Ophthalmic Conditions in Children

Educational Objectives

The goal of this program is to improve the management of ophthalmologic diseases in children. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the causes of anisocoria in children.

Summary

Anisocoria: pupils of unequal size; easily detected in light-eyed children; large pupils unable to constrict — if bilateral, consider aniridia (abnormal light reflex and nystagmus) and pharmacologic cause (atropine and anticholinergics); if unilateral, consider third nerve palsy (usually with ptosis, exotropia, and Adie pupil); Horner syndrome — small pupil; causes include birth trauma, brachial plexus injury, and neuroblastoma; presents with ptosis, inverse ptosis (lifting of lower lid), miosis, and anhidrosis; eventually causes anisocoria; persistent pupillary membrane — not highly uncommon; surgery not indicated (vision not affected)

Coloboma: if present, consider coloboma of eye, heart defects, atresia of choanae, retardation, genitourinary defects, and ear (hearing) defects (CHARGE sequence); about two-thirds due to abnormality in chromosome 8; detected on red reflex examination; almost always inferior; chorioretinal colobomas associated with vision problems

External diseases of eyelids: chalazion — chronic staphylococcal blepharitis; can be aftereffect of stye; both treated with eyelid hygiene; erythromycin ointment applied nightly for 7 to 10 days if condition persists; warm compresses recommended; scurf — blepharitis due to seborrhea; common in teenagers; surgery indicated if chalazion or lipogranuloma persistent, but most resolve

Obstruction of nasolacrimal duct: dacryocystocele — contains clear straw-colored fluid; do not probe if located above nasal canthus (may be encephalocele); generally firm and immobile; secondary infection possible; may enlarge and prolapse into nose; causes proximal and distal obstruction; 95% of dacryostenosis resolves by 1 yr

Hemangiomas: capillary — treated with β-blockers (eg, timolol); Sturge-Weber syndrome — port wine stain, seizures, and glaucoma; requires surveillance every 6 mo for first decade of life, and treatment of glaucoma; laser therapy effective in reducing morbidity; monitor pressure of eye and optic-nerve cup

Less common ophthalmic conditions: rhabdomyosarcoma — can present as preseptal cellulitis; prognosis excellent if detected early; neuroblastoma — causes “raccoon” eyes; causes of proptosis — orbital cellulitis; benign tumors; in orbital cellulitis, if eye does not move, protruding, pupil not moving, or vision poor, admission and imaging indicated (often, treated by drainage of concurrent sinusitis)

Myopia: prevalent in Asian population; causes of refractive error — too much sleep, unfamiliar objects, sudden strong light, noise, and illness and discomfort; high myopia can lead to blindness; orthokeratology — contact lenses cause flattening of cornea; does not prevent progression of myopia; sleeping with contact lenses increases risk for infection; atropine slows progression of myopia

Nystagmus: often requires referral to neurologist

Readings

Alodhayb S et al: Update on pediatric glaucoma. Semin Ophthalmol, 2013 May;28(3):131-43; Arnold RW et al: Diagnosis and management of anisocoria in a 6-month-old child. J Pediatr Ophthalmol Strabismus, 2011 Mar-Apr;48(2):71-3; Bothun ED: Ten critical diagnoses not to miss on a pediatric eye screening. Minn Med, 2009 Jun;92(6):34-7; Bradfield YS: Identification and treatment of amblyopia. Am Fam Physician, 2013 Mar 1;87(5):348-52. Erratum in: Am Fam Physician, 2013 Aug 1;88(3):159; Brémond-Gignac D et al: European Network of Study and Research in Eye Development. Visual development in infants: physiological and pathological mechanisms. Curr Opin Ophthalmol, 2011 Apr;22 Suppl:S1-8; Gandhi NG et al: Periodic unilateral eyelid retraction in a pediatric patient. J Neuroophthalmol, 2011 Dec;31(4):350-2; Gupta N et al: Clinical spectrum of pediatric blepharokeratoconjunctivitis. J AAPOS, 2010 Dec;14(6):527-9. Nishina S et al: Ophthalmic features of CHARGE syndrome with CHD7 mutations. Am J Med Genet A, 2012 Mar;158A(3):514-8; Schnall BM: Pediatric nasolacrimal duct obstruction. Curr Opin Ophthalmol, 2013 Sep;24(5):421-4; Trumler AA: Evaluation of pediatric cataracts and systemic disorders. Curr Opin Ophthalmol, 2011 Sep;22(5):365-79; Wen G et al: Multi-ethnic Pediatric Eye Disease Study Group. General health-related quality of life in preschool children with strabismus or amblyopia. Ophthalmology, 2011 Mar;118(3):574-80; Wong IB, Nischal KK: Managing a child with an external ocular disease. J AAPOS, 2010 Feb;14(1):68-77.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Frederick and planning committee reported nothing to disclose.

Acknowledgements

Dr. Fredrick was recorded at Pediatric Clinical Update — South Bay, held September 21, 2013, in San Jose, CA, and sponsored by Stanford University School of Medicine and Lucile Packard Children’s Hospital. For future CME activities, visit www.cme.lpch.org. The Audio-Digest Foundation thanks Dr. Fredrick and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP520502

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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