inside the eye

Sharp throbbing pain in the eye

First Aid

Remove dirt or an eyelash from the eye wash
The eye with clean running water for 5-10 mins
If you can see the object, Grab it with the tip of a tissue or hand kerchief to remove it.
If you can't see anything in the eye but the child complains of pain, wash the eye with cool water, which may flush out the object or bring it into view so that you can remove it.
If the eye & the skin around it are bruised (a black eye), cover the area with a wet towel or ice pack for ten minutes or longer.

Prevention always better than cure

Supervising or keeping a watchful eye on the child at home
Taking appropriate measures like avoiding sharp corners of decorative articles, show pieces, sharp edges of furniture when children are young.
Parents should be aware of hazardous nature of firecrackers , sharp objects , tools , chemicals with respect to eye & vision.

General Eye Examination: Recommendations

The American Academy of Ophthalmology (AAO) recommends the following schedule for eye examinations (for individuals with no special risk factors for vision problems or eye disease):

Age Schedule

Birth-2 yrs needs screening during regular Paediatric exams
3-5yrs needs screening every 1-2 years during regular exams
6-19yrs examinations as needed
20-29yrs One examinations per year
30-39 yrs Two examinations per year

Eye Examination for Children with Added Risk Factors

More frequent eye examinations for the following children

Infants born prematurely or with low birth weight.
Infants whose mother had rubella, sexually-transmitted disease (STD's) or HIV-related infection during pregnancy.
Family history of crossed eyes or eye disease.
Family history of high refractive error (i.e. nearsightedness, farsightedness or astigmatism).

Risk factors for school-aged children

Reading and/or learning difficulties.
Complains of headache or tired eyes.
Squinting
Needing glasses at an early age

"It is our responsibility as a parent to take the appropriate steps in maintaining the ocular health of our children"

It's Our Decision -Lets Choose Wisely!!!!

Congenital Nasolacrimal Duct Obstruction

What is Congenital Nasolacrimal Duct Obstruction?

The lacrimal glands produce trears constantly during the day to keep the eyes lubricated. The tears drain away from the eeyes through the lacrimal drainage system. Approximately 7% of infants are born with congenital obstruction of the tear drainage system in one or both eyes. This percentage is even higher in premature infants.

What is the anatomy?

The tear drain consists of two small openings called puncta. One in the upper eyelid and the other in the lower eyelid. Each of these openings leads into a small tube called the canaliculus which inturn empties into the lacrimal sac between the inside corner of the eye and nose. The lacrimal sac leads into a canal called the nasolacrimal duct that passes through the bony structures and empties tears into the nasal cavity

How does the tear drain work?

With each blink, the eyelids push tears evenly across the eyes to keep them moist and healthy. Blinking also pumps old ters into the puncta and lacrimal sac where they travel through the tear duct and drain into the nose. If the tear duct is blocked, tears back up and spill over the eyelids and run down the cheek. Tears trapped in the tear sac can become stagnant and infected

What are the symptoms of having a blocked tear duct?

The most common symptoms are excessive watering, mucous discharge, eye irritation and painful swelling in the inner corner of the eyelids. A skillful history and physical examination can usually pinpoint the cause of tearing.

Is congenital lacrimal obstruction serious?

It is important that children with excessive tearing be examined by an ophthalmologist to determine the cause of the problem. In some children excessive tearing may be due to causes other than tear duct obstruction.

What are the treatments?

Initial treatment involves massaging the area around the affected lacrimal sac to force the tears down the nasolacrimal duct and to push open the membrane causing the obstruction. The physician may also prescribe antibiotic or ointment.

If massage doesn’t relieve the obstruction probing may be necessary. Lacrimal probing is usually performed as an outpatient procedure, typically under general anesthesia. A fine metal probe is inserted thorough the punctum and passed down the duct through the obstruction. If the inferior turbinate is blocking the end of the nasolacrimal duct, it can be moved. In severe or recurrent cases, a soft rubber stent can be placed in the orifice. Antibiotic ointment or drops are prescribed after probing.

What are the risks and complications?

Minor bruising or swelling may be expected and will likely get away in one to two weeks. Occasionally , the scar tissue may block the drain again, which may require repeating the procedure. Bleeding and infection, which are potential risks with any surgery, are very uncommon. As with any procedure, there may be other inherent risks that should be discussed with your surgeon.

Is the surgery effective?

Most patients experience resolution of their tearing and discharge after probing is completed with little if any postoperative discomfort.

Who performs the surgery?

Patients are most commonly treated by Paediatric ophthalmologist under short General Anesthesia. Top