Pediatric

ophthalmology,
strabismus and
amblyopia
Dr Mahmood Fauzi
ASSIST PROF
OPHTHALMOLOGY
 Objectives
Understand the basics of pediatric ophthalmology.
Define the role of a pediatric ophthalmologist.
Rationalize why children need a different structure for eye
care.
Justify the Importance of pediatric vision screening
Review normal ophthalmic milestones.
Outline basic techniques for examining child's eyes .
Outline age specific screening and Newer pediatric vision
screening technology.
Describe select pediatric ophthalmic conditions -Refractive
errors, cataract, coloboma, retinoblastoma, retinopathy of
prematurity.
Describe etiology, risk factors, presentation ,diagnoses and
management for amblyopia and strabismus
 Basics of Pediatric
ophthalmology
What is Pediatric ophthalmology?
It is a sub-speciality of ophthalmology concerned with
eye diseases, visual development, and vision care in
children.

What is the Role of Pediatric ophthalmologists?

They focus on the development of the visual system and
the various diseases that disrupt visual development in
children.
Pediatric ophthalmologists also have expertise in
managing the various ocular diseases that affect
children. Pediatric ophthalmologists are qualified to
perform complex eye surgery as well as to manage
children's eye problems using glasses and medications.
Children are Different & need a different structure for eye care

Developing cortical connections

Window of opportunity for diagnosis and
treatmentjust like with language
development
 Ophthalmic Milestones

30 weeks - Blink to light

31 weeks - Pupils react
2 to 3 weeks - Early fixation
Horizontal gaze - Birth
Vertical - 2 months
Fixate - Birth to 3 months
Follow - 3 months
 Color ? (3 months)
Six Months Visual acuity 20/3020/40
Binocularity well developed
Field Adult-like 1 year
 Basic Techniques for Examining
Childrens Eyes
Age specific
Start with HISTORY
Moms are great
diagnosticians!
Common EXAM
components
Assessment of
vision
External anatomy
Pupil function
Motility
Ocular fundus/Red
Reflex testing
 Ocular History

Does child appear to see well distance

and near?
Any crossing?
Family history of eye disorders?
Recurrent discharge or redness?
Extreme photophobia?
NOT to worry about:
Sits close to TV a lot
 External Examination

Are eyelids symmetric?

Pupil symmetry?
Any redness, inflammation,
or discharge?
Cornea clear?
Are the eyes aligned?
 Pupil Exam
Are the pupils round?
Symmetric?
If asymmetric, is it more asymmetric in dark or light?
Reactive to light?
 Motility Assessment

Is the pupil light

reflex central?
Do the eyes
move fully in all
directions?
Pseudostrabism
us vs. true
strabismus
 Vision Assessment
Infants: Eye contact, follows face, smiles
Toddlers: Cover each eye and follows objects
(fix and follow)
Verbal: Visual acuity screening with appropriate
optotype (symbol/letters) AAPOS Vision Screening Kit
 Child abuse is a significant social problem which is associated with a high morbidity and
mortality. Shaken Baby Syndrome (SBS) is one form of physical child abuse, a non-accidental
traumatic brain injury. In 6% of reported cases of child abuse, an ophthalmologist is responsible
for initially recognizing the abuse. Perhaps the greatest diagnostic clue is a detailed history that
is incompatible with the extent and severity of the injuries found on dilated fundus exam.
Newer / improved Pediatric Vision
Screening Technology
Photoscreening
Automated refractors
VEP screening
Retinal birefringence
 The Importance of Pediatric
Vision Screening

Amblyopia affects up to 5% of the

population (>10 million Americans).
In the first 4 decades of life amblyopia
causes more vision loss than all other
ocular diseases combined!
Amblyopia has a window period for
treatment in early childhood.
Screening can prevent otherwise fatal
disorders such as retinoblastoma.
 Periodicity Table for Screening
Periodicity Schedule for Visual System Assessment in Infants and Children

Newborn to 6 months to 1 to <3 years 3 to < 5 years 5 years and older

6 months 12 months

Ocular History x x X x x
External inspection of x x x x x
lids and eyes

Red Reflex Testing x x x x x

Pupil examination x x x x
Ocular Motility x x x x
Assessment

Instrument Based x x
Screening + + *

Visual Acuity Fix and x x

follow

Visual Acuity age- x x

appropriate optotype
assessment

+: Bill using CPT 99174

: Bill using CPT 99173
*: If unable to test visual acuity monocularly with age appropriate linear optotypes, instrument-based
screening is suggested.
Age Specific Screening: NEWBORN

External evaluation for obvious ocular

malformations and infections
NOTE: Too young to evaluate alignment!!!
RED REFLEX TESTpreferably prior to
discharge from newborn nursery
Very important to r/o retinoblastoma or
congenital cataracts
If congenital cataracts not removed in first 2 to
3 months of life, permanent loss of sight occurs
Bruckner Reflex
Leukocoria is an Urgency!
Diff Dx include cataract, glaucoma, PHPV,
Retinoblastoma, Retinal detachment, etc.
In addition to sending a consult, CALL
ophthalmologist to make sure the
patient is seen ASAP!
SELECT PEDIATRIC
OPTHALMIC
CONDITIONS
 Pediatric Refractive Errors

Nearsighted
Farsighted
Astigmatism
Anisometropia
 Myopia (Near-sightedness)
Eyeball too long
Cant see far away
Correct with specs,
contact lens, or
excimer laser (older
children)
Hyperopia (Far-sightedness)
The eyeball is too
short
Accommodation
will increase the
effective lens
power in the eye
and focus at both
near and far
Accommodation Glasses
Crossing may
occur
 Astigmatism

Warpage of the
cornea like a
football
Light rays in one
axis are not
focused the same
as in opposite
axis
Corrected with
glasses
Congenital cataract refers to a
lens opacity present at birth. Congenital cataracts cover a broad
spectrum of severity: whereas some lens opacities do not progress
and are visually insignificant, others can produce profound visual
impairment.
Coloboma (from the Greek koloboma,
meaning defect, is a hole in one of the structures of the eye, such as the iris,
retina, choroid, or optic disc. The hole is present from birth and can be
caused when a gap called the choroid fissure, which is present during early
stages of prenatal development, fails to close up completely before a child
is born.
 Leucokoria Cross
eye

Retinoblastoma (Rb) is a rapidly developing

cancer that develops from the immature cells of a retina, the light-detecting
tissue of the eye and is the most common malignant tumor of the eye in
children . The most common and obvious sign of retinoblastoma is an
abnormal appearance of the pupil, leukocoria, also known as amaurotic cat's
 Dragged optic disc of
ROP

Retinopathy of
prematurity (ROP) or Terry
syndrome, previously known as retrolental fibroplasia (RLF), is a disease
of the eye affecting prematurely-born babies generally having received
intensive neonatal care, in which oxygen therapy is often used and
advantageous. It is thought to be caused by disorganized growth of retinal
blood vessels which may result in scarring and retinal detachment. ROP can
 Amblyopia
The Physician sees nothing
and the Patient very little
 What is Amblyopia?
Unilateral or bilateral decrease of visual
acuity caused by form vision deprivation
and/or
Abnormal binocular interaction for which no
organic cause can be detected
 AmblyopiaIn Other Words:
The camera (eye) is capable of
taking the picture but the computer
(brain) doesnt recognize that there
is an image.

Either use it or lose it!

Screen for Causes of Amblyopia
Refractive errors
Obstruction of optical pathway (e.g.
cataract or corneal scar)
Strabismus
Otheranything that blocks input of
visual information to the brain
Remember in the pre-verbal child, the
only way to detect amblyopia is to
indirectly detect the risk factors.
(Refractive errors, Media opacities,
Strabismus)
Treatment Amblyopia

The clinician must first rule out an organic

cause and treat any obstacle to vision (eg,
cataract, occlusion of the eye from other
etiologies).

Remove cataracts in the first 2 months of

life, and aphakic correction must occur
quickly

Treatment of anisometropia and refractive

errors must occur next

The next step is forcing the use of the

amblyopic eye by occlusion therapy
 STRABISMUS
occurs when both eyes do not look at the same
place at the same time; the eyes are unable to
align properly under normal conditions

eye(s) may turn in, out, up, or down

can be present in one or both eyes

often referred to as: cross-eyed, crossed eyes,

cockeye, weak eye, wall-eyed, wandering eyes,
and/or eye turn
 CAUSES OF
STRABISMUS
lack of coordination between the muscles of the
eye responsible for eye movement and keeps both
eyes from gazing at the same point

problems with the nerves that transmit information

to the eye muscles

problems with the control center in the brain that

directs eye movement

in adults, can be caused by stroke, thyroid

problems, brain injury, or other trauma
 RISK FACTORS
family

refractive errorsextreme
farsightedness (hyperopia) can develop
strabismus due to the amount of eye
focusing necessary to keep vision clear

medical conditionsDown syndrome

,cerebral palsy ,stroke or head injury
from: Strabismus.com
 TYPES OF
STRABISMUS
Esotropiainward turning of the eye

Exotropiaoutward turning of the eye

Hypertropiaupward turning of the eye

Hypotropiadownward turning of the eye

from: American Optometric Association

 ESOTROPIA

The left eye is turned inwardnote that the light reflection in the
eyes is not symmetric
 EXOTROPIA

The right eye is turned outwardagain, not the light reflection in the
eyes is not symmetrical
 HYPERTROPIA

The right eye is turned upwardlight reflection not symmetrical

 HYPOTROPIA

The right eye is turned downward-light reflection in eyes is not

symmetric
 WHEN DOES IT
OCCUR?
congenitaldeveloping during
infancy; 50% of children with
strabismus are born with it

acquireddeveloping in adulthood
from: Strabismus.com
 DIAGNOSIS
A comprehensive eye exam is
necessary with focus on the following:

patient history
visual acuity
refraction
alignment and focusing
eye health exam
from: American Optometric Association
 TREATMENT
there is no cure for strabismus

with treatment, the effects of

strabismus may be corrected

the goal of treatment is to help the

patient achieve as close to normal
binocular vision as possible in every
direction of gaze and at all distances
 TREATMENT
Eye Patch
The stronger eye is patched to
force the brain to interpret
images from the strabismic
eye. Eye patches will not
change the angle of the
strabismus. Typically, eye
patching is used only if
amblyopia is present.
TREATMENT
Eyeglass or
Contacts

Eyeglasses or Contacts are

used to improved the
positioning of the eye(s)
by modifying the patients
reaction to focus.
Eyeglasses and Contacts
can also redirect the line
of sight, which can help
straighten the eye.
 TREATMENT
Prisms

Prisms are used to modify the way

light and images hit the eye. The
lenses provide comfort and can help
prevent double vision from
developing.
TREATMENT
Vision Therapy

A non-surgical method of therapy

that treats the eye and the brain. An
optometrist will oversee the therapy,
which is designed to strengthen or
develop visual skills. The
optometrist may also use eyeglasses,
prisms, eye patches and
computerized medical devices
during the therapy.
 TREATMENT
Eye Surgery

Surgery may be necessary in an

attempt to align the eyes by
modifying one or more muscles in
the eye. During surgery, the muscle
positions will be changed or the
length of the muscles will be
changed. Surgery may follow a
period of eye patching and then
eyeglasses may be used after surgery
to help treat strabismus.

Surgery on medial rectus muscle of the left eye.

UN- CONVENTIONAL-ALTERNATIVE
 Primary care
physicians are
our best line of
defense for
preventable
blindness!