EYE DISORDER IN

CHILDHOOD &
ADOLESCENT
Lia Meuthia Zaini
FK Unsyiah / RSUZA

Frequent case of pediatric patients:

Refractive error
Congenital cataract
Congenital glaucoma
Amblyopia
Retinoblastoma
Ophthalmia Neonatorum
Vernal Conjunctivitis
Deviated eye / strabismus

REFRACTIVE ERROR
A refractive error means that the eye shape does
not bend light correctly, resulting in a blurred
image.
Light has to be refracted or bent by the cornea and
the lens to the retina.

REFRACTIVE ERROR

Myopia (distant objects are blurry)

- nearsightedness, is inherited and is often discovered
in childhood.
- Often progresses throughout the teenage years,
when the body is growing rapidly.

Hyperopia (close objects are blurry)

- Also known as farsightedness is usually inherited.
- Children are often hyperopic which may lessen as an
adult.

REFRACTIVE ERROR
.

Astigmatism

(blurred vision at all

distances)
- Occurs when the cornea, has an irregular
curvature/ curved more in one direction than in the
other.
- Normally the cornea is smooth and equally
curved in all directions light entering the cornea
is focused equally on all planes, or in all directions.
- This abnormality may result in vision that is much
like looking into a distorted, wavy mirror.

REFRACTIVE ERROR

Presbyopia

(aging of the lens in the eye)

After age 40, the lens of the eye becomes more

rigid and does not flex as easily. The result is that
it is more difficult to read at close range. This
normal aging process of the lens can also be
combined with myopia, hyperopia or astigmatism.

REFRACTIVE ERROR

Emmetropia

Miopia

Hipermetropia

Astigmatisma

REFRACTIVE ERROR

SYMPTOMS

Blurred vision
Difficulty reading or seeing up close
Crossing of the eyes in children
The symptoms may not necessarily mean
refractive disorder.

REFRACTIVE ERROR

Eye glasses
Contact lens
Laser (LASIK)
Others

REFRACTIVE ERROR
EYE GLASSES

Advantage :
save, user friendly,
correct all refractive errors
Disadvantage :
Uncomfortable, high refractive
errors image smaller/
higher

REFRACTIVE ERROR
SOFT CONTACT LENS

Advantage :
Good image in high refractive error, comfortable, any color
Established
Disadvantage :
Wrong administration serious side effect
Cannot correct astigmatism

REFRACTIVE ERROR
LASIK
Advantage :
Save, good image in most cases,
good patients satisfied
Disadvantage :
Side effect (+) small number
of case, expensive

REFRACTIVE ERROR
Implantable contact lens

Phacic Intra Ocular Lens

OTHER TREATMENT

CONGENITAL CATARACT

Cataract : Opacity of the lens

Congenital cataract
- 3 : 10.000 live births
- 2/3 cases are bilateral
- The most common cause: genetic mutation
- Other causes:
chromosomal abnormalities such as Down Syndrome,
metabolic disorder such as galactosemia,
intrauterine insults such as rubella infection
a part of developmental disorder of the eye such as aniridia
- Congenital unilateral cataract remains less clear

CONGENITAL CATARACT
Systemic associations
Metabolic
- Galactosemia
- Lowe syndrome
- hypoparathyroidism
Intrauterine infection
- Congenital rubela
- Toxoplasmosis
- Citomegalo virus
- Herpes symplex
- Varicella

Chromosomal abnormality
- Down syndrome
- Edward syndrome

CONGENITAL CATARACT
Management
Ocular examination
1. Density
2. Morphology
3. Associates ocular phatology
4. Other indicator of visual impairment
Systemic investigation
1. Serology
2. Urine
3. Referral to a pediatrician

CONGENITAL CATARACT
Surgical Management
1. Bilateral dense : Require early surgery
2. Bilateral partial : May not require surgery until
later, if at all
3. Unilateral dense : Merits urgent surgery (within
days) followed by aggressive amblyopia therapy
4. Partial unilateral : can usually be observed or
treated non surgically

CONGENITAL CATARACT

Visual rehabilitation
1.
2.
3.
4.

Spectacles
Contact lenses
IOL implantation
Occlusion

CONGENITAL GLAUCOMA
What Is Glaucoma ??
Glaucoma is
- Characteristic Optic Neuropathy
- Progressive visual field loss
- Raised IOP as the most important risk factor
Primary congenital or infantile glaucoma is evident either
at birth or within the first few years of life

CONGENITAL GLAUCOMA

Childhood Glaucoma
- Primary Cong / infantile glaucoma
- Glaucoma associates with cong anomalies
- Secondary glaucoma in infants and children

CONGENITAL GLAUCOMA

Pathogenesis
- Exact mechanism remains unproven
- Theories proposed by some investigators
- cellular membranous abnormality in the
trabecular meshwork
- abnormal insertion of ciliary muscle

CONGENITAL GLAUCOMA
Clinical features
- epiphora
- photophobia
- blepharospasm

classic triad of congenital

glaucoma

- Buphthalmos (enlargement of the eye)

- corneal edema
- Haabs striae
- reduce visual acuity
- astigmatism
- amblyopia
- lens dislocation
- retinal detachment

CONGENITAL GLAUCOMA

Management
- Medical management
Anti-glaucoma medication
- Surgical management
Improving aqueous outflow

AMBLYOPIA

Amblyopia is reduce of best corrected

visual acuity that could be bilateral or
unilateral, and have no association with
organic diseases of the eye and visual
pathway

AMBLYOPIA

Etiology
Visual disturbing during childhood
- Strabismus
- Anisometropia
- Isometropia ( high refractive error)
- Visual deprivation

AMBLYOPIA

Epidemiology
Prevalence : 1.6% 3.6 %
North Amerika : 2%-4%
Afro-Amerika : 2.5%
Hispanic : 2.4%
( 78% cases cause by refractive error )

AMBLYOPIA
Patophysiology

Neurologic mechanism unclear

Theory
- Disturbing of the neuron of the visual
pathway function system during childhood
- Cells on the primary visual kortex have no/
less respons toward stimulation

AMBLYOPIA

- Abnormality also happen to the neuron in lateral

geniculate body.
-Other theory : Critical periode of amblyopia has
association with the time of developing visual pathway
neuron. If this critical periode is over (child already grown
up), amblyopia could not happen anymore

AMBLYOPIA

Classification

Strabismik amblyopia
Anisometropia amblyopia
Isometropia amblyopia
Deprivation amblyopia

AMBLYOPIA
Diagnosis
- Reduce of visual acuity
- No organic diseases
- There are a history or a condition which have an
association with developing amblyopia (ptosis,
cataract, not corrected refractive error)
- Reducing of visual acuity could not corrected or
correction could not reach 6/6

AMBLYOPIA
Management
Principle :
1. Eradicate everything which can hamper vision
(cataract, ptosis, etc), if it is possible.
2. Correct refractive error
3. Use the worse eye compulsively with limiting the
use of the better eye

AMBLYOPIA
Cataract Extraction
Undertake within 2-3 months of life
Correct refractive error
Full correction with cycloplegia
Occlusion and Optical degradation
- Ful time / part time patching with the use of ocluder/
adhesive patches
- Penalisasi (instill of atropin 1%/ homatropin 5% ED) to
the better eye will force the use of the worse eye

RETINOBLASTOMA

Retinoblastoma is the most common primary,

Intraocular malignancy of childhood and accounts for
about 3% of all childhood cancer.
Presentation is within the first year of life in bilateral
cases and around 2 years of age if the tumor is
unilateral

RETINOBLASTOMA

leukocoria (the most common )

strabismus is the second most common
secondary glaucoma
diffuse retinoblastoma : red eye due to tumor induce uveitis
orbital inflammation mimicking orbital or preseptal cellulitis
may occur with necrotic tumors.
orbital invasion with proptosis and bone invasion may occur
in neglected case
rare case : metastatic to regional lymph node and brain
before detection of ocular involvement
raised intracranial pressure because of trilateral
retinoblastoma before detction of ocular involvement

RETINOBLASTOMA

RETINOBLASTOMA

Signs :
Indirect ophthalmoscope with scleral indentation :
intraocular tumor is a homogenous, dome shaped, white
lesion which becomes irregular, often with white flecks or
calcification
Endophytic tumor : white mass that may seed into the
vitreous
Exophytic tumor : forms subretinal, multilobulated
white masses with overlying retinal detachment

RETINOBLASTOMA
Investigations :
- Ultrasound
: calcification (+)
- CT Scan
: calcification (+)
- MRI
: optic nerve evaluation and detection
of extra-ocular extension or pineoblastoma
-Systemic
: to investigate the presence of metastatic
diseases

RETINOBLASTOMA
Treatment of small tumor
1. Photocoagulation
2. Cryotheraoy
3. Chemotherapy
Treatment of medium-sized tumor
1. Brachytherapy
2. Primary chemotheraphy
3. External beam radiotherapy
Treatment of large tumors
1. Chemotheraphy
2. Enucleation

OPHTHALMIA NEONATORUM
Opthalmia Neonatorum / Neonatal Conjunctivitis
develops within 2 weeks of birth as the result of infection
transmitted from mother to infant during pregnancy
Serious : - lack of immunity in the infant
- immaturity of the ocular surface

OPHTHALMIA NEONATORUM
Onset and Presentation

Etiology

Conjunctival Scraping

Within 24 hours
Mild lid edema plus water discharge

Silver nitrate

Neg. to a few PMN

2 to 4 days
Severe lid swelling, purulen
discharge

N.gonorrhea

Gram negative intracellular

diplococci

4-10 days
Variable severity of lid swelling and
serous or purulent discharge

Chlamydia

Giemsa stain for basophilic

cytoplasmic inclusion
bodies; positive direct
immunofluorescent assay

4 days to 7 days
Purulent discharge

Other
bacteria

Gram stain positive for specific

bacteria

6 days to 2 weeks
Often unilateral serous discharge
with keratitis

Herpes
simplex

Gram stain for multinucleated

giant cells, Papanicolaon intranuclear inclusion
bodies

OPHTHALMIA NEONATORUM
Diagnosis
1. Presentation : 3 19 days after birth
2. Signs : usually bilateral eyelid edema, discharge,
papilary conjunctival with pseudomembranes,
corneal complication include corneal perforation and
ulcer
3. Investigations
Laboratory finding

OPHTHALMIA NEONATORUM
Treatment
Chlamydial
Oral erythromycin ethyl succinate (2 -3weeks)
Gonoccocal
Injection of ceftriaxone or cefotaxime
Other bacterial
Chloramphenicol or neomycine ointment
Systemic antibiotics maybe consider in severe case
Herpes simplex
systemic acyclovir (14 days)
topical acyclovir (5 times daily)

OPHTHALMIA NEONATORUM
Prophylaxis
Povidone-iodine 2.5% cheap and effective
Erythromycin 0.5% ointment or tetracycline 1% ointment

DEVIATED EYE
Infantile (Congenital) Esotropia
Esotropia is eso-deviation that is not control
by fusional mechanism, so the deviation is
constantly manifest
Congenital esotropia is esotropia which the
onset at birth.

DEVIATED EYE
Infantile (Congenital) Esotropia
- Family history is often present
- Occurs in up to 30% of children with
neurologic and developmental problem

DEVIATED EYE
Management
- Correction of the refractive error
- Surgical (after correction of significant
refractive error and treatment of amblyopia)
- Botulinum toxin injection to medial rectus
muscle

DEVIATED EYE
Congenital exo-tropia
- Exodeviation of the eye before age 6
months
- often associates with neurologic
impairment or craniofacial disorder
- Treatment : Early surgery may help to
establish peripheral fusion
- potential for high grade stereopsis and
bifoveal fixation is poor

VERNAL CONJUCTIVITIS
- Vernal kerato-conjuctivitis is bilateral, recurrent disorder
in which IgE and cell mediated immune mechanism
play important roles.
-Usually present in the first decade of life
- 95% of cases remit by the late teens and the remainder
develops atopic keratokonjundtivitis
- Such patients often develop asthma and eczema in infancy

VERNAL CONJUCTIVITIS
Calcification :
1. Palpebral
2. Limbal
3. Mixed

VERNAL CONJUCTIVITIS

Diagnosis
Symptoms
Intense itching, lacrimation, photophobia, foreign body
sensation, burning, and thick mucoid discharge.
Constant blinking is also common and maybe misdiagnosed
as neurotic

VERNAL CONJUCTIVITIS

Diagnosis
Signs
Palpebral diseases
-Papillary hipertrophy
-Macropapillae/ cobblestones
-Mucus deposition
Limbal diseases
-Gelatinous papillae on the limbal conjunctiva

VERNAL CONJUCTIVITIS

Treatment
Topical
- Mast cell stabilizers
- Antihistamines
- Steroids
- Cyclosporine
- Supratasrsal steroid injection
- Systemic Immunosuppressive agent
- Oral antihistamines

VERNAL CONJUCTIVITIS

Surgery
Superficial kleratectomy
Amniotic membrane overlay graft

TERIMAKASIH