Ocular dysfunction &diseases in

childhood
 Introduction
Vision plays a huge role in a child’s sensory and motor

development undetected visual or ocular anomalies are

liable to impede normal development .
It is therefore vital, that Optometrists be aware

of the major causes of childhood visual difficulties

so that they can correctly detect, prevent or manage
as appropriate
Incidence and epidemiology of ocular
conditions
Refractive error

What is Emmetropic eye ?

 >80% of all children (1-7yrs) have cycloplegic spherical

equivalent RE of between +0.50&+3.00DS

 <5% of all (5-7yr) are more than +5.00DShyperopic , <3%

myopic and 8% >0.75DC WTR

 juvenile myopia –the most common form, onset at any age b/n

6-15yrs
What are the risk factors?
 What are the risk factors?
a. prematurity – there is increased incidence of myopia
and significant astigmatism (>2D)at birth

- increasing prematurity , ↑e in prevalence and degree of

myopia and astigmatism

- premature neonates with ROP have a higher incidence

still of associated high myopia and unlikely to regress
b. IUGR- Children of low birth weight are at
increased risk of ROP and high myopia

c. Maternal diseases- high myopia = 4x more likely in

children born to mothers with DM

d.Gender – congenital myopia is twice as likely to

occur in females as males

- High hyperopia is equally prevalent in both sexes

- High astigmatism more in females than males

e. Ethnic difference – congenital myopia high in Afro-

caribbean (especially Jewish )whereas juvenile myopia

less common

juvenile myopia more in Jewish boys than girls

High myopia more prevalent in Japanese and Chinese

children than Caucasians

f. socio-economic status= children of low SES are more

likely born premature and LBW, maternal or childhood

diseases=> increase congenital refractive error

Juvenile myopia is less prevalent in developing countries

Astigmatism – increased in children of low socio-economic

status
G. genetics and genetics conditions – juvenile myopia

shows multifactorial inheritance pattern

It has been shown that if one parent has myopic there is a

22.5% chance of a child developing myopia

Retinitis pigmentosa – progressive pigmentary

degeneration of the retina is associated with increased

myopia
Down’s syndrome – associated with increased incidence

of high myopia, hypermetropia and astigmatism . Other

ocular problems nystagmus, cataract ,blepharitis

,strabismus reduced VA and loss of color vision

Cerebral palsy – 40-76% of children have significant RE

 Strabismus: risk factors
a. Genetic predisposition – family Hx of squint has been
shown that increased incidence of exotropia and
accommodative and partially accommodative esotropia

b. Refractive error – accommodative esotropia is

associated with significant hyperopia
c. Prematurity and birth trauma- linked to infantile
esotropia and hypotropia
d. Genetic conditions – strabismus occurs in 33%
children with down’s syndrome
fragile x syndrome and albinism are associated with
increased incidence of the strabismus
e. Maternal drug use – 24% of incidence children born to
drug dependent mothers

cigarette smoking - increased prevalence of esotropia

f. Secondary to systemic conditions – comitant or

incomitant strabismus occur 2nd ry to infections /tumors
,cerebral palsy ,rubella syndrome or after trauma
g. Prevalenence and etiology of incomittant strabismus -
15% of children most commonly overaction of one or both
IO muscles, twice in ET than XT

less common causes of muscle underaction are muscle

paralysis, muscle malinsertions, muscle fibrosis and
space-occupying lesions
h. Amblyopia – non-optical and non –pathological
reduction in visual acuity

1-2% incidence in school children

I. Convergence insufficiency - is diagnosed when the NPC

is significantly greater than the normal range

Common cause of asthenopia

j. Nystagmus – visual deprivation before the age of

2years leads to pendular and horizontal nystagmus

Common causes are congenital cataract and albinism

May also be congenital and of X-linked or autosomal

dominant transmission

- Nystagmus is associated with strabismus

Pediatric ocular pathology
a. Congenital cataract - may be primary and secondary
cortical and sutural cataract are very common but do
not interfere in vision
- lamellar – the most common congenital type and
interfere vision
 About 1/3 of congenital cataract are primary & of
hereditary origin
 1/3 acquired
 1/3 idiopathic
b. Albinism - Oculocutanoues albinism is a hereditary
inability to synthesize melanin may be partial or
total . Ocular albinism affects the eyes only (X-
linked)
- Commonly associated with strabismus as there is no
foveal differentiation
c. Congenital ptosis – usually caused by dystrophy of the
levator muscle

if the pupil obscured partly may lead to ---------?

d. Epicanthus - a fold of skin very common in infants

may give rise to appearance of esotropia (psuedo-
esotropia)
Congenital optic disc anomalies

 Drusen =calcific deposits within the optic nerve

head
 Tilted discs – appear oval with an oblique vertical
axis and occur b/c the optic nerve enter the globe in

oblique angle
- usually bilateral and often associated with
inferior crescent, myopia, oblique astigmatism and
temporal field defect

 ON myelination – are common and seen as

white patches with feathered edges
 Congenital ON anomalies
 Optic disc pit - is usually a dark oval or round pit on the
disc which may lead to retinal edeoma

 Optic disc colobama – occurs due to incomplete closure

of fetal fissure
- there is a large excavation to inferior disc often
associated with reduced vision and a superior field defect
ON anomalies…
 Optic nerve atrophy – may be inherited and varying
severity

 Optic nerve hypoplasia - often associated with fetal

alcohol syndrome
And optic disc is small and usually pale
Optic disc pit
Optic nerve myelination
Tilted disc
 Buried disc drusen
/pseudopapiloedema/
Congenital ODA are often associated with mildfacial
malformations such as cleft palate ( is a condition in
which the two plates of the skull that form the
hard palate (roof of the mouth) are not completely
joined),

=> “hare-lip”(Harelip refers to a split in the lip at birth that

looks rather like the split in a hare's lip) and nasal
malformations
Papiloedeoma – results from a space –occupying
lesion may be seen in children .

- Other conditions, such as high hyperopia or

buried disc drusen may mimic papiloedema
After correction with surgery
 Fundus anomalies
1. Retinoblastoma – the most common primary
malignant intraocular tumor
- Only about 6% of children have a positive family Hx
(incomplete autosomal dominat transmision)
luecokoria – the presenting feature for 2/3 of cases,
whereas strabismus is the presenting feature of 20% of
cases

2. ROP- occurs in neonates to whom oxygen is

administered
3. congenital toxoplasmosis - results from maternal
infection give rise to chorioretinitis

4. Ocular Toxocariasis – results from ocular infestation

with intestinal round worms of cats and dogs
-In children of age b/n 6&14 give rise to retina glaucoma ,
-In younger age (2-9yrs) may induce severe chronic
endothlmities
Anterior eye infections
Blepharitis – common in childhood and often caused
by S.aureus infection
Bacterial conjunctivitis – is common and associated
with hyperemia and purulent and mucopurulent
discharge
Viral conjunctivitis –often common and usually
caused by adenovirus .
Allergic conjunctivitis – AAC is very common in
children and is self limiting
 Corneal anomalies
Microbial Keratitis caused by malnutrition,
vitamin A deficiency and measles infection is a leading
cause of childhood onset blindness in
underdeveloped countries.
Severe corneal disease is rare in the developed
Forceps trauma , metabolic disease and buphthalmos
may cause corneal opacity
 Color vision anomalies
Inherited - are congenital , lifelong and untreatable

Prevalence - around 8% males and 0.5% females

Inherited color vision anomalies results from the

absence or modification of one or more of the cone

pigments, usually red or green

Red-green deficiency more common than blue yellow

 Summary
Taking History and symptoms – as many visual anomalies

present from birth , a child usually grows up with the

assumption that the way he or she sees the world is ‘normal
Thus behavioral and neurological development adapts

accordingly
Is not common for young children to present complaining of

any visual difficulty

As a child has no reference for the standard of vision is

important to take history by questioning the parents