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Optimizing compliance in patching therapy

Introduction Conventional occlusion therapy (patching the preferred eye) remains the first line of treatment for amblyopia. One of the main predictors of success is patient compliance with occlusion therapy, that is, the ability of parents and children to carry out this treatment at home. Many factors may contribute to the family’s ability to carry out occlusion treatment. These include appropriate education, consideration of psychosocial factors, level…

Hand defects and the eye

Introduction The combination of hand and eye defects is not uncommon and may accompany several genetic disorders that include chromosomal abnormalities (trisomy 21, 18, and 13) and monogenic disorders. Interrogating The Online Mendelian Inheritance in Man (OMIM) for “hand and eye defects,” at least 118 genetic conditions are highlighted. Therefore, it is important to do a full clinical examination of the child to make a correct…

Abnormal head postures in children

Introduction The medical term for an abnormal head posture (AHP) is “torticollis,” from the Latin tortus (twisted) and collum (neck). Torticollis from eye-related problems is termed “ocular torticollis.” The assessment of AHP in a child is often multidisciplinary, involving input from pediatricians, orthopedic surgeons, neurologists, psychologists, and occupational and physical therapists. It is common for an ophthalmologist to be consulted to rule out ocular causes for…

Wobbly eyes in infancy

Introduction The infant with wobbly eyes is worrisome. While the majority have a benign etiology, this presentation may indicate severe neurological disease or even potentially lethal underlying malignancy. It is important therefore to have a diagnostic rationale for this problem. Here, I hope to share a concise clinical approach to the most common forms of nystagmus and ocular oscillations of infancy. The underlying diagnosis can be…

“My little girl tells me she sees strange things”

Introduction Unusual visual experiences are not rare in children, but are often difficult to interpret due to the difficulty for the child to express the peculiar sensation. Most complaints will be of a benign and usually transient nature, requiring only reassurance. However, a visual complaint may have a more significant meaning, indicating a serious underlying disorder. It is important to take the child's and parents' complaint…

The child with a dual sensory loss (deafblind)

Introduction Deafblindness or dual sensory loss (DSL) is a combined vision and hearing disability; affected children have complete or incomplete loss of hearing and/or vision. It can be congenital or acquired. Congenital deafblindness is defined as blind and deaf from birth or very early in life, before the development of speech (pre-lingual deafblindness). Acquired deafblindness arises after the development of language (post-lingual deafblindness). A Danish study…

“My child’s teacher says she can’t see properly”

Mode of presentation When the teacher contacts parents with a suspicion that their child has visual problems, two scenarios occur: either the parents get worried and embarrassed, or they deny the problem as many parents think that they know best. In either case, the parents have not been aware of any such problems. This may be because the child's visual disability has been constant and non-progressive…

“My child’s eyes keep watering”

Up to 20% of infants have a watery eye in the first month of life. The vast majority have an outflow problem such as congenital nasolacrimal duct obstruction (CNDO); the rest may have potentially serious problems, leading to increased tear production. Acquired watering eyes present another range of diagnoses. Congenital nasolacrimal duct obstruction and its management are discussed in detail in Chapter 18 . Signs and…

“My child seems to hate the bright light”

Introduction The child who appears to hate bright light is often experiencing photophobia, an unpleasant or painful sensory disturbance evoked by light, but may have other related painless sensations including dazzle, glare or delayed adaptation to light. Their behavior may be pathologic or part of the normal spectrum of light tolerance. When pathologic, their presentation is often related to readily detectable anterior segment disease but occasionally…

“My child keeps blinking and closing his eye”

Introduction Excessive blinking is a common reason for children to attend the ophthalmologist. The diagnosis is usually apparent after a careful history and examination. The vast majority of the time, the child will have a blinking tic, or an exacerbation of ocular surface irritation, usually allergic eye disease. Parents are often anxious that these overt, potentially stigmatizing movements could be a sign of more sinister neurological…

“My baby’s got a red eye, Doctor!”

Introduction Although most of the time the cause of a red eye in infancy is easily identified, uncomplicated and treatable, occasionally the underlying problem is serious, with potential risks for visual development or even the patient’s life. Clinical suspicion and skills are therefore required for each presentation; all infants with a red eye must have a complete ocular examination. Although ideally slit-lamp biomicroscopy should be a…

Supranuclear eye movement disorders, acquired and neurologic nystagmus

For videos accompanying this chapter see ExpertConsult.com. See inside cover for access details. Introduction Abnormal eye movements in the infant or young child can be congenital or acquired. They may be associated with abnormal early visual development, or a sign of neurologic, neuromuscular or orbital disease. Abnormal eye movements in an apparently well child should never be labeled as congenital or benign without careful investigation. This…

Nystagmus in childhood

For videos accompanying this chapter and supplementary materials see ExpertConsult.com. See inside cover for access details. Introduction Nystagmus consists of rhythmic ocular oscillations. Pathological nystagmus is involuntary, although it may be modulated when performing certain tasks such as reading. Infantile nystagmus is defined as nystagmus developing in the first 3–6 months of life. Nystagmus can be acquired later in life, usually due to neurological diseases. Patients…

Complications in strabismus surgery

For video accompanying this chapter see ExpertConsult.com. See inside cover for access details. Introduction Strabismus surgery is generally considered safe. It is, after all, a superficial, peribulbar procedure, involving surgery to the conjunctiva, Tenon’s capsule, extraocular muscle tendons, and anterior sclera. It thus avoids the inherent risks of both intraocular surgery and retrobulbar orbital surgery. Nevertheless, complications can occasionally occur and their recognition is important from…

Strabismus surgery

For videos accompanying this chapter see ExpertConsult.com. See inside cover for access details. Introduction The surgical management of patients with strabismus begins with a careful history and examination to understand current patient concerns, past treatments, and to gain an understanding of the patient’s overall medical condition. Treatment of strabismus may involve one or more of the following: observation alone, correction of refractive error, orthoptics, patching, botulinum…

Strabismus: non-surgical treatment

For videos accompanying this chapter see ExpertConsult.com. See inside cover for access details. The management of strabismus in children and adults includes a range of surgical and non-surgical strategies. Non-surgical methods are less invasive and can be used to reduce symptoms, avoid or postpone surgical intervention or as adjuvants to surgery. Non-surgical treatments include correction of refractive error, prisms, occlusion, and orthoptic exercises. While pharmacological chemodenervation…

Myasthenia gravis in children

Introduction Myasthenia gravis (MG) is a disorder of neuromuscular transmission of skeletal muscles. Fatigability and variability of skeletal muscle weakness are hallmarks of MG. MG in children is classified by the three different pathophysiological mechanisms: transient neonatal myasthenia, congenital myasthenic syndromes, and autoimmune juvenile MG. Transient neonatal myasthenia is caused by transplacental transfer of myasthenic maternal antibodies to infants. The congenital myasthenic syndromes are a group…

Ocular motor nerve palsies

Introduction Childhood cranial nerve palsies represent one of the more difficult evaluation and management challenges in pediatric ophthalmology. Severity and acuity of pediatric cranial nerve palsies can range from those that simply can be observed, to those that could represent life-threatening emergencies. Determining onset of ocular motor nerve palsies and dividing them into congenital and acquired forms aids in determining etiologies for these disorders, and therefore…