Child Ophthalmology

Question 0

Signs of neonatal conjunctivitis

Answer 0

Injected hyperaemic conjunctiva
Lid swelling
Discharge and occasionally corneal ulceration
May be unilateral or bilateral

Question 1

Neonatal conjunctivitis

Answer 1

‘Ophthalmia neonatorum’ is common infection of the eyes in babies under 4 and may be acquired from the mother, environment or staff
Can be chlamydial, gonorrhoeal or staphlococcal
Differential is nasolacrimal duct blockage

Question 2

Treatment of neonatal conjunctivitis

Answer 2

If no Hx of maternal vaginal infection then treat with lid hygiene and topical broad range antibiotic (chloramphenicol for a week QDS)
Swab for microbiology
Refer if history of maternal infection

Question 3

Chlamydial neonatal conjunctivitis

Answer 3

Likely to present 5-12 days after birth

Creamy white discharge

Question 4

Gonorrhoeal neonatal conjunctivitis

Answer 4

Typically presents 2-5 days after birth

Rapidly progressive and may led to corneal ulceration

Question 5

Staphylococcal neonatal conjunctivitis

Answer 5

Infection producing yellow discharge

Question 6

Non-accidental injury (NAI)

Answer 6

Abuse
Most common in children under 2 years old
Ranges from deliberate abuse to neglect
Likely to have systemic signs
‘Shaken baby syndrome’ is one of the commonest

Question 7

History in NAI

Answer 7

Child may be fearful, anxious or aggressive
No history, vague or inconsistent
May change through the consultation or differ between the child and the parent
There may be a delay in seeking medical help

Question 8

Common signs on NAI

Answer 8

Head injuries or fractures
Bruises on face or body
Subdural or subarachnoid haemorrhages

Question 9

Shaken baby syndrome

Answer 9

Most common form of NAI with ocular and intracranial symptoms
Caused by violent shaking, with a triad of - Encephalopathy, Subdural & Retinal haemorrhage (most common sign)
Blindness occurs in 15% of survivors due to occipital lobe damage rather than ocular trauma

Question 10

Retinal haemorrhage in NAI

Answer 10

Most common presenting symptom
Can be unilateral or bilateral
Usually at the posterior pole but can extend to the retinal periphery
A variety of ocular presentation are possible

Question 11

Management in cases of suspected NAI

Answer 11

Ensure all symptoms and histories are recorded for later legal use
Refer to consultant paediatrician and ophthalmologist
If NAI is suspected social services should be contacted later in management

Question 12

Leucocoria

Answer 12

A white pupil
When seen in children it requires urgent investigation
Check red reflex and compare between eyes
Refer to ophthalmology for full examination and fundoscopy

Question 13

Causes of leucocoria

Answer 13

Congenital cataract
Coats disease - rare idiopathic unilateral retinal telangiectasia
Persistent hyperplastic primary vitreous -embryo vitreous persists
Toxocariasis - rare worm infection acquired in early childhood
Retinoblastoma - rare but commonest eye cancer in children

Question 14

Strabismus (squint)

Answer 14

Occurs when the eyes are misaligned and so visual fields do not overlay properly
Some can be corrected semi-consciously, and are called latent squint (latent deviation or phoria), if it cannot be controlled it is called a manifest squint or tropia

Question 15

Classification of squints

Answer 15

Inwards, convergent deviation is an eso-phoria (latent) or eso-tropia (manifest)
Outwards, divergent deviation is exo-phoria (latent) or exo-tropia (manifest)
Deviation upwards is hyperphoria (latent) or hypertropia (manifest)

Question 16

Assessment of strabismus

Answer 16

Age of onset and any refractive error - Hx of birth trauma, childhood illness, maternal infection or FH of squint
Test acuity, red reflex/leucocoria and eye movements
Test for cycloglegic refraction

Question 17

Cycloglegic refraction

Answer 17

Using cyclopentolate eye drops to dilate the pupil and relax the cillary muscle to unmask any compensated refractive error
This can be used to measure underlying refractive error and correct it

Question 18

Retinopathy of prematurity (ROP)

Answer 18

The retina doesn’t develop blood vessels until the 4th month
ROP is abnormal retinal changes in preterm babies, and may be linked to oxygen supplementation given to premature babies
Range from mild vascular changes to advanced retinal scarring
50% of babies <1000g birth weight will have some ROP

Question 19

Stages of ROP

Answer 19

1) Demarcation line 2) Formation to 3D ridge
3) Fibrovascular proliferation at ridge
4) Partial retinal detachment, with macula on or off
5) Total retinal detachment
6) Aggressive posterior retinopathy of prematurity

Question 20

Management of ROP

Answer 20

All babies <1501g or born before 32weeks should be screened
Can be treated with cryotherapy or photocoagulation of the immature retina or scleral buckling surgery for tractional RD
Long term follow up for babies with stage 3 or worse
At risk of myopia, exotropic squints and amblyopia