AMBLYOPIA.ppt

EYE DISORDER IN CHILDHOOD & ADOLESCENTLia Meuthia ZainiFK Unsyiah / RSUZA

Frequent case of pediatric patients:

Refractive errorCongenital cataractCongenital glaucomaAmblyopiaRetinoblastomaOphthalmia NeonatorumVernal ConjunctivitisDeviated 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

EmmetropiaAstigmatismaHipermetropiaMiopia

REFRACTIVE ERROR

SYMPTOMS

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

REFRACTIVE ERROR

Eye glassesContact lensLaser (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 colorEstablished

Disadvantage :Wrong administration serious side effect Cannot correct astigmatism

REFRACTIVE ERROR

Advantage :Save, good image in most cases, good patients satisfied

Disadvantage :Side effect (+) small number of case, expensive

LASIK

REFRACTIVE ERROR

Implantable contact lensPhacic Intra Ocular LensOTHER TREATMENT

CONGENITAL CATARACT

Cataract : Opacity of the lensCongenital cataract3 : 10.000 live births2/3 cases are bilateralThe most common cause: genetic mutationOther causes:

chromosomal abnormalities such as Down Syndrome, metabolic disorder such as galactosemia,intrauterine insults such as rubella infectiona part of developmental disorder of the eye such as aniridiaCongenital unilateral cataract remains less clear

CONGENITAL CATARACT

Systemic associations

MetabolicChromosomal abnormality- Galactosemia - Down syndrome- Lowe syndrome - Edward syndrome- hypoparathyroidism

Intrauterine infection- Congenital rubela- Toxoplasmosis- Citomegalo virus- Herpes symplex- Varicella

CONGENITAL CATARACT

ManagementOcular examinationDensityMorphologyAssociates ocular phatologyOther indicator of visual impairment

Systemic investigationSerologyUrineReferral to a pediatrician

CONGENITAL CATARACT

Surgical ManagementBilateral dense : Require early surgeryBilateral partial : May not require surgery until later, if at allUnilateral dense : Merits urgent surgery (within days) followed by aggressive amblyopia therapyPartial unilateral : can usually be observed or treated non surgically

CONGENITAL CATARACT

Visual rehabilitation

SpectaclesContact lensesIOL implantationOcclusion

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

Exact mechanism remains unproven Theories proposed by some investigators cellular membranous abnormality in the

trabecular meshwork abnormal insertion of ciliary muscle

CONGENITAL GLAUCOMA

Pathogenesis

CONGENITAL GLAUCOMA

Clinical features

- epiphora- photophobia classic triad of congenital - blepharospasm 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 amblyopiaIsometropia amblyopiaDeprivation 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 :

Eradicate everything which can hamper vision (cataract, ptosis, etc), if it is possible.Correct refractive errorUse the worse eye compulsively with limiting the use of the better eye

AMBLYOPIA

Cataract ExtractionUndertake within 2-3 months of life

Correct refractive errorFull 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 pineoblastomaSystemic : to investigate the presence of metastatic

diseases

RETINOBLASTOMA

Treatment of small tumor PhotocoagulationCryotheraoyChemotherapy

Treatment of medium-sized tumorBrachytherapyPrimary chemotheraphyExternal beam radiotherapy

Treatment of large tumorsChemotheraphyEnucleation

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


Onset and PresentationEtiologyConjunctival ScrapingWithin 24 hoursMild lid edema plus water discharge

2 to 4 daysSevere lid swelling, purulen discharge

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

4 days to 7 daysPurulent discharge

6 days to 2 weeksOften unilateral serous discharge with keratitisSilver nitrate

N.gonorrhea

Chlamydia

Other bacteria

Herpes simplexNeg. to a few PMN

Gram negative intracellular diplococci

Giemsa stain for basophilic cytoplasmic inclusion bodies; positive direct immunofluorescent assay

Gram stain positive for specific bacteria

Gram stain for multinucleated giant cells, Papanicolaon - intranuclear inclusion bodies


Diagnosis

Presentation : 3 19 days after birthSigns : usually bilateral eyelid edema, discharge,

papilary conjunctival with pseudomembranes, corneal complication include corneal perforation and ulcer3.InvestigationsLaboratory finding


Treatment

ChlamydialOral erythromycin ethyl succinate (2 -3weeks)GonoccocalInjection of ceftriaxone or cefotaximeOther bacterialChloramphenicol or neomycine ointmentSystemic antibiotics maybe consider in severe caseHerpes simplexsystemic acyclovir (14 days)topical acyclovir (5 times daily)


Prophylaxis

Povidone-iodine 2.5% cheap and effectiveErythromycin 0.5% ointment or tetracycline 1% ointment

DEVIATED EYE

Infantile (Congenital) EsotropiaEsotropia is eso-deviation that is not control by fusional mechanism, so the deviation is constantly manifestCongenital 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

ManagementCorrection of the refractive errorSurgical (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


Calcification :Palpebral LimbalMixed


Diagnosis

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


Diagnosis

Signs

Palpebral diseasesPapillary hipertrophyMacropapillae/ cobblestonesMucus deposition

Limbal diseases-Gelatinous papillae on the limbal conjunctiva


TreatmentTopical Mast cell stabilizers Antihistamines Steroids Cyclosporine

- Supratasrsal steroid injection- Systemic Immunosuppressive agent Oral antihistamines


Surgery

Superficial kleratectomyAmniotic membrane overlay graft

TERIMAKASIH

Documents

AMBLYOPIA.ppt