Ординатура / Офтальмология / Английские материалы / Oxford American Handbook of Ophthalmology_Tsai, Denniston, Murray_2011

606 CHAPTER 18 Pediatric ophthalmology

Pediatric examination

The assessment of children (see Tables 18.4 and 18.5) requires a flexible and often undignified approach. The goal is to keep everyone—patient, parents, and extended family—on the same side. Without this it is very difficult to achieve an adequate clinical assessment and impossible to institute treatment.

The awake child

Attempt to entertain the child during history taking (e.g., with a toy) and turn the examination into a game. Explain what you are about to do (e.g., with drops) and why.

Examine opportunistically and be patient. Surprisingly, young children may be happy to be examined at the slit lamp (standing, kneeling on the chair, or sitting on caregiver’s knee). If this is impossible, consider a portable slit lamp for the anterior segment, the indirect ophthalmoscope for the fundus, and the direct ophthalmoscope for higher magnification of the macula and disc. Applanation tonometry and gonioscopy may only be possible by examination under anesthesia (EUA).

Keeping the child happy usually keeps the adults happy. Good communication is essential.

The anesthetized child (EUA)

An EUA may be indicated if detailed examination is impossible with the child awake. It may be performed when the child is being anesthetized for a different procedure, thus coordinated care with other specialists involved with the child is essential. The anesthesiologist should have appropriate experience with pediatric anesthesia.

The presence of the speculum may affect IOP and refraction. It is thus recommended that tonometry (Tonopen or Perkins) and retinoscopy be performed early in the examination and before insertion of the speculum.

Examine the anterior segment with the portable slit lamp, the operating microscope, and gonioscopy lens. Examine the posterior segment with the direct and indirect ophthalmoscope. Consider A- and B-scan ultrasonography.

608 CHAPTER 18 Pediatric ophthalmology

The child who does not see

Worldwide, there are over 1.5 million children who are blind or severely visually impaired. Major causes include inherited abnormalities (e.g., cataracts, glaucoma, retinal dystrophies), intrauterine insults (e.g., infection) and acquired problems (e.g., retinopathy of prematurity, trauma).

The ophthalmologist’s primary aim—the best possible vision for the child—must be seen in the context of the child’s overall health, quality of life, and family support. Likewise, the ophthalmologist’s contribution should be seen in the context of the multidisciplinary team, which may include pediatricians, optometrists, orthoptists, primary care physicians, specialist nurses, social workers, and teachers. The challenge to provide the best possible care for the child (and family) will depend on the following factors.

Disability

Is the visual impairment the only problem, or are there associated disabilities? These may range from mild developmental delay (e.g., motor, speech, social) to profound neurological or systemic abnormalities. In some severe diseases, life expectancy may also be considerably reduced.

Such children require the full benefit of the multidisciplinary team, usually coordinated by the pediatrician.

Treatment

What treatment might be possible now or in the future? Be realistic about what is and what is not currently possible. Ensure best visual potential with refraction, visual aids, and other supportive measures.

When more invasive treatment is indicated, ensure that the parents are fully aware of the risks, realistic outcome, and the extent of care that they will need to give in the perioperative period (e.g., drops, contact lens, frequent clinic visits).

Equipment

What equipment will help the child function best at home and at school? Reading may require Braille (it is important to start early) or large-print books (usually beneficial if reading vision is worse than N10).

Normal-sized print may be read by closed-circuit television (CCTV) magnification or by a scanner attached to a computer that has a magnified display facility or has optical character recognition with a speech synthesizer. The ease of use of standard computer systems has been revolutionized since accessibility options became a standard feature of computer operating systems (e.g., Windows®).

Schooling

Will the child manage best in a specialist school (for the blind or partially sighted) or in a mainstream school (with specialist teacher support)? This is usually determined by the level of visual impairment, any associated disabilities, and the availability of resources locally.

610 CHAPTER 18 Pediatric ophthalmology

Child abuse

The physician has a legal duty of care toward any child he or she sees. This means that if there is any concern or suspicion of possible abuse, it is the physician’s responsibility to act in the child’s best interest.

Concern might relate to injuries that are inconsistent with the mobility of the child or with the reported mechanism, histories that are inconsistent with each other or evolve with time, or an unusual relationship between the caregiver and child. Appropriate action may include discussion with a senior ophthalmologist, referral for a pediatric opinion, direct referral to social services, or consultation with the child’s teacher. It is not acceptable to ignore concerns or to assume someone else will act.

On occasion, the ophthalmologist may be asked to examine a child as part of child protective services investigations. This should be performed by the most senior ophthalmologist available in the care pediatric pateints. It is important to complete as full an examination as possible and for it to be carefully documented.

Photographs may be helpful: if a digital system is used, an unmodified printout should be made at the time and signed by two witnesses. If a report is required, this should be phrased in terms comprehensible to an educated lay public and include the examiner’s full name, qualifications, and the situation in which he or she saw the child.

Retinal hemorrhages and shaken baby syndrome

Shaken baby syndrome (SBS)

Retinal hemorrhages in the absence of bony injury or external eye injury may arise from severe shaking of young children (shaken baby syndrome). They are not diagnostic of abuse and must be taken in the context of the whole patient.

Alternative mechanisms

Additional consideration for other putative mechanisms of retinal and intracranial hemorrhage include the following:

•Normal handling (e.g., vigorous play): it is highly unlikely that the forces required to produce retinal hemorrhage in a child <2 years of age would be generated by a reasonable person during the course of vigorous (even rough) play.

•Short-distance falls: in a child with retinal hemorrhages and subdural hemorrhages who has not sustained a high-velocity injury and in whom other recognized causes of such hemorrhages have been excluded, child abuse is the most likely explanation; rarely, accidental trauma may give rise to a similar picture.

•High cervical injuries: cervical injuries alone do not result in retinal bleeding, unless combined with circulatory collapse.

•Hypoxia: acute hypoxia from transient apnea has not been shown to result in the SBS picture, unless combined with circulatory collapse.

•Intracranial bleeding: Terson syndrome (retinal hemorrhages secondary to intracranial bleeding) is rare in children and any hemorrhages tend to be concentrated around the optic disc.

612 CHAPTER 18 Pediatric ophthalmology

Table 18.6 Poor vision: outline of causes

Table 18.7 Abnormal ocular alignment: outline of etiologies and key features

Table 18.8 Abnormal eye movements: outline of etiologies and key features

COMMON CLINICAL PRESENTATIONS 613

Common clinical presentations: red eye, watery eye, and photophobia

Red (Table 18.9) or watery eyes (Table 18.10) are among the most common ocular presentations in primary care. Often these are relatively benign conditions, many of which may be successfully treated by general practitioners.

However in the presence of atypical features (particularly visual symptoms), more serious diagnoses should be considered. The presence of photophobia is usually an indication of more severe ocular pathology (Table 18.11).

•Examination: ophthalmic ± refractive, neurological, systemic (as indicated).

Red eye(s)

Table 18.9 Red eye: etiologies and key features

614 CHAPTER 18 Pediatric ophthalmology

Photophobia

Table 18.10 Watery eye: etiologies and key features

Watery eyes

Table 18.11 Photophobia: etiologies and key features

Anterior segment disease

COMMON CLINICAL PRESENTATIONS 615

Common clinical presentations: proptosis and globe size

Abnormalities of the whole globe are usually congenital and represent developmental abnormalities. Abnormal protrusion of the eye (proptosis) usually represents an acquired, progressive disease.

Proptosis

Abnormal protrusion of the eye (proptosis) is uncommon, but usually signifies severe orbital pathology (Table 18.12). Acute onset in an ill child may represent orbital cellulitis, an ophthalmic emergency. Orbital tumors (Table 18.13) usually present with more gradual proptosis, although rhabdomyosarcoma is well known to present acutely, mimicking orbital cellulitis.

Table 18.12 Proptosis: etiologies and key features