Children's eye doctor

Lens subluxation: This case presented as a refractive change in a 13 year old with Marfans syndrome. Examination revealed lens subluxation; note the radial strands of zonules next to the lens. This case was managed with surgical removal of the lens and secondary IOL placement as a 2 stage procedure. Careful patient and parent counselling took place to explain risks and benefits of each option.

Part of my practice involves assessing and treating adult patients for cataracts and squint/strabismus (misalignment of the eyes). The case above is from an adult patient who presented with double vision and partial ptosis (drooping of the eyelid). These signs evolved over time to become a complete ptosis and examination revealed a third nerve palsy. Neuroimaging was carried out; the first image shows a T2 weighted MRI and the second image is of an MRA both showing dilation of the internal carotid arteries with ectasia. This is an unusual cause of a compressive third nerve palsy which causes progression of this nature. Unfortunately, interventional treatment is not routinely offered for carotid ectasia as the risk of rupture is low with an otherwise high-risk procedure. This lady was therefore conservatively managed with close monitoring. Some important learning points from this case are as follows: ☆Signs of a third nerve palsy include ptosis (complete or partial), restricted elevation and adduction +/- pupil involvement ☆Pain and/or pupil involvement can indicate intracranial aneurysm therefore require urgent investigation and treatment ☆Microvascular causes are not uncommon but evolving signs must be further investigated. ☆MRI is more sensitive than CT for small lesions e.g. infarction, abscess or tumour ☆CT is more sensitive than MRI for haemorrhage or calcification ☆Medical third nerve palsy usually recovers or improves after 3 -6 months ☆Strabismus surgery is complex and should only be considered for residual deviations after 6-12 months.

Case of the Day: Traumatic choroidal rupture. The OCT image above was taken after a tennis ball injury in an 11 year old boy. He presented with reduced vision (6/36) and was diagnosed with a classic Choroidal neovascular membrane following this injury- see the fundus fluorescein angiogram (2nd image). The child was treated with 0.05ml Intravitreal Lucentis with parental consent under General anaesthetic. The child had a good outcome (3rd OCT image) with a final visual acuity of 6/12, 9 months after initial presentation and after 6 lucentis injections.

As I am weaning my 7 month old, food and its influence on health has not been more important and interesting for me. So, when I came across this study which links higher lutein levels (the antioxidant found in green leafy vegetables and eggs) in children to improved academic performance you can be sure the kale came out! Read and enjoy getting the kids to eat their greens.
https://www.aop.org.uk/ot/science-and-vision/research/2017/06/23/have-you-eaten-your-greens-its-all-in-the-eye

Why do my baby's eyes look crossed? This is one of the most common presenting problems in my practice. A newborn baby struggles to see with any clear focus and therefore will tend to have a drift in the eyes either inwards (esotropia) or outwards (exotropia). Usually babies will start gaining ocular muscle control by the age of 3 to 4 months and the drift (or squint) is no longer seen. The important thing is that any constant drift of the eye needs to be seen by an ophthalmologist as there are many reasons for this that will need to be investigated and treated.

In the UK the first newborn eyetest happens in hospital before mother and baby are discharged home. The test mainly involves using the device above (a direct ophthalmoscope) in order to view the 'red reflex'. This is used to view the reflection of light from the retina at the back of the eye. A normal red reflex will be a pink coloured reflection in each eye and indicates that light is travelling to and from the back of the eye normally i.e there is nothing obstructing the light which could affect visual development. It is important that the direct ophthalmoscope is used and not an ordinary pentorch as the ophthalmoscope has several lenses which give the ability to magnify up to 15 times and a bright light source, allowing the clinician to clearly visualise the reflex. This newborn check is followed by another similar check at the 8 week follow up with the General Practitioner.

Case of the day:
Pilocytic astrocytoma.
6 year old presenting with 9 diopter left/right vertical deviation. 2 month history of painless infraorbital swelling. The MRI shows a sagittal non-contrast T1 weighted image showing a high signal intensity extraconal, anterior, homogeneous infra-orbital cystic lesion measuring 2.5cm x 2cm. No brain abnormalities were found. The lesion was removed completely using a transconjunctival approach. Histology confirmed Grade 1 Pilocytic astrocytoma. Ocular alignment was restored to orthophoria after surgery and parents and child were happy. 😊

This is one of my newborn's favourite toys. The firefly is perfect for babies as it incorporates bright colours as well as high contrast (see the second picture of the black and white portion). Both of these aspects stimulate the retinal photoreceptors and help visual development.

What does my newborn baby see? This is a question often asked by parents. To begin with a newborn's vision is quite blurry and they tend to see mainly in contrast therefore turning towards bright light sources or windows. A newborn's eyes will wander and not fix on anything specific. In the first month they will start to focus on objects 20cm to 30cm away, i.e. mainly parents faces. Then within the first 2 months a baby will start to fix on an object and follow it, this is mainly bright coloured objects i.e. red or black and white high contrast objects. Fixing and following is a good initial test of vision. Parents should be told what to look for and any concerns raised immediately with healthcare providers.

Case of the Day: Retinitis Pigmentosa (RP). A group of rare genetic conditions that involve a loss of the cells in the retina. These are the fundus photographs of a 15 year old girl presenting with RP. The final image is the OCT scan of both macula showing left cystoid macula oedema (CMO). Remarkably the vision was maintained at 6/6 right eye and 6/9 left eye. Common symptoms of RP include night blindness and loss of peripheral vision. There is typical bone spicule pigmentation in the periphery of the retina with retinal vessel attenuation and a classic waxy appearance to the optic disc. Investigations include electrodiagnostic testing, genetic testing and regular visual field test and OCT scans. Treatment is still supportive and includes sight impairment registration. It is important that careful discussion involving children and parents is undertaken to identify any visual aids or support that may be needed.

Posters are a great way of explaining a diagnosis or eye condition! Here is one I use in my practice when explaining eye conditions to parents and adults.

A common struggle faced by parents is how to keep glasses on their child. A useful tip I suggest in my practice is to put the glasses on whilst the child is sleeping so they will be less noticeable and therefore less likely to take them off!

This is a case of a child who presented with reduced vision. The child had recently bought a laser pointer from school and unfortunately whilst playing had shone it into the left eye. Note the disruption of the outer retinal layers in the foveal region in the OCT image above. Parents should be aware of the dangers related to laser pointers which, at present, are readily avaible to buy in the UK.

How to examine a newborn baby? This is a question I often get asked by my junior colleagues as it takes skill and a level of experience to be able to comfortably perform this task. My number one tip is to swaddle the baby and to learn how to do this correctly can make the difference between a good examination and a poor one. Once swaddled the baby is usually calm and can be moved into the correct position for examination. I lie the baby on an examination table, with help from my nurses, I move around the baby in order to view the complete retina. This involves moving baby's head from left to right and changing the angle of the examination lens. This is a skill that I have learnt from my training and I implement on a weekly basis when examining babies with retinopathy of prematurity (ROP) in the neonatal intensive care unit (NICU). The second image shows the swaddles I am currently using to calm my newborn!