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0208 816 8584
TITLE: Presentation 5 Joe Abbott

DATE: 19th February 2017

NUMBER OF SPEAKERS: 1 Numbers Speakers

TRANSCRIPT STYLE: Intelligent Verbatim

FILE DURATION: 30 Minutes 12 Sec

JA: Joe Abbott


GP Eye Health Network: Paediatric Ophthalmology, Mr J Abbott

JW: I’ve been a Consultant at the children’s hospital, soon to be Children’s Women’s Hospital, for five years and I’m gonna talk to you about paediatric ophthalmology. There’ll be some opportunity for me to ask you questions and you to ask me questions.

So, this was the title I was given: common eye conditions, what they are, what GPs need to know, paediatric ophthalmology.
So, this is what I’m gonna talk to you about. What do paediatric ophthalmologists do? I think that’s quite useful cos it, sort of gives you a menu of the sort of serious stuff that you need to keep an eye out for that needs referral.
How to assess an eye problem in a child? So, this is a very broad talk really, cos a lot of the lessons for paediatric ophthalmology are applicable to the whole of ophthalmology. So, if I’m repeating anything you’ve heard already, please just get me to skip on. They’ve got plenty that I can cover.
Conditions which require referral. So, these, I’ve stratified these according, to their urgency and their seriousness. So, emergency problems, urgent problems and routine problems.
Conditions which I’m very grateful to you guys for managing in primary care and some tips around that. And some sort of danger scenarios and pitfalls.
So, that’s what we’re gonna look at. So, what does a paediatric ophthalmologist do? Well, more than my adult colleagues. I can say that, cos I don’t think there are any in the room. We kind of consider the whole patient [laughing] and so, we can consider the whole child, but particularly the fact that the eye is part of the nervous system. And obviously, our area then is to focus in on the bits of the eye that can go wrong in kids.
So, forgive me for the sort of self‑evident, anatomical drawings, but self‑evident labels. But I thought you might need that cos that’s my Sankey diagram. [laughing]. But these are the bits that can go wrong. And sort of a whistle stop tour of the serious stuff that we do at the Children’s Hospital. Retinopathy of prematurity. When the lens is opaque. Paediatric cataracts. Ptosis, which his actually, quite a serious problem if it happens during visual development and can need surgical correction. Iritis. Uveitis. Glaucoma. Opaque corneas, corneal problems of one sort or another. Mentioned glaucoma already. Retinoblastoma, we’re one of the two national services for retinoblastoma. Rarely, retinal detachments. Optic nerve problems of a whole variety of different sorts and perhaps one of the most important things is papilloedema. That’s … and I’m gonna go in to that in some detail about what that looks like and what can mimic that. And the sort of bread and butter stuff about straightening eyes that are not straight, so, squint surgery.
And, but as I mentioned, we consider the child in the context of their life. So, we’re liaising with schools, families, primary care, you guys, optometry, teachers, sensory support people of various, different sorts, low vision services. So, our role is both in the hospital but we’re kind of looking outwards on behalf of the child quite a bit.
So, how to assess an eye problem. So, this is whizzing through how to assess an eye, particularly, in a child. So, you gather the clinical information. You either make, a decision to refer and then you decide. I think it’s helpful to be mindful of the urgency. And I’ve put in the talk, appropriate contact numbers for our hospital and ways to get hold of us according, to which of those urgencies you decide applies. Or you might decide, right I know what this is, I’m gonna make a diagnosis and I’m gonna manage this.
So, how do you acquire the clinical information? Well this is a sort of silly way of remembering this, but this is a vexed man from Mr Messerschmidt and if he was a constable, he’d be PC VEXd. So, PC VEXd is a way to remember to gather the clinical information.
So, presenting complaint, it’s pretty, self-evident. Vision has … so on referrals that we receive, some of these bits are sometimes missing. Sometimes you can’t gather this information cos the … if it’s a child it’s not always possible. But these are really, important measures of vision and visual field, in particular.
Pupils in particular will get all of us out of trouble on occasion, to spot dangerous pathology. Eye movements, limitations, what the eyes are doing in the primary position. I’m gonna show you some pictures about that. And, when you’re examining the eye, it’s useful to think anatomically from front to back, so, lids, cornea, anterior chamber, lens, retina. And I appreciate, and it’s impossible to see all, of these things in all children but to have that sort of mental structure in mind is helpful. And really, importantly, for paediatric ophthalmology as distinct from other walks of ophthalmology, what’s happening in terms of developmental progress and that can be helpful thing as well if there’s a neurodegenerative sort of context then that completely changes the type of pathology we might be thinking about.
So, visual acuity, what does that mean? This is something, you know, see, got wrong quite frequently from colleagues in the hospital and from primary care. So, visual acuity, how … it’s your ability to distinguish two spots in space. So, on a chart, a big spot gives you a big thing. Two spots a distance apart give a big angle at the eye. And a small thing, a small letter, give a small angle at the eye. And that’s all you’re measuring with visual acuity.
So, people get confused with this, 6/6 or 20/20 terminology. If you think of it as a fraction, 66/66, 20/20 is 100% and worse vision where you can only see a shape 10 times bigger is 10% of the vision. So, forgive me for going through that but I think that’s often quite a helpful little reminder. And when you’re testing vision, children and adults, remember to ask: do they wear glasses. If they don’t wear glasses to look through a pinhole can correct for the equivalent of glasses. And really, importantly, what’s the vision with each eye, otherwise you’ll miss uniocular pathology. So, simple stuff, picks up really, important information.
How do you assess visual fields? And actually, you can do this in really, tiny kids. As, long as they’re old enough to play with you, you can get some idea of visual fields. So, a few very simple questions. Get them to look at your face. Are there any bits of the face missing? So, if they’ve got … you know, we’re talking about rarities and serious stuff. But if there’s a homonymous hemianopia and they’re missing the right half of their visual field with both eyes. They might tell you that half of the face they can’t see when they’re looking at your nose. You’ll have seen this probably with stroke patients more often than children, actually.
So, cortical field loss. Look at me and point at which hand is moving. So, this is a quick way of testing the visual field. So, you get them to fixate with you and you can identify a hemianopia by waving one hand or the other.
And more subtle stuff is, cover one eye, get the patient to look back at you and you can test their different quadrants. And again, they are very important, cos that only by doing this would you pick up a bitemporal hemianopia. Something that points to a pathology around the pituitary. So, we’ll revisit this during the talk but it’s really, important.
Has anybody else gone through this sort of stuff this morning? Do you want me to go through the examination sort of things? Okay, so, RAPD, this should play, he says.
FS1: Okay, if you go back and click on [unclear 00:07:51], just if you look behind your back and see there’s an arrow on the slide there’s a … you move the thin pointer.
JA: Yeah.
FS2: … to the [unclear 00:07:58] …
FS3: Look at the main slide.
FS2: … looking at the main slide on the screen.
JA:Yeah, right. So, relative afferent pupil defect, we’re looking for here. So, this arrow represents the light. The two pupils are doing the same thing. So, when you shine the light on, the pupils constrict. And you get that slight relaxation afterwards which can … it’s called a hippus which can confuse people. But that’s a normal … a video of a normal situation. You turn the lights off, the pupils get bigger. You put the light on the eye and both constrict.
So, what we’re looking for with an RAPD is when there is a problem between the eye and the brain. So, in a second the video will mimic that. And so, here when you shine the light on the left eye, hang on a minute, the eye with the problem will dilate. You didn’t get much chance to see that. But let’s see if I can get that back.
So, right towards the end of the video there, when the light comes across to the left eye, the pupil dilates. So, that means that there’s less signal going through that left eye to the brain and then that’s a really, important sign to tell you that there is an objective problem with the vision. So, you’re not relying on subjective responses. So, the light goes across the left eye and the pupil dilates. And that there, that’s the key thing that you’re looking for with a relative afferent pupil defect.
So, it’s a really, useful sign, cos kids, like all of us try and kid people sometimes. And to have an objective test of vision rather than a subjective test is really, useful and quite a simple thing to do.
So, ocular movements. So, I just wanna show you this cos it’s where this is the light bounces off the cornea, gives you an important clue as to the alignment of the eye. So, any suggestions as to what’s going wrong here? If you look, it’s subtle but where … if you look at where the light is, the corneal reflex, it’s different on the two eyes. So, have we got an esotropia, are the eyes pointing in or have we got an exotropia. So, popular votes are dangerous things, aren’t they, these days, but [laughing].
So, who votes for esotropia? Who thinks this is an esotropia, eyes are pointing in? So, the light reflex here is slightly further to the outside of the cornea. So, no one votes for esotropia? A few votes for esotropia. So, who thinks it’s an exotropia and the eyes are pointing out? Even less votes [laughing]. So, yeah, you’re quite right. So, it’s a subtle thing. And, so, look in the primary position. That can often give you the clue. And then when you actually, get the patient to move their eyes around, it becomes obvious sometimes.
So, this patient, the left eye won’t abduct. There’s sixth nerve palsy. So, that’s a very different situation to this situation, where again, you’ve got an esotropia but the angle between the two eyes stays the same wherever this child is looking. So, as opposed to this patient who, when they looked to this way, the eyes are both pointing at the same thing. When they look this way, in this picture, there’s a big difference between the … so that’s call incomitant and that’s a concomitant squint. So, concomitant means the angle’s always the same, incomitant means the angle changes. This is worrying cos this could be … this is much more likely to be a neurological problem. This is much less worrying and this is what you see in common childhood squints.
So, concomitance and incomitance, whether the angle’s changing between the eyes depending on where patients look.
So, the other bits of the examination. What does the surface look like? Fluorescein, I don’t know how many of you have access to Fluorescein on a regular basis? Good, so really, useful to reveal corneal problems. It sticks to breaks in the epithelium of the cornea if you shine your blue light on it.
So, this is a large epithelial defect. This is what you see if there’s something stuck underneath the eyelid. It’s like a dry … it’s like a windscreen wiper scratching at the windshield. So, if you see that, you know that there’s something hidden underneath the eyelid. And you could have a go at removing it with a cotton bud and inverting the lid.
This is a severe chemical injury. So, I only mention … put this in because chemical injuries are a genuine emergency problem, as I’m sure you know. And need irrigating right then and there. And this is a very serious one. If you see this as well, this is a bad sign. This means that the chemical injury has extended to the conjunctiva and these … this bit of the conjunctiva nourishes the cornea. So, this cornea is gonna really struggle to heal. And very serious injury could well be blinding.
Other, I mean, these are obviously, serious problems. But these are things that you might see on the ocular surface. Traumatic injuries that to be able to describe this, this is a corneal laceration and the iris prolapsing out and a cataract.
So, ophthalmoscopy tips. Tweed is optional. You don’t have to wear tweed [laughing] and you don’t have to have a beard. [laughing] It’s not a very paediatric sort of slide this, is it? But for kids, if you’ve got a little baby, if they’re fed and examining them, you’ll know these tricks I suspect. But colleagues in the adult ophthalmology world forget this, that if a baby’s, got a full tum, then they’ll sleep through a lot of things and you can get a really, good look at their eyes. And that can be a useful tip. So, in clinic quite a frequently, if a baby is of that age, between sort of, well birth and about two, perhaps that’s not right. Perhaps birth and a year of age and if they will go to sleep, we’ll give them the chance to do that and have another go at looking at their eyes. And it can often avoid a trip to theatre.
So, you need, for direct ophthalmoscopy, you need a dark room and a bright light. And you can dilate the pupils very safely with 1% Tropicamide in all children.
Red reflux examination. That test, what happens, if you shine the light in at the front of the eye, bounces off the back of the eye and comes back for you to see it. So, here that’s what’s happening. And if it doesn’t do that, it means there’s a problem. If it’s dark like this, it means there’s a problem anywhere along the cornea, the anterior chamber, the lens, the vitreous, the retina might be detached and it’s a very, very specific … sorry, very, very sensitive thing. So, it will tell you if there’s a problem with any of those things. But it’s very poorly, specific. So, it doesn’t tell you what’s going on but it tells you with quite a high degree of reliability if there’s something serious happening.
So, if you see this problem, so, fundoscopy, seeing the fundus is a hard skill to acquire. Doing a red reflex examination is not. And the findings that you get are to be taken very seriously if there’s an asymmetry.
So, conditions to refer urgently. I just thought I’d put this in. Sometimes we don’t get … we don’t see patients as urgently as we like, because I think you probably are familiar with this. The optometrist will send a patient along to see you and say, please refer to the hospital but they don’t necessarily give you any paperwork. And that presents us with a problem just as it presents you with a problem, cos then we have to go back to the optometrist and ask for that paperwork. So, if that can be appended to referrals, great.
Similarly, with second opinions we have to go the first hospital and get information. And occasionally we get adults sent to the Children’s Hospital which is not easy for us to deal with. So, they get sent on and that leads to delay.
So, what’s really, urgent? So, really, urgent things in this city, I’m talking about genuine emergencies, they go to the Eye Centre still. So, there, that’s a contact number for the Eye Centre, City Hospital.
So, these are the true paediatric emergencies. Open traumatic eye injuries. These are nasty ones. Serious ocular trauma with a hyphaema here, blood in the anterior chamber. Nasty chemical injury. This is infected cornea with that hypopyon, that’s called the white bit with the flat top in the front of the eye. Papilloedema, so swollen discs in a child. This is sort of, on the border between emergency and urgent but it’s certainly, something to clearly take very seriously. So, severe corneal infections are actually life threatening in neonates. And I don’t … So, this is something which is not … this is a herpetic ulcer of the cornea. Quite a common problem in adults with Zovirax topically, it will get better and is not a great emergency. But in children you can get disseminated CNS infection if they’re very, very young and certainly any child that’s immunosuppressed. And orbital cellulitis again, can lead to spreading infection. So, those are the things that have a very high degree of urgency about them.
This is a … anyone guess what this is? What foreign body that might be? [unclear audience 00:17:16]. It’s a biro. So, that’s the tip of the biro. And it’s the plastic shaft. And this is just in here to remind me to remind everybody that the Eye Centre is not a safe place to send people who … so, this is an eye injury but this, it’s not a good idea to send this patient to the Eye Centre cos it’s remote from emergency medical care. So, it would be much more appropriate to send this to neurosurgery and then get us to see.
Anyway …
MS: [unclear 00:17:44] cellulitis then. Is that the children’s slide in the [unclear 00:17:49]?
JA: Right. Good question. So, yeah, I think that would be, yes, because that would be admitted under paediatrics. I think that would be perfectly appropriate to send it to us at the children’s, via the casualty, yeah.
Papilloedema. So, what’s papilloedema? This is a retinal cell that sends its axon down the optic nerve. And this space around it is the CSF, the fluid around the brain. And if the pressure goes up here, it pinches the nerve, the nerve becomes swollen. So, that’s what we’re looking for. That’s what papilloedema is. So, a normal nerve and a swollen nerve.
So, I just thought I’d show you some pictures of a child who’s gone from normal nerve to swollen nerves and we can look at all the different features that occur. So, here we’ve got normal, with normal degree of convolution of the vessels. The vessels are not dilated, they’re not tortuous. The disc is nicely outlined. And as t the pressure goes up the vein becomes more dilated and tortuous and you lose that clear boundary around the nerve.
This is a girl who had a shunt in and the neurosurgeons were turning up and down the flow on the shunt. So, the pressure was too high here. And then they increase the flow, so, her pressure went down. So, you can see the blood vessels have improved but she’s still got that blurred disc margin which takes longer to improve. And then they turned down the flow on the shunt and she gets worse again. And you get these haemorrhages as well. So, this is rip roaring hard to miss papilloedema. Haemorrhages are much easier to see than blurred disc margins which are not easy to see. And I’m not saying for a second that this is an easy thing to spot in a wriggly child, but papilloedema is something that, if recognised, it clearly needs to be acted upon. And, so, she then got better this girl and her nerves improved and improved.
And this is a rip roaring papilloedema where you start to also get exudates. These little white dots coming towards the fixation. And these are the sight threatening bit of papilloedema. So, I put this in because after … this is what it looks like on cross section of the nerve. The nerve is heaped up liked that. It helps to have that image in mind. And afterwards the nerves become pale and they lose that heaped up appearance. This is a cross sectional view of the nerve. If you’re really, good at fundoscopy, and the best instrument for seeing it, is the direct ophthalmoscope, you’ll see the veins at the back of the eye pulsate. So, do you see that pulsing there. That’s a spontaneous venous pulsation which is a very, very clear sign of a normal intracranial pressure. So, just there, it’s one of the best clinical signs because you can’t get that in the context of raised intracranial pressure.
Anyway, so, there are lots of funny things that can happen to nerves and as I said, it’s not an easy task to tease out the exact cause of a … but I think to be able to identify a normal nerve from an abnormal nerve is a useful skill.
So, what’s urgent? So, urgent stuff, these are our contact numbers at the Children’s Hospital. That’s a fax number and a telephone number and these are the sort of things that we expect to see coming in. So, they’re things really that are … have a very sensitive time frame.
So, this just shows what happens to the brain between two weeks of age one year of age. So, it gets … there’s a huge amount of organisation that goes on. And if anything’s interrupting the vision during these sensitive periods it has an urgency about it that doesn’t apply to the adult world. So, a cataract in a 60‑year old is not usually an urgent problem. In a new born baby, that’s a very urgent problem. The surgery has to happen at six weeks of age to give them the best outcome. So, we need to see those quickly. So, child with loss of red reflex or a white reflex is a serious problem cos it might be a cataract. At this age, we are very worried, you know, in early childhood we’re worried about that. We need to see them quickly. It raises the prospect of tumours in the eye. Glaucoma in infancy. So, cloudy large corneas, I’ll show you some pictures in a minute. Watery eyes. And clearly, sudden onset neurological problems. Acute onset squint. Sudden onset visual loss. These sort of things, are worrying and particularly if part of a systemic syndrome. And progressive proptosis. So, it doesn’t happen much but orbital tumours are worrying and need to be seen clearly very quickly.
So, the not urgent things, and by the way this an email for the Eye Department for clinical queries. This is looked at every day. So, these are the things like haemangiomas on the eyelids, lumps and bumps around the eyes. Watery eyes in children over 12 months. Under 12 months there’s a good chance that they’ll resolve and don’t need referral. And all these different types of ocular surface disease which are quite common in children. Corneal problems that are a bit less urgent, particularly, if they’re older. Squints and non‑acute neurological problems, like, anisocoria, if the pupils are different sizes on each side. And we get a lot of these referrals from opticians, less so, from GPs where there’s a higher eye pressure measured in the community.
So, I haven’t got long left actually. I’m gonna skip through a few slides cos I think one of the most important bits will be the sort of pitfalls and the danger clinical scenario. So, I’m gonna show you those bits if I may. You’ll know lots about these conditions.
Chalazia that you see often. A few tips about this, omega-3 in the diet has shown to make the Meibomian secretions more runny and less likely to build up and lead to chalazia. And it is a self-limiting condition albeit on an unpredictable timescale. So, those can be quite reasonably managed in primary care provided they’re not associate with a precept and not sure if they might be orbital cellulitis.
And these sort of, acute allergic problems are self-limiting. If you see that sort of bulbous ballooning of the conjunctiva, usually means something’s gotten in the eye that’s irritated the eye and that’ll go within 24 hours. But if allergic problems are starting to look more like this where there are limbal follicles or certainly any corneal problems, then they need referral.
Right, let’s, as I mentioned, some danger scenarios. So, which squints are dangerous? So, there are three squints here and esotropia, convergent squint, a divergent squint and another divergent squint. And look carefully at the pupil. So, this is the dangerous one. This is a … so this is an … we don’t know why this is an exotropia but this one we can have a fair stab at saying that this is associated with a posterior communicating artery aneurism or some pathology there that’s … and if it is a posterior communicating artery aneurism, it’s life threatening and needs urgent referral. Much commoner in adults than children but we do some them in peculiar connective tissue disorders in kids when there are aneurismal changes intracranially. Rarely, but, I’m trying to help you spot the ones that are really, dangerous.
So, other danger features. If it’s sudden onset and it wasn’t infantile and onset, if a child is saying they’ve got double vision that means that it was sudden onset and that’s a worrying thing. Clearly, any associated neurological features, any associate loss of vision. If any of these, so this squint might be secondary because this left eye had lost vision. So, if that was the case, it may be that an RAPD here, would be the only clue to you. So, if you look for an RAPD and a squint and it’s a new onset, that’s a worrying thing. It means that the squint is secondary to loss of vision. So, the binocular lock between the eyes has gone because one of the eyes has lost vision. So, the squints that follow a cranial nerve pattern are dangerous too, clearly.
So, I don’t think we’ll go through that in the interests of time. I’ve told you about these two already, the concomitant and the incomitant squint. So, who votes for this being the dangerous one? Any votes? Popular vote. Who votes for this one being the dangerous one? Okay, good, exactly.
So, which watery eyes are dangerous? And you’re gonna know that these are dangerous. [laughing] Cos, you get what … So, but you need to look carefully for this infiltrate in a child associated with lid margin disease. So, have a careful look at the cornea. The Fluorescein would help you identify this. And this is a real pitfall. I really, feel for your guys. I look after a lot of children with glaucoma and you’ll probably see one or two children with glaucoma in an entire career. And they’ll mixed in amongst the haystack of millions of babies with watery eyes that you’ll see over a career.
So, if you see a child with watery eyes, always think is the cornea big, like it is here. Is it cloudy? If it’s either of those two things, be thinking this could be congenital glaucoma or infantile glaucoma and need and urgent referral. And you know, it’s difficult to spot because most, probably not most, but a significant minority of the children I see with glaucoma have been misdiagnosed for a fair few visits to primary practice … primary care, being told that it’s a watery eye related to nasolacrimal duct dysfunction. So, if you think of it, you’ll spot it. But it’s a rarity.
And this is just to say, that often those kids with glaucoma, the parents will say, everyone says, they’ve got such beautiful big eyes. Disney eyes. And you’ll that time and … so, if you hear that again think oh there might be something going on here that’s not just a watery eye.
And which, I think this is the last one. Which reduced visions are dangerous. So, this relates back to what I was saying at the beginning about the importance of checking for the visual field. So, again, rarities, but they do happen if you’ve got pituitary tumours in children, craniopharyngiomas, and then they will give a neurological type field, a bitemporal hemianopia.
So, and you can check for these things if you try in kids. And it helps to tease out the ones, you get quite a few kids that might try it on a bit with reduced vision. And I think you probably refer most of them which is very valid. But to have an idea of the urgency and the seriousness of the problem from doing a field examination is really, helpful.
Last one. Which red reflex problems are dangerous? This is okay, red reflex both sides. White reflex here, that’s a problem. Okay. What about that one?
[unclear audience responses 00:28:47]
JA: Right, it’s … it could be, but if the white … if this eye was white then that could be the reflex bouncing off the nerve. But on … in short, if you see an asymmetry which is there when you look with your direct ophthalmoscope as well, they need referral. But you’re … I heard somebody mutter about flash photo bouncing off the nerve. That won’t happen when you look with your direct ophthalmoscope. And the time when it happens on the flash, is actually, this one.
This, when the camera is temporal to fixation. So, the child’s looking over there, the optic nerve is nasal to fixation. So, that’s the one could be just the flash. And when you look with your direct ophthalmoscope everything looks fine.
But this one unlikely to be. We’ve looked at that picture before. You know, this is another worrying one, leukocoria. Loss of the red reflex there. Loss of the red reflex there. All of these, apart from that one, would warrant a referral urgently.
So, there we go, that’s the last slide. So, what do paediatric ophthalmologists do? We’ve talked about that. What to … how to assess a child? Conditions which require referral and the urgency of the them. Conditions to manage in primary care. I whizzed through that a bit, I’m sorry. And hopefully some useful danger scenarios.
Thank you very much. [unclear 00:30:08].


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