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3 - Y5 Paeds > Eye disease > Flashcards

Eye disease Flashcards

1
Q

How might visual impairment in an infant or young child present?

A

Visual impairment may present in an infant or young child with:

  • Obvious ocular malformation, e.g. absence of red reflex
  • Not smiling responsively by 6wks
  • Concerns about poor visual responses, incl poor eye contact
  • Nystagmus, roving eye movements
  • Squint
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2
Q

What is retinopathy of prematurity?

A

A potentially blinding vaso-proliferative eye disorder that primarily affects premature low BW infants

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3
Q

Aetiology of retinopathy of prematurity?

A

The retina has no blood vessels in it until 16wks gestation

  • The vessels grow out from the optic disc, only fully reaching the periphery of the eye 1 month after birth
  • The incompletely vascularised retina is susceptible to oxygen damage, esp in preterm infants
  • Retinopathy of prematurity is a proliferative disorder of this immature retinal vasculature
    • Affects developing blood vessels at the junction of the vascularised and non-vascularised retina
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4
Q

Pathophysiology of retinopathy of prematurity?

A
  • Normally, retinal vessels grow in relative hypoxia
  • After premature birth, the retina is exposed to increased oxygen → reduced levels of vascular endothelial growth factor (VEGF) → halts vascular growth
  • But the eye continues to grow → peripheral area of hypoxic retina à this ischaemia leads to increased levels of VEGF
  • This leads to angiogenesis in the retina → the new vessels formed are more tortuous and fragile → increased risk of haemorrhage, retinal detachment, fibrosis and blindness
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5
Q

RFs for retinopathy of prematurity?

A
  • prematurity (esp <32wks),
  • low birth weight (<1500g),
  • oxygen therapy,
  • comorbidities (resp distress, IVH)
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6
Q

Epidemiology of retinopathy of prematurity?

A

Mostly occurs in extreme low birth weight infants → develops in 16% of all premature births; 35% of very low BW

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7
Q

Signs and symptoms of retinopathy of prematurity?

A
  • Picked up on screening
  • Can lead to visual loss and blindness
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8
Q

Ix for retinopathy of prematurity?

A
  • Eyes of susceptible preterm infants (<1500g or <32wks gestation) are screened by an ophthalmologist (with ophthalmoscope)
  • Retinal imaging may be done
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9
Q

Mx for retinopathy of prematurity?

A

Prevention:

  • Using reduced concentrations of O2 when ventilating

Mx:

  • Laser therapy to ablate new vessels
  • Reduces visual impairment
  • Intravitreal anti-VEFG (anti-vascular endothelial growth factor) may also be used
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10
Q

Complications and prognosis of retinopathy of prematurity?

A

Complications:

  • Severe visual impairment/blindness; myopia, amblyopia, strabismus
  • Complications of treatment: conjunctival haemorrhages, laceration, cataracts

Severe bilateral visual impairment occurs in 1% of very low BW infants

Requires yearly follow-up due to complications

Lower survival rate (due to prematurity itself)

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11
Q

What is strabismus?

A

Misalignment of the visual axes

Aka squint

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12
Q

Aetiology of strabismus?

A

Normally both eyes fixate (look at) the object of interest, but in strabismus one eye fixates and the other is deviated Usually caused by refractive error

  • Can also be caused by cataracts, retinoblastoma and other intraocular causes à must be excluded
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13
Q

What are the 2 types of strabismus?

A
  • Concomitant (non-paralytic)
    • Common; thought to be a complex genetic trait
    • Usually due to a refractive error in one/both eyes à correction of refractive error often corrects squint
    • The squinting eye usually turns inward (convergent), but can turn outward (divergent) or vertical
  • Paralytic
    • Rare; can be sinister
    • Due to paralysis of motor nerves (e.g. by underlying SOL) à squint varies with gaze direction
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14
Q

RFs for strabismus?

A
  • FHx,
  • prematurity,
  • refractive error
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15
Q

Epidemiology of strabismus?

A

Common

Transient misalignment is very common up to 3mo

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16
Q

Signs and symptoms of strabismus?

A
  • Eye misalignment
  • Amblyopia
  • Diplopia (often absent in children due to suppression; if present it only occurs when both eyes are open)
  • Intermittent closure of one eye
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17
Q

Ix for strabismus?

A
  • Red reflexes
    • Should be checked in any infant with a squint (rule out retinoblastoma)
  • Corneal light reflex test
    • Used by non-specialists to detect squints
    • Pen torch is held at a distance to produce reflections on both corneas simultaneously
      • If the light reflection does not appear in the same position in the two pupils, a squint is present
  • Cover test
    • Child looks at toy/light
      • If the fixing eye is covered, the squinting eye moves to take up fixation
    • Not appropriate in young children (needs co-operation)
  • Further testing by ophthalmology:
    • Simultaneous prism and cover test (SPCT) → to measure angle of strabismus
    • Vision testing → look for double vision, incomplete eye movements
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18
Q

Mx for strabismus?

A

Refer all squint persisting >3mo to ophthalmology

  • Treat underlying cause if possible
    • Correction of refractive errors with glasses
  • Treat amblyopia (see complications)
  • Surgery
    • Not usually needed
    • Used to strengthen or weaken the functions of muscles
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19
Q

Complications and prognosis of strabismus?

A
  • Amblyopia
    • Potentially permanent reduction of visual acuity in an eye that has not received a clear image
    • Affects 2-3% children
    • Causes are squint, refractive errors and obstruction to the visual pathway (e.g. cataract)
      • May occur in squint when the brain is unable to combine the markedly differing images from each eye à the vision from the squinting eye is ‘switched off’ to avoid double vision
    • Treatment is by tackling the underlying condition, and patching the ‘good’ eye for specific periods of the day to force the ‘lazy’ eye to work and therefore develop better vision
      • Early treatment is essential → after 7yo improvement is unlikely
  • Psychosocial problems
    • Due to cosmetic implications
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20
Q

What is hypermetropia?

A

A refractive error, aka long-sightedness

NB the refractive errors are hypermetropia, myopia, astigmatism (abnormal corneal curvature) and amblyopia

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21
Q

Aetiology of hypermetropia?

A

Eye has insufficient optical power for its refractive length à light from an object is focussed behind the retina à blurred image

Mild hypermetropia is common in early childhood à overcome through accommodation (changing the shape of the lens of the eye)

  • Usually resolves by 3yo
22
Q

RFs for hypermetropia?

A
  • FHx (but most are sporadic),
  • congenital cataracts,
  • micropthalmia
23
Q

Signs and symptoms of hypermetropia?

A
  • Difficulty viewing near objects; distant objects are sharply focussed
  • May lead to eye strain (due to extra accommodative effort) and headache
  • Young children may rub their eyes, have poor eye contact, squint
  • School-aged children may present with behavioural problems
24
Q

Ix for hypermetropia?

A
  • Orthoptist-led vision screening is done at 4-5yo in UK
  • Tests for visual acuity vary depending on the age of the child
    • 6-8wks: face fixation, following a large coloured toy
    • 6 months: preferential looking tests of acuity (Keeler/Teller cards - based on preference for patterns)
    • 12 months: fixates 1mm crumb
    • 1-2yrs: preferential looking tests of acuity (Cardiff cards – assess eye movement to determine if child can see picture)
    • 2-3yrs: names or matches pictures in linear array (Kay pictures or Lea symbols)
    • 3yrs+: names or matches letters (e.g. Sonksen logMAR, crowded logMAR); older children can do Snellen chart
  • Assessment of refractive error
    • Objective refraction: uses retinoscope to determine nature of error
      • Doesn’t require input from patient; can be done in young children
    • Subjective refraction: uses a series of lenses to measure the error
      • Requires patient participation; can’t be done in young children
25
Q

Mx of hypermetropia?

A

Mild hypermetropia may not need spectacle correction

Convex (plus) lenses

Contact lenses can be used in older children

Laser treatment to the cornea later in life

26
Q

Complications of hypermetropia?

A
  • Squint
  • Amblyopia
  • Increased risk of glaucoma
27
Q

What is myopia?

A

A refractive error, aka short-sightedness

28
Q

Aetiology of myopia?

A

Eyes have excessive optical power for the length of the eyeball à focus the image in front of the retina

  • Due to physiological variation in the length of the eye, or an excessively curved retina
29
Q

RFs for myopia?

A
  • FHx,
  • prematurity,
  • Marfan’s syndrome,
  • Ehlers-Danlos syndrome
30
Q

Epidemiology of myopia?

A

Usually presents in adolescence; uncommon in young children (but more common in premature children)

Affects 1 in 4 adults in UK

31
Q

Signs and symptoms of myopia?

A
  • Distant objects are blurred; close-up objects are in focus
  • Rub eyes, squint, behavioural problems
32
Q

Ix for myopia?

A
  • Orthoptist-led vision screening is done at 4-5yo in UK
  • Tests for visual acuity vary depending on the age of the child
    • 6-8wks: face fixation, following a large coloured toy
    • 6 months: preferential looking tests of acuity (Keeler/Teller cards - based on preference for patterns)
    • 12 months: fixates 1mm crumb
    • 1-2yrs: preferential looking tests of acuity (Cardiff cards – assess eye movement to determine if child can see picture)
    • 2-3yrs: names or matches pictures in linear array (Kay pictures or Lea symbols)
    • 3yrs+: names or matches letters (e.g. Sonksen logMAR, crowded logMAR); older children can do Snellen chart
  • Assessment of refractive error
    • Objective refraction: uses retinoscope to determine nature of error
      • Doesn’t require input from patient; can be done in young children
    • Subjective refraction: uses a series of lenses to measure the error
      • Requires patient participation; can’t be done in young children)
33
Q

Mx of myopia?

A

Concave (minus) lenses

Contact lenses can be used in older children

Laser treatment to the cornea later in life

34
Q

Complications of myopia?

A
  • Squint
  • Amblyopia
  • Increased risk of retinal detachment, cataracts, glaucoma
35
Q

What is retinoblastoma?

A

A malignant tumour of retinal cells

36
Q

Aetiology of retinoblastoma?

A

Can be unilateral or bilateral, familial or spontaneous

All bilateral tumours and 20% of unilateral tumours are hereditary

  • The retinoblastoma susceptibility gene is on chromosome 13 (RB1 gene)
  • Dominant inheritance but incomplete penetrance à only 10% with hereditary mutations have FHx
  • Spontaneous retinoblastoma also involves the RB1 gene (mutation)
37
Q

RFs for retinoblastoma?

A

FHx

38
Q

Epidemiology of retinoblastoma?

A

Rare (50 new diagnoses/yr in UK)

Accounts for 5% of severe visual impairment in children

Usually presents within first 3yrs of life

39
Q

Signs and symptoms of retinoblastoma?

A
  • White pupillary reflex (leukocoria) replaces the normal red one
  • Strabismus
40
Q

Ix for retinoblastoma?

A
  • Regularly screen children if FHx of hereditary retinoblastoma
  • Fundoscopy and examination under anaesthetic
    • Appear as a chalky, white-grey retinal mass; often multifocal
      • May show retinal detachment and vitreous and/or subretinal seeding
  • Ophthalmic USS
    • At initial clinical examination or as part of the examination under anaesthesia
  • MRI head/orbit
    • Not needed for diagnosis
    • Performed to exclude concomitant primitive neuroectodermal tumour in pineal gland (trilateral retinoblastoma) and to detect metastases
  • Molecular testing
    • For mutation in RB1 gene
    • For family planning and screening for secondary cancers
41
Q

Mx for retinoblastoma?

A

Aims to cure, yet preserve vision

  • Chemotherapy
    • Esp for bilateral disease, to shrink the tumours
    • Followed by laser treatment to the retina
  • Radiotherapy
    • May be used for advanced disease; more often used for recurrence
  • Enucleation (removal) of the eye may be necessary for advanced disease
42
Q

Complications and prognosis of retinoblastoma?

A
  • Vision damage
    • E.g. due to intra-retinal haemorrhage from chemotherapy, cataracts after radiation, optic nerve atrophy after carboplatin therapy
  • Second malignancy (esp sarcoma) in survivors of hereditary retinoblastoma
    • Chemo/radiotherapy can cause lymphoma and leukaemia

Most patients are cured, but many are visually impaired

43
Q

What is conjunctivitis?

A

Inflammation of the conjunctiva (the mucous membrane that covers the front of the eye and lines the inside of the eyelids)

Classified as:

  • infectious or non-infectious,
  • and as acute, chronic or recurrent
44
Q

Aetiology of conjunctivitis?

A

Can be caused by bacteria, viruses, allergic or immunological reactions, mechanical irritation or medicines

  • Bacterial causes:
    • S. pneumoniae, S. aureus, Moraxella catarrhalis, H. influenzae
    • In neonates: N. gonorrhoeae, Chlamydia
  • Viral causes:
    • HSV, adenovirus, VZV, molluscum contagiosum, coxsackie, enteroviruses
    • HSV eye disease:
      • Can cause blepharitis or conjunctivitis à may extend to cornea to cause dendritic ulceration à corneal scarring and loss of vision
    • Viral conjunctivitis is highly contagious
  • Mechanical: caused by chronic conjunctival irritation
  • Allergic: can be atopic or non-atopic
    • See allergic rhinitis
45
Q

What is the neonatal presentation of conjunctivitis?

A
  • Sticky eyes are very common, starting on 3rd/4th day of life
  • More troublesome discharge with eye redness may be caused by Staph/Strep infection
  • Purulent discharge with conjunctival injection and eyelid swelling may be due to gonococcal infection
  • Purulent discharge with swelling of eyelids at 1-2wks of age suggests Chlamydia trachomatis
    • Can also present shortly after birth
46
Q

RFs for conjunctivitis?

A
  • exposure to infected person,
  • infection in one eye (can spread to other),
  • allergen exposure,
  • atopy
47
Q

Epidemiology of conjunctivitis?

A

Very common

Bacterial conjunctivitis is most common in children (and viral is more common in adults)

48
Q

Signs and symptoms of conjunctivitis?

A
  • Red eye and conjunctival injection
    • Often bilateral (always bilateral in allergic)
  • Discharge:
    • Watery discharge in viral
    • Ropy, mucoid discharge in allergic
    • Purulent discharge in bacterial
  • Itching
    • Most common in allergic
  • Eyelids stuck together in the morning
  • Conjunctival follicles
    • Round collections of lymphocytes which appear as small dome-shaped nodules, most prominent in the lower eyelid (inferior fornix)
    • Seen if caused by viruses, atypical bacteria and toxins
  • Papillae
    • Cobblestone appearance of flattened nodules with vascular cores
    • Seen in allergic conjunctivitis
49
Q

Ix for conjunctivitis?

A
  • Clinical diagnosis
  • Identify cause:
    • Consider rapid adenovirus assay to identify adenovirus conjunctivitis
    • If gonococcal infection suspected: urgent gram stain and culture
    • If chlamydial infection suspected: immunofluorescence staining
  • If suspicion of HSV: urgent ophthalmic assessment with slip lamp examination of cornea
50
Q

Mx for conjunctivitis?

A

Neonatal:

  • Sticky eyes: clean with saline or water; resolves spontaneously
  • If caused by staph/strep infection: topical antibiotic eye ointment, e.g. chloramphenicol, neomycin
  • If caused by gonococcal infection: start treatment immediately (as permanent loss of vision can occur)
    • IV cephalosporin (ceftriaxone) (+ topical, e.g. ciprofloxacin ophthalmic)
  • If caused by chlamydial infection: oral erythromycin for 2wks (+ topical, e.g. erythromycin ophthalmic)
    • Also check and treat mother and partner

Allergic:

  • See allergic rhinitis

Bacterial:

  • Topical broad-spectrum antibiotics
    • E.g. azithromycin, erythromycin for 7-10d
  • If moderate-severe or resistant: topical fluoroquinolones, e.g. ciprofloxacin drops

Viral:

  • Topical antihistamines and artificial tears for symptomatic relief
51
Q

Complications and prognosis of conjunctivitis?

A

Complications:

  • Loss of vision (in chlamydial, gonorrhoeal, adenoviral and HSV) if not treated promptly

Bacterial and viral are generally self-limiting over 5-10d

Allergic conjunctivitis usually responds to treatment but usually as seasonal exacerbations

3 - Y5 Paeds (13 decks)

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