What is cataract?
A cataract is a condition in which the natural lens of the eye becomes cloudy. The blurring can have various shapes and sizes. It can cover a portion of the lens or the entire lens. About 3 in 10,000 children develop cataract, but the percentage varies from country to country. Cataract causes reduced vision because it does not allow light to reach the inner retina, and then the optic nerve. Thus the vision does not develop normally and the child may be left with severely impaired vision in its whole life. Direct intervention at the appropriate time required to prevent permanent visual impairment.
Why some children are born with cataracts or manifest it later?
Children’s cataract often occurs due to abnormal development of the lens during the embryonic period. Malformations of the lens that are accompanied by other physical abnormalities, usually due to genetic or metabolic disorders. Children’s cataract can appear at birth or develop as the child grows. However, most are not associated with other disorders. Finally, cataract can occur after a serious eye injury (traumatic cataract).
All childhood cataracts need to be removed?
No. Some cascades that are small and / or eccentric need not be surgically removed because in these cases the vision develops satisfactorily.
What forms of cataracts appear in children?
The human natural (crystalline) lens comprises a central portion (core) and the distal portion (cortex). The entire lens is in a thin capsule (cortex of the lens). The blurring can occur in any or all portions of the lens.
At what age need the infantile or juvenile cataracts to be removed?
Cataracts that cause severe vision impairment must be removed as soon as a safe surgery is permitted. The vision develops from birth until about the first years of school life. The normal development demands the capture of clear images of the eye, so the visual centers of the brain that receive these images, to mature properly. If one or both eyes, due to cataract, do not send clear images to the brain, then the visual centers will not mature as they should, and the child will stay with seriously impaired vision throughout its life. Accordingly, surgical removal of a visually significant cataract should be done in the years that vision is still growing, and requires (in addition to surgery) sometimes specific strengthening exercises as well.
How is surgery performed, to remove the cataract and restore the visual function of the eye?
The operation is performed under general anesthesia and with special tools and instruments, removes the cloudy lens and special operations are performed at the rear of the lens capsule. But after the operation an organ of the eye is missing (the lens) that should be replaced to make the eye able to focus. There are three ways to achieve this: 1) by positioning a lens within the eye (intraocular lens), a method preferred in older children, 2) by placing a contact lens on the eye surface (preferably a small infant), 3) using spectacles (selected sometimes bilateral cases).
What are the risks of cataract surgery in infants and children?
The execution of the procedure of pediatric cataract from an experienced surgeon is quite safe. However, there is no surgery as not to present any risk of complications. The complications that may arise after a childhood cataract surgery are: infection, retinal detachment, glaucoma, displacement of the intraocular lens, clouding of the optical axis.
What is exactly is the congenital glaucoma?
It is rare but very destructive to the sight, if not diagnosed and not treated early. The semantics of congenital glaucoma include tearing, photophobia, corneal clouding, increasing the size of the cornea, high intraocular pressure, optic disc cupping. The congenital glaucoma may occur at birth or develop during the infancy period. Increasing the size of the cornea is observed congenital glaucoma only during the first two years of life rather than later.
Syndrome of dysgenesis of the anterior molecule, such as Reiger syndrome, Peter abnormality, aniridia, are often accompanied by secondary glaucoma in childhood. Treatment includes drug therapy initially, but the final treatment is surgery. Unfortunately, sometimes despite treatment, the visual effects are not so favourable. Regular monitoring is required throughout lifetime.
What exactly is nystagmus?
It is a situation in which the child shows an abnormal continuous, rhythmic eye movement (usually horizontal, but may be vertical, oblique, circular or complex). Nystagmus can be congenital (infantile) or acquired.
What is infantile nystagmus?
It appears in the first six months of life. It may be due to eye problems or a disturbance of oculomotor mechanisms in the brain. The albinism, malformations of the optic nerve, congenital cataracts and retinal dystrophies are common eye causes of infantile nystagmus.
Children with infantile nystagmus should be checked in detail by a child opthalmologist and pediatrician, in order to identify the cause of nystagmus. Most patients with nystagmus exhibit a neutral gaze zone, where eye movements are reduced or stopped. This way, these children see better. This zone varies from child to child and to “place” their eyes in the buffer zone, using a compensatory head position (torticollis).
Nystagmus does not subside by itself. These patients need to be monitored for the development of their vision. Surgical treatment is only recommended for two reasons in infant nystagmus. To address the compensatory head position and to reduce the speed of movement of the eyes.
How is strabismus surgery exactly done?
During strabismus surgery, the surgeon attempts to weaken or strengthen some extraocular muscles (responsible for the position and movement of the eyes). These muscles behind the eye (starting from the back wall of the orbit), then march forward and “embrace” the eye and eventually overgrow (“stack on”) onto the sclera ( the white part of the eye).
There are different techniques the surgeon selects each time, to achieve the result pursued. The preoperative planning of the surgery is very important, although several times intraoperative adjustments are required.
Surgery is performed fine tools minutes and it lasts from 45 to 60 minutes, depending on the case. In children general anesthesia is required, and in adults there is the option of local anesthesia with anesthetic drops.
Strabismus surgery with adjustable sutures:
This is a technique used only in adults and it is useful, several times. In cases where the preoperative control does not guarantee the accuracy of postoperative outcome (e.g. when preceded by other interventions strabismus, when changing diplopia when there are limiting factors of eye movement, thyroid disease, etc.), then the surgeon chooses either to perform all the surgery under local anesthesia, or to perform surgery under general anesthesia and leave a suture to a temporary post. After hours or on the day of surgery, the patient will be awake and cooperative, regulates (using local anesthetic drops) the final position of the mouse (by tightening or loosening that suture).
What exactly is pore obstruction?
It is a condition in which an infant, even from birth, manifests tearing daily and sometimes eye gum in one or both eyes. Although maybe this image is due to a transient infection (conjunctivitis), that normally subsides after instillation of antibiotic drops, continuous infections are often due to obstruction of the nasolacrimal duct.
What does nasolacrimal duct obstruction mean?
Tears are produced continuously by the lacrimal glands and then through the punctal (puncta) – the canaliculi (canaliculi) and the end of the lacrimal sac and the nasolacrimal duct (tear duct), flow into the nose. 6% of infants are born with narrowing or clogging of the “drainage” system of the tear, frequently at the level of the nasolacrimal duct (tear duct), in one or both eyes. However, in 90% of these infants, the problem will be automatically solved, sometime during the first year of life. This usually occurs due to changes in terms of anatomical relationships of the region due to the development of the baby’s face. Children with nasolacrimal duct obstruction (NDO) constantly appear with a tearful eye (or eyes), and very often produce eye gum (due to contamination of the local microbes of the skin of the eyelids). Each infection treated with a few days of topical antibiotic therapy.
In case of relapse, the child should be assessed by a child optthalmologist, who usually recommends:
- Local massage (massage) the area of the lacrimal sac (the doctor needs to show you how to run the massage correctly)
- A few days of antibiotic treatment (drops) when an infection is present (green-yellow eye gum). If there is only little whitish eye gum, then antibiotic drops are not required.
Catheterization of the tear duct (surgical intervention of a few minutes, under mild general anesthesia with a mask) is recommended:
- to be done if the problem still exists and the child has turned a year old
- to be done earlier in the first year if the infections are continuous and resistant to topical antibiotic therapy and massage
- to be done earlier if serious infection occurs (dacryocystitis)
The whole process takes a few minutes, it is performed in a surgical space (for safety), under mild general anesthesia (with mask). The surgeon inserts afine wire tool through the natural pathways of the “sewage” system of tears without sections, with special handling for the purpose of opening the stenosis or occlusion. Then the child is recovering for some time and goes home. The appropriate surgery time is not the same in each case. But in general it is good to be done during the first 18 months of life, because as the child grows, the relapse rate increases. The surgery has a high success rate in experienced hands (90-95%). Sometimes, however, the resource can be closed again and a second attempt boring may be needed. Only in rare cases, where the pore closes for the third time as well, the opening is accompanied by insertion of special silicone tubes.
Child and glasses
Refractive errors (myopia, hyperopia, astigmatism):
Occur in approximately 20% of children with different weight. The refractive errors not allow focusing the image on the retina, resulting in blurred vision. They are the most common and most easily treatable visual disturbances, with glasses, contact lenses or refractive surgery in adulthood. These refractive errors can occur at any age. The cause of their appearance is not known. Hereditary and environmental factors are implicated, but it seems that the causes are multifactorial. Today we believe that when one of the parents wears glasses from their childhood, then every child of this couple has a 25% chance to present a refractive error once in their life, while the chances increase to 50% when both parents wear glasses. The hyperopia and astigmatism are most frequently at pre-school age, and myopia at school age.
Most infants have mild hyperopia, which gradually decreases and eventually disappears during the first years of life. In a proportion of pre-school children this does not happen. The refractive error remains or increases, so they do not focus well and the development of sight does not follow a normal course. Some of these children have suspicious symptoms, others do not. This depends on the age and the child’s activities. Often, they have strabismus, poor balance, being accustomed to look from close distances, inability to draw in boxes etc. These children should be directly controlled by a child opthalmologist. Because, as mentioned above, some children do not develop semeiotics, the value of preventive controls of sight in early childhood is important.
Not addressing a significant refractive error in the preschool age, may lead to amblyopia (lazy eye), difficult to reverse in school years, it can leave the child with a visual disability which could have been avoided. Myopia is the usual refractive defect of the school age. In many children, there is an inherited predisposition, but for it to be manifested, “favourable” environmental conditions should coexist as well. Some of these are the hours of everyday activities from a close distance, poor lighting and bad posture, poor diet, situations that unfortunately characterize the life of the modern child.
Not accidentally, the increase in the proportion of children who have refractive errors, nor the reduction of the average age of occurrence. Myopic children often complain that they do not see well at the table, they are leaning when they read, half close their eyes when watching TV, etc. And these children should visit an ophthalmologist. Time use of corrective glasses is identified as appropriate and they should follow the instructions of the child ophthalmologist. Sunglasses, absorbent to ultraviolet and blue radiation, necessary are for children. Usually recommended at ages greater than 3 years, especially when they are close to beaches, swimming pools, snow etc.
Prevention for children:
Preventive Ophthalmologic monitoring is addressed to all children under school age and is primarily aimed at early detection of visual problems, in order to address them promptly. Most preventive checks are attempting to locate cases amblyopia, strabismus and significant refractive errors (myopia, hyperopia, astigmatism), while more specialized programmes are developed to detect other rarer diseases.
Every newborn baby knows the world through its senses. Good vision will help to communicate, to move, to learn. The children’s eyesight develops gradually from birth to 7 years old. To develop properly, need the organs of vision (eye and visual system) have been properly structured. Damage to the eyes in infancy should be treated immediately because it may result in permanent disorders, visual and developmental. Checks should start at the hospital, where the child ophthalmologist controls the integrity of the eye structure, excluding any anomalies conformation (eg. Microphthalmia, colobomas, cataract, etc.).
7-8% of preschool children suffer from eye problems (strabismus, amblyopia, myopia, hyperopia, astigmatism, etc.), which can cause permanent impairment of vision. Sometimes these problems are not apparent and the diagnosis is done after a random test. Their early treatment leads to complete cure, while late treatment does not always work. For this reason, children at the age of 3-4 years should be checked with tests appropriate to their age, by experienced ophthalmologists, in childhood vision. A child is not a miniature adult. So the vision differs from that of adults, at least during the years of its development. The ex-ante controls during the preschool years are necessary. At this age, children co-operate in an excellent.
What exactly is Retinopathy of Prematurity (RoP)?
The Retinopathy of Prematurity (RoP) concerns premature babies and is in fact a disorder of the development of the network of retinal vessels (abnormal development of neovascularization and fibrous connective tissue) with potentially devastating consequences for the subsequent visual function of the eye. In most cases it occurs in both eyes. It is characterized as one of the most common causes of childhood blindness worldwide. Nowadays the rapid progress of Neonatology has enabled the survival of very premature babies. However, newborns born prematurely (the duration of the pregnancy is less than 32 weeks, birth weight less than 1500 grams) are at increased risk of Retinopathy of Prematurity.
What might be the main causes of retinopathy of prematurity (RoP)?
The disease is characterized, undoubtedly, as multifactorial. However, the main causes are:
- short gestation (low weight)
- administering oxygen to the patient unit (the hyperventilation of the infant plays a critical role in removing the proper maturation of blood vessels of the eye and in the subsequent development of the disease)
- a history of anemia, cerebral hemorrhage, blood transfusions, and respiratory infections (separately or a combination there of
What can cause the retinopathy of prematurity (RoP)?
Generally, children with retinopathy of prematurity should be closely monitored because they have an increased chance of developing:
- high myopia
- amblyopia (lazy eye)
- high vision loss (up to blindness)
Diagnosis and treatment:
The diagnosis is performed by the technique of the funduscopy. This examination is essential in all premature infants one month after birth. The most effective treatment is the application of photocoagulation laser with the basic objective to regress the development of pathological neovascularization. It is a therapeutic intervention that reduces at least 50% the likelihood of severe vision loss, but attributes only if applied in a suitable time. In an advanced disease stage where tractions appear at the fundus of the eye with a threat of detachment, we intervene surgically. Lately, in the context of clinical research protocols, intraocular drug therapy (with or without concomitant photocoagulation laser) is applied as well.