Friedman pediatrics Flashcards
DDx for photophobia and tearing in pediatric patient
nasolacrimal duct obstruction (NLDO)
cornea abrasion/FB
iritis
congenital glaucoma
Congenital glaucoma Rx
Topical meds: NOT brimonidine (assoc/w/death)
Surgical options:
1.5 yo, cloudy cornea, or two failed goniotomies)
Correct refractive error, amblyopia
Other options: trab w/MMC and glaucoma drainage implant, cycloablation.
Tests for watery eye in pediatric patient
Mucoid reflux with digital pressure over the lacrimal sac and conjunctivitis
dye disappearance test,
Jones I and II test
nasolacrimal irrigation
Dye disappearance test
POSITIVE when decreased clearance of fluorescein after 5 min
Jones I vs. II test
Jones I (physiologic)
POSITIVE when normal
NEGATIVE when no dye recovered on cotton tip at inferior meatus
1/3 false-negative rate in normal
Jones II (nonphysiologic)
POSITIVE when normal
NEGATIVE when no dye recovered after lacrimal irrigation with saline (through inferior punctum and canaliculus)
1) If dye is retrieved in the basin with no reflux, a partial nasolacrimal duct obstruction is suggested since dye can be irrigated through under nonphysiologic conditions.
2) If the irrigant retrieved is clear, no dye reached the lacrimal sac, and a punctal or canalicular obstruction is suspected.
3) If there is reflux from the upper punctum, there is an obstruction at or below the sac.
4) If there is reflux around the irrigating cannula, the obstruction is likely at the level of the common canaliculus.
Basic secretion test
Following topical anesthesia, measure filter paper at 5min
Normal?
>5mm
Schirmer I vs. II
Schirmer I No topical anesthesia Measures basic and reflex tearing Measure filter paper at 5min Normal? >10mm
Schirmer II No topical anesthesia Measures reflex tearing Use cotton tip to irritate nasal mucosa Measure filter paper at 5min Normal? >15mm
Valve at the beginning and end?
Valve at the beginning?
Rossenmuller
Valve at the end?
Hasner
Empties under which turbinate?
Inferior turbinate
DCR creates passage by?
Middle turbinate
Near cribiform plate
Most common organism for dacryocystitis?
Strep pneumo > Staph & H. flu
Most common organism for canaliculitis?
Actinomyces (Gram+ rods with sulfur granules)
Congenital NLDO location?
usually 2/2 membrane over valve of Hasner.
>usually spontaneously resolves with massage and warm compresses +/- abx gtts (like polytrim) if crusting
>if not resolved at 13 mo –> NLD probing
Questions to ask when evaluating strabismus:
Visual acuity +/- amblyopia? Refractive error AC/A ratio deviation measured at distance and near deviation: in/comitant? A or V pattern? oblique muscle overaction DVD? latent nystagmus? cross-fixate? suppression scotoma?
surgical Rx for DVD
bilateral superior rectus recession
inferior rectus resection
inferior oblique weakening or anterior transposition
congenital motor nystagmus
Horizontal, conjugate
Onset
congenital motor nystagmus Associated with?
Associated with? Ocular albinism Achromatopsia Leber’s Congenital Amaurosis Aniridia
Esotropia + Nystagmus?
Esotropia + Nystagmus?
Nystagmus Blockage Syndrome
(Esotropia that “eats up” prism)
Rx for congenital motor nystagmus
base-OUT prism glasses to stimulate convergence and therefore dampen the nystagmus.
If head turn > 50% of time to keep eyes in null point, then consider Kestenbaum procedure
Spasmus nutans
asymmetric typically horizontal “shimmering” nystagmus* = LOW-amplitude, HIGH-frequency nystagmus
Usually benign, typically resolves by age 6
TRIAD:
(1) head nodding
(2) monocular or ASYMMETRIC nystagmus
(3) torticollis (i.e. abnormal or stiff neck position).
*can also be vertical or rotary. It is typically of the pendular variety.
Spasmus nutans Associated with?
Associated with?
Chiasmal glioma
Tumors of the parasellar/hypothalamic area can present with a nearly indistinguishable nystagmus (Heimann-Bielschowsky phenomenon); therefore perform neuroimaging in all cases of spasmus nutans (controversial).
-nystagmus resembling spasmus nutans can occur in children with certain retinal disorders:
CSNB or rod/rod-cone dystrophy. Therefore, do ERG if patient has abnormal eye exam (pupils, DFE)
down syndrome associated eye disorders
refractive error (MC hyperopia) strabismus nystagmus amblyopia lid abnormalities (epicanthal folds, upward slanting of palpebral fissures, blepharitis, NLDO) keratoconus iris Brushfield spots cataracts glaucoma
Recommendations for down syndrome
route eye care and correct any associated disorders as a regular child
Head position for SO palsy
chin DOWN
face turned to OPPOSITE side and head tilted to OPPOSITE shoulder
Rx for SO palsy
For isolated palsy: observation and prism glasses or occlusion of one eye to alleviate the diplopia, which may improve with time
If it does not and is stable for at least 6 mo, can consider muscle surgery
Knapp classification
Harado Ito procedure (lateral transposition of SO tendon)
Prism Adaptation Test
In prism adaptation, the patient is fitted with prisms of sufficient magnitude to permit alignment of the visual axes. In many cases, this step provokes a restoration of sensory binocular cooperation in a form of fusion and even stereopsis. This technique simulates orthotropia and possibly offers some predictive value of whether fusion may be restored when the patient undergoes surgical alignment.
In some patients, however (especially those with acquired esotropia), placement of such prisms increases the deviation. In such cases, anomalous retinal correspondence based on the objective angle may drive the eyes to maintain this adaptive alignment even with prismatic correction. After wearing such prisms, the patient returns with a greater angle of deviation. Prism adaptation is used by some ophthalmologists in patients with acquired esotropia. The patient is reexamined every 1–2 weeks and given larger prism correction, if needed, until the deviation no longer increases. Surgery is then performed on the new, larger, prism-adapted angle. The Prism Adaptation Study demonstrated a smaller undercorrection rate when surgery was based on this deviation compared to standard surgery
V pattern XT Rx
1) correct any refractive error and Rx amblyopia present
2) over-minus spectacles to induce accmmodative convergence, fusional convergence training with progressive base-OUT prism or prism therapy with base-in prisms.
3) If ocular misalignment is present > 50% of the time, then surgery is necessary
V pattern XT Rx - surgery
1) prism adaptation test to uncover full amount of deviation
2) surgical correction: R & R or both eyes with bilateral lateral rectus recessions
3) V pattern corrected with horizontal rectus muscle transposition in direction of desired weakening
(MALE = medial recti moved towards the Apex of the pattern or lateral recti moved towards empty space of patter) or with Oblique muscle weakening.
