EYE DISORDER IN

CHILDHOOD &
ADOLESCENT
Lia Meuthia Zaini
FK Unsyiah / RSUZA
Frequent case of pediatric patients:

Refractive error
Congenital cataract
Congenital glaucoma
Amblyopia
Retinoblastoma
Ophthalmia Neonatorum
Vernal Conjunctivitis
Deviated eye / strabismus


REFRACTIVE ERROR




A refractive error means that the eye shape does
not bend light correctly, resulting in a blurred
image.

Light has to be refracted or bent by the cornea and
the lens to the retina.

REFRACTIVE ERROR



Myopia (distant objects are blurry)
- nearsightedness, is inherited and is often discovered
in childhood.
- Often progresses throughout the teenage years,
when the body is growing rapidly.

Hyperopia (close objects are blurry)
- Also known as farsightedness is usually inherited.
- Children are often hyperopic which may lessen as
an adult.

REFRACTIVE ERROR



.
Astigmatism (blurred vision at all distances)

- Occurs when the cornea, has an irregular
curvature/ curved more in one direction than in the
other.
- Normally the cornea is smooth and equally
curved in all directions light entering the cornea
is focused equally on all planes, or in all directions.
- This abnormality may result in vision that is much
like looking into a distorted, wavy mirror.
REFRACTIVE ERROR



Presbyopia (aging of the lens in the eye)

After age 40, the lens of the eye becomes more
rigid and does not flex as easily. The result is that
it is more difficult to read at close range. This
normal aging process of the lens can also be
combined with myopia, hyperopia or astigmatism.


REFRACTIVE ERROR





Emmetropia
Astigmatisma
Hipermetropia
Miopia
REFRACTIVE ERROR



SYMPTOMS


Blurred vision
Difficulty reading or seeing up close
Crossing of the eyes in children
The symptoms may not necessarily mean
refractive disorder.
REFRACTIVE ERROR



Eye glasses
Contact lens
Laser (LASIK)
Others
REFRACTIVE ERROR






EYE GLASSES


Advantage :
save, user friendly,
correct all refractive errors

Disadvantage :
Uncomfortable, high refractive
errors image smaller/
higher

REFRACTIVE ERROR



SOFT CONTACT LENS




Advantage :
Good image in high refractive error, comfortable, any color
Established

Disadvantage :
Wrong administration serious side effect
Cannot correct astigmatism

REFRACTIVE ERROR


Advantage :
Save, good image in most cases,
good patients satisfied

Disadvantage :
Side effect (+) small number
of case, expensive



LASIK
REFRACTIVE ERROR



Implantable contact lens
Phacic Intra Ocular Lens
OTHER TREATMENT
CONGENITAL CATARACT




Cataract : Opacity of the lens
Congenital cataract
- 3 : 10.000 live births
- 2/3 cases are bilateral
- The most common cause: genetic mutation
- Other causes:
chromosomal abnormalities such as Down Syndrome,
metabolic disorder such as galactosemia,
intrauterine insults such as rubella infection
a part of developmental disorder of the eye such as aniridia
- Congenital unilateral cataract remains less clear

CONGENITAL CATARACT




Systemic associations

Metabolic Chromosomal abnormality
- Galactosemia - Down syndrome
- Lowe syndrome - Edward syndrome
- hypoparathyroidism

Intrauterine infection
- Congenital rubela
- Toxoplasmosis
- Citomegalo virus
- Herpes symplex
- Varicella


CONGENITAL CATARACT




Management
Ocular examination
1. Density
2. Morphology
3. Associates ocular phatology
4. Other indicator of visual impairment

Systemic investigation
1. Serology
2. Urine
3. Referral to a pediatrician



CONGENITAL CATARACT




Surgical Management
1. Bilateral dense : Require early surgery
2. Bilateral partial : May not require surgery until
later, if at all
3. Unilateral dense : Merits urgent surgery (within
days) followed by aggressive amblyopia therapy
4. Partial unilateral : can usually be observed or
treated non surgically

CONGENITAL CATARACT



Visual rehabilitation

1. Spectacles
2. Contact lenses
3. IOL implantation
4. Occlusion
CONGENITAL GLAUCOMA



What Is Glaucoma ??
Glaucoma is
- Characteristic Optic Neuropathy
- Progressive visual field loss
- Raised IOP as the most important risk factor

Primary congenital or infantile glaucoma is evident either
at birth or within the first few years of life

CONGENITAL GLAUCOMA







Childhood Glaucoma

- Primary Cong / infantile glaucoma
- Glaucoma associates with cong anomalies
- Secondary glaucoma in infants and children


- Exact mechanism remains unproven
- Theories proposed by some investigators
- cellular membranous abnormality in the
trabecular meshwork
- abnormal insertion of ciliary muscle
CONGENITAL GLAUCOMA


Pathogenesis

CONGENITAL GLAUCOMA




Clinical features

- epiphora
- photophobia classic triad of congenital
- blepharospasm glaucoma



- Buphthalmos (enlargement of the eye)
- corneal edema
- Haabs striae
- reduce visual acuity
- astigmatism
- amblyopia
- lens dislocation
- retinal detachment
CONGENITAL GLAUCOMA



Management
- Medical management
Anti-glaucoma medication

- Surgical management
Improving aqueous outflow


AMBLYOPIA


Amblyopia is reduce of best corrected
visual acuity that could be bilateral or
unilateral, and have no association with
organic diseases of the eye and visual
pathway
AMBLYOPIA


Etiology

Visual disturbing during childhood
- Strabismus
- Anisometropia
- Isometropia ( high refractive error)
- Visual deprivation
AMBLYOPIA


Epidemiology

Prevalence : 1.6% 3.6 %
North Amerika : 2%-4%
Afro-Amerika : 2.5%
Hispanic : 2.4%
( 78% cases cause by refractive error )
AMBLYOPIA

Patophysiology

Neurologic mechanism unclear

Theory
- Disturbing of the neuron of the visual
pathway function system during childhood

- Cells on the primary visual kortex have no/
less respons toward stimulation

AMBLYOPIA


- Abnormality also happen to the neuron in lateral
geniculate body.

-Other theory : Critical periode of amblyopia has
association with the time of developing visual pathway
neuron. If this critical periode is over (child already grown
up), amblyopia could not happen anymore
AMBLYOPIA


Classification

Strabismik amblyopia
Anisometropia amblyopia
Isometropia amblyopia
Deprivation amblyopia

AMBLYOPIA


Diagnosis

- Reduce of visual acuity
- No organic diseases
- There are a history or a condition which have an
association with developing amblyopia (ptosis,
cataract, not corrected refractive error)
- Reducing of visual acuity could not corrected or
correction could not reach 6/6


AMBLYOPIA




Management

Principle :

1. Eradicate everything which can hamper vision
(cataract, ptosis, etc), if it is possible.
2. Correct refractive error
3. Use the worse eye compulsively with limiting the
use of the better eye
AMBLYOPIA




Cataract Extraction
Undertake within 2-3 months of life

Correct refractive error
Full correction with cycloplegia

Occlusion and Optical degradation
- Ful time / part time patching with the use of ocluder/
adhesive patches
- Penalisasi (instill of atropin 1%/ homatropin 5% ED) to
the better eye will force the use of the worse eye


RETINOBLASTOMA

Retinoblastoma is the most common primary,
Intraocular malignancy of childhood and accounts for
about 3% of all childhood cancer.






Presentation is within the first year of life in bilateral
cases and around 2 years of age if the tumor is
unilateral
RETINOBLASTOMA

leukocoria (the most common )
strabismus is the second most common
secondary glaucoma
diffuse retinoblastoma : red eye due to tumor induce uveitis
orbital inflammation mimicking orbital or preseptal cellulitis
may occur with necrotic tumors.
orbital invasion with proptosis and bone invasion may occur
in neglected case
rare case : metastatic to regional lymph node and brain
before detection of ocular involvement
raised intracranial pressure because of trilateral
retinoblastoma before detction of ocular involvement

RETINOBLASTOMA

RETINOBLASTOMA

Signs :
Indirect ophthalmoscope with scleral indentation :
intraocular tumor is a homogenous, dome shaped, white
lesion which becomes irregular, often with white flecks or
calcification
Endophytic tumor : white mass that may seed into the
vitreous
Exophytic tumor : forms subretinal, multilobulated
white masses with overlying retinal detachment
RETINOBLASTOMA

Investigations :
- Ultrasound : calcification (+)
- CT Scan : calcification (+)
- MRI : optic nerve evaluation and detection
of extra-ocular extension or pineoblastoma
-Systemic : to investigate the presence of metastatic
diseases



RETINOBLASTOMA

Treatment of small tumor
1. Photocoagulation
2. Cryotheraoy
3. Chemotherapy

Treatment of medium-sized tumor
1. Brachytherapy
2. Primary chemotheraphy
3. External beam radiotherapy

Treatment of large tumors
1. Chemotheraphy
2. Enucleation


OPHTHALMIA NEONATORUM
Opthalmia Neonatorum / Neonatal Conjunctivitis
develops within 2 weeks of birth as the result of infection
transmitted from mother to infant during pregnancy

Serious : - lack of immunity in the infant
- immaturity of the ocular surface



OPHTHALMIA NEONATORUM
Onset and Presentation Etiology Conjunctival Scraping
Within 24 hours
Mild lid edema plus water discharge

2 to 4 days
Severe lid swelling, purulen
discharge

4-10 days
Variable severity of lid swelling and
serous or purulent discharge


4 days to 7 days
Purulent discharge

6 days to 2 weeks
Often unilateral serous discharge
with keratitis
Silver nitrate


N.gonorrhea



Chlamydia




Other
bacteria

Herpes
simplex
Neg. to a few PMN


Gram negative intracellular
diplococci


Giemsa stain for basophilic
cytoplasmic inclusion
bodies; positive direct
immunofluorescent assay

Gram stain positive for specific
bacteria

Gram stain for multinucleated
giant cells, Papanicolaon -
intranuclear inclusion
bodies
OPHTHALMIA NEONATORUM
Diagnosis

1. Presentation : 3 19 days after birth
2. Signs : usually bilateral eyelid edema, discharge,
papilary conjunctival with pseudomembranes,
corneal complication include corneal perforation and
ulcer
3. Investigations
Laboratory finding
OPHTHALMIA NEONATORUM
Treatment

Chlamydial
Oral erythromycin ethyl succinate (2 -3weeks)
Gonoccocal
Injection of ceftriaxone or cefotaxime
Other bacterial
Chloramphenicol or neomycine ointment
Systemic antibiotics maybe consider in severe case
Herpes simplex
systemic acyclovir (14 days)
topical acyclovir (5 times daily)
OPHTHALMIA NEONATORUM
Prophylaxis

Povidone-iodine 2.5% cheap and effective
Erythromycin 0.5% ointment or tetracycline 1% ointment
DEVIATED EYE

Infantile (Congenital) Esotropia
Esotropia is eso-deviation that is not control
by fusional mechanism, so the deviation is
constantly manifest
Congenital esotropia is esotropia which the
onset at birth.
DEVIATED EYE

Infantile (Congenital) Esotropia
- Family history is often present
- Occurs in up to 30% of children with
neurologic and developmental problem
DEVIATED EYE

Management
- Correction of the refractive error
- Surgical (after correction of significant
refractive error and treatment of amblyopia)
- Botulinum toxin injection to medial rectus
muscle
DEVIATED EYE

Congenital exo-tropia
- Exodeviation of the eye before age 6
months
- often associates with neurologic
impairment or craniofacial disorder
- Treatment : Early surgery may help to
establish peripheral fusion
- potential for high grade stereopsis and
bifoveal fixation is poor


VERNAL CONJUCTIVITIS
- Vernal kerato-conjuctivitis is bilateral, recurrent disorder
in which IgE and cell mediated immune mechanism
play important roles.

-Usually present in the first decade of life

- 95% of cases remit by the late teens and the remainder
develops atopic keratokonjundtivitis

- Such patients often develop asthma and eczema in infancy
VERNAL CONJUCTIVITIS
Calcification :
1. Palpebral
2. Limbal
3. Mixed








VERNAL CONJUCTIVITIS

Diagnosis

Symptoms
Intense itching, lacrimation, photophobia, foreign body
sensation, burning, and thick mucoid discharge.
Constant blinking is also common and maybe misdiagnosed
as neurotic

VERNAL CONJUCTIVITIS

Diagnosis

Signs

Palpebral diseases
-Papillary hipertrophy
-Macropapillae/ cobblestones
-Mucus deposition

Limbal diseases
-Gelatinous papillae on the limbal conjunctiva
VERNAL CONJUCTIVITIS
Treatment
Topical
- Mast cell stabilizers
- Antihistamines
- Steroids
- Cyclosporine
- Supratasrsal steroid injection
- Systemic Immunosuppressive agent
- Oral antihistamines
VERNAL CONJUCTIVITIS
Surgery

Superficial kleratectomy
Amniotic membrane overlay graft






TERIMAKASIH