TASHA TAN MDMBA 070011

Patients Data
y A. G. y 4 months old y Female y Filipino y Resides in Marikina y Roman Catholic y Mother:

60% Reliable

Chief Complaint:

Opacity in the middle of both eyes

Subjective Findings: HPI

y 2 months y PTA y Leukocoria, OU y Child did not follow

objects or respond to visual stimuli y Consult at the QMMC Ophtha OPD



s/p Lensectomy of OD

ADMISSION

Birth History
y Born Full Term to a G3P3 (3003) mother y Delivered via NSD in a lying in and assissted by a

midwife and OB-Gyne y Birthweight = 7.2 lbs y Mother had a total of 12 prenatal check-ups in a private clinic y Mother had an asthma attack on her 8th month of pregnancy

Past Medical History

y s/p Lesectomy OD y No other previous surgeries or hospitalizations y Currently taking  Iron supplements  Vitamin C supplements  Multivitamins y No known food or drug allergies y Newborn Screening was normal

Family History
y Cataract  Maternal Grandfather Senile mature cataract  Paternal Uncle

Personal and Social History

y Both parents are college graduates and work as

supervisors y Is usually left at home with aunt when parents are at work

Immunization History

y 1 BCG y 3 Hepatitis B y 2 DPT y 2 OPV

Physical Examination
AT THE OPD JULY 28, 2010

Vital Signs
y Heart Rate y Respiratory Rate y Temperature

102 bpm 24 rpm 36.9

Physical Examination: HEENT

y HEENT  Intact tympanic membrane  Nose midline, symmetrical, with no discharge  No Tonsilopharyngeal congestion  No palpable cervical lymph nodes, flat neck veins

Physical Examination: Eyes; VA

y OD:  Able to follow bright colored objects and light beyond midline y OS:  No regard for bright colored objects or light

Eye Examination
y Gross Examination  Eye position symmetric.  Lids
OU

- No hyperpigmentaion, contusions, erythema, tenderness, palpable masses. - No matting.

Lashes
OU

Eye Examination
y Gross Examination


 

Conjunctiva. OU - No swollen glands. Bulbar conjunctiva clear. Palpebral conjunctiva pink. Scleara OU Unicteric Cornea. OU - Cornea clear with no lesions, opacities, mass. Anterior chamber. OU - formed and clear. Pupils OU - Pupils are symmetric and round, measure 3 mm, equally brisk and reactive to light.

 

Eye Examination
y Extra Ocular Muscles

Eye Examination
y Tonometry


Unremarkable

y Ophthalmoscopy.


OD
dull red orange reflex. Clear media with peripheral opacity
Slightly

OS
Very

dull red orange reflex. Hazy media.



Cup disk ratio and macula were not appreciated because of the dull red orange reflexes and cloudy media.

Cranial Nerves: Optic Group

y II
   

(Ophthalmic)
Difficulty to assess optic disc, retina on fundoscopy Sensitive to light source in a dark room With visual fixation Pupils equal, 2-3mm, EBRTL | partial ROR, OU

y III


(Oculomotor)

No ptosis, outward, downward, adduction or elevation displacements of both eyes Intact EOMs

Cranial Nerves: Brachiomotor Group and Tongue

y IV (Trochlear)  No appreciated upward and outward eye deviation y VI (Abducens)  No medial deviation of the eyes  No nystagmus yV


(Trigeminal)
Corneal response in both eyes

y VII (Facial)  Corneal / Blink reflex present

Salient Features
History Physical Exam

y Age (4 months) y Leukocoria y Does not seem to

y Lens Opacity y Visualization of fundus

difficult

notice or fixate on objects

Differentials
y Retinoblastoma y Congenital Cataract

Admitting Diagnosis
SENILE MATURE CATARACT, OS

Course in the Wards

Day 1

y Assessment  Congenital Cataract, OS y Plan  Moxifloxacin eye drops

1 drop Q4

 

DAT, NPO past midnight Lensectomy with partial anterior vitrectomy, OS

Day 2

y Subjective  Irritable when wearing the eye patch y Objective  Unremarkable findings on general physical examination

Day 2 July 29, 2010

y Assessment  Congenital Cataract, OS  s/p Lensectomy with partial vitrectomy OU y Plan  Moxifloxacin eye drops

1 drop Q4 1 drop Q1 1 drop Q8

Prednisone eye drops

Atropine eyed drops

Day 3 July 29, 2010

y Subjective  Better activity  Left eye now able to see light and follow objects y Objective  Otherwise unremarkable findings

Operative technique
y Patient Supine y Anesthesia inducted y Asepsis and antisepsis y Sterile drapes placed y Lid retractors placed y Stab incision at 2 o clock position y Intracaneral tryphan blue y Irrigation of tryphan blue

Operative technique
y Intracaneral OVD y Main port incision at 10 o clock position y Anterior capsulotomy y I and A of lens material y Part anterior chamber vitrectomy y Final I and A y Suturing with nylon 10-0 (corneal suture) y Eye patching

Intra Operative Findings

y OD  Distinct disc border  Slightly dull/hazy media  No detachment  (+) ROR  CDR 0.3, AVR 2:3  Refraction:05:21 5s +3.00s

Intra Operative Findings

y OS  White cortical material not seen anymore  No detachment  (+) ROR  CDR 0.3, AVR 2:3  Refraction:19.5s c 2.00 cyl x 150 +3.00 sph

Intra Operative Findings

y Cornea OD: y IOP OD:

V 11 H 11 8.5 10.0

OS:

V: 11.5 H: 11.5 10.2 10.9

OS:

Day 3

y Assessment  Congenital Cataract, OS  s/p Lensectomy with partial vitrectomy OU y Plan  Moxifloxacin eye drops

1 drop Q4 1 drop Q1 1 drop Q8

Prednisone eye drops

Atropine eyed drops

Advised
y Follow-up y Wearing of protective eye patch y Compliance to medications y Watch out for postoperative complications, consult

should be done

Congenital Cataract
y Congenital (infantile) cataracts  Present at birth or appear shortly thereafter  May be unilateral or bilateral y About one-third of cataracts are hereditary y Another third are secondary to metabolic or

infectious diseases or associated with a variety of syndromes. y The final one-third result from undetermined causes.

Congenital Cataract
y Congenital lens opacities are common and often

visually insignificant. y A partial opacification or one out of the visual axisor not dense enough to interfere significantly with light transmissionrequires no treatment. y Dense central congenital cataracts require surgery.

Congenital Cataract
y Congenital cataracts that cause significant visual loss y y

y y

must be detected early Large, dense white cataracts may present as leukocoria (white pupil), noticeable by the parents, Unilateral infantile cataracts that are dense, central, and larger than 2 mm,will cause permanent amblyopia if not treated within the first 2 months of life. Symmetric (equally dense) bilateral cataracts may require less urgent management. When surgery is undertaken, there must be as short an interval as is reasonably possible between surgery on the two eyes.

Congenital Cataract
y Lens extraction through a small limbal incision

utilizing a mechanical irrigation aspiration handpiece. y Phacoemulsification is rarely required. y The posterior capsule and anterior vitreous are removed using a mechanical vitreous suction-cutting instrument.
 

Prevents formation of secondary capsular opacification or after-cataract Avoids the necessity for secondary surgery and enhances early optical correction.

Congenital Cataract
y Complications are similar to those reported with

adult cataract procedures. y Optical correction can consist of spectacles in older bilaterally aphakic children y Most childhood cataract operations are followed by contact lens correction y Use of intraocular lenses in early childhood is becoming increasingly frequent. I
 

Lessens the difficulty of optical rehabilitation associated with contact lenses in children May need to be changed as the eye develops.

Congenital Cataract
y The visual prognosis for childhood cataract patients

requiring surgery is not as good as age-related cataract. y Amblyopia and occasional anomalies of the optic nerve or retina limit the degree of useful vision that can be achieved. y The prognosis for improvement of visual acuity is worst following surgery for unilateral congenital cataracts and best for incomplete bilateral congenital cataracts that are slowly progressive.