PEDIATRIC OPHTHALMOLOGY

Prima Sugesty, MD
Medical Faculty, Universitas Jenderal Soedirman
Ophthalmology Department, RSUD Prof. dr. Margono Soekarjo
CONTENTS
01 Growth & Development of the Eye

02 Visual Assessment & Refractive Errors

03 Leukocoria

04 Congenital Glaucoma
 01
Growth &
Development
of the Eye
 GROWTH and DEVELOPMENT of the EYE

o Human eye undergoes dramatic anatomical & physiologic development throughout infancy &
early childhood
Dimensions of Newborn & Adult Eyes
Newborn Adult
Axial length (mm) 14.5 – 15.5 23.0 – 24.0
Corneal horizontal diameter (mm) 9.5 – 10.5 12
K value (diopters) 52.00 42.00 – 44.00

o The refractive state of the eye changes as the eye’s axial length increases & the cornea and the
lens flatten

o Visual development is highly complex maturational process (ocular changes and neural
development)
 ABNORMAL GROWTH and DEVELOPMENT of the EYE

o Major congenital anomalies occurs in 2% - 3% of live births

o Cause: chromosomal abnormalities, multifactorial disorders, environmental agents, idiopathic

Types of Congenital Anomalies
Anomaly Defect Ocular Example
Agenesis Developmental failure Anophthalmia, aniridia, congenital aphakia
Hypoplasia Developmental arrest Optic nerve hypoplasia, microphthalmia
Hyperplasia Developmental excess Distichiasis
Dysraphism Failure to fuse Choroidal coloboma
Failure to divide or canalize Congenital nasolacrimal duct obstruction
Persistence of vestigial structure Persistent fetal vasculature
 ABNORMAL GROWTH and DEVELOPMENT of the EYE

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 02
Visual
Assessment &
Refractive
Errors
 VISUAL MILESTONE

Infants Toddlers Pre-schoolers School-age

(birth – 14 mos) (14 mos – 2.5 y.o) (2.5 – 5 y.o) (5 – 18 y.o)

o Newborn can see object next to them with

their peripheral side vision -> see light & o Clear, single,
dark, blink reflex o Distance vision comfortable
o 2 – 4 mos: focusing & tracking moving nearing 20/20 vision at all
2 y.o o Recognizes
object distances
o 5 – 8 mos: reaching, recognizing, recalling Picture matching o Knows letters &
complex visual
o 9 mos: look for hidden toys shapes & letters some words
 VISUAL ACUITY

Monocular HOTV Visual Acuity Test

Age (y.o) Mean VA Threshold VA

Definition Expected VA 2.5 20/30 20/63
3 20/30 20/50

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4 20/25 20/40
5 20/20 20/32
o Preverbal children: motor and sensory
response to a threshold stimulus of known size at Rule of 8
known distance
Age (y.o) Rule of 8 Expected VA
o Preliterate but verbal children: smallest target of
known size at known testing distance correctly 2 8-2=6 20/60
verbally identified by a child 3 8-3=5 20/50
o Literate children: ability to see two separate
4 8-4=4 20/40
object separately (resolving power of the eye)
5 8-5=3 20/30
6 8-6=2 20/20
 VISUAL ACUITY ASSESSMENT

Infants Toddlers Pre-schoolers School-age

(birth – 14 mos) (14 mos – 2.5 y.o) (2.5 – 5 y.o) (5 – 18 y.o)

o Broken wheel test

o Qualitative  fixation behavior
o Fix & follow
o Central steady maintain
o Optokinetic drum test
o Quantitative
o Visual Evoked Potential
o Preferential looking test
o Cardiff acuity test
o Boek’s candy test
o Sheridan’s ball test
o Miniature toy test
o o
Worth Ivory ball test
o Marble game test
o Dot visual acuity test
o Allen pre-school test
o Kay picture test o Snellen chart
o Tumbling E chart o E chart
o Sheridan Gardiner chart o Landolt’s ring
o HOTV chart
chart
Sjogren’s isolated hand o HOTV chart
figure test o Bailey Lovie chart
o Ffook’s test
o LEA symbols/ Patti pics
test
VISUAL ACUITY ASSESSMENT
REFRACTIVE ERRORS

Consideration of prescribing glasses for children:

o Is the refractive error within the normal range
for the child’s age?
o Is the refractive error affecting child’s daily
activities?
o Child’s accommodation amplitude
o Is the refractive error amblyogenic?
 AMBLYOPIA

Strabismic amblyopia
Refractive amblyopia Results from competitive or
Results from consistent retinal inhibitory interactionbetween
defocus in 1 or both eyes neurons carrying nonfusible input
from the 2 eyes
Anisometropic amblyopia
Dissimilar refractive errors in 2 eyes
Anisohyperopia > 1.50D
Anisoastigmatism > 2.00D
Anisomyopia > 3.00D

Isoametropic amblyopia Visual deprivation amblyopia

Similarly large uncorrected refractive
errors in both eyes
Hyperopia > 4.00 – 5.00 D
Myopia > 5.00 – 6.00 D
Astigmatism > 2.00 – 3.00 D
Due to an eye abnormality that
obstructs the visual axis or
otherwise interferes with central
vision
 03
Leukocoria
 DIFFERENTIAL DIAGNOSIS

Familial Exudative Vitreoretinopathy

01 Retinoblastoma 06 Failure of peripheral retina to vascularize, mimicking RoP
Malignant intraocular tumor -> cat’s eye appearance Autosomal dominant, autosomal recessive, X-linked
Norrie Disease
02 Cataract 07 X-linked recessive disorder of retinal dysplasia
Opacity of the lens, uni/ bilateral
Boys  born blind, hearing impairment, intellectual disability
Female (carrier)  peripheral retinal abnormalities
Persistent Fetal Vasculature
03 Regression failure of hyaloid vasculature & primary Choroidal Coloboma
08 Rare, partial absence of retinal pigment epithelium & choroid
vitreous
Most frequently located in the inferonasal quadrant
Retinopathy of Prematurity (RoP)
04 Retinal vascular abnormality in premature infants 09 Retinal detachment
(birth weight of ≤1500 g or gestational age ≤ 30
weeks)

10 Uveitis
Coats Disease
05 Xanthocoria
Retinal vascular abnormalities
male > female (± 6 - 8 y.o)
 DIFFERENTIAL DIAGNOSIS

Persistent Fetal
03
Vasculature
01 Retinoblastoma

02 Cataract

05 Coats Disease

Retinopathy of Prematurity (RoP)

04
 DIFFERENTIAL DIAGNOSIS

Familial Exudative
06 07 Norrie Disease
Vitreoretinopathy
08 Choroidal Coloboma

10 Uveitis

09 Retinal detachment
 04
Congenital
Glaucoma
 CONGENITAL GLAUCOMA

A Sporadic, autosomal recessive

Trias congenital glaucoma epiphora, photophobia, blepharospasm

B Other signs: corneal opacity, Haab’s striae, corneal diameter enlargement,

buftalmos, increasing intra ocular pressure, cupping optic nerve head

Differential diagnoses: megalocornea, epiphora e.c. obstruction of

C nasolacrimalis duct, secondary glaucoma due to tumor, persistent anterior
fetal

D Treatment: surgery (goniotomy, trabeculotomy, trabeculectomy)

THANK YOU