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Paediatric Opthlamology & Ocular Misalignment (Strabismus) Main Conditions 1) Amblyopia 2) Strabismus 3) Leucocoria Skills 1) Examination of eyes in Children

in different age groups a. Vision b. Amblyopia 2) Cover test & motility examination 3) Red reflex Vision in Children - Change in the visual acuity with age o 6/300 at birth o Slow gets better o Until 6/9 6/6 @ 36 months Then 6/6 6/5 at 5+ year old - Pre-verbal children o Fixing and following Binocular Uniocular o Fixation preference Objection to occlusion o Forced preferential looking tests Teller cards Cardiff acuity cards o Picture tests Allen pictures Kay pictures o Sheridan-Gardner test (matching) o Snellen Chart Amblyopia 1) Unilateral/bilateral reduction of best corrected visual acuity a. Onset in visually immature individuals (<7 years) b. That cannot be fully attributable to organic ocular abnormalities 2) Caused by abnormal visual stimulation during sensitive period of visual development 3) Visual acuity criteria for amblyopia a. Unilateral amblyopia i. Difference in best visual corrected acuity between 2 eyes 1. 2 or more snellen lines b. Bilateral amblyopia i. BCVA of 6/12 or less 4) Anatomical & Pathophysiological Changes a. Lateral geniculate nucleus primary visual cortex i. Development of these regions is incomplete at birth 1. Persists into the postnatal period b. Critical period:

i. Time frame early in life during which there is plasticity within the visual system 1. Particularly the visual cortex c. Experiment: Sutured lids of 1 eye in the newborn kitten amblyopia i. Examined cortical response to visual stimuli d. Cortex contained no binocularly driven cells i. Normal number of monocularly driven cells from the good eye 5) Causes of Amblyopia a. Refractive Error i. Anisometropia (1 eye) 1. Hyperopia > 1.5 D 2. Myopia -3-4 D 3. Astigmatism 1.5D ii. Ammetropia (Either eye) 1. Hyperopia >5D 2. Myopia <-8 D iii. Astigmatism >2.5D b. Stimulus Deprivation i. Ptosis (congenital) ii. Horners syndrome iii. Capillary haemangioma iv. Anterior segment disease v. Cataract congenital vi. Hyphemia c. Strabismus amblyopia i. Develops in children with strabismus who favour 1 eye for fixation most of the time 1. Exotropia 2. Esotropia ii. Adults: double vision iii. Children: will suppress: 1. The immature brain will suppress the image d. Management of Amblyopia Depends on the Cause i. Provide a clear retinal image 1. Identify & correct any refractive error 2. Cycloplegic refraction 3. Fulltime spectacle wear for refractive amblyopes 4. Spectacle wear throughout period of visual immaturity 5. Spectacle wear alone may correct mild degrees of refractive amblyopia 6. Remove any obstacles in the visual axis ii. Correct ocular dominance 1. Gold standard a. Patching of the sound eye to force fixation by the amblyopic eye 2. Atropine penalization a. 0.5 1% topical atropine in good eye b. Blur caused by the atropine fogs the good eye sufficiently i. Fixation is switched to the amblyopic eye 3. Not useful in dense amblyopia, not very effective in myopes

iii. Parental counselling 1. Treatment compliance is the most critical factor for a successful outcome 2. Treatment is only possible within a critical period (<8 years old) a. Best time to correct amblyopia i. Infancy ii. Early childhood 3. Only way to get over a lazy eye a. Force the bad eye to work 4. Treatment gets more difficult as the child grows older 5. Future career choices may be limited Strabismus 1) Ocular mis-alignment a. Orthophoria i. Ideal condition of ocular balance b. Hetero-phoria (latent strabismus) i. Ocular deviation kept latent 1. Fusional mechanism of the eye c. Hetero-tropia (manifest strabismus) i. Ocular deviation that is manifest and not kept under control by the fusional mechanism 2) Hetero-tropia Classification a. Intermittent or Constant b. Movement i. Horizontal 1. Eso or Exo-deviation ii. Vertical 1. Hyper or Hypo-deviation iii. Torsional 1. Incyclo or Ex-cyclo-torsion iv. Combined c. Monocular or alternating d. Concomitant or incomitant i. Con-comitant: 1. Deviation is constant regardless of the direction of gaze or fixating eye 2. Types: a. Congenital estropia b. Accomodative estropia i. Wear glasses: straight c. Intermitttent exotropia i. When tired ii. In-comitant: 1. Mostly paralytic or restrictive 2. Right 4th nerve palsy 3. Left 6th nerve palsy 4. Right 3rd nerve palsy 5. Thyroid eye disease e. Congenital or Acquired 3) Assessment of the Squint a. Test vision b. Hirschberg light test (Corneal light reflex)

i. Psuedo-convergent squint 1. Caused by the fold of skin that covers the inner part of the eye/broad nasal bridge (epicanthic fold) 2. Common in Asian children, a. Especially Chinese 3. No treatment is necessary Leucocoria White Pupil - Examination: red reflex is gone 1) Causes a. Retinoblastoma i. Commonest intra-ocular malignancy in childhood ii. Usually presents before 3 years iii. Heritable and non-heritable forms 1. Heritable: usually bilateral iv. Treatment: local or systemic 1. Save life 2. Save eye 3. Save vision b. Retinopathy of prematurity i. Affects immature vasculature in eyes of premature babies ii. Mild with no visual defects 1. Aggressive with new blood vessel formation (neovascularization) 2. Progresses to retinal detachment blindness iii. Risk factors: 1. Low birth weight 2. Early gestation 3. Supplemental oxygen c. Opthalmic Neonatorum i. Neo-natal conjunctivitis (within 1 motnh of birth) ii. All should be referred iii. Causes: 1. Gonococcal a. Meningitis b. Hyper-purulent discharge corneal perforation 2. Chlamydial a. Pneumonitis i. Treatment for above both systemic antibiotics 3. Bacterial 4. Viral 5. Chemical d. Cataract e. Persistent fetal vasculature

Cover test i. Cover-uncover 1. Left eye turned in (convergent squint) a. Occlusion of the right eye causes the left eye to turn out to fixate 2. Right eye will turn in as the same direction as the left eye ii. Alternate cover (reveals latent squint) 1. Breakdown in fusion a. When cover: the covered one is turning 2. When you cover the other eye, it fixates towards the centre a. Therefore there may be a lag iii. Cover test with prisms f. Eye movements i. Test extra-ocular movements in all 9 positions of gaze ii. Check versions (bino-cular) and ductions (monocular) g. Stereoacuity i. 3D vision: a measure of how well both eyes fuse images together h. Refraction i. Full eye and neurological assessment Constant, Untreated Squint 1) Ambloypia a. Child does not use the squint eye to see 2) Poor binocular vision a. Ability to appreciate depth or stereo-vision requires both eyes to be aligned i. Sot that they are used as a pair 3) Abnormal head posture a. Head tilt/turn to keep both eyes aligned