5/13/2013

1

Common Pediatric Ophthalmologic Topics for p g pthe General Practitioner

Christi M Willen M DChristi M. Willen, M.D.Assistant Professor, Pediatric Ophthalmology

University of KentuckyDepartment of Ophthalmology

Faculty Disclosure

I have no financial interests to disclose.

5/13/2013

2

Educational Need

There is often inadequate training in pediatric residencies concerning ophthalmologic issuesresidencies concerning ophthalmologic issues. Since the pediatrician is often the first person a child with visual issues sees, it is imperative that pediatricians be able to recognize common pediatric ophthalmologic entities and treat or refer as appropriate.

Objectives

Upon completion of this educational activity, you will be able to diagnose common pediatricwill be able to diagnose common pediatric ophthalmologic problems.

5/13/2013

3

Expected Outcome

As a result, you should be able to appropriately treat many common pediatric ophthalmologictreat many common pediatric ophthalmologic problems. You should also be able to recognize problems which require referral and be able to make an appropriate, timely referral.

Photo Acknowledgment

All photos are derived from a variety of sources and are included solely for educationaland are included solely for educational purposes.

5/13/2013

4

Common Eye Problems in Children

Strabismus

A bl i Amblyopia

The Red Eye

Nasolacrimal duct disorders

Chalazia

www.aapos.org

Strabismus

Esotropia

P d t i Pseudoesotropia

Infantile

Accommodative

Acquired

Exotropia

Constant

Intermittent

http://media.summitmedicalgroup.com

5/13/2013

5

Esotropia

Pseudoesotropia

Wid fl t l b id12

Wide, flat nasal bridge

Prominent epicanthal folds

4

6

8

10

Row 1 Row 2 Row 3 Row 40

2 www.aapos.org

Pseudoesotropia

Evaluation

C l li ht fl Corneal light reflex

Cover test

http://pedclerk.bsd.uchicago.edu

http://ars.els-cdn.com

5/13/2013

6

Infantile Esotropia

Onset prior to 6 months of agemonths of age

Usually neurologically normal

Large deviation

Usually surgicaly g

Prior to 24 months of age

www.aapos.org

Neonatal alignment

Sondhi et al1, 2271 newborns:67% exodeviation67% exodeviation

30% straight

2% variable exo- and esodeviation

1% esodeviation

B 2 th ll d i ti l dBy 2 months, all esodeviations resolvedBy 6 months, 97% exodeviations resolved

Sondhi N, Archer SM, Helveston EM. Development of normal ocular alignment. J Pediatr Ophthalmol Strabismus. 1988;25:210-11.

5/13/2013

7

Accommodative Esotropia

Usual onset 6 mths to 7 years7 years

Usually intermittent, becomes constant

Associated with amblyopia

Treat with spectacle correction +/- bifocal +/- surgery

0

5

10Column 1Column 2

http://www.pedseye.com/

Acquired Esotropia

Onset after 6 months

N t i t d ith Not associated with accommodation

Amblyopia treatment

Prompt surgical correction

http://telemedicine.orbis.org

5/13/2013

8

Red Flags for Esotropia

Acute onset

Di l i Diplopia

Abduction deficit

Neurologic signs

www.quizlet.com

Exotropia

Constant

I t itt t Intermittent

www.aapos.org

5/13/2013

9

Constant Exotropia

Congenital exotropia

C t t t i Constant exotropia present before 6 months

Large angle

High association with neurologic or gcraniofacial abnormalities

http://lh5.ggpht.com

Intermittent exotropia

Onset usually before age 5age 5

Worse at distance

Worse when tired or ill

Squint one eye in q ybright light

Treat with patch, glasses, surgery (often deferred)

http://www.pedseye.com

5/13/2013

10

When to refer

Congenital Esotropia/ExotropiaEsotropia/Exotropia

4 months

Other Esotropia/Exotropia

Next available appt.

UNLESS

Red flags are present

Sixth nerve palsy suspected

http://www.health.state.mn.us

Amblyopia

Decreased vision not attributable to eye or

Cells in primary visual cortex lose ability toattributable to eye or

posterior visual pathway

2-4% in North America

Vi l it 20/400

cortex lose ability to respond to stimulation from the eye

Visual acuity 20/400 at birth

5/13/2013

11

Amblyopia

Strabismus

U l f ti Unequal refractive errors

Deprivation

http://spinoff.nasa.gov

http://www.familyeyecareofroswell.comhttp://www.pedseye.com

Amblyopia Treatment

Correct significant refractive errors

Remove obstacle Remove obstacle

Patching

Atropine sulfate drops

Greatest response in children <7, but some older children have dramatic response

Holmes JM, Lazar EL, Melia BM, Astle WF, Dagi LR, Donahue SP, Frazier MG, Hertle RW, Repka MX, Quinn GE, Weise KK; Pediatric Eye Disease Investigator Group. Effect of age on response to amblyopia treatment in children.Arch Ophthalmol. 2011 Nov;129(11):1451-7

www.geteyesmart.org

5/13/2013

12

The Red Eye

Conjunctivitis

I f ti Infectious

Allergic

Uveitis

Trauma

Foreign body Foreign body

www.gp-training.net

Conjunctivitis Infectious

80% bacterial

S f Self-limited

polymyxin B sulfate and trimethoprimophthalmic solution

Allergic

W t di h

http://www.health.state.mn.

Watery discharge

Itching

OTC ocular antihistamine ketotifenfumarate

http://www.betadineforekc.com

http://www.theeyepractice.com

5/13/2013

13

Conjunctivitis – when to refer

Skin lesions

C l i l t Corneal involvement

Lack of discharge

Significant photophobia

Does not resolve Does not resolve within 2 weeks http://www.accesspediatrics.com

Uveitis

Pain, redness, photophobiaphotophobia

JIA – often asymptomatic

http://upload.wikimedia.org

http://25.media.tumblr.com

5/13/2013

14

Trauma

Subconjunctival hemorrhagehemorrhage

Suspected abuse

Hyphema

https://s3.amazonaws.com

http://medicalpicturesinfo.comhttp://www.optocase.com

Corneal Abrasion

Stain with fluorescein

Observe with a blue light forObserve with a blue light for fluorescein uptake

Treat with erythromycin or bacitracin ointment

www.sightnation.com

5/13/2013

15

Foreign body

Red eye

I it ti Irritation

Unilateral

Corneal abrasion

/http://www.eyesurgeryinberkshire.co.uk

Nasolacrimal disorders

Dacryocele

D titi Dacryocystitis

Nasolacrimal duct obstruction

http://

www.eyeplastics.com

5/13/2013

16

Dacryocele

Bluish swelling below medial canthusmedial canthus

Present at birth

Early referral and decompression

http://webeye.ophth.uiowa.edu

Dacryocystitis

Infection of lacrimal sacsac

Medical urgency –same day referral

Admission, IV abx

Surgical gdecompression

http://one.aao.org

5/13/2013

17

Congenital Nasolacrimal Duct Obstruction

5% of full term newbornsnewborns

Epiphora, mucoiddischarge

Reflux of cloudy fluid with digital pressure

90% spontaneous resolution within 1 year www.pedseye.com

NLD obstruction

Lacrimal sac massagemassage

Avoid long term abx use

www.aapos.org

5/13/2013

18

Congenital Glaucoma

Epiphora

Ph t h bi Photophobia

Blepharospasm

Corneal clouding

Corneal enlargement

http://openi.nlm.nih.gov

Chalazia

Inflammatory, granulomatousgranulomatous lesions

Meibomian gland obstruction

www.eyeconditions.cataract-surgery.info

www.revophth.com

5/13/2013

19

Chalazia

Warm compresses

M Massage

Baby shampoo lid scrubs

Can take weeks to months to resolve

www.pediatriceyemd.com

Summary

Variety of common pediatric eye disorders can be managed by primary care physiciansbe managed by primary care physicians

Don't hesitate to refer

When in doubt . . .call us!!

5/13/2013

20

References

American Academy of Ophthalmology Basic and Clinical Science Course, Section 6, Pediatric Ophthalmology and Strabismus, 2005-2006.

Sondhi N, Archer SM, Helveston EM. Development of normal ocular alignment. J Pediatr Ophthalmol Strabismus. 1988;25:210-11.

Holmes JM, Lazar EL, Melia BM, Astle WF, Dagi LR, Donahue SP, Frazier MG, Hertle RW, Repka MX, Quinn GE, Weise KK; Pediatric Eye Disease Investigator Group Effect of age onPediatric Eye Disease Investigator Group. Effect of age on response to amblyopia treatment in children.Arch Ophthalmol. 2011 Nov;129(11):1451-7