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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 : Infantís perception

Vision contributes a great deal to an infantís perception of the world.

Many parents naturally are concerned about their childís 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

 Exotropia Left Eye

Esotropia Left Eye

Esotropia 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
  • Childís eyes do not appear straight.

  • Childís 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
  • Before the child is 3 months old

  • Between the ages of 6 months and 1 year

  • At about 3 years of age

  • 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,

  • Musculer 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).

Astigmatism   
Blurred Vision
  • Astigmatism usually occurs when the front surface of the eye, the cornea, has an irregular curvature .

  • Astigmatism in children is very common.

  • About 3% of schoolage children have significant amount of astigmatism.

  • 2 % of preschoolers experience astigmatism

Symptoms
  • Blurred vision

  • Difficulty reading or seeing up close

  • Crossing of the eyes in children

  • Headache

  • Eye Strain

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 donít 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

Congenital glaucoma refers to glaucoma which can be either present at birth or appear any time during the first three or four years of life.

  • 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

Look 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 doesnít 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.

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