Financial Disclosure

[Pages:14]Ophthalmological Conditions in the

Neonates

Ashley S. Ko MD Pediatric Ophthalmology and Strabismus Clinical Instructor, Department of Ophthalmology

University of British Columbia

Acknowledgement: Scott A. Larson MD Department of Ophthalmology, University of Iowa

Financial Disclosure

? None

Objectives

? Review common and "not to be missed" ophthalmological conditions in neonatal / paediatric population

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Infectious Disease

? Conjunctivitis ? Keratitis ? TORCH

Neonatal Conjunctivitis

? aka Ophthalmia neonatorum ? Presents before 1 months of age ? < 1% - 12% ? Infectious vs. Non-infectious

Etiology

? Infectious agents:

? Bacterial

Chlamydia trachomatis Streptococcus Staphylococcus E. coli Haemophilus Nisseria gonorrheae

? Viral

Herpes simplex

? Non-infectious: Silver Nitrate

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Work-Up

? May include:

Image by Eshel Ben-Jacob:

? Conjunctival scraping with gram stain

? Cultures: blood agar, chocolate, viral

? Chlamydial antibody stain or DNA testing (amplification)

? HSV culture, DFA or PCR (many false negatives for ocular surface infections)

Presentation

Within 24 hrs Mild lid edema,

Watery discharge

2-4 Days Severe lid edema, purulent discharge

4-10 Days Variable lid edema,

purulent or serous discharge

6 - 14 Days Unilateral lid edema,

serous discharge, keratitis

Etiology

Conjunctival scraping

Silver nitrate

Normal

Neisseria gonorrhorea Chlamydia

Gram stain - intracellular diplococci

Giemsa stain - basophilic intracytoplasmic inclusions

Other bacteria

Gram stain positive

HSV

Gram stain multinucleated giant cells

Adapted from: Pediatric Ophthalmology & Strabismus, Wright & Spiegel eds. p.336, 2003

Prophylactic Treatment

? Antenatal care ? Postnatal care

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Empirical Treatment

? Gonoccal infection: (start immediately when suspected) ? Topical erythromycin ointment QID and Ceftriaxone (25-50 mg/kg/ IM/IV x1) ? Consider concomitant infection with chlamydia and/or syphilis

? Chylamydial infection: ? Topical erythromycin ointment QID and oral erythromycin (30-50 mg/kg/day div QID x 14 days)

? Bacterial infection ? 4th Generation Fluoroquinolone (gatifloxacin, moxifloxacin)

HSV Keratitis

? May involve: ? Cornea, conjunctiva, retina (rare)

? Consider systemic involvement

Treatment

? Systemic: ? Acyclovir IV or PO

? Topical: ? Viroptic gtt (be aware of corneal toxicity)

? Adjunctive topical antibiotic

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Other Congenital Infections

? Toxoplasmosis ? CMV ? Syphilis ? Rubella

Lacrimal Disorders

? Nasolacrimal Duct Obstruction ? Dacryocele

Congenital Nasolacrimal Duct Obstruction

? Extremely common (20% at birth) ? Most often blocked at valve of Hasner ? Most resolve spontaneously - observe for the first year

of life ? Symptoms:

? Mucopurulent discharge ? Minimal or no eyelid swelling or redness

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Dacryocele

? Aka: amniocele, dacyocystocele ? Blockage above and below the lacrimal sac ? Often becomes infected ? Cyst may extend under inferior turbinate and obstruct airway ? Bilateral common ? Treatment:

? Don't drain through skin (creates fistula) ? Probe via canaliculus +/- stent

Leukocoria

"White pupil"

Differential Diagnosis

? Cataract ? Vitreous hemorrhage ? Optic disc / chorioretinal coloboma ? Coats' Disease ? Norrie Disease ? Retinoblastoma ? Strabismus ? Anisometropia

...and more!

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Congenital Cataract

? Incidence: 1 - 6 per 10,000 (U.S.) ? Worldwide incidence: unknown ? 60% - isolated ? 20% - systemic disease related ? 20% - inherited

American Academy of Ophthalmology

Treatment

? Surgery and after care ? Early treatment

? First 3 months of life - critical vision development period

? Unilateral cataract more visually disruptive

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Surgery

? When: 4 - 6 weeks ? Other considerations:

? Intraocular lens vs. aphakia ? Contact lens vs. spectacle ? Parents should be made aware of long-term amblyopia treatment post-surgery

Retinoblastoma

? Most common paediatric intraocular malignancy ? Incidence - 1:20,000 ? Mutation in RB-1 gene (tumor suppressor gene) ? 45% of those with an inherited RB-1 gene

mutation will develop retinoblastoma

Cloudy Cornea

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