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Case – Paediatric ophthalmology

Sarah presents to your rural general practice with her 10 month old
‘Harry’. She says that Harry went to his first childcare session a few
weeks ago and one of the carers suggested that Sarah have his
eyes reviewed by a doctor. The carer says that she had noticed that
Harry had one eye that seems to not look where the other eye was
looking. Sarah noticed it for the first time about 1 month ago but
thought he would just grow out of it. She had a brother who had a
lazy eye and wore glasses at school.
1. Take a paediatric history for Harry and a focused history on his
presenting complaint. What developmental milestones should
you be assessing for in a 9 month old child?
2. Explain the eye examination that you would do on Harry and
what positive and negative findings you may be looking for.
3. How would you explain to Sarah about ‘lazy eye’ and how
common is it? What treatment options might be available for
Harry?

DO NOT LOOK ANY FURTHER

Developmental milestones for a child of 10 months of age: PHYSICAL CHARACTERISTICS AND MOTOR SKILLS A 9 month old has usually reached the following milestones: • Gains weight at a slower rate -. even when they are not seen (object constancy) • Responds to simple commands • Responds to name • Understands the meaning of "no" • Imitates speech sounds .Paediatric history Pregnancy Birth Neonatal history Immuisation Weight/Height/HC Nutritional status Family history of strabismus and a history of children in the family wearing glasses.5 centimeters per month • Bowel and bladder become more regular • Puts hands forward when the head is pointed to the ground (parachute reflex) to protect self from falling • Is able to crawl • Sits for long periods • Pulls self to standing position • Reaches for objects while sitting • Bangs objects together • Can grasp objects between the tip of the thumb and index finger • Feeds self with fingers • Throws or shakes objects SENSORY AND COGNITIVE SKILLS The 9 month old typically: • Babbles • Has separation anxiety and may cling to parents • Is developing depth perception • Understands that objects continue to exist.about 15 grams per day. Directed history. If intermittent ask about the conditions in which it is most common such as viewing objects in the distance or near object focus. Constant or intermittent. 1 pound per month • Increases in length by 1.

and therefore do not look at the same object at the same time. If the strabismus is not treated.• May be afraid of being left alone • Plays interactive games." Causes Six different muscles surround each eye and work "as a team" so that both eyes can focus on the same object. This loss of vision is called amblyopia. When this occurs. As a result. Another name for amblyopia is "lazy eye. the problem is present at or shortly after birth. the cause is unknown. Other disorders associated with strabismus in children include: • Apert syndrome • Cerebral palsy • Congenital rubella . Most of the time. Strabismus Strabismus is a disorder in which the two eyes do not line up in the same direction. one eye looks at one object. such as peek-a-boo and pat-a-cake • Waves bye PLAY To help the development of the 9 month old: • Provide picture books • Provide different stimuli: ◦ Go to the mall (people) ◦ Go to the zoo (animals) • Build vocabulary by reading and naming people and objects in the environment • Teach hot and cold through play • Provide large toys that can be pushed to encourage walking • Sing songs together • Avoid television time until age 2 • A transition object may help decrease separation anxiety What is strabismus? Occurs between 1-2% of the population. In more than half of these cases. In most children with strabismus. In children. and not with muscle strength. these muscles do not work together. while the other eye turns in a different direction and is focused on another object. This confuses the brain.one from each eye. two different images are sent to the brain -. the eye that the brain ignores will never see well. the brain may learn to ignore the image from the weaker eye." Sometimes amblyopia is present first. This is called congenital strabismus. In someone with strabismus. The condition is more commonly known as "crossed eyes. and it causes strabismus. the problem has to do with muscle control.

Symptoms can include: • Crossed eyes • Double vision • Eyes that do not align in the same direction • Uncoordinated eye movements (eyes do not move together) • Vision or depth perception loss It’s important to note that because children can develop amblyopia so quickly. Eye tests include: • Corneal light reflex • Cover/uncover test • Retinal exam • Standard ophthalmic exam • Visual acuity A brain and nervous system (neurological) examination will also be performed. Farsightedness may be a contributing factor.• Hemangioma near the eye during infancy • Incontinentia pigmenti syndrome • Noonan syndrome • Prader-Willi syndrome • Retinopathy of prematurity • Retinoblastoma • Traumatic brain injury • Trisomy 18 Strabismus that develops in adults can be caused by: • Botulism • Diabetes (causes a condition known as acquired paralytic strabismus) • Guillain-Barre syndrome • Injury to the eye • Shellfish poisoning • Stroke • Traumatic brain injury • Vision loss from any eye disease or injury A family history of strabismus is a risk factor. . Exams and Tests A physical examination will include a detailed examination of the eyes. Treatment The first step in treating strabismus in children is to prescribe glasses. This forces the weaker eye to work harder. Symptoms Symptoms of strabismus may be present all the time. Tests will be done to determine how much the eyes are out of alignment. or may come and go. if needed. especially in children. they may never have double vision. Amblyopia or lazy eye must be treated first. Any other disease that causes vision loss may also cause strabismus. A patch is placed over the better eye.

eye muscle surgery may be needed. the eyes may look straight but vision problems can remain. the vision loss will need to be corrected before strabismus surgery can be successful. About one-third of children with strabismus will develop amblyopia. Because many children will get strabismus or amblyopia again. However. the younger a child is when the surgery is done. With early diagnosis and treatment. . Vision may affect the ability to play sports. Eye muscle repair surgery does not fix the poor vision of a lazy eye. the better the result. they need to be monitored closely. Adults with mild strabismus that comes and goes may do well with glasses and eye muscle exercises to help keep the eyes straight. When to Contact a Medical Professional Strabismus requires prompt medical evaluation. If the eyes still do not move correctly. More severe forms of adult strabismus will need surgery to straighten the eyes. A child may have to wear glasses after surgery. Outlook (Prognosis) After surgery. it is very important to use the patch or eyeglasses as directed. A patch forces the child to see through the weaker eye at first. Different muscles in the eye will be made stronger or weaker.Your child may not like wearing a patch or eyeglasses. and for adults driving may be more difficult. Delayed treatment may lead to permanent vision loss in one eye. In general. the problem can usually be corrected. The child may still have reading problems in school. If strabismus has occurred because of vision loss. Call for an appointment with your health care provider or eye doctor if your child: • Appears to be cross-eyed • Complains of double vision • Has difficulty seeing Note: Learning difficulties or problems at school can sometimes be due to a child's inability to see the blackboard or reading material.