Eye disorders in children

Alka Sara Saju

External structures of eye
Anatomy of eye
Conjunctivitis
 Definition

• Inflammation of conjunctiva.
 Etiology

• Viral
• Bacterial
• Allergic
• Foreign body/chemicals
Clinical manifestations
• Bacterial conjunctivitis:
• Purulent discharge
• Crusing of eye lids
• Inflammed conjunctiva
• Swollen lids
 Viral conjunctivitis

 Occurs with URI

 Serous ( watery discharge)

 Inflammed conjunctiva

 Swollen lids
 Allergic conjunctivitis

 Itching

 Watery to thick, stringy discharge

 Inflammed conjunctiva

 Swollen lids
 Conjunctivitis caused by foreign body
• Tearing
• Pain
• Inflammed conjunctiva
• Usually only one eye is affected
 Chemical conjunctivitis
• Mild eyelid edema
• Sterile, non purulent eye discharge
(fuloria & krieter, 2002)
Management

• Treat the cause

• Viral conjunctivitis : self limiting
• Treatment is limited to removal of accumulated
secretions

• Bacterial conjunctivitis : topical antibacterial agents eg. Polysporin, sodium

sulfacetamide, trimethoprim and polymyxin
• Fluroquinolones : approved for children > 1year old
• Best antimicrobial agent available ( Lichenstein , rinchart , 2003)

Eye drops may be used in day time and ointment at bedtime ( ointment remains
in eye for longer time)
 Nursing care
• Keep eye clean
• Administer ophthalmic medications
• Remove accumulated secretions by wiping from inner to outer canthus
• Prevention of infection to other family members
• Child should refrain from rubbing the eye
• Teach hand washing technique
Keratomalacia
 Keratomalacia

• Keratomalacia is an eye disorder that involves drying and

clouding of cornea due to vitamin A deficiency
 Causes
• Decreased vitamin A intake

• Poor metabolism ( eg. in case of celiac syndrome and ulcerative colitis)

• Insufficient conversion, storage , absorption and transport of vitamin A

• Infants and children who are allergic to milk are at high risk
 Role of vitamin A
• Vitamin A is required to maintain epithelia of cornea and
conjunctiva
 PATHOPHYSIOLOGY
Presice mechanism is not known
Lack of vitamin A

Atrophic changes in normal mucosal surface

Loss of goblet cells

Replacement of normal epithelium by inappropriate keratinized squamous epithelium

• In addition substantia propria of cornea breaks down and liquefies

Keratomalacia

Cornea becomes totally opaque

Blindness
 Clinical manifestations
• Highly perforated and soft cornea
• Changes in vision
• Wrinkling and cloudiness in cornea
• Corneal ulcers
• Decreased night vision
• Photophobia
• Corneal scar
• Dryness of ocular glands like lachrymal glands, cornea and
conjunctiva
• Formation of bitots spots
 Diagnosis
• History
• Physical Examination
• Eye examination
• External appearance
• Visual acquity
• Eye movements
• Visual field
• Slit lamp examination of conjunctiva and cornea
• Blood studies (beta carotene and vitamin A levels)
 TREATMENT
• Vitamin A Supplementation
• Mild to moderate deficiency : 10,000mcg of fat soluble vit A x 10
days
• Severe cases : 50,000mcg of fat soluble vit A for several weeks
• A single dose of 1lakh mcg vit A will prevent vit A deficiency in
children for about 6 months
• Treatment of secondary cause if any
 Dietary sources
• Fish liver oil
• Butter
• egg
• Green leafy vegetables
• Cod liver oil
• Carrot
• Pumkin
• Milk and milk products …etc…
CONGENITAL / DEVELOPMENTAL
GLAUCOMA
 CONGENITAL/ DEVELOPMENTAL
GLAUCOMA

• Congenital glaucoma are a group of diverse disorders in which

abnormal high intraocular pressure results due to
developmental abnormalities of angle of anterior chamber
obstructing the drainage of aqueous humur.
 Types
• Primary developmental/ congenital glaucoma

• Developmental glaucoma with associated congenital ocular

anomalies

• Developmental glaucoma with associated systemic abnormalities

Primary developmental/ congenital glaucoma

• Refers to abnormally high intraocular pressure which results due to

developmental anomaly of the angle of anterior camber not associated with
any other systemic anomaly.
• Depending on age of onset developmental glaucomas are termed as:
• 1. Newborn glaucoma /true congenital glaucoma :
• IOP is raised during intrauterine life
• Child is born with ocular enlargement
• Accounts for 40% cases
2. Infantile glaucoma

• Labelled when disease manifests before child’s third birthday.

• Accounts for 55% of cases
3. Juvenile glaucoma

• When disease occurs after 3 years of age but before adulthood.

• Also known as Juvenile Primary Open Angle Glaucoma ( JPOAG)
• About 35% patients with JPOAG are myopes
• Has strong autosomal dominant inheritance .
• Genetic anomaly on long arm of chromosome 21
 Buphthalmos
• When disease manifest prior to 3 years
the eye ball enlarges so, the term
buphthalmos is used.

• Buphthalmos – bull like eyes

• It results from the retention of aqueous

humour the term hydrophthalmos is
also suggested
 Pathogenesis
• Maldevelopment of neural crest derived cells of trabeculum
including the iridotrabecular junction ( trabeculodysgenesis)

• Impaired aqueous outflow

• Increased intra ocular pressure

• TRABECULODYSGENESIS : ABSENCE OF ANGLE RECESS WITH IRIS

HAVING FLAT/ COCAVE INSERTION INTO SURFACE OF
TRABECULUM
 Clinical Manifestations
• Lacrimation
• Photophobia
• Blepherospasm
• Corneal edema
• Corneal enlargement
• Tears and breaks in descement’s membrane(Haab’s strial)
• Sclera becomes thin & appears blue due to underlying uveal tissue
 ASSESSMENT
• Measurement of intraocular pressure
• Measurement of corneal diameter
• Slit lamp examination
• Ophthalmoscopy
• Gonioscopic examination : (to evaluate the internal drainage system of the
eye, also referred to as the anterior chamber angle. The "angle" is where the
cornea and the iris meet. )
 Treatment
• Medications are not very effective so treatment is primarily surgical

• IOP must be lowered by hyperosmotic agents, acetazolamide and beta-

blockers, till surgery is taken up
 Surgery
• Inscisional angle surgery –
• 1. Internal approach –goniotomy
• 2. External approach – trabeculectomy
• Goniotomy : Incision is made in the angle approximately
midway between the root of iris and Schwalbe’s ring .
 Trabeculectomy : useful when corneal clouding prevents
visualization of angle or in case goniotomy has failed

• Vertical scleral incision is

made after making a
conjunctival flap and partial
thickness skin flap

• Break is created in the inner

wall of schlemm’s canal
• Combined trabeculectomy and trabeculotomy
Cataract
 Congenital/ Developmental Cataract
• A cataract is a clouding of the lens in the eye which leads to
a decrease in vision .

• Cataract may be present at birth (congenital) or it may develop

later ( developmental)
 Pathogenesis
• Lens is formed in layers

• Central nucleus being the earliest formation around which

concentric zones are laid down

• This process continues till late adolescence

• Developmental cataract has a tendancy to affect the particular
zone which was being formed

• As time goes on the opacity is deeply buried in the lens

 Causes
• Cause is unknown
• Possible factors include
• Maternal and infantile malnutrition
• Maternal infections by viruses eg. Rubella
• Deficient oxygenation owing to placental hemorrhages
• Hypocalcemia and storage disorders
 Types
• Punctate cataract
• Zonular cataract
• Fusiform cataract
• Coronary cataract
 Assessment

• Assessment of vision
• Occular status
• Intraocular pressure
• Fundus examination to rule out associated diseases like retinoblastoma
• B scan Ultrasonography – to assess posterior segment of eye –to rule
out retinal detachment
• A scan ultrasonography – to compare axial length of two eyes
• Assessment of density of cataract.
 Treatment

• Not indicated unless vision is impaired

• Central cataract
• Good vision through clear cortex
• Mydriasis if required
• Monitor distant and near vision
• Look for progression of cataract until puberty
• If opacity is large and dense – cataract surgery

• Intraocular lens may be implanted after surgery

• Lamellar cataract – surgery not advisable until child is 1-2 years

old

• Pediatric cataracts are soft and can be aspirated through incisions

that are 1-1.5mm in size at the limbus
Childhood blindness
 Childhood blindness
• Important public health problem in developing countries

Prevalence
• In india 0.8 /1000 children
• Currently 270,000 blind children in india
 Causes
• Vitamin A deficiency
• Measles
• Conjunctivitis
• Ophthalmia neonatorum
• Injuries
• Congenital cataract
• Retinopathy
• Glaucoma in childhood
 Vision 2020

• Right to sight initiative in India

AIM:
• To eliminate avoidable causes of childhood blindness by
the year 2020
 Activities

• Detection of eye disorders

• At the time of primary immunization
• At school entry
• Periodic checkup every 3 years for normal children and every
year for those with defects
• Preventable childhood blindness should be taken care
through effective measures

• Prevention of xerophthalmia
• Preventions and early treatment of trachoma by active intervention
• Refractive errors to be corrected at primary eye care centers
• Childhood glaucoma to be corrected promptly
• Harmful/ traditional practices need to be avoided .
• Prevention of retinopathy of prematurity by proper screening and
monitoring.
• Curable childhood blindness

• Retinopathy of prematurity , corneal opacity and other causes

to be taken care by experts at secondary and tertiary level eye
care services
 Nursing care

• Disturbed sensory perception (visual) related to altered sensory

perception secondary to altered status of sense organs.

• Anxiety related to changes in health status ( alteration in vision)

and unmet needs.
• Risk for injury related to falls secondary to impaired vision

• Deficient knowledge regarding disease condition,prognosis,

treatment and discharge needs related to lack of exposure.
 The First Blind Athlete in the Olympics

Marla Runyan was 9

years old she developed
a form of macular
degeneration that left
her legally blind
 The Blind Surfer

Derek Rabelo isn't your average

surfer.

Far from it, since Derek was born

with congenital glaucoma.

However, that didn't stop the 20-year-

old Brazilian from learning to surf
when he was just three years old.
 Srikanth Bolla- The blind CEO who built a
50 crore company

CEO of Hyderabad-based
Bollant Industries, an
organisation that employs
uneducated disabled
employees to manufacture
eco-friendly, disposable
consumer packaging solutions