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Pediatric Ophthalmology

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					  Pediatric Ophthalmology


                  ,
   Alan A. Norman, MD
   Michael G. Hunt, MD
   Eric A. Packwood, MD
     May 29, 2010




                          “Clear Vision for the Future”




How is Pediatric Ophthalmology
          Different?
Developing eye is a consideration.
Developing brain is a consideration.
              lifelong.
Outcomes are lifelong
Outcomes needs to be durable.




     What will be covered?

Childhood Glaucoma
Childhood Nasolacrimal Duct Stenosis
Childhood Cataracts




                                                          1
       Pediatric Glaucoma




               History

Buphthalmos related to high IOP in 18th
century
      1900’
Early 1900’s - goniodysgenesis recognized
as etiology




                                            2
               Types
Classified by location of dysgenetic
structures ( angle, iris and cornea )
Primary congenital glaucoma 1:10000
or as high as 1:1250 in Slovakia Roms




                                        3
              Genetics

GLC3A – located on 2p21
GLC3B – located on 1p36
Axenfeld-Rieger–
Axenfeld-Rieger– 6p25 (FOXC1)
Aniridia – 11p13 (PAX6)




          Complications

 Buphthalmos (12mm during first year)
 Haab’s Striae (12.5mm or more)
          sclera
 Thinned sclera, axial myopia and
 astigmatism
 Optic nerve glaucomatous damage
 (reversible)




Pediatric Glaucoma Treatments

Medications
Trabeculotomy
Goniotomy
Trabeculectomy
Cyclodestruction
Glaucoma Drainage Implants




                                        4
Pediatric Glaucoma Treatments

Medications
  Beta Blockers (Timolol, betaxolol)
  Carbonic Anhydrase Inhibitors (dorzolamide,
  brinzolamide)
  Prostaglandin Analogs (latanoprost,
  travaprost)
  Combination formulations (Cosopt, Combigan)




Pediatric Glaucoma Treatments

Medications
  Alpha 2 agonists (brimonidine)
  Cholinergic/adrenergic
  Oral drugs (acetazolamide)




Pediatric Glaucoma Treatments

Goniotomy
Trabeculotomy
Trabeculectomy
            Trabeculotomy-
Combination Trabeculotomy-
Trabeculectomy
Goniotomy for Uveitic Glaucoma




                                                5
          Pediatric Goniotomy

  Tilt patient’s head
  Assistant is key (traction sutures or locking
  forceps)
  Make incision low on limbus
  Use cohesive viscoelastic (Healon GV)




Pediatric Glaucoma Treatments

Goniotomy video




   Pediatric Glaucoma Treatments

  Goniotomy
  Trabeculotomy
  Endolaser
  Trabeculectomy
              Trab-
  Combination Trab-Trab
  Goniotomy for Uveitic Glaucoma




                                                  6
      Pediatric Trabeculotomy

        5-
6-0 or 5-0 Polypropylene (Prolene)
2 incisions 180 degrees away
iProbe




      Pediatric Trabeculotomy

Trabeculotomy video




        Pediatric Glaucoma

Goniotomy for Uveitic Glaucoma
 Ho, Walton article Glaucoma 2004
    71% success rate




                                     7
Pediatric Glaucoma Drainage
           Implants
Use as large a valve as possible
Ahmed Valve Flexible Plate
Can use in each quadrant




Pediatric Glaucoma Drainage
           Implants




                                   8
  Pediatric Glaucoma Drainage
             Implants
Corectopia due to iris enclosure around
tube
Induced restrictive strabismus
Erosions of tube or plate
Corneal decompensation due to
endothelial dysfunction




           Pediatric
   Endocyclophotocoagulation
ENDO OPTIKS
  0.2 mW
  Continuous setting
  Treat ciliary processes until white and
  shrunken




        Pediatric
Endocyclophotocoagulation




                                            9
           Pediatric
   Endocyclophotocoagulation
Can treat 360 degrees (270 degrees usual)
Hypotony (eye pressure too low) is rare




                Trans-
      Pediatric Trans-scleral
      Cyclophotocoagulation
Diode laser probe (G probe - Iridex)
  1750 mW
  2000 ms
  3.5mj/burst
  1 application per clock hour up to 360
  degrees




                                            10
                Trans-
      Pediatric Trans-scleral
      Cyclophotocoagulation
Take care to locate ciliary body in
buphthalmic or highly dysmorphic eyes




                Trans-
      Pediatric Trans-scleral
      Cyclophotocoagulation
Multiple treatments if needed
Difficult to titrate effect
Risk for phthysis
Reserved for intractable glaucoma or
patients with poor visual prognosis




       Pediatric Glaucoma

 One of the most challenging disease
 entities
 Surgical and medical treatment
 Vigilance and continuity of care




                                        11
Nasolacrimal Duct Obstruction

5% of children born with NLDO
Most resolve by 6 months
Simple plumbing / drainage
Generally benign
Can be acquired – trauma or inflammation




                                           12
Nasolacrimal Duct Obstruction

Generally responds well to treatment
What we do:
  Periodic usage of antibiotic drops as needed
  Tear sac push
  Probe after 6 months (before 11 months) in
  office




   NLDO Treatment Options

Simple probe/irrigate
+ balloon dilation
+ silicone tube stent (bi or monocanalicular)
Infracture inferior turbinate
Dacryocystorhinostomy (laser and open)
Conjunctivorhinostomy (glass tube)




                                                 13
14
Nasolacrimal Duct Obstruction

(In office tear duct probe video)




                                    15
Nasolacrimal Duct Obstruction

(Operating room suite tear duct probe
video)




                                        16
  Pediatric Cataracts and Lens
          Abnormalities
Nucleus develops at 6 weeks gestation.
                 epithelium-
Lens material is epithelium-derived.
P di t i lens is soft and gel-lik
Pediatric l   i             l
                   ft d gel-like.
Amblyopia is main cause of vision loss.
Outcome needs to be durable.




                                          17
18
Pediatric Cataracts and Lens
        Abnormalities

 Multiple types of congenital cataracts
   Congenital / Hereditary
   Persistent fetal vasculature
   Lens subluxation
   Traumatic cataracts
   Non-
   Non-traumatic acquired cataracts




                                          19
20
21
How is Pediatric Cataract Surgery
 Different from Adult Surgery?
Eye wall is flaccid
Eye can be smaller
Vitreous is usually a solid gel
Must plan for the future decades
Beware social situation




                                    22
How is Pediatric Cataract Surgery
 Different from Adult Surgery?
Vitreous can be your friend
  < 6 years of age – must take posterior capsule
      p                         y
  and perform subtotal vitrectomy




    Post YAG Capsulotomy




                                                   23
  Pediatric Cataracts and Lens
          Abnormalities
Multiple types of congenital cataracts
Persistent fetal vasculature
Lens subluxation
Traumatic cataracts
Non-
Non-traumatic induced cataracts




          “Clear Vision for the Future”




                                          24

				
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