Pediatric Ophthalmology (Qureshi, 3/19/25)

 A recording of this presentation is available HERE. 

My notes:

In pediatric patients, any condition that affects the amount of light passing through the eye will negatively affect the brain's ability to learn and see and result in permanent vision loss. 

Therefore, it is essential to treat pediatric eye disorders as quickly as possible!!

Common causes of childhood blindness, worldwide

• corneal scarring
• vitamin A deficiency
• measles
• opthalmia neonatorum
• harmful eye practices
• infective corneal ulcers
• congenital cataracts
• uncorrected refractive errors
• retinopathy of prematurity
• congenital glaucoma

WHO estimates 19 million visually impaired children worldwide, 1.4 million preventable blindness

Common pediatric eye disorders

• Amblyopia: a decrease in visual development that occurs when the brain doesn't get visual stimulation from the eyes (one or both eye send distorted image to brain, even when glasses are use). Only children get amblyopia, can result in permanent vision loss if not treated in child. Most common cause of vision loss in adults 20-70 is untreated amblyopia
• refractive amblyopia is treatable with glasses/patching
• patch the good eye, let the bad eye function, it works! but does not fix strabismus
• alternatively, drop of atropine in the good eye, to allow bad eye to see better (limits vision in good eye to a certain amount)
• deprivation amblyopia: if you have cataract or congenital ptosis blocking the pupil, very bad for visual development (poor prognosis within even 6 weeks, e.g. cataract, corneal ulcer, congenital ptosis)
• the primary care physician detects amblyopia (e.g. red light reflex), ophthalmology treats it
• asymmetric red light reflex>> urgent eval < 6 weeks of age
• Strabismus: ocular misalignment, "to squint or look obliquely", affects 4% of children <6 years, 30-50% results in reversible amblyopia (vision loss)
• strabismus testing: light reflex is the key (see image below)
• pseudostrabismus: looks like esotropia but light reflex is centered on the pupils (common in kids of Asian descent)
• surgical repair

• Congenital Cataracts: 1/3 hereditary, 1/3 associated with other disorder, 1/3 idiopathic
• must remove within 3 months to prevent irreversible vision loss
• Congenital Ptosis: must be able to see pupil, if kid is using a chin up position, vision is not a threat (ptosis is there, but vision is safe) 
  
  
  
• Horner Syndrome: when you see ptosis, check the pupils. The ptotic eye (SNS innervates the eyelid mm but also the iris dilator), if pupil assymetry with ptosis, patient needs brain/neck/upper chest imaging to follow nerve plexus to make sure there is no problem along the plexus causing the ptosis (e.g. tumor)
• Nevus of Ota: low percentage develop glaucoma (see R eye below, grey in sclera and skin)
• 
• Congenital Glaucoma: enlarged cornea, tearing eyes, spasmodic to light, can develop serious vison loss, need urgent treatment. Very different than an adult. In a kid you should be able to see swollen cornea,  almost like a corneal ulcer or maybe like one eye is bigger than the other. Should be referred urgently

• Retinoblastoma of childhood 
• most common ocular tumor or childhood
• usual onset < 4 years
• 25% present with strabismus
• treatment: radiation, chemo, possibly enucleation
• require systemic work up, including r/o pineal gland and bone tumors
• 
  
  
  
• Red eyes
• Nasolacrimal duct obstruction is very common, usually presents as tearing, common, 5% of newborns, 
• no rush to refer >>90% regress by 12 months (95% by 18 months)
• surgical treatment occurs 18-24 months w/nasolacrimal probe
• Dacryocystocoele (image below): within first few weeks of life, infection and bump w/preseptal cellulitis due to imperforate valve. Have to treat preseptal cellulitis with IV abx and then sedate and probe. It looks better after abx butu if you don't create the passage, it will recur.
  
  
  
• Blepharitis: Very common, redness in conjunctiva and redness in eyelids>> treat the eyelids (warm compresses, abx drops despite no infection> glands work and eyes work better). Can also have stye. Erythromycin ointment doesn't work, but Maxitrol drops do work.

• Neonatal conjunctivitis: neonatal gonorrhea (very violent, first day of life), chlamydia, chemical, HSV (4-5 weeks of life).
• need systemic treatment AND ointment
• Allergic conjunctivitis: itchy red eyes, papillae, zaditor drops OR systemic allergy treatment, temporary steroids okay w/taper if really bad
• vernal conjunctivitis is severe form of allergic, can lead to shield ulcers, giant papillae, often in young men
• Styes: obstruction of meibomian glands, very common 
• hordoleum is a blocked gland
• chalazion is the more chronic granulomatous form
• warm compresses, maxitrol (neomycin/polymyxin/dexamethasone) ointment, only if superinfection can consider antibiotic
• 

Pediatric Vision Screening

Direct visual acuity screening is gold standard

• Start screening age 3/4 w/HOTV or heart/house/square tools for refractive problems

(Tumbling E hard to do with young kids)

• Age 4-5, use HOTV card but can use "match card", looking for 20/40 vision (doesn't have to be better), one eye should NOT be way better than the other> this should trigger referral
• Age 5+, looking for 20/30 or better, move to Sloan Letters and repeat  q1-2 years