Pediatric Ophthalmology and Strabismus

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 1: In congenital ptosis, surgery should be performed at the earliest to prevent amblyopia. Which of the following operations is not typically used for the correction of congenital ptosis?

• A. Blaskowics' operation
• B. Everbusch's operation
• C. Frontalis sling operation
• D. Modified Burrow's operation (Correct Answer)

Pediatric Ophthalmology and Strabismus Explanation: ***Modified Burrow's operation*** - The **Modified Burrow's operation** is primarily used in oculoplastic surgery for the correction of **entropion** or **ectropion**, and to resect redundant skin and muscle, not for ptosis correction. - It involves removing a strip of skin and orbicularis muscle, which does not address the underlying levator muscle weakness or disinsertion typical of congenital ptosis. *Blaskowics' operation* - This procedure involves an **anterior approach** to resect and advance the **levator aponeurosis** and Müller's muscle. - It is used for **mild to moderate congenital ptosis** with residual levator function (levator function >4-5 mm). *Everbusch's operation* - An **external approach** to resect the **levator muscle** or aponeurosis to elevate the eyelid. - It is used for **moderate congenital ptosis** where there is some residual levator function. *Frontalis sling operation* - This is a **suspension procedure** that connects the eyelid to the **frontalis muscle** using autogenous fascia lata, silicone rod, or other materials. - It is the procedure of choice for **severe congenital ptosis with poor levator function** (<4 mm), allowing the patient to use the frontalis muscle to elevate the eyelid.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 2: A 2-year-old child presents with unilateral leukocoria and poor vision. What is the most likely diagnosis?

• A. Congenital cataract
• B. Retinoblastoma (Correct Answer)
• C. Endophthalmitis
• D. Coats disease

Pediatric Ophthalmology and Strabismus Explanation: ***Retinoblastoma*** - **Leukocoria** (white pupillary reflex) is the **most common presenting sign** of retinoblastoma, occurring in approximately 60% of cases - The combination of **unilateral leukocoria** and **poor vision** in a **2-year-old child** (peak age 18-24 months) is highly suggestive - It is a **rapidly growing malignant intraocular tumor** arising from the neural retina, requiring urgent evaluation and treatment - Other presenting features may include **strabismus**, **red eye**, and in advanced cases, **proptosis** *Congenital cataract* - Can also present with **leukocoria** due to opacification of the lens - However, congenital cataracts are typically **bilateral** (75% of cases) and diagnosed earlier in infancy - The **static, non-progressive nature** distinguishes it from the rapidly growing retinoblastoma - Family history and associated systemic conditions (TORCH infections, metabolic disorders) are common *Endophthalmitis* - Severe **intraocular infection** affecting vitreous and aqueous humor - Typically presents with **acute pain**, **severe redness**, **hypopyon**, and **rapid vision loss** - Usually follows **penetrating trauma** or **intraocular surgery**, which would be uncommon in a 2-year-old - **Leukocoria without acute inflammatory signs** makes this diagnosis unlikely *Coats disease* - Characterized by **abnormal telangiectatic retinal vessels** with **exudative retinal detachment** and **yellow subretinal exudates** - Can present with leukocoria (yellow reflex due to lipid deposits) in young children - However, it typically affects **older children** (mean age 5-8 years), is predominantly **unilateral**, and has a **more indolent course** - More common in **males** and usually lacks the rapid progression of retinoblastoma

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 3: Appropriate treatment for mild congenital ptosis?

• A. Frontalis sling procedure
• B. Antibiotics and hot compression
• C. LPS Resection (Correct Answer)
• D. Wedge resection of conjunctiva

Pediatric Ophthalmology and Strabismus Explanation: ***LPS Resection*** - **LPS (levator palpebrae superioris) resection/advancement** is the most common surgical treatment for congenital ptosis, especially in mild to moderate cases. - This procedure strengthens the levator muscle, improving eyelid position and is appropriate when the **levator function is good** (typically greater than 4mm). *Frontalis sling procedure* - The **frontalis sling procedure** is generally reserved for severe congenital ptosis with poor levator function (<4mm) or in cases where the levator muscle is absent or highly dysfunctional. - It uses the frontalis muscle to lift the eyelid indirectly, which is less ideal for mild ptosis. *Antibiotics and hot compression* - **Antibiotics and hot compression** are treatments for infectious or inflammatory conditions of the eyelid, such as a **hordeolum** (stye) or **chalazion**. - They are not effective treatments for anatomical defects like congenital ptosis, which requires surgical intervention. *Wedge resection of conjunctiva* - **Wedge resection of the conjunctiva** might be used in some cases of conjunctival prolapse or for correction of specific conjunctival lesions or abnormalities. - It is not a standard or appropriate treatment for congenital ptosis.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 4: In infants of diabetic mothers (IDM), when is ophthalmologic evaluation indicated?

• A. At the time of diagnosis
• B. Only if visual symptoms develop (Correct Answer)
• C. After 5 years routinely
• D. After developing diabetes

Pediatric Ophthalmology and Strabismus Explanation: ***Only if visual symptoms develop*** - Unlike **retinopathy of prematurity**, infants of diabetic mothers (IDMs) do not have a higher incidence of **retinopathy** or other **ocular abnormalities** at birth or in early infancy. - **Ophthalmologic evaluation** is generally reserved for IDMs who develop specific **visual symptoms** or signs of ocular pathology. *At the time of diagnosis* - Routine ophthalmologic screening at the time of diagnosis of IDM is **not standard practice**, as the risk of **congenital ocular anomalies** is not substantially elevated to warrant universal screening. - Initial management focuses on metabolic stability, especially **glucose control**, and screening for other common IDM-related complications like **cardiac defects** or **respiratory distress**. *After 5 years routinely* - There is **no evidence or recommendation** for routine ophthalmologic screening of IDMs specifically at the age of 5 years. - Regular **well-child check-ups** include basic vision screening, which would identify significant refractive errors or strabismus, but not specifically for diabetes-related ocular issues. *After developing diabetes* - While it is true that individuals with **type 1 or type 2 diabetes** require regular **ophthalmologic evaluations** for **diabetic retinopathy**, this refers to the child developing diabetes later in life, not being an IDM. - Being an IDM is a **risk factor for developing diabetes** later in life, but it doesn't automatically mean they have diabetes-related ocular issues from birth.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 5: Obstacles in concomitant squint are:

• A. Sensory obstacles
• B. Motor obstacles
• C. Central obstacles
• D. All of the options (Correct Answer)

Pediatric Ophthalmology and Strabismus Explanation: ***All of the options*** - **Concomitant squint** involves **sensory obstacles** (e.g., amblyopia, eccentric fixation), **motor obstacles** (e.g., muscle imbalance, inadequate fusional vergence), and **central obstacles** (e.g., defective brain processing of visual information). - All these factors interact to cause and maintain the misalignment of the eyes. *Sensory obstacles* - These include conditions like **amblyopia** (lazy eye) due to suppression of the deviated eye's image, and **eccentric fixation**, where the fovea is not used for central vision. - While significant, sensory obstacles alone do not fully explain concomitant squint, as motor and central components are also crucial. *Motor obstacles* - These involve issues with the **extraocular muscles**, such as imbalance in muscle tone, or problems with the **neural control** of eye movements, leading to a deviation that is relatively constant in all gaze positions. - Motor obstacles are a key component but are often influenced by central and sensory factors. *Central obstacles* - These refer to problems within the brain's visual pathways and centers responsible for **fusion**, **vergence**, and maintaining **ocular alignment**. - Defective processing of visual input or an inability to maintain binocular vision can directly contribute to squint, highlighting the brain's role in coordinating eye movements.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 6: A 26-year-old female presents with an insidious onset of diplopia on alternate cover test, exhibiting a right hypertropia that worsens on right head tilt and left gaze. Which muscle is paralyzed?

• A. Left superior rectus
• B. Right superior oblique (Correct Answer)
• C. Right inferior rectus
• D. Left inferior oblique

Pediatric Ophthalmology and Strabismus Explanation: ***Right superior oblique*** - A paralyzed **right superior oblique** muscle causes a **right hypertropia** that worsens on **right head tilt** (positive Bielschowsky's head tilt test) and **left gaze**, which are classic signs of a **fourth nerve palsy**. - The superior oblique muscle is responsible for **intorsion**, **depression**, and **abduction** of the eye, and its weakness leads to characteristic vertical and torsional diplopia. - This presentation follows the **Parks-Bielschowsky three-step test**: hypertropia increases on contralateral gaze and ipsilateral head tilt. *Left superior rectus* - Paralysis of the **left superior rectus** would cause a **left hypotropia** (left eye lower than right), not a right hypertropia that worsens on right head tilt. - It would worsen on **left head tilt** and **left gaze** (ipsilateral to the affected muscle). - Its primary action is **elevation**, with secondary actions of **adduction** and **intorsion**. *Right inferior rectus* - Paralysis of the **right inferior rectus** would cause a **right hypertropia** that worsens on **right gaze** and **right head tilt**. - However, it would worsen on **downgaze** (not left gaze), which is a key differentiating feature from superior oblique palsy. - Its primary action is **depression**, with secondary actions of **adduction** and **extorsion**. *Left inferior oblique* - Paralysis of the **left inferior oblique** would cause a **left hypotropia** that worsens on **right gaze** and **right head tilt**. - This does not match the clinical presentation of right hypertropia worsening on left gaze and right head tilt. - Its primary action is **elevation**, with secondary actions of **abduction** and **extorsion**.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 7: The image given below shows:

• A. Dark adaptation curve (Correct Answer)
• B. Visual evoked response
• C. Contrast sensitivity plot
• D. Electroretinography curve

Pediatric Ophthalmology and Strabismus Explanation: ***Dark adaptation curve*** - The image displays the change in **threshold luminance** over time, specifically showing two distinct phases of recovery of sensitivity: an initial rapid phase (cones) and a later, slower, more sensitive phase (rods). - This bimodal curve is characteristic of the **dark adaptation process**, where the eye adjusts from bright to dim light, increasing its sensitivity to light stimuli. *Visual evoked response* - A **visual evoked response (VER)** measures the electrical signals generated in the brain in response to visual stimuli. - VER graphs typically show amplitude and latency of brain activity, not a curve of threshold luminance over time. *Contrast sensitivity plot* - A **contrast sensitivity plot** illustrates the ability to distinguish between different levels of contrast at various spatial frequencies. - This is usually depicted as a curve showing contrast sensitivity as a function of spatial frequency, which is different from the time-dependent threshold luminance shown. *Electroretinography curve* - **Electroretinography (ERG)** measures the electrical responses of various retinal cell types to light stimuli. - An ERG curve typically shows a characteristic waveform with specific a-wave and b-wave components, representing photoreceptor and bipolar cell activity, which is not what is presented in the image.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 8: Shortening of 2 mm of axial length of the eyeball causes?

• A. 3D myopia
• B. 2D myopia
• C. 6D hypermetropia (Correct Answer)
• D. 1D hypermetropia

Pediatric Ophthalmology and Strabismus Explanation: ***6D hypermetropia*** - A 1 mm shortening of the **axial length** of the eyeball typically results in approximately **3 diopters** of hypermetropia. - Therefore, a 2 mm shortening would cause **6 diopters** (2 mm x 3 D/mm) of hypermetropia. *3D myopia* - Myopia (nearsightedness) is caused by an **eyeball that is too long** or a cornea that is too steeply curved, not by a shortened axial length. - A 2 mm shortening would cause **hypermetropia** (farsightedness), not myopia. *2D myopia* - This option incorrectly identifies both the **type of refractive error** (myopia instead of hypermetropia) and the magnitude of the change. - Shortening of the axial length makes the eye effectively **farsighted**, not nearsighted. *1D hypermetropia* - While reflecting the correct type of refractive error (hypermetropia), the **magnitude is incorrect**. - A 1 mm change in axial length results in about 3 diopters, so 2 mm would be **6 diopters**, not 1 diopter.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 9: Primary objective of the use of atropine in anterior uveitis

• A. Rest to the ciliary muscle (Correct Answer)
• B. Helps in preventing posterior synechia formation
• C. Increase blood flow
• D. Increase supply of antibody

Pediatric Ophthalmology and Strabismus Explanation: ***Rest to the ciliary muscle*** - Atropine is a **cycloplegic** agent that paralyzes the **ciliary muscle**, thereby alleviating pain caused by spasms and inflammation in anterior uveitis. - This **cycloplegia** is the primary therapeutic goal, as it reduces **ciliary spasm** and the associated pain. *Helps in preventing posterior synechia formation (secondary effect)* - While atropine's **mydriatic** action (pupil dilation) helps prevent the formation of **posterior synechiae**, this is a beneficial secondary effect and not its primary objective in alleviating symptoms or pain. - The dilation breaks existing synechiae or prevents new ones from forming by moving the iris away from the lens capsule. *Increase blood flow* - Atropine's primary action is anticholinergic, leading to **cycloplegia** and **mydriasis**, not a direct increase in ocular blood flow. - Increased blood flow is not a targeted therapeutic effect of atropine in acute anterior uveitis. *Increase supply of antibody* - Atropine does not directly influence the immune system or increase the supply of antibodies to the inflamed eye. - Its mechanism of action is limited to blocking muscarinic acetylcholine receptors.

Pediatric Ophthalmology and Strabismus Indian Medical PG Question 10: In blowout fractures, which of the following is seen?

• A. Bulbar hemorrhage
• B. None of the options
• C. Enophthalmos (Correct Answer)
• D. Exophthalmos

Pediatric Ophthalmology and Strabismus Explanation: ***Enophthalmos*** - A **blowout fracture** of the orbit typically involves the orbital floor or medial wall from direct trauma to the eye or periorbital region. - The fracture allows orbital contents (fat and muscle) to herniate into the maxillary sinus or ethmoid sinuses, **increasing orbital volume**. - This increased volume causes the eye to recede backward into the orbit, resulting in **enophthalmos** (sunken eye appearance). - **Key clinical features**: enophthalmos, diplopia (due to inferior rectus/medial rectus entrapment), restricted eye movements, infraorbital nerve hypoesthesia. *Exophthalmos* - **Exophthalmos** (proptosis) is forward protrusion of the eye, occurring when orbital volume is **decreased** or orbital contents are **increased** (e.g., thyroid eye disease, orbital tumors, orbital hemorrhage). - This is the **opposite** of enophthalmos and would not occur in a blowout fracture where orbital volume increases. *Bulbar hemorrhage* - **Subconjunctival hemorrhage** may occur as an associated finding from ocular trauma but is not a characteristic or defining feature of blowout fractures. - Many types of blunt ocular trauma can cause conjunctival hemorrhage without orbital fracture. *None of the options* - Incorrect because **enophthalmos** is the classic and characteristic finding of orbital blowout fractures.

Pediatric Ophthalmology and Strabismus Flashcard 1 of 10

Question: What is the visual acuity of a newborn?_____

Answer: 6/60

Pediatric Ophthalmology and Strabismus Flashcard 2 of 10

Question: By _____ months, macular stereopsis and accommodation reflex are fully developed.

Answer: 6

Pediatric Ophthalmology and Strabismus Flashcard 3 of 10

Question: _____ is the most common type of squint seen in children around 2-3 years

Answer: Accommodative esotropia

Pediatric Ophthalmology and Strabismus Flashcard 4 of 10

Question: Retinopathy of prematurity (ROP), previously known as retrolental fibroplasia, is a disease of the eye that affects _____ babies.

Answer: prematurely born

Pediatric Ophthalmology and Strabismus Flashcard 5 of 10

Question: _____ test is used to approximate the angle of manifest deviation in strabismus by placement of prisms in front of the fixating eye until the corneal light reflections are symmetrical

Answer: Kimsky

Pediatric Ophthalmology and Strabismus Flashcard 6 of 10

Question: Measurement of fusion reserve is done using a _____ or _____

Answer: synoptophore

Pediatric Ophthalmology and Strabismus Flashcard 7 of 10

Question: _____ test is used to approximate the angle of manifest deviation in strabismus by placement of prisms in front of the fixating eye until the corneal light reflections are symmetrical

Answer: Kimsky

Pediatric Ophthalmology and Strabismus Flashcard 8 of 10

Question: Maddox tangent test is used to check for heterophoria for _____ vision

Answer: distance

Pediatric Ophthalmology and Strabismus Flashcard 9 of 10

Question: Maddox wing test is used to check for heterophoria for _____ vision

Answer: near

Pediatric Ophthalmology and Strabismus Flashcard 10 of 10

Question: Colobomas are an embryological defect that is caused when the _____ fails to close completely before the child is born

Answer: choroid fissure