Presentation on theme: "Dr. Mariya Nazish Memon MBBS,FCPS,Fellow Pead Ophth & strabismus(ASEH) Senior Registrar, Head of Unit Pediatric Ophthalmology and Strabismus Liaquat university."— Presentation transcript:
Dr. Mariya Nazish Memon MBBS,FCPS,Fellow Pead Ophth & strabismus(ASEH) Senior Registrar, Head of Unit Pediatric Ophthalmology and Strabismus Liaquat university Eye hospital, Hyderabad
OBJECTIVES Enlist common causes of white pupil in children Identify the child with serious visual and life threatening problem Understand the immediate need of referral to Ophthalmologist
Leucokoria White pupillary reflex “amaurotic cat’s eye” Greek word “leucos” (white) and “korê” (pupil)
Causes of White Pupil in children Cataract Retinoblastoma Retinopathy of prematurity Persistent fetal vasculature Coats disease Toxocariasis Coloboma (fissure or cleft) of choroid or optic disc Retinal dysplasias Uveitis Vitreous hemorrhage
Importance Infancy and early childhood is an important time for visual development. The eyes grow and emmetropise Vision improves Stereopsis matures Accommodation develops
Congenital cataract Opacification of the crystalline lens present at the time of birth or develop after birth during maturity period of the lens
Important facts 33% - idiopathic - may be unilateral or bilateral 33% - inherited - usually bilateral 33% - associated with systemic disease - usually bilateral Other ocular anomalies present in 50%
Causes of cataract in healthy neonate Hereditary (usually dominant) Idiopathic With ocular anomalies. PHPV Aniridia Coloboma Microphthalmos Bupht halmos Iatrogenic pediatric cataract Laser photoablation for ROP or tumor External beam radiation steroid therapy Damage to posterior capsule due to posterior vitrectomy
Causes of cataract in unwell neonate Intrauterine infections Rubella Toxoplasmosis Cytomegalovirus Herpes simplex Varicella Metabolic disorders Galactosaemia Hypoglycaemia Hypocalcaemia Lowe syndrome Chromosomal abnormalities Down syndrome (trisomy 21) Patau syndrome (trisomy 13) Edward syndrome (trisomy 18)
Management OCULAR EXAMINATION Visual behavior Density of cataract Morphology Associated ocular pathology Pupillary reflex Ocular Ultrasound(B Scan)
Systemic investigations Serology: TORCHS titre and VDRL Urine analysis: for amino acids(lowe syndrom) and reducing substance after drinking milk(galactosaemia) Blood test: Fasting blood sugar,serum calcium and phosphours, red-cell GPUT and galactokinase level
Indications for Surgery A. Bilateral dense Cataracts B. Unilateral dense Cataracts C. Partial unilateral /bilateral cataract
Management Surgery: o Lens matter aspiration, posterior capsulotomy, anterior vitrectomy +/_ IOL implantation Visual rehabilitation: o Spectacles o Contact lenses o IOL implantation o Ambyopia therapy
Retinoblastoma Most common intraocular tumour of childhood May be heritable(40%) or non-heritable(60%) Located chromosome- 13q14 malignant transformation of primitive retinal cells before final differentiation. As these cells disappear in the first few years of life, the tumour is seldom seen after 3 years of age
Leukocoria - 60% Strabismus - 20% Secondary glaucoma Anterior segment invasion Orbital inflammation Orbital invasion Presentations of Retinoblastoma
Signs/Growth pattern Endophytic Exophytic
Investigations Ultrasound C T Scan
Poor Prognostic Factors Optic nerve involvement Choroidal invasion Large tumour Anterior location Poor cellular differentiation Older children
MANAGEMENT Depends on size, location and staging of tumour Treatment of small (3 mm diameter) tumours Photocoagulation Cryotherapy Chemotherapy Medium sized (upto 12 mm) tumours Chemotherapy External beam radiation Large tumours Chemotherapy Enucleation
Treatment Extraocular extension Chemotherapy Radiotherapy Metastatic Disease High dose chemotherapy Intra-thecal chemotherapy Total body radiotherapy
Follow-up Heritable Retinoblastoma patients can develop recurrences and need to be followed up regularly Examine the patients every 6-8wks till 3yrs,every 6 months till the age of 5 yrs and then annually till the age of 10 years.
RISK FACTOR Major Risk Factor: Prematurity < 32 weeks gestation (< 30 weeks) Low birth weight < 1500 gm (<1250 gm) Supplemental Oxygen. Minor Risk Factor: Maternal: Complications of pregnancy, use of beta blockers. Fetal: Hypercarbia, Sepsis, Vitamin E deficiency, Intraventicular haemorrhage, Recurrent apnea, RDS, Indomethacin treatment for PDA.
Stage:5. Funnel shaped Total retinal detachment
SYMPTOMS Symptoms of severe ROP include: Nystagmus (Abnormal eye movements) Amblyopia (Lazy eye) Strabismus (Crossed eyes) Myopia (Severe near sightedness) Leucocoria (White-looking pupils ) Glaucoma Cataract Retinal detachment
Screening for ROP All pre mature born at or before 32 weeks of gestation All premature with birth weight of 1500 gms or less Screening should start 4 weeks after birth
Management In 80% of infant ROP will regress spontaneously Treatment is indicated in stage 3 disease Argon laser in the periphery Cryotherapy (trans-scleral) Anti VEGF intravitreal injection RD surgery for stage IV and V
Persistent fetal vasculature(PFV/PHPV) Unilateral Failure of regression of primary vitreous/hyaloid system Typically present with leukocoria,squint or Nystagmus Persistent anterior fetal vasculature Persistent posterior fetal vasculature Visual prognosis depends on amount of microphthalmia and involvement of posterior pole
Persistent anterior fetal vasculature Retrolental mass with elongated ciliary processes Advanced cases ass:with Cataract formation
Persistent posterior fetal vasculature Confined to posterior segment Dense white membrane or prominent retinal fold extends from optic disc to ora serrata,ass:with retinal detachment.
COATS DISEASE Idiopathic retinal vascular talengiectasia with intraretinal and sub retinal exudation and retinal detachment Unilateral Seventy-five percent are male Presents in 1 st decade(avg:5yrs) with unilateral visual loss, strabismus and leucokoria
Ocular Toxocariasis infestation of dog with Toxocara canis Human infestation:accidental ingestion of soil or food contaminated with ova shed in dog faeces Very young children who eat dirt or are in close contact with puppies are at risk In human intestine,ova develop into larva,penetrate intestinal wall and travel to various organs.liver,lungs,skin,brain and eyes. Larva die,disintegrate and cause an inflamatory reaction and granuloma formation.
Ocular Toxocariasis Presents as strabismus, leukocoria or unilateral visual loss Ch:Endophthalmitis: (2-9yrs)mey cause cyclitic membrane and white pupil. Posterior pole granuloma in an otherwise quiet eye.(6-14yrs) may resemble endophytic Rb.
Coloboma of Choroid/Optic disc Incomplete closure of the embryonic fissure Unilateral /bilateral Sharply circumscribed, white area devoid of blood vessels in the inferior fundus Large Coloboma may involve the disc and give rise to leucokoria Complication: Retinal detachment
Retinal Dysplasia Faulty differentiation of retina and vitreous Isolated or ass:with systemic conditions such as Norrie disease and incontinentia pigmenti Presents with congenital blindness with roving eye movement Pink or white retrolental masses resulting in leucokoria microphthalmos,shallow anterior chamber and elongated ciliary processes
Retinal Dysplasia Norrie disease: XL reccessive Males are blind at birth or infancy Sys:cochlear deafness,mental retardation Incontinentia pigmenti XL Dominent Affecting girls and lethal in utero for boys One third children develop retinal detachment in 1 st yr of life Vesiculobullous rash on trunk and extremities Malformation of teeth,hair,nails,bones and CNS
Conclusion Family physician play crucial role in the management of eye problem in children Vision screening even with limited equipments can identify most important causes of visual loss