Pediatric Ophthalmology and Strabismus
Paediatric ophthalmology and strabismus tests development as much as diagnosis: the same deviation has different urgency at 6 months and at 6 years. Expect amblyopia, esotropia, exotropia, leukocoria and retinopathy of prematurity.
Core rules
- Amblyopia: reduced acuity without structural cause, from strabismus, anisometropia or deprivation. Treat by correcting refractive error, patching or atropine penalisation; adherence falls when patching exceeds 2–6 hours a day.
- Accommodative esotropia: onset around 2–3 years, hyperopia of +2.00 to +6.00 D, angle reduced by plus lenses. Prescribe the full cycloplegic refraction and treat amblyopia.
- Infantile esotropia: onset before 6 months, large angle, alternating fixation; surgery after correcting refractive error.
- Intermittent exotropia: divergence on distance fixation, control worsens with fatigue; observation, over-minus lenses or surgery depending on control.
- Leukocoria: retinoblastoma, congenital cataract, persistent fetal vasculature, Coats disease, toxocariasis. Any child with a white pupil needs urgent examination under anaesthesia.
- Retinopathy of prematurity: screen infants under 32 weeks or under 1500 g; treat type 1 disease with laser or anti-VEGF.
- Congenital glaucoma: buphthalmos, corneal haze, tearing and photophobia; examination under anaesthesia and goniotomy or trabeculotomy.
Worked example
A 4-year-old presents with a 25-prism-diopter esotropia at distance and near, and cycloplegic refraction is +4.00 D in both eyes. With the full correction the deviation falls to 6 prism dioptres and stereopsis is present. This is partially accommodative esotropia. You prescribe the full hyperopic correction, treat any residual amblyopia with patching, and observe the small residual angle rather than operating immediately, because the accommodative component is doing most of the work.
Traps
Prescribing an undercorrected cycloplegic refraction, operating on a fully accommodative esotropia, and missing retinoblastoma in a child with a squint and a white reflex.