Chapters Transcript Common Pediatric Eye Problems: When to Hold'em and When To Fold'em Gregg Lueder, MD, reviews some common pediatric eye problems. What I wanna talk to you about. First of all, I have no financial disclosures. And what I'm planning to talk to you about this morning is, uh just some common pediatric eye problems and specifically kind of focus on things that you can manage yourselves or at least start to manage, uh or things that you should just sort of give up and, and send them to us. Uh This is pretty informal. So questions, uh you can use the chat box. I'm not, I don't use Microsoft teams much. So I'm not really adept at this, but if you have uh chat questions, go ahead and do them and I, what I'll do is after each case, we'll stop and, and answer questions because I think that'll be easier than waiting till the end and trying to go back. So jump right in. So first case there's a four month old child mom, um brings the child in her dad and says that the eye reflex looks funny and she's noted a little bit of drifting of the eye child is otherwise healthy and you do your exam and this is what you see. So I'll let you look at that for a second and the question here is hold them or fold them. And the answer to this one is this is Leuko Coria or cat eye reflex and this one is a definite fold them, send them to us. So you recommend evaluation by a pediatric ophthalmologist and mom thinks fine that the next appointment's in five weeks. Little trick question here. What do you do? You arrange for earlier referral? This is one of the, the things in ophthalmology that we need to see quickly. So the cat I reflex typically results from an abnormal reflection from something inside the eye that's, that's not red. So the the normal red reflex that you get is actually off the retina, which is has a really healthy blood supply. So it has that red tinge to it. Um But we actually usually the red reflex you're trying to get out of in your photos. But we like that in ophthalmology because it means things are good. If it's a real ab uh abnormal red reflex, it's almost always something serious and it requires prompt evaluation. So the least likely thing, but the most serious thing that would cause uh an abnormal red reflex is retinoblastoma. It's a tumor that arises early in life usually in the first two years and it presents either with Leuko Coria, the abnormal red reflex or sometimes it for business. Because if it's, if the tumor is big enough that it affects the vision and the eye doesn't see well, uh the eye may wander. So that can be the first sign of it. The thing that's important about retinoblastoma is the cure rate is excellent if it's confined to the eye. So if we can treat it before it gets outside the eye, 95 plus percent cure. But if it gets outside the eye, it's, it's really difficult to treat and it, it's potentially lethal. So it requires prompt treatment. It's one of the few life-threatening things that we see in pediatric ophthalmology. So is a schematic here on the left. This is a, a view of the eye. So the front's the, the cornea up here, this is the pupil and normally this the red is the retina, which again gives you the white uh the red reflex. But if you have something blocking it, in this case, a large tumor, the light reflects off the tumor and and therefore it's it's white appearing. This is an interesting case. So this is a child who came in for a routine checkup. I think it's so sold to the pediatrician. And if you look at the left eye, the pediatrician thought everything was fine. But then the child started to look off to the right a little bit and he noticed this little bit of abnormal reflex here. And then when the child looked way to the right, the reflex was gone. So it went from red to gray and on the exam, they referred the child in and on the exam, the child actually had a tumor on the nasal side of the eye. So when the light was going directly back, it reflected off the retina and it was white. But as the child looked this way and the light came in this way, the reflection became white. And we had several of these Children and most retinoblastoma by the time it's diagnosed, the tumor is large enough that we usually actually have to remove the eye to prevent spread. Um But we had a number of Children who um similar to this one, the, the first sign was the abnormal red reflex noted during a long um And the only kids who had unilateral retinoblastoma whose eyes were saved were those that were detected by the the pediatrician during a child exam. So shout out to you guys on that one. The other important thing that can cause an abnormal red reflex is infantile cataract. There, there's a long list, but the retinoblastoma cataract are the two most common and that produces the reflex due to the due to the opacity of the lens in the front of the eye. And the main issue here, it's not a life threatening thing, but it's a vision threatening thing. So if a child has a large cataract, it has to be removed within the first couple of months of life. Otherwise you'll develop dense amblyopia because in in amblyopia what happens as I'm sure you all know if one eye sees well and the other one doesn't, the baby's eye will start paying all your attention to the eye that doesn't have a problem and ignoring the eye that does. And the cataract, if it's dense, they'll completely ignore it and, and it requires early treatment to get a, a chance of vision in the eye. And there are large of types of cataracts, the cataracts kind of like a, a flat disc and it can be the back or the front or the whole thing. And this is just a, a an example. So this is a dense cataract on the, on the right eye. This is the, the child's under anesthesia. That's why they have a little speculum in there. This is one sort of the center of the eye. This is uh the back part. You can't tell that by looking at it, but that's the back surface of the lens. This is called the nucleus. It's the center part of the lens. But they all uh you can, you can see that something is abnormal and wouldn't expect you to know exactly what it is in the, in where in the lens or what kind of cataract, but there's something there that needs to be evaluated. So the important thing here is the evaluation of the red reflex that should be part of, of, of the red, the the well child exam and the best way to do that is use the direct ophthalmoscope, which is the little handheld thing with the dial on it, dim the lights in the room and then you sit about 2 to 3 ft away from the child and shine the light in the eye and then you can use the little dial on the side to focus it. Yeah, again, this is the correct ophthalmoscope. This is not a child obviously, but, but the, the, the just is just so how to do the exam, you dial it in, you focus on the face and then what you can see is the red reflex in both eyes. And then you can also do a quick che test for ST business because the red reflex should be in the same point in both pupils. So it takes about 1015 seconds to do. And you've, you've done a really important part of the exam. The A AP actually has a, um, a handout that's available on the website that kinda goes through this and it talks about how to do it and then shows you sort of little pictures of, of the different possible abnormalities. So the actual most likely thing that we see most commonly, but the least serious is something called pseudo Leora. And that's where the, the, the light appearance is real. In other words, what you're seeing is that there's a white reflex there, but there's nothing wrong and what that results from an off axis reflection from the optic nerve head and it's always seen in the eye that's looking toward the nose. So I don't know how well you can see that picture. But in this picture, the child is looking this way and the abnormal reflexes in this eye, same child, they're looking this way and the abnormal reflexes in this eye. And what happens in this is that the nerve, this is a schematic at the back of the eye. So this is the retina, this is the phobia, the center of vision. These are the blood vessels and this is the optic nerve and the optic nerve typically has a whitish appearance. So if the light happens to catch the child uh optically right here, that uh reflex will fill the pupil and it'll be white. And the question then is how can you tell the difference between real and pseudo Coria? And the answer is that you can't. So there's really no way to do that. And so again, because you can't tell us this retinoblastoma is a cataract or is it, is it pseudo? Um you send them to uh so that out and, and when I see these Children again, probably I would say 80% something like that or pseudo, but I always tell them it's a sign of the good pediatrician they're sending them in because you guys can't figure that out in the office. And I explained to him it could be serious. And um and reassure him everything is fine but tell him it's important that they were they were sent in. So that's the first case. So does anybody have any questions on that one? You can either do chat or you know, I we'll have questions again at the end but alright, move on to case 210 year old child history of recent eyelid swelling, minimally tender child's afebrile otherwise healthy and that's what you see on your exam. Just look at that for a second. So hold them or fold them this well and that is a hold them initially. Usually we recommend warm compresses. And then um and if we see the kids in the office, we usually just recheck by phone in a couple of weeks to see how they're doing. So, a Chian is the most common thing we see in the eyelid. And we have these my bian glands that line the lid that produce mucus that help stabilize the tears. And what happens in a, in a shalaan or sty or all of the different names. But they're all basically the same thing is that the gland gets blocked and then the oil builds up and the oil is irritating and it creates inflammation and, and uh swelling. Um initially, it can be fairly striking and we'll talk about that the, the, the inflammation and we'll talk about that in a minute, but then it typically settles down into a visible lump, the best treatment is uh worm compresses. And then baby shampoo is also helpful because the the what's blocked is oil and shampoo breaks oil down. So uh the, the pro and especially toddlers, this is difficult to do warm compresses. So what I usually recommend to the family is do it during bath time and take a warm washcloth and just hold it over the eye for a minute or two while the toddler is distracted, you can play with some bath toys or something like that and then take the washcloth. Put a little, we use baby shampoo because of the because it's no more tears. You put a little baby shampoo on the washcloth and then just gently wash the eye and that's really about all you're gonna get in. Most toddlers, older kids, you can do it for a few minutes, um, a day, once or twice a day, but you really don't have to do more than them. The main concern initially is, is differentiating a Asian from precept cellulitis. And um the, the initially in preceptor cellulitis, the inflammation is diffuse and clain tends to be focal but often it presents with the whole lids kind of red and you usually see a nodule. Whereas in precept cellulitis you don't and, and the other important thing is otherwise healthy and acting normal. The Chileans usually don't bug him too much. Whereas the child with precept cellulitis will often be ill. Typically have a fever most commonly it's due to sinus disease, but not always. So, this eye is pretty inflamed, but you can see there's this sort of lump here, lump here, lump here. Child's obviously happy smiling. Um, but if it's early on and you can't tell for sure. I, I think it's always fine to try a course of oral antibiotics. If, if you're concerned about precept cellulitis, orbital cellulitis is much more serious. That's the whole lids swollen and then the, the eye actually often will become proto, it'll, it'll bulge forward. The, the movements of the eye may be limited, it quite painful, usually decreased vision and almost always sinus disease. So here you can see this dense sinusitis and the whole eye is being pushed forward from that and those Children need to be admitted for IV antibiotics and, and they sometimes, uh, respond just antibiotics, but sometimes the ent surgeons have to go and drain the, the sinuses chronic CIA. Um, if they're typically there for a month or a couple of months, and patients have been doing what they're supposed to, then occasionally we have to go in and, and surgically drain them. Usually what's happened is the body sort of walled off and it can't get in there to break it down, um, tends to be successful. And in another, this is a shot out here, I'm down at South this morning. Um, but for the CS CC, there's both the, the, the, uh, campus out west and down south is, they have a really nice outpatient surgery center and this is a thus sty surgery. She had a bath. She came in, she had anesthesia. She got some apple juice, uh, two hours before woke up, uh, talked to the doctor and then went to build a beer. And so one child actually, and aside, I had a child once he was about 53 and the older sibling, it had Sir CC for business and the three year old was in, uh, and also had business. It often runs in families. And, um, when I was starting to talk to the family, I said, well, you know, little bill, he's gonna need surgery, the three year old and then the five year old spontaneously goes, you lucky kid because he'd had such a good experience at the CS CC. So they have a really nice staff, they run it really well and they take good care of the kids. All right. Any questions about Cesia? All right on to case 3, 3.5 year old otherwise healthy. And the family comes in and says we see the eye drifting out sometimes and it seems to be worse when, um, she's tired, you do your exam, visions 2025 and both eyes normal. When you look at the pen light reflection, that's equal. You do a cover test where you cover the two eyes and you don't see any movement. So, is that a hold them or so, this patient probably has intermittent exotropia and I would recommend referring to a pediatric ophthalmologist and let me explain it to you. So, intermittent es esotropia is when the eyes cross, that is more common in infants. That's the we usually see in infants, but it can occur in older Children. Exotropia usually occurs in older kids, also can occur in infants but much less commonly. Most Children with exotropia, both eyes see, well, it's usually intermittent. It's usually worse when the kids are tired or kind of zoning out. And, and it's also importantly, it's worse at distance, not close. So the parents often won't notice it regularly because typically they're interacting with their child at dinner or reading a book or something where they're looking at him. Uh, but they're not looking at him when they're looking far away. One mom I had, um, noticed it when she'd be preparing dinner and the child was in the high chair and she was on the other side of the kitchen and she'd see it and sometimes the preschool teachers will notice it at, at, uh, school and in the office you might not see much. Even photo screening might be normal or cover tests might be normal because those are done with the kids looking things up close. So it's hard to elicit. And that's why in our offices we have, this is the chair here and down at the other end of the room we have things that'll interest them. We have, uh, video cameras, we have little toys that, um, uh, make little noises and stuff and then we have a bunch of, of cartoons that we can click through to get the kids to look at. And, and then often even for me in the office, if I'm looking at them up close, we hold up a little toy and you have the, excuse me, child, look at it. You won't see much. But when you get him to look down at the other end of the room, you'll not the eye drifting out. So the other important point about intermittent exotropia is usually the vision is normal in both eyes. They usually don't have amblyopia, but it could be due to decreased vision. So the presenting sign of a cataract or retinoblastoma retinal problem, anything that affects vision, if the vision decreases, the eye is uh more likely to wander and it can drift out. So it's another reason for evaluation and for, for our residents who I teach them that if they, if the child has to business, you have to check everything to make sure there's not, it's not business secondary to another eye problem um that, that we need to treat. All right, any questions about exotropia? All right, we'll go on to case 44 week old female family comes in and, and says the baby doesn't seem to be seeing well, exams otherwise normal. A child born at term uncomplicated pregnancy and delivery. There's no family history of any eye problems in Children. When you do your exam, uh they, they look normal pupils react, the red reflexes are normal. Do the test that I showed you earlier and this one is a hold em or fold them. And this one I'd recommend holding as the child is one month old and this is what we call delayed visual maturation. And I recommend rechecking the child around two months of age. Most babies will start tracking uh and following within the first few weeks, some babies literally come out of the birth canal looking around the room but others, it, it can take a month or two before they'll see. So if everything else is normal, I usually recommend waiting until two months of age before a referral. So when I say if everything else is normal, what exactly does that mean? So 01 important point and this is for you and then also if we see the child and I'll, I'll talk about what we do in a second, but I always tell the parents, we can't be sure there's not a problem, but this is not necessarily abnormal and we have to wait a little while. We don't wanna do a bunch of tests if they're not necessary. So we're gonna give the baby a little bit more time and if it doesn't get better, then we will start doing some other testing so on when we see the kids. So if they say that child comes in, in a month, you see them, they come back at two months, the parents are still concerned and say, ok, now it's time to see the ophthalmologist and we'll see him at 2 to 3 months of age on the history. It's more common in kids that are premature, any child who has significant illness, cardiac disease, things like that. It's just like the whole baby takes time to sort of get in sync with things. So those are things that would go along with delayed visual maturation and some normal babies will actually take 3 to 4 months before they start to track. So these are the things that are reassuring if you have again normal history, both medically and and pregnancy. And I'm always, it's always nice if the parents see at least a little bit of vision, like they say, yeah, I think she's seeing a little bit. That's, that is reassuring. If the baby, you, when we do our exam, if the pupils react, that's a good sign. If there's no nice stags and if in our exam, if there's nothing structural abnorm abnormal, there's no cataract, the retina looks normal, the optic nerves look normal and if that's the case. So if we see the child at 3 to 4 months of age, I'll, I'll do the same thing. I'll say it looks like everything's gonna be ok. But we need to check back in a couple of months. And then if the babies come in at six months, usually they're gonna be seeing, we don't have to do anything else. But the worrisome signs would be basically the opposite of all those things. If there are other signs of developmental delay. If the, if the family comes in at three months and the parents say we don't think she's seeing anything at all, then I, then I really worry because the parents are usually really accurate with that. If they say I, I think he or she sees a little bit, I it's it's helpful. But if they don't see anything that really raises red flags, if the baby doesn't react to light in the office, that's a big concern. If the pupils don't respond, that's a big concern. And then no is also a sign usually that something else is going on and nystagmus, shaking of the eyes usually will start to appear about 2 to 3 months of age. And nystagmus can either be what we call primary meaning the eyes are ok. But the eyes shake and in those kids, the vision is usually all right. But a baby who has significant vision problem, typically in both eyes, bilateral, um nystagmus is a sign that something is wrong. So when we see nystagmus, we have to ask, is it just nystagmus and the eyes are ok? Or is it nystagmus? Because there's some underlying problem and and that's our job to, to figure out. And then on the exam, we might see a cataract, we might see a co a colon of the retinas or retinopathy prematurity or something else that's causing the problem. And then that leads to further evaluation and that would depend on, on exactly what we saw as to what we're gonna do. And there's a long list of possibilities. It can be due to a neurologic disorder. We call that cortical visual impairment. So analogy the eyes like a camera, the optic nerves like a cable and the brains like the computer. If the, if there's a problem in the central nervous system, the eyes themselves might be ok. But the child doesn't see because of the problem in the, in the brain. Uh babies that are markedly premature Children um with metabolic disorders or other neurological disorders. It, it, it can often lead to vision problems and then the underlying eye disease again, large differential cataract retinal optic nerve hyperplasia. Long list of, of disorders. All right. Any questions on babies that don't see? All right, we'll move on. Uh This is case number 56 week old baby. Uh parents had noted a little red spot in the eye at one week of age and it is enlarging Unsteadily sense and this is what you see on your examination and let you look at that for a second and this is a hold them or fold them and this one is a periocular hemangioma. This is a fold them, not because a hemangioma in and of itself is dangerous, but because it's a threat to the vision. So the the problem with the periocular hemangioma is again, it's the risk of amblyopia and it could either be big enough that it actually includes the, the vision which this one is close to. It's you can see it's, it's causing ptosis and blocking part of the vision. And then more subtly it can cause a stigmatism. So, astigmatism, when I describe this to parents, the ice is like a sphere, it's like a basketball. And if it's bigger than normal, you're nearsighted. If it's smaller than normal, you're farsighted. But if it's pushed from one other kind of like a football shape, that's what astigmatism is and it creates a blur. So in this case, if the child had a hemangioma in the, in the normal eye, there's no uh blur and they, they see well, the other eyes blurred because of astigmatism and then they can develop embryo because their brain says this IC is fine. So I'm gonna pay attention to that and I'm gonna ignore the eye that, that has the problem. And this is a really ii a cool story. I think treatment of hemangioma my 30 plus year career is the thing that was the biggest best change I I saw in any other disorder. So hemangioma we used to have to treat with, we'd inject steroids and it worked, didn't work greatly. Uh And there were complications, you could have problems with skin. There's rarely, you could actually have little um um pieces of, of uh the steroid that could block the uh the vessels in the eye leading to vision loss. So it was, it was not a great treatment. Um but that we had, and then there's this study that was done in 2008. So they had a child who um had systemic hemangioma actually had high output cardiac failure. So that this child had been treated with steroids. And then they put the child on propranolol and the child started to get better systemically. But what I love about this is that they were paying attention to other things. So seven days after they started propranolol, the child looked like this, six months still on propranolol and then nine months look like this. And so these people, these these, there are stories like this in medicine where people um it's kind of like Fleming, discovering penicillin. He had the little Petri dish and he looked at it one day and uh you guys are probably familiar with this story and there, there were bacteria but there are little places where the bacteria weren't growing. And instead of just saying, oh, that's weird. And he throwing it away, he thought, what's the deal? And then real then based on that observation, it, it led to the discovery of penicillin. So these people, uh, made this observation and then within a short period of time, like a year or two, we were all treating these babies with propranolol. And it's been remarkable and, and, uh, I haven't had to do a steroid injection in years. We have a couple of kids. It's, it's about 90 to 95% effective. If it doesn't work, then sometimes we have to surgically remove these. But it, it, it is, is, yeah, it's really cool. Um So if it's a little, if you catch a ti a small one, so if you see a baby at one week and they've got imaging in their eyelid, you can actually use topical timolol, one of the um glaucoma medicines. If they get bigger, you have to use systemic because the, the, the, the topical only works for a short distance beneath the skin. And this is one of the kids uh that we saw this big hemangioma, that child can barely see and within a short period of time, it, it starts to work within a day or two and this child ended up like this and then I just have an assign. Um I think there are a lot of problems with the health care system and that's not the point of this talk, but this one I can't ignore. So Propranolol that you use generic oral Propranolol is $14 for 100 and 80 CCS. Some company went out and got FDA approval for treatment for proliferating, he infantile hemangioma it's called and they, they marketed under hemang. And the cost for that is $602 for 100 and 80 ccs. And what's the difference between the two? Nothing? It's exact same thing. So, um this has to do with the, the way the FDA approves things. But uh if you have a child with hemangioma, you can use oral propranolol and save the family a lot of money. So many questions about hemangioma. All right. Number six, I'm sure you're all familiar with this 13 month old with a history of excess tearing, recurrent crust on awakening. The parents have to wipe it off every morning. Child's otherwise healthy, hold them or fold them three months old. This is a holdem says nasal laal duct obstruction. And uh we usually recommend uh massage and I'll talk about that in a minute and then topical antibiotics. If it's really gunky, if it's really crusty that they have, they can't wipe the eye. They, they, they can't clear the eye without a lot of wiping, you can use those too. So, nasal lacrimal obstruction uh occurs uh from a blockage of the tear duct and what I tell the parents, it's kind of like a, a pipe. So the tears are made up here. They flow down the lacrimal sac into the uh down into the nose. And most of these babies have a low membrane down here. Um And so what happens? It's like a clogged pipe. The, the tears can't drain, they just, and it flows on the cheek. It looks like the kids are crying and then we have normal fluoro bacteria that normally rinse through here. But if there's this blockage, you get this chronic low grade infection and that lachrymal sac is a warm moist environment. So it's a, it's a really good Petri dish for bacteria. Most kids outgrow it by nine months of age or so. And I recommend topical antibiotics just as needed again. It's not the typical, you know, seven day course, it's, I tell the families, if it's really gunky, you can't wipe it off, you can use it for a couple of days, but explain to them that the, the antibiotics aren't gonna cure it. They're just gonna temporarily make it better. And most of the time what happens is they, they use the antibiotics, it gets better and then they stop them in a few days later, it starts to gunk up again and then massage and I'll show you that in a second. And, um, uh, if it persists at some point, then you refer for probing, usually around nine months of age or so. Some people do it in the office and younger kids under just holding them down. I, I, they're older and do it in the operating room. Glaucoma massage. I've seen all people do it all sorts of different ways. So they'll push over here, they'll push down here and most of the time they're doing this. But if you feel the only place you can access the, the lacrimal sac is right at the inside corner of your eye right here like it is in the picture. And if you do it yourself, if you put your finger up there, it almost a, a description. It's almost like there's a little BB under the skin and they just, I tell the parents just to press there because if you go down the nose and you can feel again, if you're do this yourself right. When you go down from there, it's bone. So there's no way you can get to that so that you just press like a little button uh 2 to 3 times a day. I also tell the parents there's not, it's not really clear whether massage does anything. It seems to make sense to me mechanically. The idea is you push on it, you force fluid down to get it to open up, but it's not been proven that it works. And so I tell parents, if it's, if it's driving the baby, mm and they feel like terrible parents doing it all the time that they don't have to do. And so there, there's more than one acceptable approach in terms of treatment. Again, some people will probe awake in the office when the kids are little. I wait till they're older and do it in the operating room and the, the patterns depend on, on who you refer to, but they're, they're both acceptable or sort of pluses and minuses of doing it each way. The one exception is um neonatal Dacryocyst seal. And what happens in that is that this is a baby. So usually it shows up within the first week of life and you have this little blue mass right at the corner of the eye and they, they have this hyper purulent infection. Although sometimes it's so locked off, you can't see it. But if you press on that sack, you'll, you'll see this purulent stuff. And the reason this is important is these babies almost always have a cyst in the nose and it can actually be big enough that the babies sometimes can present with respiratory compromise. And this is an example if it's by the airway is blocked by this cyst and it can cause this very severe infection. And uh babies are relatively immunocompromised. So this, this is the one thing that requires early treatment. And usually we take these, we, if I see the Children like we, we will give a little trial of antibiotics. But if it doesn't get better quickly, then we go to the operating room and we do a probing and we remove that cyst and the success rate of that is excellent. The other important thing is what else could cause excess tearing. And the main thing to be aware of is glaucoma. And in glaucoma, what happens is that the pressure in the eye rises, the eye stretches and then the cornea itself becomes edematous and it causes light sensitivity. So these kids tear not because the tears are backed up. This is a production problem, they're tearing because their eyes irritated. And the key thing here on exam is that the cornea is kind of cloudy and you can actually see this difference between the two eyes. This one's larger because of the glaucoma now. Uh But in the history, uh the important thing to ask is is whether the child's irritated. If it's like kids with lacrimal obstruction, it's, it's interesting, they can have this really gunky eye, they've got all this crust and they're usually happy smiling kids. And as I say, it usually bothers the parents more than it does to the child. But if the child's photophobic doesn't like being in light, then you, your radar has to be up that something else is going on and glaucoma needs, it's like cataract, it needs to be treated early to give the kids the best chance of, of vision. All right. And any questions on lacrimal obstruction. All right. Going to case six, this one's a five year old whose parents know it. Eye crossing over the past couple of weeks, child's otherwise history. Your his, your questions, no headache, no clumsiness, no diplopia, neurological resistance, negative child's doing well in kindergarten. Nothing else going on. There's a family history is your cousin and on your exam, um vision is good in both eyes, the movements are full, meaning the eyes can move fully but they're crossed. So when you look at in esotropia, if you do a penlight exam, the reflection, the eyes will be in. So the reflection will be off to the side of the, of the cornea. So is this a hold em or fold them? It's a fold them, you want to send that child in. But the key thing here, this is acute esotropia. And what I recommend is refer to pediatric ophthalmology. So if you have a child like this, unless there's something else on the exam or history concerning those kids don't need to be referred to the emergency room. We'll talk about that in just a second. So the question here when you have acquired your business, meaning it's not there as a baby, it shows up later. Is it just the eyes or is it something going on in the central nervous system? And because of that, the eyes are crossing and that's what we have to figure out versus secondary. So, primary meaning it's just the eyes, the kids are otherwise healthy. The key one of the key things is they don't have deploy, they don't have double vision. So most of the kids who show up like this, they've probably had a, a subtle bit of crossing that was small enough that it wasn't detectable but their brain adapted to it. So, one of the interesting things about business in Children is that they're not diploic, they don't have double vision, um, as opposed to as an adult. If we, if I, I started to cross or drift, we'd see double, but they don't. And that's reassuring. There are no neurologic symptoms. Um, and there's often a family history, not always but often a family history of um, Mr Business secondary, meaning something's going on in the brain that's causing it. They will have usually nausea, vomiting, the typical things you associate with that and diplopia. So if you have a five year old who's had normal vision their whole life and all of a sudden the eye crosses, they actually will see diplopia. So if I have a five year old with diplopia, again, raises the radar going on. Headache, nausea, et cetera. And, and usually there's no family history to business on the exam. Uh In the primary, the vision is normal, the movements are full, the eyes can move fully side to side. If you're able to see the optic nerves with the direct, they look normal. Whereas secondary, you might have decreased vision, the movements are limited. And I'll show a picture of that in a moment. And excuse me, if you're able to see the um discs, if the pressures in the brain is high, you usually see Papal if it's a primary eye problem. You refer to pediatric ophthalmology. If you think there's a cranial nerve palsy, then I would refer that to pediatric neurology. And actually that one I would send to the emergency room. Oftentimes if they see neurology, we'll also see an ophthalmology, you'll see him. And if ophthalmology sees them first and we detect piled Dema we'll refer to to neurology. So it'll go, uh, back and forth quickly and it, it, it doesn't make a big difference which one, which one of us the child sees first, but you, they need to be seen quickly. So six nerve palsy isn't a child, but it would look the same way. So the six cranial nerve uh gets the uh mo moves the eye out. So in this patient, you're seeing the six cranial nerve on the left doesn't work. So the eye can't move out. So when looking straight ahead, this eye is fine and this eye is way turned in and then you try and look to the left but the eye can't move. So the right eye moves in and the left eye can't move. So a six nerve palsy would be uh one of the causes of straba and then a third nerve palsy, the third nerve uh elevates the lid. It constricts the pupil and of their four extra muscles, there are two up and down, two side to side. One twists in and one twists up. And the third cranial nerve uh affects four of those. So the child with the third nerve palsy has tosis. And then you lift the lid, you can see the pupils large picture, but here's the pupil here and the pupil is much larger and the only two muscles that work are the outer muscle and the one that brings the eye down, so the eyes down and out. So third nerve palsy again, um, would be one that you'd, you'd send in the emergency room or, or call ophthalmology and have them seen the same day. But one of the common causes of acute crossing in older kids, it's called accommodative esotropia. So it's because the kids are far sighted. So almost all Children in the first few years are far sighted and there's a lens in the eye, the the the natural lens can focus to correct farsightedness. So probably 95% of Children the first couple years of life are far sighted, but very few need to wear glasses. But there's a reflex with focusing that causes the eyes to turn in. So if the kids are more far sighted than normal, they have this big focusing effort which drives the eyes to cross and it gets better with glasses. So that's the picture above without and down below, the eyes are straight and you can see the corneal reflex. This is a nice picture here. The corneal reflex is right in the cornea, you can tell that eyes cross looking at it. But if you look at the the reflex, it's off to the side. And then here it's, it's in both. It's centered in both. But you don't wanna send, this is, this is why if you have a healthy child, you don't wanna send him to the emergency room. So we have a, a series of Children who went, who had this and instead of seeing an ophthalmologist, they went to the emergency room and, and they would get admitted, they had an M Ria couple got lumbar punctures and then finally they got an ophthalmologic exam and then they realized it was just glasses. So that's the take home point for this one. So the bottom line here is hold them or fold them. And if you're not sure this is for the old timers here in the office, this for you young people. It's called the telephone. It's this thing that you, you call people on and, and talk. It actually is attached to the wall. Um And, and we use Epic now and when Epic started, I, I wasn't a huge fan but um there are a lot of things I like about it and one of the things I know some of you guys that are on this list this morning, um just will send a note and saying I'm seeing this child, he has this, what do we need to do? Um And I'm usually pretty good about getting back if I'm in town. So feel free to send chat to any of us, there's uh Larry Tyson, Andrew Lee, Margaret Reynolds. And I uh and we're all happy to ask that if you're on Epic, um or you can send an email uh or you can call. Created by Presenters Gregg Lueder, MD Pediatric Ophthamology View full profile
