Childhood Disorders of the External Eye

Vision Preferences in Infants

Infants prefer patterned visuals such as human faces and bold shapes, which significantly aid in their visual development and testing.

Eye Examination and Screening

Important Checks:

  • Newborn inspection for major visual disabilities, specifically focusing on congenital cataracts, which can significantly affect vision if not addressed early.

  • Screening for retinopathy of prematurity (ROP), a condition affecting premature infants that can lead to blindness if undiagnosed and untreated.

  • Regular eye checks should be conducted at 6-8 weeks to assess early development and again at 4.5-5 years to ensure proper vision as the child grows.

  • Continued screening from ages 11-14 is essential, particularly to identify changes as children move into adolescence.

Neonatal Eye Examination

Assessment during neonatal examinations should include:

  • Observing for redness, size, and symmetry of the eyes to detect any abnormalities.

  • Checking the clarity of the cornea and lens, as congenital conditions can sometimes be visibly apparent.

  • Addressing any familial concerns about inherited eye conditions or historical parental issues with eye health.

Ocular Defects

Many congenital ocular defects, such as coloboma, may go undetected during initial examinations. Therefore, robust recording methods and comprehensive histories are crucial in identifying these conditions to prevent future complications.

Ptosis Terminology

  • Ptosis: Refers to a drooping eyelid, which can affect one or both eyes and may significantly impact vision.

  • Epicanthus: A skin fold covering the inner canthus, which may give the appearance of narrow palpebral fissures.

  • Telecanthus: Increased distance between the inner canthi of the eyes, which can alter facial aesthetics and affect ocular alignment.

  • Hypertelorism: Refers to an increased distance between the orbits, often indicative of underlying syndromic conditions.

Consequences of Ptosis

Ptosis can lead to several complications, including:

  • Induction of astigmatism due to abnormal eyelid positioning, leading to distorted vision.

  • Risk of amblyopia if the affected eye is not adequately stimulated, which is crucial during early development.

  • Compensatory head postures that can lead to neck strain and discomfort over time.

Types of Ptosis

  • Congenital: Inherited characteristics that affect the function of eyelid muscles and are present at birth.

    • Features: Absence of skin crease, lid lag on downgaze, superior rectus weakness. Unilateral or bilateral.

  • Neurogenic: Conditions affecting the third cranial nerve (III nerve palsy) can result in ptosis due to nerve dysfunction.

    • E.G. Marcus Gunn ptosis - abnormal synchronicity of the 3rd and 5th CN = lid goes up when eating

    • E.G. Myasthenia gravis - ptosis varies during the day. Tends to come when patient is fatigued.

  • Myogenic: Related to muscle diseases such as muscular dystrophy, affecting the eyelid's ability to maintain position.

  • Mechanical: Caused by physical obstructions such as lumps or lesions on the eyelid, for example, meibomian cysts.

Associated Conditions

  • Horner's Syndrome: This condition includes mild ptosis and may involve heterochromia and anhidrosis, enopthalmos and slightly lower IOP, requiring careful evaluation of the pupillary response and possible neurological assessment.

  • Myasthenia Gravis: An autoimmune disorder that can manifest as subtle bilateral ptosis, necessitating management by specialists.

Ptosis Management

Referrals for medical evaluation are recommended when congenital abnormalities or syndromes are suspected. In severe cases where vision is obstructed, surgical interventions may be necessary to reposition the eyelid adequately and for CHP if marked. Urgent surgery for marked ptosis for newborns that obstructs line of sight. If not marked, better to leave till 4-5 years of age.

Eyelid Lumps in Children

Common types of eyelid lumps include:

  • Inflammatory: Conditions such as meibomian cysts (chalazion - away from the lid margin) and hordoleum (styes - inflammation of eyelash follicle on the lid margin) which may require medical treatment or drainage. Molluscum contagiosum = viral. Self-limiting or can incise the system with general anaesthetic.

    • E.g. Capillary haemangioma: Tend to resolve in 5-7 years. Treatment: Propranolol

    • Sturge Weber Syndrome: doesn’t cross midline - redness

  • Tumors: Can vary from benign lesions to malignant growths; regular surveillance is essential for early detection.

    • Coloboma of the eyelid or iris - missing tissue

    • Haematoma: Extra tissue in conjunctiva, encroaching on cornea

Epiphora in Infancy

Blocked tear ducts often resolve naturally by 12 months. If symptoms persist, non-invasive interventions such as gentle massage (may have a bluish bump on lacrimal sac) or surgical probing may be necessary to prevent complications. Eyes may be sticky, but no redness (DD from a blocked duct to conjunctivitis or glaucoma)

Opthalmia Neonatorum

<4 weeks of birth.

  • Chlamydia trachomatis: 7-28 days peak in week 2. Uni + bilateral. Pseudomembranous (also strep)

  • Neisseria gonorrhoea: 4-7 days. Bloodstained conjunctivitis. Corneal penetration - blindness

  • Herpes simplex: Part of the general infection. Bilateral.

Conjunctivitis

Symptoms typically include redness, discharge, and always bilateral (may start as unilateral). Doesn’t affect vision. Types include:

  • Bacterial: Often characterized by thick, purulent discharge.

  • Viral: Usually associated with clear discharge and may be linked with upper respiratory infections.

  • Allergic: Often occurs seasonally or in response to specific allergens, with symptoms of itching and tearing.

  • Traumatic: Resulting from injury or chemical exposure; requires immediate evaluation.
    Treatment should be tailored based on the causative agent to ensure effective management.

Red Eyes in Infants

It is crucial to distinguish between conjunctivitis and potentially serious conditions such as glaucoma or tumors. A comprehensive examination can help identify other possible underlying issues.

Infantile glaucoma: possible large cornea, photosensitivity

Key Notes on Other Eye Conditions

  • Cellulitis: This can manifest as preseptal or orbital cellulitis, both of which require urgent treatment to mitigate risks of intracranial infections. Usually unilateral.

    • Pre-septal: respiratory infection. Associated eyelid infection or trauma

    • Orbital: Mostly under 5. Most secondary to sinusitis.

  • Allergic Reactions: Can present around the eyes with varying symptoms, necessitating prompt identification and management.

    • Papilliary allergic conjunctivitis: More common in boys. Cobblestone papillae. Atopic conditions - more likely to have asthma, and hayfever.

  • Herpes Simplex: affecting skin and causing dendritic ulcer - uncommon in children.

  • Phthisical eye: Long term uveitis, IOP very low and completely blind. Calcium deposition under the surface of the cornea, occasionally comes through epithelium = agonising pain. Calcium needs to be removed.