Paediatric Ophthalmology is a sub-specialty which provides a comprehensive assessment of all aspects of visual concerns in children. A broad spectrum of eye conditions is assessed, from a simple chalazion to potentially life or vision threatening concerns, such as ocular/periocular tumours and congenital cataract. Specific to visual development in children is the appropriate and prompt management of amblyopia and strabismus. Eye traumas occur frequently in children and need to be assessed swiftly: ocular foreign bodies, intraocular haemorrhages, periocular lacerations, penetrating eye injuries and orbital fractures in children need urgent medical and often surgical management. Leukocoria, anisocoria, amblyopia and strabismus are important paediatric eye concerns which need timely assessment and treatment.
Leukocoria (“white” pupillary reflex) is a significant ophthalmological sign that must not be missed particularly in children, given its potentially life and vision threatening link with the diagnosis of retinoblastoma and congenital cataract. Retinoblastoma is the most common malignant paediatric ocular tumour arising from the retinal layer and can potentially be fatal if left untreated. Management includes urgent Paediatric Oncology consultation with neuroimaging studies, followed by intervention, which may involve chemotherapy, laser treatment as well as surgical intervention, including enucleation. Congenital cataract can lead to dense amblyopia with irreversible vision loss without appropriate intervention. Management of congenital cataract includes rigorous amblyopia treatment and, if indicated, spectacle as well as surgical intervention (lensectomy with or without intraocular lens placement).
Anisocoria refers to unequal size of the pupils and is most commonly without visual or systemic sequelae, occurring naturally in about 20% of the normal population. However, it can rarely be associated with potentially serious conditions, such as neuroblastoma (in the presence of Horner’s Syndrome) in children (as well as carotid dissection, most typically in adults). Horner’s syndrome is caused by a disruption of the sympathetic innervation of the eye and presents with anisocoria, typically in conjunction with ptosis and iris heterochromia. Horner’s Syndrome can be associated with neuroblastoma, 3rd most common malignant paediatric tumour. Children who are Horner’s Syndrome suspects, therefore, need to undergo further investigation, including tests for urine catecholamines, plasma metanephrines, and, if indicated, neuroimaging studies. (In adults, carotid dissection and apical lung tumour need to be considered; further work-up includes topical cocaine test and, if indicated, neuroimaging studies.) Anisocoria can also be associated with 3rd cranial nerve palsy, which can portend potentially fatal central aneurysm (most typically involving posterior communicating artery). Other ocular signs in 3rd cranial nerve palsy include limitation of eye movement and strabismus (commonly, exotropia). Pupil involving (i.e., with anisocoria) 3rd cranial nerve palsy requires immediate assessment and management.
Amblyopia, sometimes called “lazy eye”, can lead to profound and irreversible vision loss in children. Amblyopia refers to reduced vision in one eye or both eyes due to abnormal visual development when the neural pathway between the eye and brain does not form properly during infancy and childhood. Risk factors for amblyopia span a broad spectrum, including congenital cataract, ocular misalignment (strabismus) and anisometropia (difference in refractive error between the eyes). Amblyopia needs to be managed promptly using occlusion (i.e., patching) or in some cases atropine penalization as well as spectacle, where indicated; surgical intervention may be a consideration if, for instance, the removal of a structural obstruction, such as cataract or corneal opacity, can clear the visual axis. Delayed and inappropriate amblyopia management can lead to irrecoverable vision loss in children. Amblyopia is a leading cause of potentially preventable vision loss in children and needs to be screened and effectively managed.