21.12.2016
Pediatric ophthalmology
Pediatric ophthalmology
What makes it so special to talk about?
 normal visual function in an infant is of vital
developmental importance
 direct history taking impossible
 evaluation of children age dependent
 limited concentration and (cooperation)
 role of parents
Christina Gerth-Kahlert
University Hospital Zurich, Department of Ophthalmology
SEW2017
Pediatric ophthalmology
What makes it so special to talk about?
Pediatric ophthalmology
What makes it so special to talk about?
 sensitive phase in visual development
 sensitive phase in visual development
 not specialized on eye segment but on age
 not specialized on eye segment but on age
 not only looking at eyes
 not only looking at eyes
 not only looking at the child but at the family
bilateral vitreous
hemorrhages
in a 4 week old boy
= Stickler Syndrome
Axenfeld Rieger Syndrome
History
Parents are almost always right!
Examination
..can be fun!
.........or very difficult
How did the parents observe/ interprete the visual development?
..........the kids feel when you are nervous about the examination
Does the child meet the milestones?
How is the general development?
Onset of squint/ nystagmus might be difficult to remember.
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Visual performance
looking at light/ faces/ object/ OKN?
Inspection
head posture?
following it?
protest when covering one eye?
pupillary reaction to light?
Documentation:
fixation (CSM)
central/ steady/ maintained
eye muscle paresis lids
Inspection
Inspection
Brückner test!!
Brückner test!!
face morphology
transparency of refractive media? Equal red reflex from both
fundi?
Orthoptic examination
Anterior segment examination
tools: ophthalmoscope/ flash light/ slid lamp
•
•
•
•
•
•
motility
nystagmus?
accomodation
Hirschberg test
simultaneous and alternating cover test
random dot stereopsis (Lang, house fly)
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Posterior segment examination
retinoscopy
tools: ophthalmoscope
indirect (20/ 28 lens)
Refraction!!
ROP
macular hypoplasia
How to assess visual acuity
Preferential looking
• [Optokinetic nystagmus]
• preferential looking
• visual-evoked potentials
Preferential looking
Preferential looking
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Preferential looking
Lea test
age-dependent tests
Normal development
‘Newborns can see.
They prefer to look at faces.
They can even discriminate between mouth opening, tongue
protrusion, and rapidly imitate either.‘
Preference: simple objects with high contrast
Normal development: visual acuity
Normal development: visual field
Superior
100
0.7
90
80
70
0.6
60
50
40
Visual acuity
0.5
30
20
10
0.4
PL
Temporal
0
OKN
Nasal
2 months
1 year
Grown up
VEP
0.3
0.2
0.1
Inferior
0
0
1
2
4
6
9
12
18
24
30
36
Age in months
D. Taylor: Paediatric Ophthalmology, 1997/ H. Kaufmann: Strabismus, 1995
D. Taylor: Paediatric Ophthalmology, London 1997
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Normal development: alignment
• at birth:
Normal development: refraction
• at birth: hyperopia, large standard deviation
20% orthotropic
(+ 2.0 Dpt., SD 2.75), range -7 till +11
1 month: 30% orthotropic
• at 10 years of age: smaller hyperopia, smaller
3 months: 70% are orthotropic
standard deviation (+1.0 Dpt., SD 1.61)
6 months: 98% are orthotropic
• development of fusional abilities and stereopsis between
month 2 and 6
Normal versus abnormal visual development
‚I think my baby can‘t see‘
Normal versus abnormal visual development
‚I think my baby can‘t see‘
no/ poor visual response
history
external eye examination
abnormal external eye exam
no/ poor visual response
history
external eye examination
normal external eye exam
 nystagmus
abnormal external eye exam
e.g.
microphthalmia
cataract
corneal opacities
albinism
non recordable
ERG
LCA
Normal versus abnormal visual development
‚I think my baby can‘t see‘
Normal versus abnormal visual development
‚I think my baby can‘t see‘
no/ poor visual response
history
external eye examination
normal external eye exam
 nystagmus
optic nerve hypoplasia
abnormal external eye exam
e.g.
microphthalmia
cataract
corneal opacities
albinism
no/ poor visual response
history
external eye examination
normal external eye exam
 nystagmus
retinal /
 normal
optic nerve
anterior &
changes
posterior
eye exam
abnormal external eye exam
e.g.
microphthalmia
cataract
corneal opacities
albinism
congenital idiopathic nystagmus
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Normal versus abnormal visual development
‚I think my baby can‘t see‘
no/ poor visual response
history
external eye examination
normal external eye exam
 nystagmus
retinal /
optic nerve
changes
abnormal external eye exam
e.g.
no
microphthalmia
nystagmus
normal
cataract
anterior &
corneal opacities
DVM
posterior
albinism
CVI
eye exam
oculomotor
problems
congenital
idiopathic
nystagmus
Thank you for your attention!
DVM delayed visual maturation
CVI cerebral visual impairment
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