PEDIATRIC-OPHTHALMOLOGY

PEDIATRIC – OPTHALMOLOGY

EYE SIGNS IN PEDIATRICS

DR. P.SELVARAJ MD. DCH.,
CONSULTANT PEDIATRITIAN
SRM GENERAL HOSPITAL
RAMAPURAM
CHENNAI – 600089 TAMILNADU

ABSTRACT:

In a busy general practioner’s office practice, inspection of eye can be often missed, unless the patient’s complaints point towards eyes. 19 clinical conditions can be diagnosed by inspection of eyes alone if one includes eyes also in the cursery exam. All conditions discussed briefly.

KEY WORD:

· Bitots Spots
· Keratomalasia
· Film star Eyelashes
· Cretinism
· Leukocoria
· Down’s syndrome
· Cataract
· Kayser – Fleischer ring
· Phlectan
· Hydrocephalus
· Naso lacrimal duct obstruction
Aim:
To focus important ‘Eye Signs’ on naked eye examination by inspection alone. Commonest conditions met in the day to day practice while dealing with the children is emphasized. Only external & surface manifestations on the eyeballs are considered. Internal, retinal, optic disc manifestations & ocular syndrome manifestations are not aimed at. It is hoped that this article may be found also useful for a paediatric post graduate/ undergraduate student both for exam point of view & practical usability.

Introduction:

“Eyes don’t see what the mind doesn’t. Therefore it is important that a clinician remembers to look into eyes of children whenever and wherever necessary as a routine examination. Many important diagnosis can be missed if eyes are not looked into. Eye is only a small part of the body reflecting great pathological – events taking place inside body as a whole sometimes very early and sometimes late. Though it is late its significance may be great. (Eye is said to be the window of the brain. This is mainly true with regard to fundus specially during seizure episodes to assess evidence of raised intra- cranial tension where there is a blurred disc margin on fundus examination by opthalmoscope.)

1.Clinical Conditions:

Nineteen important clinical signs pertaining to various clinical –Pathological states are discussed, in brief. Their significance is not only helpful for diagnosis and treatment, but can also alert a physician a possible and impending risky situations likely to be met by the practicing physician during busy hours leading to medico- legal implications.

Vitamin A deficiency – due to nutritional deficiency. The conjunctive of sclera are dull / brownish / silvery scales / plaques/ loose conjuctive with fissues / folds / furrows / Bitots spots / corneal ulceration with different colours and opacification / wrinkling / cloudiness of cornea ( Keratomalacia) & melting of cornea

Film Star Eye lashes:

Dense abnormally long & curved eye lashes on both upper & lower eye lids. Usually seen as a Vit A difficiency as an associated sign along with other signs of malnutrition with or without evidence of primary complex clinically or radiologically. In a well nourished child such a sign may be due to hyper vitaminosis A

Keratomalacia in AGE

Acute onset of keratitis leading to ulcer cornea and eventual blindness observed in most of the diarrhoeal states. During a diarrohoeal episode, inflammed intestinal mucosa can not absorb Vit A. If there is an associated lack of Vitamin A storage in liver, it leads to a sudden lowering of circulating serum vitamin A level which in turn predisposes to development of keratitis. Hence the convenient dictum in all diarrhoeal cases is to give vitamin A 7500 μg as a single stat dose IM Xeropthalmia is a permanent corneal lesion and can not be cured medically though corneal transplantation is the final answer. Medical treatment with injection Vitamin A 7500 μg daily once till healing takes place is recommended.

Exopthalmose:

Sign of hyper thyroidism when the eye is made to look downwards the upper eye lid lags behind. Impairment of convergence and retraction of upper eyelid and in frequent blinking may be present.

Confirm diagnosis by other signs & symptoms as in adults. Blood T3 T4 raised TSH suppressed.

Congenital hyperthyroidism

(Neonatal hyper thyroidism)
Eyes are widely opened and appear exophthalmic all other equivalent signs & symptoms of adults present. Associated jaundice plus or minus
T4 level markedly elevated
Can be due to maternal diseases

Cretinism ( genitically determined)

Narrow palpabral fissure. Very small portion of cornea seen. Confirm with associated signs & symptoms like a. prolongation of neonatal physiological jaundice b. no social smile c. No head control at age 6 months d. lack of alert appearance e. female sex preponderance f. Lithargic state g. Low T3 , T4 & high TSH

Difficult to describe in words. Has to be appreciated by photo or actual looks by visualization

The eye signs & facies are abnormal and is kept in exams for spotter – diagnosis

Treatment: Thyroxine – life long – mental retardation preventable

Diminished Visual acuity

Infant or young child, having poor Visual attention, inability to fixate on an object or reduced response to bright light may suggest diminished acuity of vision.
Nystafmus may be a sign of decreased vision.

Leukocoria: (white pupil) or cats’ eye appearance

Sign of unilateral retinoblastma in the age group of 1 -3 yrs. Strabismus occular misallignment is the first sign of ocular malignancy in 25% of cases. Typically diagnosed in the first year of life in the familial & bilateral cases where both pupils will appear white.

Down’s syndrome:

Distance between central points of both cornea will be greater than normal
Epicanthic folds present
Palpabral fissure tilted upwards and laterally & bilaterally (oblique)
Confirmed by
1. Associated flat nasal bridge
2. Single palmar crease
2. Protruding tongue
3. Mal formed ear lobes
4. Mental retardation
5. High arched palate
6. CHD (VSD)
7. Decreased acetabular / iliac angles (X- ray pelvis)
8. Trisomy 21 ( chromosomal analysis)

Anaemia ( Pallor):

Routinely inspected to see the inside of lower eye lid for presence of pallor. In a neonate it may be a congenital problem either in the bone marrow or red cell destruction due to various causes notably maternal malaria during pregnancy leading to congenital malaria . In Rh incompatibility the yellow colour seen in a pale background

10. Icterus:

Jaundice in a neonate on D1, D2, D3 could be due to blood group incompatibility specially Rh. It is a sign of Hepatitis and Hepato- biliary disease. Currently Leptospirosis and hepatitis A are predominent causes ( most children immunized with Hep-B Vaccine) still blood test for HBs – AG has to be done to rule out ‘Hep B’ or ‘Non- B’ jaundice on D3 and after in a neonate especially in a premature baby is often due to physiological jaundice

11. Phlectanular kerato conjunctivitis:

One or two isolated blood vessels running from angle of eye ending and merging in the lateral margin of cornea, usually unilaterally. It is a sign of Tuberculosis and hence requires confirmation by investigations. It is due to allergy to bacterial (AFB) Protein .

12. Measles conjunctivitis:

Like any other conjunctivitis there is florid inflammation of both conjunctivae Eyes & lower eye lids are deeply inflamed. Associated oral inflammation signs plus fever after D3 confirms. Often there is continuous cough day & night . Maculo – popular rash all over the body is pathagnamonic & diagnostic

13. Madras Eye/ Bombay Eye/ Acco

Purulent conjunctivitis of sudden onset. Often there is widespread diseases in the community as an epidemic. Prior to actual conjunctivitis, puritus, intense over both eyes are significant , conjunctivitis within 24 hrs of pruritis is important. Profusely purulant conjunctivitis within 24 hrs of birth may be due to Gonococcal infection. When conjunctivitis occurs sporadically with closure of eyelids due to purulent material the cause is bacterial often. Antibacterial eye drops recommended for both.

14. Naso Lacrimal duct obstruction

Usually seen in Neonates or young infants.Purulent secretions formed in either eye or both eyes at medial aspect. Gentle rubbing on the surface marking of Naso lacrimal duct 25 times x 2-3 times daily for 1-2 weeks with eyedrops improves condition. Usually reported to doctor after 1-2 weeks of eye drops alone not improving situation without physiotherapy of facial skin.

15. Dehydration:

Eye balls are sunken. Conjuctiva dry, cornea dry only in severe dehydration. Lacrimation less in a crying child. History of diarrhoea /vomiting confirms along with the other signs of clinical dehydration

15. Cataract : ( often Congenital)

May be unilateral or Bilateral may be obviously visible or by ophthalmic microscope usually due to congenital Rubella as a sole finding or with after associated findings like microcephaly , Hepatosplenomegaly CHD/VSD + CNS signs

17. Kayser – Fleis cher ring

Due to deposition of copper in Descemets membrane of over the iris muscle and appears as a fine golden ring around cornea, best appreciated by slit lamp. This is pathagnomonic & diagnostic of wilson’s diseases ( Hepto lenticular degeneration) Any liver disease above age 5 should be thought of and excluded wilson’s disease. Many wilson’s disease in children appear and mimic as an ordinary Hepatitis with jaundice whenever neurological symptoms occur with a liver dysfunction, serum ceruloplasmin level estimated and also urinary copper excretion done.

18. Hydrocephalus:

Eye sign is setting sun appearance on both eyes. Depending upon degree of intra - cranial pressure and CSF obstruction the eye balls are tilted forwards to down wards and the disappearance of significant portion of cornea underneath the lower eyelid is appreciable confirmation by measurement of head circumference 2 to 2-5 cm more than normal is significant. Otherwise serial CT scan brain & serial head circumference measurements are mendatory. This will rule out development of ventriculomegaly and fecilitate early surgical treatment for correction ( Ventriculoperitoneal shunt). This should be strongly suspected in all cases where corrective surgery for meningo – myeerocele’ already done as CSF obstructive signs and symptoms most likely to develope in such infants. Early VP shunt procedure lessens risk of neuronal degeneration of brain tissue.(Brain atrophy)

19. Impending Death

Corneal haziness in a case of very severe dehydration over 15 %, all vital parameter’s come down gradually for a stand still. If cornea is shining it is a sign of life. The lacrimal secretion stops when all after body function stops due to decreasing general blood circulation. It is a sign of end stage of any disease more so and earlier in dehydration .First there is cloudiness, haziness and dusty opacification of transparency of cornea leading to opacification. There is diminished eye ball movements. Puplis are dilating and sluggishly reacting to light gradually unfolding the impending death signs. The HR& RR are gradually coming down. Thus the signs of tissue death noticed earlier in eyes than in any other organs.


Conclusion

The basic rule of clinical medicine is inspection, palpation , percussion and auscultation we skip over occasionally during busy hours this important inspection aspect as we know the diagnosis through other sources many times. Jaundice, anaemia, cataract missed in infants. Like touching anterior fontenalle as routine in a neonatal exam or looking for meconium for anal patency at birth during neonatal resuscitation, looking at eyes routinely can give valuable information in all age groups, more so in pediatrics. One may not make exact diagnosis on inspection. But it will be helpful far further investigation & confirmation. Eye is not only the window of the brain but also the window of the practicing physicians mind. It is the physician’s choice to keep the window closed or open however.

References

Test book of pediatrics: Waldoo Nelson 14th edition 1992
Text book of principles of internal medicine by Harrisons 8th edition 1977
American Academy of ophthalmology 1999- 2000 ( Peadiatric ophthalmology)