Presentation on theme: "White Pupillary reflex in children"— Presentation transcript:
1White Pupillary reflex in children Dr. Mariya Nazish MemonMBBS,FCPS,Fellow Pead Ophth & strabismus(ASEH)Senior Registrar , Head of UnitPediatric Ophthalmology and StrabismusLiaquat university Eye hospital, Hyderabad
2OBJECTIVES Enlist common causes of white pupil in children Identify the child with serious visual and life threatening problemUnderstand the immediate need of referral to Ophthalmologist
3Leucokoria White pupillary reflex “amaurotic cat’s eye” Greek word “leucos” (white) and “korê” (pupil)
5Causes of White Pupil in children CataractRetinoblastomaRetinopathy of prematurityPersistent fetal vasculatureCoats diseaseToxocariasisColoboma (fissure or cleft) of choroid or optic discRetinal dysplasiasUveitisVitreous hemorrhage
6ImportanceInfancy and early childhood is an important time for visual development.The eyes grow and emmetropiseVision improvesStereopsis maturesAccommodation develops
7Congenital cataractOpacification of the crystalline lens present at the time of birth or develop after birth during maturity period of the lens
8Important facts 33% - idiopathic - may be unilateral or bilateral 33% - inherited - usually bilateral33% - associated with systemic disease - usually bilateralOther ocular anomalies present in 50%
9Classification of congenital cataract Anterior polarPosterior polarCoronaryCortical spoke-likeLamellarCentral pulverulentSuturalFocal dots
10Causes of cataract in healthy neonate Hereditary(usually dominant)IdiopathicWith ocular anomalies. PHPVAniridiaColobomaMicrophthalmosBuphthalmosIatrogenic pediatric cataractLaser photoablation for ROP or tumorExternal beam radiationsteroid therapyDamage to posterior capsule due toposterior vitrectomy
12Management OCULAR EXAMINATION Visual behavior Density of cataract MorphologyAssociated ocular pathologyPupillary reflexOcular Ultrasound(B Scan)
13Systemic investigations Serology:TORCHS titre and VDRLUrine 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
14Indications for Surgery Bilateral dense CataractsUnilateral dense CataractsPartial unilateral /bilateral cataract
16Retinoblastoma 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
22MANAGEMENT Depends on size, location and staging of tumour Treatment of small (3 mm diameter) tumoursPhotocoagulationCryotherapyChemotherapyMedium sized (upto 12 mm) tumoursExternal beam radiationLarge tumoursEnucleation
24Follow-upHeritable Retinoblastoma patients can develop recurrences and need to be followed up regularlyExamine 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.
29STAGINGStage:5.Funnel shaped Total retinal detachment
30SYMPTOMS Symptoms of severe ROP include: Nystagmus (Abnormal eye movements)Amblyopia (Lazy eye)Strabismus (Crossed eyes)Myopia (Severe near sightedness)Leucocoria (White-looking pupils )GlaucomaCataractRetinal detachment
31Screening for ROPAll pre mature born at or before 32 weeks of gestationAll premature with birth weight of 1500 gms or lessScreening should start 4 weeks after birth
32Management In 80% of infant ROP will regress spontaneously Treatment is indicated in stage 3 diseaseArgon laser in the peripheryCryotherapy (trans-scleral)Anti VEGF intravitreal injectionRD surgery for stage IV and V
33Persistent fetal vasculature(PFV/PHPV) UnilateralFailure of regression of primary vitreous/hyaloid systemTypically present with leukocoria,squint or NystagmusPersistent anterior fetal vasculaturePersistent posterior fetal vasculatureVisual prognosis depends on amount of microphthalmia and involvement of posterior pole
34Persistent anterior fetal vasculature Retrolental mass with elongated ciliary processesAdvanced cases ass:with Cataract formation
35Persistent posterior fetal vasculature Confined to posterior segmentDense white membrane or prominent retinal fold extends from optic disc to ora serrata,ass:with retinal detachment.
36COATS DISEASEIdiopathic retinal vascular talengiectasia with intraretinal and sub retinal exudation and retinal detachmentUnilateralSeventy-five percent are malePresents in 1st decade(avg:5yrs) with unilateral visual loss, strabismus and leucokoria
37Ocular Toxocariasis infestation of dog with Toxocara canis Human infestation:accidental ingestion of soil or food contaminated with ova shed in dog faecesVery young children who eat dirt or are in close contact with puppies are at riskIn 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.
38Ocular ToxocariasisPresents as strabismus, leukocoria or unilateral visual lossCh:Endophthalmitis:(2-9yrs)mey cause cyclitic membrane and white pupil.Posterior pole granuloma in an otherwise quiet eye.(6-14yrs) may resemble endophytic Rb.
39Coloboma of Choroid/Optic disc Incomplete closure of the embryonic fissureUnilateral /bilateralSharply circumscribed, white area devoid of blood vessels in the inferior fundusLarge Coloboma may involve the disc and give rise to leucokoriaComplication: Retinal detachment
40Retinal Dysplasia Faulty differentiation of retina and vitreous Isolated or ass:with systemic conditions such as Norrie disease and incontinentia pigmentiPresents with congenital blindness with roving eye movementPink or white retrolental masses resulting in leucokoriamicrophthalmos,shallow anterior chamber and elongated ciliary processes
41Retinal Dysplasia Norrie disease: XL reccessive Males are blind at birth or infancySys:cochlear deafness,mental retardationIncontinentia pigmentiXL DominentAffecting girls and lethal in utero for boysOne third children develop retinal detachment in 1st yr of lifeVesiculobullous rash on trunk and extremitiesMalformation of teeth,hair,nails,bones and CNS
42ConclusionFamily physician play crucial role in the management of eye problem in childrenVision screening even with limited equipments can identify most important causes of visual loss