23. paediatric ocular pathology- external eye Flashcards
what does the external eye consist of?
eyelids , conjunctiva, cornea, orbit ( a bit)
what is the normal corneal diameter of a child (0-16)?
around 12mm
what condition is presented in this image?
RE opthalmos
What should you do differently when testing a child?
Working with Children
• Attitude
— The child and family at the centre
— involve them
• Talk to the child and parents
— Sense - don’ t ignore the child
— Don’ t shout!
• Don’ t touch
• Be on the same level
Tip: Leave ophthalmoscopy till end, get parent to touch their forehead and touch the parent instead of child
—>Babies have an innate preference to look at patterns, such as a face
This is the basis of vision testing in infancy
& why parents are such good historians
What eye screening is done to babies?
• Inspected at birth for anomalies, specifically cataract
• Screening for retinopathy of prematurity ( eye disease that can happen in babies born early/ born <3pounds at birth = abnormal blood vessels to grow in the retina & can lead to blindness.)
• 6-8 week eye check ( by paed/health visitor)
• Children with major disabilities require full ophthalmic assessment
• Vision check by orthoptist 4.5 to 5 years
• Continue, if in place, vision & colour screening @ 11-14 years
In neonatal (newborn) eye exams, what are we looking for ?
• Redness
• Size & Symmetry
— Globes
— Corneae
— Pupils (check all normal sizes)
. Clarity
— Corneae
— Lens
• Family queries (check family hx)
What is a Coloboma/ how is it caused ?
Coloboma (of the iris, ciliary body, choroid, retina and/or optic nerve) derive from failed or incomplete closure of the embryonic fissure (around 4-5 wks gestation ) during development.
What is a ptosis?
— Drooping of eyelid ,
usually upper ( can be either )
What is the epicanthus?
— Vertical fold of skin over inner canthus
What is a telecanthus ?
— Increased distance between inner canthi
What is hypertelorism ?
Increased inner & outer canthal distances - ie
orbits set wider apart
What are the classifications of a ptosis?
• Congenital
— Isolated -ptosis on its own - no other symptoms
— As part of a syndrome -eye lid has sympathetic, 3rd and 5th nerve supplying it
(Always think is it purely an eye problem or a systemic condition ?)
• Neurogenic
— Illrd nerve palsy
— Horner’s
— Marcus Gunn
• Myogenic (muscles )
— Myasthenia - Gravis - common in elder pxs
— Progressive external ophthalmoplegia
-> Eyelid muscles + EOMs involved
• Mechanical
— Lump e.g. - meibomian cyst or tumour
what are the consequences of ptosis?
· Vision
· Refractive status
-Can induce astigmatism & thus:
· Amblyopia
· Compensatory head posture
· Cosmesis - surgery better at age 4-5 years of age - however some parents may not wait as long
- amblyopic ptosis (complete ptosis that obscures sight) = surgical treatment a few days after birth
what is congenital ptosis?
caused by:
- Dystrophy/dysgenesis of levator palpebrae superioris
· Features:
- 1 or 2 eye lids
- Absence skin crease
- Lid lag on downgaze
- Superior rectus weakness (elevation)
- Normal eyelids - note creases
- Note absence of eyelid crease - feature of congenital ptosis & due to abnormal insertion of levator tendon
what is marcus gunn ptosis?
-neurogenic
· Also known as jaw winking
- When baby drinks from bottle/eats something, eyelid shoots up
· Elicit by asking the patient, usually a child to chew something
· Due to abnormal connections between levator and Lateral pterygoid muscle i.e 3rd and 5th cranial nerves
· The condition is an abnormality of 3rd and 5th cranial nerves
what is Horners syndrome?
Ptosis
- Less than 2 mm - very mild
· Heterochromia if present at birth/congenital
- Congenital only - usually develops 1-2 years after birth
· Enophthalmos (sunken eye)
- Very subtle
· Anhidrosis
- Unable to sweat normally on affected side
· miosis - constricted pupil
· Lower IOP on affected eye - subtle
Image: what is Horners syndrome?
What are the neurogenic causes of ptosis ?
ptosis due to 3rd oculomotor palsy
· Ptosis (complete) due to 3rd nerve palsy
- Pupil fibres - superficial sensitive to compression
- Unilateral ptosis
· If px has a unilateral complete ptosis with eye movement abnormality - the lesion is either in nucleus or orbit
What is aberrant regeneration of 3rd nerve palsy ?
aberrant regeneration of 3rd nerve palsy
· Aberrant regeneration of 3rd nerve following trauma
· Branches of 3rd nerve are misdirected (aberrant regeneration)
· Right 3rd nerve palsy - when px tries to look up, the affected RE moves out and down
o When px looks down RE moves out and up as well
What is the management of ptosis ?
· Refer for medical opinion:
- If there is a possibility of a medical condition/syndrome
- If unsure ask other people/refer
· May need to correct:
- Refractive error which may cause Amblyopia
- Compensatory head posture - If marked
- Cosmetic - best left until child is 4-5 years old
· Surgery & ptosis props (not children):
- Urgency according to impact on child
-> If obscuring vision requires correction immediately ( because will cause ambly quickly)
-> Otherwise around 4-5 years achieve better results
Name the types of eyelid lumps
INFLAMMATORY=
-Meibomian cyst
- Hordeolum
- Molluscum contagiosum
· Stasis (fluid in meibomian ducts)
· Tumour
- Benign e.g neurofibroma
- Malignant
· Hamartoma - developmental abnormalities
· Hemangioma-> Treated with propanolol
what is Sturge Weber’s syndrome?
-follows the nerve that does not cross the midline
-‘port wine stain birthmark, present at birth, rare neurological disorder’
what is capillary haemangioma?
- difficult to treat
- tend to resolve around 5-7 yrs
- effective treatment = propranolol
what is a chalazion (meibomian cyst) & how is it treated?
-blockage of the meibomian gland duct, with retention of secretion
( doesnt involve lid lashes like a stye and point of cyst = midway of the tarsus & NOT on lid margin)
treatment:
· Tend to resolve over weeks or many months
· Use warm compresses
· (sometimes forms abcess /nodule is large and gets removed) –>Incise and curette - but requires general anaesthetic in the child
-antibiotics not useful- unless acute (severe) stage
what is a hordeolum (stye) & treatment?
-an infection of the meibomian gland (internal)
-infection of eyelash follicle and corresponding glands of zeis & moll (external)
treatment:
-warm compress
-topical antibiotics
what is molluscum contagiosum/ treatment?
-type of wart that can occur anywhere on body
-a viral infection of the skin that occurs commonly in children.
-benign
-can cause secondary follicular conjunctivitis
treatment:
-usually self limiting
-best left alone or curetted ( scraped off)
what is a dermoid cyst?
Dermoid cyst - may be associated with coloboma in Goldenhar’s syndrome
limbal dermoid cyst (image)- congenital benign tumour.
goes into ant chamber sometimes
what causes epiphora in infancy & features?
Watery eye in babies = extremely common
· due to blocked nasolacrimal systems
-epiphora
-stickiness
-NO redness- important distinction
what is the treatment for epiphora in infancy?
o Most resolve spontaneously by 12 months
o No antibiotics unless extra infection involved
o Massage of lacrimal sac (can sometime see bulge there)
o If does not resolve consider syringe & put probe in under general anasthetics
what is ophthalmia neonatorum and its cause?
· a type of conjunctivitis present within 4 weeks after birth
· causes:
- baby passing through birth canal - if mum has chlamydia then baby will pick up chlamydia trachomatis when passing through
- can also be caused by mother having gonorrhea (causes Neisseria gonorrhea)
what are the types of pathogens involved in ophthalmia neonatorum (conjunctival inflammation).
· Chlamydia trachomatis -STD, chlamydial conjunctivitis (bacterial)
· Neisseria gonorrhea -gonococcal conjunctivitis (bacterial)
· Herpes simplex- viral conjunctivitis
describe chlamydia trachomatis’s effect on neonates:
o occurs 7-28 days post birth - peak in week 2
o Unilateral or bilateral
o Pseudomembranous (also strep)–> Looks as if a membrane lining conjunctiva
describe Neisseria gonorrhoea effect on neonates:
o tends to occur 4-7 days after birth
o Massive-bloodstained conjunctivitis
o Corneal penetration - blindness
- only gonorrhoea and streptococcus can penetrate an intact cornea + cause blindness (normally a v good barrier to infection)
o green pus can be squeezed out underneath eyelid - needs to be treated very seriously
describe herpes simplex effect on neonates:
As part of a generalised infection
o Bilateral
o No dendritic ulcer like in teen/adult but generalized infections
o More serious as can infect brain
describe the symptoms and aetiology of childhood conjunctivitis?
- Bilateral, although one eye commences first (will show up by 24/48hrs as bilateral)
- Conjunctival redness & discharge
- Itchiness
- no severe pain
- Vision unaffected (if affected-is something else)
· Aetiology
Infection:
- Bacterial or Viral (often involves cornea also)
- Allergic (e.g. vernal)
- Trauma
· Treatment
- Depends on cause
what are some differential diagnosis’s with red eyes in infancy?
- Blocked nasolacrimal ducts do not cause red eyes
— Most resolve by 12 months - Conjunctivitis is bilateral
- When these rules are not obeyed, consider the
alternatives :
–>Infantile glaucoma
–>Tumour of eyelid
Don ‘t be too casual - can be caught out
what are some infantile glaucoma characteristics?
-If eyes/cornea larger than adult = buphthalmos = a risk factor
- Hazy cornea = also Risk f, for glaucoma
(The cornea size in a neonate -reaches adult size ,3 months after birth)
Phlyctenular Conjunctivitis characteristics?
· Occurs 5-6 years
· Few symptoms
· Blepharoconjunctivitis symptoms
· Most with staphylococcal lid disease.
· No direct agent - by some form of immunological mechanism
image: nodular inflammation of the cornea or conjunctiva & Small, yellow-gray, raised bumps form on the eye
what is vernal disease? /characteristics/treatment
Occurs in children with hx of atopy- e.g. asthma or eczema, hay fever .
-more boys> girls
–>cobblestone appearance - papillae (compared to red but smooth appearance of bacterial conjunctivitis as seen previously)
treatment: lodoxamide
describe childhood herpes simplex
· Occurs in young children
· Presents bilaterally
· Affecting skin
· Causing dendritic ulcer in older children
· Dendritic ulcers are rather uncommon in children
what are limbal dermoids? (hamartoma)
Abnormal overgrowths of abnormally located tissue Including, skin, hair, sebaceous glands etc
· Tissue destined for skin but never reached its destination!
· Limbal dermoids - can shave off surface to make it smooth but can’t remove entire cyst as grow as far back into AC
· increase in size with age
· not malignant
· dermoid = tissue in wrong location
