case - paediatric ophthalmology

8/18/2019 Case - Paediatric Ophthalmology

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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 frst childcare session a ewwee s ago and one o the carers suggested that Sarah ha!e hiseyes re!iewed "y a doctor. #he carer says that she had noticed thatHarry had one eye that seems to not loo where the other eye wasloo ing. Sarah noticed it or the frst time a"out 1 month ago "utthought he would $ust grow out o it. She had a "rother who had ala%y eye and wore glasses at school.

1. #a e a paediatric history or Harry and a ocused history on hispresenting complaint. &hat de!elopmental milestones shouldyou "e assessing or in a ' month old child(

). *+plain the eye e+amination that you would do on Harry andwhat positi!e and negati!e fndings you may "e loo ing or.

,. How would you e+plain to Sarah a"out ‘la%y eye’ and howcommon is it( &hat treatment options might "e a!aila"le orHarry(

- / # 2/3 456#H*6


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Paediatric historyPregnancy7irth/eonatal history8mmuisation&eight9Height9HC/utritional status4amily history o stra"ismus and a history o children in the amilywearing glasses.

-irected history.Constant or intermittent. 8 intermittent as a"out the conditions inwhich it is most common such as !iewing o"$ects in the distance ornear o"$ect ocus.

-e!elopmental milestones or a child o 10 months o age:

PH3S8C2 CH262C#*68S#8CS 2/- ; # 6 S 8 S2 ' month old has usually reached the ollowing milestones:

< =ains weight at a slower rate >> a"out 1? grams per day@ 1pound per month

< 8ncreases in length "y 1.? centimeters per month

< 7owel and "ladder "ecome more regular< Puts hands orward when the head is pointed to the groundAparachute reBe+ to protect sel rom alling

< 8s a"le to crawl< Sits or long periods< Pulls sel to standing position< 6eaches or o"$ects while sitting< 7angs o"$ects together< Can grasp o"$ects "etween the tip o the thum" and inde+

fnger< 4eeds sel with fngers< #hrows or sha es o"$ects

S*/S 63 2/- C =/8#8D* S 8 S #he ' month old typically:

< 7a""les< Has separation an+iety and may cling to parents< 8s de!eloping depth perception< 5nderstands that o"$ects continue to e+ist@ e!en when they

are not seen Ao"$ect constancy< 6esponds to simple commands< 6esponds to name

< 5nderstands the meaning o EnoE< 8mitates speech sounds


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< ;ay "e a raid o "eing le t alone< Plays interacti!e games@ such as pee >a>"oo and pat>a>ca e< &a!es "ye

P 23 #o help the de!elopment o the ' month old:

< Pro!ide picture "oo s< Pro!ide diFerent stimuli:

G =o to the mall ApeopleG =o to the %oo Aanimals

< 7uild !oca"ulary "y reading and naming people and o"$ects inthe en!ironment

< #each hot and cold through play< Pro!ide large toys that can "e pushed to encourage wal ing< Sing songs together< 2!oid tele!ision time until age )< 2 transition o"$ect may help decrease separation an+iety

&hat is stra"ismus(ccurs "etween 1>) o the population.

Strabismus

Stra"ismus is a disorder in which the two eyes do not line up in thesame direction@ and there ore do not loo at the same o"$ect at thesame time. #he condition is more commonly nown as Ecrossed

eyes.ECausesSi+ diFerent muscles surround each eye and wor Eas a teamE sothat "oth eyes can ocus on the same o"$ect.8n someone with stra"ismus@ these muscles do not wor together. 2sa result@ one eye loo s at one o"$ect@ while the other eye turns in adiFerent direction and is ocused on another o"$ect.&hen this occurs@ two diFerent images are sent to the "rain >> one

rom each eye. #his con uses the "rain. 8n children@ the "rain maylearn to ignore the image rom the wea er eye.8 the stra"ismus is not treated@ the eye that the "rain ignores willne!er see well. #his loss o !ision is called am"lyopia . 2nother name

or am"lyopia is Ela%y eye.E Sometimes am"lyopia is present frst@and it causes stra"ismus.8n most children with stra"ismus@ the cause is un nown. 8n morethan hal o these cases@ the pro"lem is present at or shortly a ter"irth. #his is called congenital stra"ismus.;ost o the time@ the pro"lem has to do with muscle control@ and notwith muscle strength.

ther disorders associated with stra"ismus in children include:< 2pert syndrome

< Cere"ral palsy< Congenital ru"ella

http://www.nlm.nih.gov/medlineplus/ency/article/001014.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001014.htm


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< Hemangioma near the eye during in ancy< 8ncontinentia pigmenti syndrome< /oonan syndrome< Prader>&illi syndrome< 6etinopathy o prematurity< 6etino"lastoma< #raumatic "rain in$ury< #risomy 1I

Stra"ismus that de!elops in adults can "e caused "y:< 7otulism< -ia"etes Acauses a condition nown as acJuired paralytic

stra"ismus< =uillain>7arre syndrome< 8n$ury to the eye< Shellfsh poisoning< Stro e< #raumatic "rain in$ury< Dision loss rom any eye disease or in$ury

2 amily history o stra"ismus is a ris actor. 4arsightedness may "ea contri"uting actor@ especially in children. 2ny other disease thatcauses !ision loss may also cause stra"ismus.SymptomsSymptoms o stra"ismus may "e present all the time@ or may comeand go. Symptoms can include:

< Crossed eyes< -ou"le !ision

< *yes that do not align in the same direction< 5ncoordinated eye mo!ements Aeyes do not mo!e together< Dision or depth perception loss

8t’s important to note that "ecause children can de!elop am"lyopiaso Juic ly@ they may ne!er ha!e dou"le !ision. Exams and Tests2 physical e+amination will include a detailed e+amination o theeyes. #ests will "e done to determine how much the eyes are out oalignment.*ye tests include:

< Corneal light reBe+< Co!er9unco!er test< 6etinal e+am< Standard ophthalmic e+am< Disual acuity

2 "rain and ner!ous system Aneurological e+amination will also "eper ormed.Treatment

#he frst step in treating stra"ismus in children is to prescri"eglasses@ i needed.

2m"lyopia or la%y eye must "e treated frst. 2 patch is placed o!erthe "etter eye. #his orces the wea er eye to wor harder.

http://www.nlm.nih.gov/medlineplus/ency/article/001020.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002274.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003434.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003396.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001020.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002274.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003434.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003396.htm


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3our child may not li e wearing a patch or eyeglasses. 2 patchorces the child to see through the wea er eye at frst. Howe!er@ it is

!ery important to use the patch or eyeglasses as directed.8 the eyes still do not mo!e correctly@ eye muscle surgery may "eneeded. -iFerent muscles in the eye will "e made stronger orwea er.*ye muscle repair surgery does not f+ the poor !ision o a la%y eye.2 child may ha!e to wear glasses a ter surgery. 8n general@ theyounger a child is when the surgery is done@ the "etter the result.2dults with mild stra"ismus that comes and goes may do well withglasses and eye muscle e+ercises to help eep the eyes straight.;ore se!ere orms o adult stra"ismus will need surgery tostraighten the eyes. 8 stra"ismus has occurred "ecause o !isionloss@ the !ision loss will need to "e corrected "e ore stra"ismussurgery can "e success ul.Outlook (Prognosis)2 ter surgery@ the eyes may loo straight "ut !ision pro"lems canremain.

#he child may still ha!e reading pro"lems in school@ and or adultsdri!ing may "e more diKcult. Dision may aFect the a"ility to playsports.&ith early diagnosis and treatment@ the pro"lem can usually "ecorrected. -elayed treatment may lead to permanent !ision loss inone eye. 2"out one>third o children with stra"ismus will de!elopam"lyopia.7ecause many children will get stra"ismus or am"lyopia again@ they

need to "e monitored closely.When to Contact a Medical Pro essionalStra"ismus reJuires prompt medical e!aluation. Call or anappointment with your health care pro!ider or eye doctor i yourchild:

< 2ppears to "e cross>eyed< Complains o dou"le !ision< Has diKculty seeing

/ote: earning diKculties or pro"lems at school can sometimes "edue to a childLs ina"ility to see the "lac "oard or reading material.
http://www.nlm.nih.gov/medlineplus/ency/article/002961.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003029.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002961.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003029.htm

case - paediatric ophthalmology

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