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 Flashcard 1 of 5

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

Answer: 6/60

Pediatric Ophthalmology and Strabismus Flashcard 2 of 5

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

Answer: 6

Pediatric Ophthalmology and Strabismus Flashcard 3 of 5

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 5

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 5

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