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Toronto Notes 2019 Pediatric Ophthalmology Retinopathy of Prematurity
Definition
• vasoproliferativeretinopathythatisamajorcauseofblindnessinthedevelopedworld
Risk Factors
• non-blackrace(blackinfantshavelowerriskofdevelopingROP) • earliergestationalage,birthweight<1500g
• highoxygenexposureafterbirth(iatrogenic)
Classification (ROP Staging)
• stage1:faintdemarcationlineatthejunctionbetweenthevascularandavascularretina • stage2:elevatedridge
• stage3:extra-retinalfibrovasculartissueextendingintovitreous
• stage4:partialRD(4A:macula“on”,4B:macula“off”)
• stage5:totalRD
• plus (+) disease: dilatation and tortuosity of retinal vessels
• threshold disease: stage 3+ in zones 1 or 2 with circumferential extent of ROP involvement in 5
continuous or 8 cumulative clock hours (1-12)
Treatment
• laserablationiscurrentlythetreatmentstandardforstages1-3;anti-VEGFintravitrealinjectionsare undergoing clinical trials
• Stage4-5istreatedwithvitrectomy/scleralbuckle(goalistoreleasevitreoustractionalforcesonthe retina)
Prognosis
• higherincidenceofmyopiaamongROPinfants,eveniftreatedsuccessfully • stage4Band5havepoorprognosisforvisualoutcomedespitetreatment
Nasolacrimal System Defects
Definition
• congenitalobstructionofthenasolacrimalduct(failureofcanalization),usuallyoccursat1-2moofage
Signs and Symptoms
• epiphora(overflowoftears),crusting,discharge,recurrentconjunctivitis
• canhaverefluxofmucopurulentmaterialfromlacrimalpunctumwhenpressureisappliedover
lacrimal sac
Treatment
• massageoverlacrimalsacatmedialcornerofeyelid
• vastmajorityspontaneouslyresolvein9-12mo,otherwiseconsiderreferralforductprobing
Ophthalmia Neonatorum
Definition
• newbornconjunctivitisinfirstmonthoflife
Etiology
• chemical/toxic:silvernitrate,erythromycin(secondarytoprophylaxis,self-limiting)
• infectious:bacterial(e.g.N.gonorrhoeae–mostcommon,C.trachomatis),herpessimplexvirus
Treatment
• systemicantibioticswithpossiblehospitalizationifinfectiousetiology
Congenital Glaucoma
Definition
• elevatedIOPwithinthefirstyearoflife
Etiology
• notentirelyknown–maybeduetoinadequatedevelopmentofanteriorchamber
• sporadicandhereditary(autosomalrecessive);malesmoreoftenaffected
• secondarycongenitalglaucomacanbeassociatedwithocularandsystemicdisorders
■ ocular: aniridia, microcornea, megalocornea, cornea plana, iridoschisis, microphthalmos, persistent hyperplastic primary vitreous, posterior polymorphous dystrophy
■ systemic: Prader-Willi, trisomies, fetal alcohol syndrome, mucopolysaccharidoses and many others
Clinical Features
• photophobia,epiphora,andblepharospasm
• cloudycorneaduetoedema;Haab’sstriaeduetobreaksinDescemet’smembrane
Ophthalmology OP39
Anti-VEGF Drugs for Treatment of Retinopathy of Prematurity (ROP)
Cochrane Database Syst Rev 2018;1:CD009734 Summary/Conclusions: Review of 6 RCTs/Quasi- RCTs comparing anti-VEGF agents vs. conventional therapy for ROP (n=383).
• Insufficient data precludes strong conclusions for routine use of intravitreal anti-VEGF agents for treatment of ROP
• Intravitreal bevacizumab/ranibizumab as monotherapy reduces risk of refractory errors during childhood.
• Intravitreal pegaptanib + laser therapy reduces the risk of retinal detachment for type 1 ROP
• Effect on other critical outcomes and long-term systemic adverse effects are unknown
Gonococcal infection is the most serious threat to sight as it can rapidly penetrate corneal epithelium, causing corneal ulceration
Epiphora in children – rule out congenital glaucoma