Peds Misc Flashcards
Infant IOP
The normal IOP of the newborn child is quoted to be 10 to 12 mmHg. By 8 years of age, the mean normal IOP rises to approximately 14 mmHg.
Infants with primary congenital glaucoma often have IOPs in the 30 to 40 mmHg range, and may still have IOPs in the 20 mmHg range under general anesthesia.
Infant c/d
According to the BCSC, most normal newborn eyes have cup-to-disc ratios of less than 0.3. In addition, there is usually less than 0.2 difference between the cup-to-disc ratios between the two eyes of a child.
As you probably know, “reversal of cupping” is a phenomenon that may occur after a child with congenital glaucoma is adequately treated with glaucoma surgery. After significant lowering of intraocular pressure, the magnitude of cupping may decrease dramatically in these patients.
NLDO
Start with Crigler massage
Explanation: Most pediatric ophthalmologists would proceed with a simple probing of the nasolacrimal duct in the office (if possible). This procedure has a success rate of upwards to 90% if performed properly. If the epiphora persists after this procedure, the next step in management is either a repeat probing, intubation, or inferior turbinate infracture. DCR is the final option for children with congenital NLDO since it is much more extensive of a procedure.
20/400 va
VA at birth: the fovea does not have the density of cones that is found in the adult retina. It reaches the same density of cones after 1 year of life.
Also, positive OKN response (VA at least 20/400).
In general, the goal of the OKN drum is to elicit the optokinetic reflex whereby the patient will demonstrate a quick refixation movement in the opposite direction of the rotating bars.
In children with horizontal nystagmus, it may be difficult to see this endpoint reflex if the drum is rotated horizontally. This is because the reflex may be hidden by the already-abnormal horizontal movements.
In this case, it is more proper to rotate the OKN drum vertically and to see if a vertical nystagmus reflex movement occurs.
If such a vertical reflex occurs, the child’s visual acuity is usually 20/400 or better.
Hyperopia
The measured hyperopia usually INCREASES until the child is 5 to 7 years old. After this time, the physician may be able to slowly decrease the amount of hyperopic correction in order to stimulate some fusional divergence.
It is important to counsel the parents that glasses will have to be worn for many years to successfully treat accommodative esotropia.
Eye contact
The normal baby will begin to make eye contact and react with facial expressions at approximately 6 weeks of age.
Vernal keratoconjunctivitis
This boy presents with the characteristic symptoms and signs of vernal keratoconjunctivitis. This allergic entity typically occurs in children within the first 2 decades of life during the spring or fall.
Classic ocular signs include: (1) giant papillary conjunctivitis (as shown in the photograph) (i.e. papillae are >1 mm in diameter); (2) “Horner-Trantas dots” which are jelly-like limbal nodules representing degenerated eosinophils; and a (3) “shield ulcer” which is a corneal epithelial defect involving the upper half of the cornea.
Eye movements absent at birth
Vertical eye movements may not be developed until 6 mo of age
Newborn eye
axial length: 15-17 mm; corneal horizontal diameter: 9.5-10.5 mm
Cornea thickness- newborn
The average thickness of the newborn cornea is 960 microns. This corneal thickness decreases dramatically within the first 6 months of life to approximately 520 microns.
Mild corneal edema is very common among newborns, especially those born prematurely. This patient should be observed only at this time. Presently, he does not display the features of congenital glaucoma given his normal IOPs and corneal diameters.
Cornea and/or RP
cornea + RP: Hurler, Scheie
RP: Hunter, Sanfilippo
cornea: Moquio, Maroteaux-Lamy
neither: Sly
Fusional amplitudes
For distance fixation at 6 meters, the normal convergence fusional amplitudes is ~14 prism diopters; divergence fusional amplitudes ~6 prism diopters; and vertical fusional amplitudes ~2.5 prism diopters.
JIA
Juvenile idiopathic arthritis (JIA) is the most common cause of uveitis in the pediatric age group. The main subgroups of JIA are: (1) oligoarthritis; (2) rheumatoid factor (RF)-negative polyarthritis; (3) psoriatic arthritis; (4) enthesitis-related arthritis; and (5) systemic arthritis (i.e. Still’s disease).
Of these, anterior uveitis (10-30% of cases) is most likely to occur in the oligoarthritis variety. This subgroup is defined by a persisting arthritis that lasts greater than 6 weeks and affects 4 or less joints during the first 6 months of the disease. RF is almost always absent in these patients. ANA is typically positive in both the oligo- and polyarthritis varieties.
Anterior uveitis occurs in approximately 10% of patients in both the RF-negative polyarthritis and psoriatic arthritis subgroups. Uveitis rarely ever occurs in systemic arthritis (i.e. Still’s disease).
Virchow’s law
Craniosynostosis occurs when there is premature closure of 1 or more of the cranial sutures. When this occurs, bone growth cannot occur perpendicular to the suture line, but can still occur parallel to it. This bone growth pattern is called “Virchow’s law”.
sarcoidosis
The slit-lamp photo depicts the classic “mutton-fat” keratic precipitates of a granulomatous uveitis. The abnormally elevated ACE level implies a diagnosis of sarcodosis which may present differently in children as compared to adults.
In young children (<5 years old), lung involvement in sarcoidosis is much less frequent, but associated rash and arthritis are more frequent. As in adult ocular sarcoidosis, anterior uveitis is much more common than panuveitis.
Lastly, one must keep in mind that the ACE level in normal children is typically higher compared to adults. Therefore, a borderline elevated ACE should not be used as the sole way to diagnose sarcoidosis in young children.
