Dr. Syarifah Rohaya, Sp.

M
Ilmu Penyakit Mata
 Patients  < 13 yo
 Challenges
 Complete ophthalmological examination :
 Diagnose
 Staging of the disease
 Management
 Pearl and pitfalls
 Make the child feel comfortable
 Long history – taking session -> Big NO NO NO
 Ophthalmology
examinations
ANAMNESA
(ancilliary test if
DIAGNOSE
needed)
 Anamnesa
 Chief complaint
 Other complaint
 Natural history of the disease
 Past medical and ocular histories
 Other disease
 History of the pregnancy, labour / delivery,
growth and development
 Family history
EXAMINATIONS
 Visual acuity
 Tailored to the child’s age and ability
▪ 2 – 3 m.o : fix and follow
▪ 6 m.o : fixate on moving toys/ targets
▪ CSM
▪ 3 y.o : illiterate E game
▪ 4 – 6 y.o : snellen letter charts, landolt C, HOTV

 Visual acuity with refractive correction

 Any signs of squints  poor VA
 Inspections :
 Globe position  Hirschberg test
 Globe movement  ductions and versions
 Eyelid disorders
 Loupe & flash light  segment examination :
 Conjunctiva, cornea, AC, iris, pupil and lens
 Slit lamp biomicroscope examinations
 Funduscopy : direct ophthalmoscope
 Intra ocular pressure examination :
 Digital
 Schiotz tonometry
 Tonopen
 Ancilliary test ;
 Preferential looking
 Streak retinoscopy
 Autorefractometry
 Anel test
 Laboratory
 Histopathology
 USG, CT Scan, MRI
 Consultation with another dept
 Examination with GA
DIAGNOSE
ETIOLOGY : OBSTRUCTION BELOW SACCUS
SIGN AND SYMPTOM : EPIPHORA
MANAGEMENT :
- CONSERVATIVE : MASSAGE, ANTIBIOTIC IF NEEDED,
ANEL TEST
- OPERATIVE : PROBING, SILICON INTUBATION, DCR
 OPHTHALMIA NEONATORUM
 Conjunctivitis < 1 months
 Etiology :
 Chemical
 Bacterial
 Chlamydial
 Viral
 Ag Nitrat 1% ed ( prophylactic treatment )
 Conjunctival injection +
 Watery secret
 Management : stop the eyedrop
 < 1 weeks
 Sign and symptoms :
 Conjunctival injection +
 Eyelid edema
 Keratitis  corneal ulcer  perforation
 Early diagnose and early management
 CONJUNCTIVAL SECRET  GRAM STAIN  DIPLOCOCCUS GRAM
NEGATIVE INTRASELLULAR
 HOSPITALIZED  ISOLATION
TREATMENT & MANAGEMENT
a. Topical : Penicillin G 15.000 – 30.000 IU/ml eyedrop every 10 min
b. Sistemic : Penicillin G 50.000 IU / kg BW IM divided into 2 dose /
day for 7 days, or Ceftriaxone IV/ IM 30 – 50 mg/Kg/day for 7 days
 Discharge  bacteria in conjunctival secret  negative  in 3
consecutive days

 Parents should be examined also  gonococcal urinary tract

infection +
CHLAMYDIAL CONJUNCTIVITIS
3-10 days old
Giemsa stain  intra cytoplasmic inclusion bodies +
Sign and symptoms : conjunctival injection, eyelid edema,
chemosis, pseudo membran & purulen secret
Treatment : Self limited disease
Preventive treatment for pneumonitis, rhinitis, otitis :
Erythromycin 50 mg / kgBW,
in 4 divided dose for 10-14 days
Erythromycin eye ointment

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 HERPETIC CONJUNGTIVITIS

 2 weeks old
 Etiology : Herpes Simplex Virus
 Sign and symptoms : eyelid vesicle, folicle,
conjunctival injection , serosanguinus secret,
geographic keratitis
 Treatments:
Topical trifluridine 1 %
Topical vidarabine 3 %
Acyclovir sistemic
19
 Bilateral conjunctival inflammation,
reccurents, seasonal allergic reaction, mast
cell / lymphocyte-mediated allergic
response, tropical climate
 Male : children and young age
 Afternoon redness and itchy
 Divide into 2 clinical signs:
1. Palpebral - superior tarsal conjunctiva
- giant papil (cobble stone)
2. Limbal - Trantas dot in limbus
 TREATMENT & MANAGEMENT
- Cromolyn sodium topical

- Corticosteroid topical  acute condition

- Vasoconstrictor – anti histamin topical

- Cold compress
- 1:10.000 births
- 2/3 bilateral cases
- Neonatal – 4 years old
- The causes : the angle is covered by a thin
membrane, inhibit aquous flow
- Clinical manifestasion:
- Visual acuity, nystagmus
- Epifora, fotofobia, blefarospasme (TRIAS)
 CORNEA
- oedema (e.c IOP )
- Ø children if > 13 mm  glaucoma suspect
- Haab Striae (tear of membrane Descemet), it cause
scar tissue
 Buphthalmos (Ø cornea > N)
 Refraction error :
 Myopia
 astigmatism
▪ e.c. the eye ball >
▪ corneal irregularity
 Examinations
- IOP :Tonopen, Goldmann applanation
- Gonioscopy
- Funduscopy  C/D 

 Managements
 Medicamentosa :
Carbonic anhydrase inhibitor : acetazolamide (diamox, glaucon)
Topical Beta Blocker : Timolol 0,25%
Topical Mioticum : Pilocarpin

 Surgical : Goniotomi, Trabekulotomi, Trabekulektomi

 Cataract which appears since the baby’s birth
(unilateral / bilateral)
 Baby who was born by a mother with
 Rubella
 Toxoplasmosis
 Diabetes mellitus

 Histoplasmosis
 Hipoparatiroidism
 Clinical signs :
- Leukocoria
- Blured fundus reflex
- Nistagmus
- Strabismus
- Fotofobia
- Sistemic disorder (sometimes)
- Decrease visual acuity
- Developmental delayed
 USG is needed
DIFFERENTIAL DIAGNOSIS OF LEUKOCORIA
Congenital cataract Persistent hyperplastic Inflammatory cyclitic
primary vitreous membrane

Unilateral or bilateral Unilateral Unilateral or bilateral

Coats disease Posterior pole toxocara Advanced retinopathy
granuloma of prematurity

Always bilateral but

Unilateral Unilateral may be asymmetrical
 It could accompany by other herediter diseases :
 Microphthalmos

 Keratoconus

 Aniridia

 Ectopia Lentis

 Coloboma

 1/3 : Idiopathic
 Complications
 Ambliopia  the stimuli at macula lutea is not
enough macula can’t develop normally

 Management
 Surgery : cataract extraction

 total cataract and monocular cataract  poor

prognoses (ambliopi) surgery should do as soon
as possible (age of less than 2 months old)
 Intra Ocular malignancy tumor,
 From Retinal tissue
 Affected : young children < 5 yo
 Unilateral / bilateral
 It can expand to extraocular  Come through the
sclera cavum orbita  push forward the eyeball
(proptosis) extend through N.II  intracranial
 RETINOBLASTOMA
 Subjective signs :
- Visual acuity 
- Leucocoria ( no red reflex)
- Strabismus
- Glaucoma
- Tumor mass in cavum orbita with calsification

 Objective signs :
- “ white reflex” @ pupil = cat’s eye
- Squint
- Red eye
- Visual acuity 
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PRESENTATIONS OF RETINOBLASTOMA

• Leukocoria - 60% • Strabismus - 20% • Secondary glaucoma

• Anterior segment invasion • Orbital inflammation • Orbital invasion

 RETINOBLASTOMA
 Additional Examination
- X Photo Ro
- USG
- CT Scan, MRI
- Pathology
Anatomy

36
 RETINOBLASTOMA
 MANAGEMENTS :
a. Fotocoagulation
b. Radiotherapy
c. Cryotherapy
d. Chemotherapy
e. Enucleation
f. Excenteration
 Retrolental Fibroplasia (old term)
Premature baby (< 1500 gr)
The cause of blindness in USA (550 babies/year)
Retinal vascularization:
Sentrifugal rule from optic disk n.II (it start at 4th month
gestation)
Gain the nasal oraserata at 8th month gestation
Gain the temporal oraserata at 9th month gestation
If the process is impaired ROP
 The changes at the border between
vasculature retina and avasculature retina
 Management :
Some patient : spontaneous regression
Cryotherapy
Laser fotocoagulation
Vitreoretinal surgery
Greece : Xero = dry , Ophthalmia = eye
Xerophthalmia : dryness because lack of vitamin A

WHO:
250 million preschool children suffered from Vit A
deficiency, 3 million of them suffered from
Xerophthalmia and 300 thousand suffered from
blindness
 Xerophthalmia Classification according to WHO :
 XN : night blindness
 X1A : Conjunctival Xerosis
 X1B : Bitot spot
 X2 : Corneal Xerosis
 X3A : Corneal ulcer (<1/3 corneal)
 X3B : Keratomalasia (>1/3 cormea)
 XS : Corneal scar
 XF : xerophthalmia fundus
 DRY EYE  BITOT SPOT
 MANAGEMENTS
Vitamin A can improve the condition at 1 – 2 week
The vitamin A dose regards to the children’s age:
 < 6 month : 50.000 IU
 6 -12 month : 100.000 IU
 > 12 month : 200.000 IU

The same dose is continued until 1-2 week

The corneal shape is cone
Degenerative disorder, bilateral, rare, herediter
It is accompanied by descemet membrane rupture
Blurred vision
Management :
Contact lens
Keratoplasty
Congenital
Axial length of the eye ball is< 15 mm
Causes : genetic, intra uterine infection,
pesticide, radiation
The cause of blindness (11,5%) in blind
rehabilitative school
 Dr HARIWATI, SpM
DR LELY RETNO WULANDARI
DEPARTMENT OF OPHTHALMOLOGY
FACULTY OF MEDICINE
BRAWIJAYA UNIVERSITY
THANK YOU