COMMON EYE DISORDERS IN CHILDREN

INTRODUCTION Childhood eye disorders in the tropics include conditions that occur in children all over the world, and those that only occur in children in the tropics. Eye disorders that occur in children in the tropics are consequences of socio-economic and environmental conditions in the tropics. They are mainly preventable conditions and may cause avoidable blindness. The prevalence of childhood blindness in the tropical and other developing countries exceeds 0.05% compared to the prevalence of less than 0.03% in the industrialized countries. Anatomy of the Eye The eye is embryologically derived from the brain. Anatomically, it still retains its embryologic connections to the brain. Important parts of the eye include: Anterior chamber The area bounded in front by the cornea and in the back by the lens and filled with aqueous fluid. The posterior chamber is the area behind the iris, but in front of the lens, that is filled with aqueous fluid. The aqueous fluid is a clear, watery solution in the anterior and posterior chambers. The choroid, which carries blood vessels, is the inner coat between the sclera and retina. The cillary body is an unseen part of the iris and these together with the ora serrata form the uveal tract. The conjunctiva is a clear membrane covering the white eye (sclera).

 The cornea is a clear, transparent portion of the outer coat of the eye ball through which light passes to the lens. The iris gives the eyes colour and it functions like the aperture in a camera, the aperture itself is known as the pupil. The lens focuses light on the retina. The macula is a small area in the retina that provides the most central, acute vision. The optic nerve conducts visual impulses to the brain from the retina. The pupil is the opening or aperture of the iris. The retina is the inner most coat of the back of the eye, formed of light sensitive nerve endings that carry the visual impulse to the optic nerve. The sclera is the white of the eyes. The vitreous is a transparent, colourless mass of soft, gelatinous material filling the eyeball behind the lens. Common eye disorders in children. (a) Disorders of the eyelids. (b) Obstruction of the lacrimal apparatus. (c) Disorders of the conjunctiva. (d) Disorders of the cornea. (e) Abnormalities of iris and pupil. (f) Abnormalities of the lens. (g) Disorders of retina and vitreous. (h) Abnormalities of the optic nerve. (i) Orbital abnormalities

Disorders of the eyelids. (i) Epicanthus This is a congenital malformation characterized by a concave bilateral lid fold at the inner angle of the lids. It is normal in the Mongolian race, is found in children with Downs syndrome. If epicathus is marked, it may give the appearance of a convergent squint, since the pupil is closer to the lid fold at the inner angle than at the outer angle. No therapy is indicated. (ii) Sty (hordeolum) This is an acute suppurative inflammation of the eyelash follicle and/or its associated glands (the sebaceous gland of Zeis). Usually a purulent infection caused by staphylococcus aurens. There is localized oedema, redness near the lid edge and pain, with the point of maximum tenderness over the affected gland. Treatment Application of hot compresses to hasten resolution, as well as topical antibiotics. Systemic antibiotics should be given in severe cases, especially if there is a surrounding cellulitis. Analgesics may be given for pain. Incision and drainage should be done when pointing occurs, this may have to be carried out by a specialist. (iii) Chalazion (Internal Hordeolum) This is a relatively painless mass that may result from obstruction, retention and chronic granulomatous inflammation of one of the tarsal gland (Meibomian) in the upper or lower lid. This is also called internal

Hordeolum because it usually points on the conjunctiva side of the eyelid when it becomes secondarily infected; it results in a suppurative inflammation. The small mass may resolve or gradually grow larger in size. It may cause a ptosis by virtue of its weight, dragging the lid down. Pressure of the swelling on the globe may lead to corneal distortion and astigmatism. Treatment: Local Measures: When the area is chronically infected or the condition is recurrent, antibacterial ointments may be used. Surgical measures: Give Local anesthesia and open the Chalazion by conjunctiva incision and curettage by the ophthalmologist. (iv) Ptosis (drooping of the upper eyelids). Ptosis is characterized by drooping of the upper eyelid below its normal level. Could be congenital as a result of faulty development of the levator muscle or its innervating branch of the 3 rd cranial nerve. There may be associated weakness of the superior rectus muscle. Congenital ptosis may be accompanied by a marked epicanthus. It is generally bilateral but frequently asymmetric. Acquired ptosis is seen less often in children and but if it occurs, it may suggest neurologic disease. Sight ptosis results from interruption of cervical sympathetic (Horners Syndrome). Ptosis may result from trauma. Treatment: To prevent visual loss, early plastic surgery is indicated when ptosis is moderate or severe and interferes with vision. In patients with milder forms of ptosis, no surgical treatment is required except for cosmetic reasons. Prognosis is excellent for surgical cure when levator paralysis is partial.

Obstruction of the Lacrimal Apparatus (Dacryostenosis) congenital nasolacrimal duct obstruction due to incomplete canalization of the nasolacrimal duct with a residual membrane at the lower end of the nasolacrimal duct, where the duct enters the nasal cavity. Dacryostenosis is one of the most common congenital abnormalities of the eye. It may also be acquired. Trauma concomitant to silver nitrate or penicillin instillation, as well as chronic conjunctivitis, may predispose to the development of this disorder. Tearing and conjunctivitis may be noted. Mucopurulent discharge is often present or may be expressed from the lacrimal sac. The condition may be unilateral or bilateral. Treatment Local Measures: The lacrimal sac should be gently messaged, using a pumping action with a small finger in the lacrimal fossa. If infection is present, local chemotherapy with sodium sulfacetamide ophthalmic drops is advised. In 95% of cases, correction occurs spontaneously or following message. Surgical Measures: Probing is easily and safely performed in patients after 6 9 months of age. Dacryocystitis Infants with congenital nasolacrimal duct obstruction may develop acute infection and inflammation of the nasolacrimal sac. systemic signs of infection such as fever and irritability. agent. Dacryoadenitis With Dacryocystitis the sac area is swollen, red and tender and there may be This infection requires prompt treatment with antibiotics mainly an anti-staphylococcal

This acute inflammation of the lacrimal gland is uncommon in childhood. It may occur with mumps or infectious mononucleosis, usually bilateral, subsiding in a few days or weeks. Chronic dacryoadenitis is associated with certain systemic diseases which include tuberculosis, syphilis, and sarcoidosis. Disorders of the conjunctiva. Conjunctivitis Inflammation of the conjunctiva mucous membrane due to reaction to wide range of bacterial ,viral agents, allergens, irritants, toxins and systemic diseases. Conjunctivitis is common in childhood and may be infectious or non-infectious. Ophthalmia Neonatorum Ophthalmia neonatorum is a form of conjunctivitis occurring in infants less than 4 weeks of age. It is the most common eye disease of new born. The abnormality is commonly bilateral although it could be unilateral. Time of onset is often a good guide as to the causative agent. Causative agents include:a. Silver nitrate: This is by far the most common cause. Onset is in the first 2 days of life, usually the first. b. Gonococci or staphylococci: The onset is at any time after birth, usually between the second and fifth days. c. Chlamydiae: The onset of inclusion is between the 3 rd and 14th day. Clinical Findings Symptoms and signs. 1. Silver nitrate conjunctivitis: The mucopurulent discharge may become purulent if secondary infections occur. 2. Gonococcal or staphylococcal conjunctivitis: The discharge is frankly purulent and very profuse.

3. Chlamydiae conjunctivitis: Laboratory Findings 1. Silver nitrate conjunctivitis.

The discharge is moderately profuse.

Characteristically, the conjunctiva in the lower fornix is hypertrophied.

Smears of pus reveal cellular debris but few, if any bacteria. Bacteriologic cultures yield negative results early in the cause of the disease. 2. Gonococcal or staphylococcal conjunctivitis: Gram stained smears from the discharge reveals gram-negative intracellular diplococci (gonococci) or gram-positive cocci in clusters (staphylococci). 3. Chlamydiae conjunctivitis: confirm the diagnosis. Chlamydia. Treatment Silver nitrate conjunctivitis responds well to saline irrigation and is usually self-limited. Bacterial conjunctivitis requires prompt therapy with chemotherapeutic agents such as sodium sulfacetamide, bacitracin. Topical and systemic chemotherapy is advisable for treatment of patients with gonococcal conjunctivitis. Patients with Chlamydiae conjunctivitis should be treated with 10% sodium sulfacetamide drops or ointment or tetracycline ointment instilled every 2-4 hours for 2-4 days. Prophylaxis Recently silver nitrate prophylaxis has been shown to be inferior to instillation of tetracycline ointment and only marginally superior to simple cleaning of the eyes of the newborn at birth. It is therefore recommended by WHO that Credes prophylaxis be replaced with a combination of cleaning and instillation of tetracycline ointment into each eye of the infant The demonstration of inclusion bodies from smear of conjunctiva scraping and a monocytic cell response Giemsas stain is required for isolation of

at birth in National programmes for the prevention and control of Ophthalmia neonatorum. Prepartum therapy of gonorrhea infected mothers should be treated prior to delivery and may prevent gonococcal conjunctivitis but instillation of tetracycline eye ointment with meticulous eye cleaning affords an additional advantage. Prognosis The prognosis with treatment is generally very good, and cure should result within 2 4 days. Acute Purulent Conjunctivitis Characterized by generalized conjunctiva hyperemia, oedema, mucopurulent exudates and various degrees of ocular discomfort. Acute purulent conjunctivitis is usually as a result of bacterial infection. The most frequent causes are Haemophilus Influenzae, streptococcus pneumonia, Beta-hemolytic streptococci and staphylococcus aurens. Treatment: Acute purulent conjunctivitis is managed with antibiotic eye drops or eye ointment. Chloramphenical or Gentamycin eye drop are effective and should be given 2 to 6 hourly for at least ten days. Viral Conjunctivitis This is the commonest form in children. Viruses of epidemic keratoconjunctivitis include adenovirus type 3, 8 or 19, and herpes simplex. Viruses typically cause acute conjunctivitis associated with watery discharge and follicular reaction. Usually bilateral except that caused by molluscum contagiosum which is unilateral. Subconjunctival haemorrhages and pseudomembrane occur in severe cases. Viral conjunctivitis may also be complicated by an inflammation of the iris and cillary body.

Treatment of most viral conjunctivitis is supportive. The lesions are selflimiting. Prevention of viral conjunctivitis during epidemics is by meticulous hand washing and avoidance of picking of the eyes. spread is by close person to person contact fomites. Allergic Conjunctivitis This is one of the commonest ocular conditions seen in children in the tropics. Tissue swelling is often considerable because of the looseness of the tissue. This allergic disorder is characterized by the presence of oesinophils in conjunctiva scrapings. The history of other allergic disorders in the individual or the family is important in the diagnosis. 3 main types are: (a) Vernal keratoconjunctivitis (spring catarrh) This is a bilateral recurrent 1gE mediated inflammation of the conjunctiva, also called spring catarrh because it tends to occur during the warm spring month in temperate climates. In the tropics, however, it is seen virtually all the year round with exacerbations during the dry season and cold harmattan period. Pre-pubertal males are more commonly affected than females. The commonest symptom is itching which is often intolerable. There is associated secretion of tenacious, stringy and sticky discharge. Due to scratching with dirty hands, and therapeutic interference by parents, secondary infection may occur, making the discharge intermittently purulent. scarring. Treatment: Identification and removal of offending antigen where possible. If the diagnosis is certain, corticosteroid drops and cold compresses could be used for initial short-term control and during severe exacerbations. For long-term control and prophylaxis, mast cell stabilizers such as sodium Other complications include superior punctuate epithelial erosion, exudates coated macro-erosions and sub-epithelial This is because

cromoglycate drops (2%) may be used. Parents/patient should be educated on the usual course and prognosis of the disorder. (b) Seasonal allergic Conjunctivitis: This is a bilateral allergic conjunctivitis which occurs in children or young adults who often also have hay fever. It is acute in onset and may be recurrent. Symptoms are those of severe itching and tearing. There are scanty conjunctiva signs. Hx of hay fever is important or helpful in arriving at a correct diagnosis. Treatment is with 2% sodium cromoglycate drops and systemic antihistamines. blindness. (c) Phlyctenular Keratoconjunctivitis This is a unilateral, localized hypersensitivity reaction of the conjunctiva. It consists of a bulbar conjunctiva nodule measuring 1 3mm in size. It progresses irregularly towards the central cornea, followed by a group of blood vessels which lead to corneal vascularization, it commonest complication. The vascularization causes corneal scaring and reduced vision. A Phlyctenular is considered to be a delayed hypersensitivity to bacterial protein, particularly tuberculoprotein. Presence of Phlyctenular conjunctivitis should be regarded as evidence of tuberculosis, particularly in an undernourished child, until proven otherwise. Thus while treatment is initiated with topical steroids to suppress the hypersensitivity and allow healing, the child should be fully investigated for systemic tuberculosis. Disorders of the Cornea Keratitis This is an inflammation of the cornea. The healthy cornea possesses no blood vessels and is clear. Any blood vessels or opacities seen in it are pathologic. Health education is helpful in preventing

Aetiology (1) Keratitis may be due to Vit A deficiency occurring in malnourished children, in allergic children on restricted diets and in children with biliary tract anomalies which interfere with absorption of Vit. A. (2) Bacterial ulcers caused by bacteria including streptococcus pneumonine, haemolytic streptococci, klebsiella pneumoniae, Pseudomonas aeruginosa and Moraxella lacunata. (3) Phlyctenular Keratitis hypersensitivity reaction to the presence of tuberculoprotein. (4) Interstitial keratitis associated with congenital or acquired syphilis or may follow infectious diseases such as herpes zoster, mumps and tuberculosis. (5) Mycotic ulcers usually associated with the penetration of the cornea with vegetable material e.g. a stick. (6) Viral keratitis may be due to herpes simplex or vaccinia. Bacterial Keratitis Presents with a gray area of infiltration of the cornea associated with dilatation of the circumcorneal blood vessels; producing the characteristic cillary flush. There is more pain than is expected from such a small lesion and the corneal epithelium is markedly hazy. Treatment: The area enlarges and spreads very rapidly; a level of pus often appears in the anterior chamber. Early specific local and systemic antibiotic therapy is imperative and must be based on findings obtained from scrapings and cultures from the ulcer itself. Neomycin polymyxin bacitracin ophthalmic ointment or gentamycin solution (2 10 mg/ml) against pseudomonas ulcers mainly.

Viral Keratitis. The dendrite is suggestive of herpes simplex, which may also present as stippling or as a geographic corneal ulcer. usually present. Treatment: For patients with Herpes simplex and vaccinia keratitis, use 0.1% idoxuridine topically. Corticosteroids should never be used in viral keratitis. Xerophthalmia This is a description of all ocular disorders resulting from the systemic deficiency of vitamin A in the body. Commonly caused by inadequate intake of Vitamin A in the diet. It can also be due to impaired absorption of Vit A from the gut, either due to malabsorption syndrome or inadequate fat and oil in the consumed food. Can also be due to an increased demand in the presence of normal intake. diarrhoeal disease. Xerophthalmia is characterized by a cornea that has lost its luster and appears cloudy and dry (xerosis). The stages and degree of the illness is classified by WHO as thus: XN Night Blindness XIA Conjunctiva xerosis XIB Bitots spot X2 Corneal Xerosis X3A Corneal ulceration affecting 1/3 of the corneal X3B Corneal ulceration affecting 2/3 of the cornea. XS = Corneal scar XF Xerophthalmia fundus. Increased demand is a common occurrence in growing children and during illnesses like measles and Corneal hyperesthesia is

Healing of these lesions results in scaring. If the papillary area is involved, blindness results. Treatment: Corneal ulceration is treated by a specialist. Definitive treatment is with the administration of Vit A 200,000 I.U daily for 2 days and 7 th day for children above 8kg and above 1 year children; under 1 yr of age and under 8kg, half of the above dose is given. Primary prevention: is through health education. Secondary prevention of blindness from Xerophthalmia requires periodic administration of Vit A to children at risk. This can be combined with routine childhood immunization schedules. Trachoma This is a preventable chronic, granulomatous keratoconjunctivitis which is endemic in many tropical and developing countries. illness is common in children under 10yrs of age. Aetiology: Trachoma is caused by Chlamydia trachomatis. The disease is spread from person to person through the mixing of ocular discharges. The organism is highly virulent. The intracellular nature of the organism makes treatment and eradication by the bodys immune system difficult. Clinical features: Infection of the epithelial cell by C. Trachomatis provokes an acute inflammation. This manifests clinically as papillae and small follicles in the upper tarsal conjunctiva and vascular membrane invasion of the upper cornea (pannus). This is followed by the sub-acute inflammation stage, which manifests clinically with an increase in the number of papillae as well as larger follicles associated with conjunctiva oedema. On the cornea, the pannus extends and follicles appear near the upper limbus. Healing occurs with scarring. On the cornea, the pannus continues extending and healing of the corneal follicles results in The inflammatory disease affects the cornea, bulbar conjunctiva, and the upper eye lid. This

depressions, covered by transparent epithelium called Herberts pits. Herberts pits are characteristic of trachoma. Later the inflammation subsides and only scars, pannus and Herberts pits remain. The degree of scarring depends on the severity and duration of the inflammation. With recurrent, exposure and reinfection, the scarring becomes quite extensive, resulting in turning of the upper lid margin (entropion) carrying the eye lashes with it. The eye lashes thus turn inwards rubbing on and damaging the cornea (trichiasis). Treatment: Chlamydia Trachomatis is sensitive to tetracycline. The topical 1% ointment is quite adequate. Several regimes are used: i. ii. iii. Twice daily for 5 days in a month for a total of 6 months. Once daily for 10 days in a month for a total of 6 months Twice daily for 6 weeks continuously.

Retinopathy of Prematurity This is a disease of the retina that occurs primarily but not exclusively in preterm infants. It is invariably bilateral and leads to wildly disorganized retinal vascular over growth and permanent blindness. Aetiology 1. Prematurity 2. Prolonged use of high oxygen tension 3. Repeated top-up blood transfusion in the new born. Treatment: In selected cases, cryotherapy to the avascular retina has been shown to reduce the more severe complications of progressive ROP to some extent. Prevention: Prevention of ROP ultimately depends on the prevention of premature birth and its attendant problems. Use of supplemental vitamin E for its antioxidant properties in infants at risk for ROP.

Retinoblastoma Retinoblastoma is the most primary malignant intraocular tumour of childhood. The average age of diagnosis for bilateral tumours is 12 months; unilateral cases are diagnosed on average of 21 months. Occasionally the tumor is discovered at birth, during adolescence, or even in adulthood. The clinical manifestations of retinoblastoma vary depending on the stage at which the tumour is detected. The initial sign in the majority of patients is a white papillary reflect (Leukocoria). Leukocoria results because of the reflection of light off the white tumour. The second most frequent initial sign of retinoblastoma is strabismus. Less frequent presenting signs include pseudohypopyon, caused by tumour seeding in the anterior chamber of the eye; hyphema (blood layered in front of the iris), secondary to iris neo vascularization, vitreous haemorrhage or signs of orbital cellulitis. On examination, the tumour appears as a white mass which is sometimes small and flat, but sometimes large and protuberant. The mass may appear nodular and tumour seeding may be evident. Retinoblastoma gene is a recessive suppressor gene located on chromosome 13 at the 13q 14 segments and some children have systemic features of the 13q deletion syndrome. Treatment of the tumour depends on the size and extent of the involvement of the surrounding tissue. The suspicion of retinoblastoma requires prompt referral to an ophthalmologist. Orbital and Periorbital cellulitis Cellulitis is often secondary to sinusitis and may also occur as a complication of trauma and septicaemia. The most common organisms are streptococci, staphylococci and haemophilus influenza.

Periorbital cellulitis is characterized by erythema and swelling of the eyelids. The conjunctiva and orbital tissues are not involved. Preauricular lymphadenopathy may not occur. Orbital cellulitis is marked by erythema and swelling of the eyelids, conjunctiva chemosis, proptosis, limitation of ocular movements, fever and leucocytosis. Complications include meningitis and cavernous sinus thrombosis. Treatment consists of use of hot packs and specific systemic antibiotics. Incision and drainage of loculated abscesses is occasionally necessary.