Paediatric Ophthalmology Flashcards
Visual acuity testing in newborn - types and their general process
Fix and follow
Spinning baby test
Preferential looking
Visual evoked potentials
Pre-verbal so look at eye movements
Visual acuity testing in newborns - what is fix and follow test?
Use pen torch / silent toy
Move slowly from left to right (immature eye movements)
See if child fixes and follows target
Record as ‘fixes and follows’
Visual acuity in newborns - what causes child not to follow in fix and follow test?
Can’t see
Not interested
Drowsy
Visual acuity in newborns - what is spinning baby test?
Spin child and observe nystagmus
There will be nystagmus in opposite direction to rotation if child can see
There will be post rotational nystagmus after stopping spinning
If nystagmus persists - severely visually impaired
Visual acuity in newborns - what is preferential looking
Cards with different sized grating patterns on one side and plain on other side
Child will look at grating side of card if normal vision
Visual acuity in newborns - what is visual evoked potentials
Electrodes places on child’s head
Record signals when child sees pattern on screen
Visual acuity in infants (0-3) - what type of visual acuity test is used?
Cardiff Cards
Cards with line drawings of familiar objects, on upper or lower half of card and with different line thicknesses
Show cards quickly at 1m + observe vertical eye movements
Visual acuity in toddlers (1.5-4) - what type of visual acuity test is used?
Kay picture tests
Book of cards with line drawings
Child can name or match using matching cards
Single - one drawing on each card
Crowded - four drawings; better sensitivity
Visual acuity in children (4-5) - what type of visual acuity test is used?
Keeler crowded LogMAR test
Book with each page containing four letters
Child names letters or uses matching card
Strabismus - what is strabismus?
Malalignment of the two eyes
What is heterophoria
Latent strabismus
Malalignment only present on dissociation with cover-uncover test
Both eyes look straight but deviate on dissociation
What is heterotropia
Manifest strabismus
Malalignment constantly present
One eye not directed towards fixation point
What is concomitant strabismus
Deviation remains same in all directions of gaze
What is incomitant strabismus
Deviation changes with direction of gaze
What is amblyopia
‘Lazy eye’
Vision developmental disorder where one eye fails to achieve normal visual acuity
Due to insufficient use of eye during visual development so the brain suppresses image from the eye, disrupting visual development in that eye
What is pathophysiology of concomitant strabismus
Failure for binocular single vision to develop
Due to disruption in vision in one eye
Risk factors: hypermetropia, developmental abnormalities, family hx of trabismus or refractive error
What is binocular single vision
Use of both eyes together to achieve binocular depth perception
What are causes of concomitant strabisums
Reduced vision in one eye:
Retinoblastoma
Cataracts
Anisometropia (different refraction in two eyes)
What are causes of incomitant strabismus
Congenital: CN palsies
Acquired: secondary CN palsies, thyroid eye disease, orbital floor fracture
What is pathophysiology of incomitant strabismus
Angle of deviation changes with direction of gaze
Acquired incomitant strabismus causes diplopia
Child may have compensatory head tilt to minimise diplopia
Young child may suppress second image and develop amblyopia
What is the role of orthoptists in management of strabismus
Assess visual acuity Measure strabismus Assess eye movements Assess binocular vision (inc stereopsis) Monitor amblyopia therapy with patching
What are the tests for strabismus
Cover-uncover test: detects presence of strabismus, cover fixating eye and see if other eye moves to take up fixation
Alternate cover test: detect latent strabismus, rapidly cover each eye and observe movement of eye to take up fixation
What is the management of strabismus in children
Correct refraction - glasses
Amblyopia therapy - patch
Surgery
How do you correct refractive error in strabismus
In esotropia with high hypermetropia
Glasses - correct strabismus and improve visual acuity, surgery may not be needed
How do you treat amlyopia
Patch on good eye worn for several hours a day
Encourages amblyopic eye to develop vision
Unsuccessful after 7yo
What is surgical management of strabismus
In esotropia:
recess medial rectus
resect lateral rectus
How do you manage strabismus in adults
Treat underlying cause
Prism incorprated into glasses - joins diplopia
Strabismus surgery - if BSV not restored once EOM recover
Neonates - what is leukocoria
White pupillary reflex on opthalmoscopy
Indicates severe ocular pathology and is amblyogenic
What are the causes of leukocoria
Retinoblastoma Coloboma Congenital Retinopathy of prematurity Non-accidental injury
What is retinoblastoma
Malignant tumour of retina - most common intraocular tumour of childhood
Most sinister cause of leukocoria
What are features of congenital cataracts
Leukocoria Concomitant Strabismus Amblyopia Nystagmus Can be bilateral - visually inattentive
What are causes of congenital cataracts
Idiopathic
Familial autosomal dominant
Galactosaemia
Rubella infection
How do you manage congenital cataracts
Urgent referral
Cataract surgery
Amblyopia therapy
What is coloboma
Hole in any structure of the eye, due to failure for choroidal fissure to fuse during embryological development
What are features of coloboma
Choroido-retinal coloboma, optic disc coloboma: leukocoria, severe amblyopia
Iris coloboma: misshaped pupils, posterior eye normal, normal visual acuity
What is retinopathy of prematurity (ROP)
Incomplete retinal vascularisation causes hypoxia and stimulates neovascularisation
New vessels leak and cause scarring
Why do you get leukocoria in ROP
It occurs only in late disease due to tractional retinal detachment
What is the management for ROP
Ablation of avascular retina
Laser - reduce VEGF production
Sight threatening conditions of neonates - What is Ophthalmia neonatorum? What is the management?
Purulent conjunctivitis of newborn within few days of birth
It is a notifiable disease
Organisms: Neisseria gonorrhoea (acute), Chlamydia trachomatis (subacute)
Systemic + topical antibiotic treatment
Referral of parents to STD clinic
Sight threatening conditions in neonates - What is buphthalmos
Congential glaucoma
Can cause defective vision or blindness
What are features of buphthalmos
Large, watering photophobic eyes
corneal clouding
raised intraocular pressure
Sight threatening conditions in neonates - what is anopthalmos? what is micropthalmos?
Anopthalmos - absence of eye
Microphthalmos - small remnant of eye
What is the management for Anophthalmos/microphthalmos?
Promote growth of bony orbit
Expand soft tissues of orbit
Ocular prosthesis
Sight threatening conditions in neonates - what is a differential for buphthalmos?
Congenital Nasolacrimal duct obstruction - watery eyes in neonates but without large eye
What is congenital nasolacrimal duct obstruction
Common condition where there is a delay in opening of nasolacrimal duct at inferior meatus
What is the management for congenital NLDO
Reassurance - 90% resolves in 1 yr
Massage over lacrimal sac at medial canthus
If mucocoele at medial canthus - dacryocystorhinostomy
Persistant after 1 yr - syringe and probing under GA
Common paediatric conditions - what are common eyelid lumps
Capillary haemangioma
Stye
Chalazion
Molluscum contagiosum
What is capillary haemangioma
Benign swelling of capillaries at superonasal orbit or eyelid
Occurs shortly after birth and grows in size for 6 months
Can lead to mechanical ptosis and amblyopia if ptosis covers visual axis or weight causes astigmatism
What is molluscum contagiosum
Pearly umbilicated itchy nodules on hands, face, trunk and around eyes
Caused by viral infection
Leads to follicular conjunctivits if at lid margin
What is limbal dermoid
Benign congenital tumour at limbus
Associated with Goldenhar’s syndrome
What is dermoid cyst
Smooth round non-tender immobile lump on orbital rim
What is dermolipoma
Benign congenital conjunctival fatty lesion
Lies close to lacrimal ductile openings - risk of dry eyes from ductile damage, caution in excision
What are the causes of ptosis in children
Congenital - levator muscle myopathy (often unilateral)
Acquired - third nerve palsy
Inflammatory - vernal keratoconjunctivitis
What is the management of ptosis in children
Surgery
Poor levator function - frontalis suspension
Good levator function - levator resection (anterior or posterior LR)
Lid covers visual axis - urgent frontalis suspension
Slight ptosis - wait surgery until >4yo
What are the types of cellulitis that can occur in the orbit
Preseptal cellulitis: limited and less severe
Orbital/post-septal cellulitis: medical emergency
What is preseptal cellulitis
Inflammation of eyelids only
What are features of preseptal cellulitis
Inflamed lids: swollen, red, tender, warm
White eye, No proptosis, normal eye movements, normal optic nerve function
How do you treat pre-septal cellulitis
IV antibiotics - in children similar to orbital cellulitis bc high risk of progression due to orbital septum not fully developed
What are features of orbital cellulitis
Inflamed lids
Proptosis
Reduced eye movements
Optic nerve dysfunction: RAPD, VA, colour vision
What is the management for orbital cellulitis
Blood culture - Strep pneumoniae, Staph aureus, H influenzae
CT - exclude sinusitis and subperiosteal abscess
IV antibiotics
