This document discusses key visual milestones in infant development and common pediatric eye conditions. It provides guidelines for screening infants for conditions like strabismus, nasolacrimal duct obstruction, capillary hemangioma, and neurofibromatosis. Symptoms, signs, differential diagnoses, and management approaches are summarized for each condition.

1. BRIDGING THE GAP BETWEEN
OPHTHALMOLOGISTS &
PEDIATRICIANS
By: Othman Al-Abbadi, M.D
Supervisor: Dema Otoum, M.D

2. VISUAL MILESTONES

3. Birth
Poor eyesight
Blink in response to bright light
or touching eye
Eyes are sometimes
uncoordinated, may look
crossed-eyed
1 month
looks at faces and pictures with
contrasting black and white
images
Can follow an object up to 90
degrees
Watches parent closely
Tears begin to work
2-3 months
Looks at hands
Follows light, faces, and objects

4.  It's normal for a newborn's eyes to wander or
cross occasionally during the first few months
of life.
 By the time baby is 4 to 6 months old, the eyes
usually straighten out.
 If one or both eyes continue to wander in, out, up,
or down - even intermittently -it's probably due
to strabismus.

5. 4-5 months
Beginning to reach hands to
objects
Can stare at block
Will look at self in mirror
Will look at own hand
5-7 months
Has full color vision
Able to see at longer distances
Can pick up a toy that is
dropped
Will turn head to see an object
Likes certain colors
Will touch image of self in mirror
7-11 months
Can stare at small objects
Begins to have depth perception
Plays peek-a-boo
11-12 months
Can watch objects that are
moving fast

6. 12-14 months
Able to place shapes in proper
holes
Becomes interested in pictures
Recognizes familiar objects and
pictures in books, may point to
some objects when asked,
"Where is the ...?"
Points and gestures for objects
and actions
18-24 months
Able to focus on objects near and
far
Can point to body parts (nose,
hair, and eyes) when asked

7. NASOLACRIMAL DUCT
OBSTRUCTION

8.  Tears normally drain through small openings in
the medial part of the upper and lower eyelids
called puncta and enter the nose through the
nasolacrimal duct.
 Tear duct obstruction prevents tears from
draining through this system normally.
 If the tear duct is blocked, there will be backflow
of tears and discharge from the eye

10. • Congenital NLD obstruction results from
incomplete canalization of the NLD.
• Symptoms gets aggravated by nasal infection,
discharge, or any mass occupying pathology
blocking the opening of the NLD.
• Epiphora affects at least 20% of neonates, but
spontaneous resolution occurs in over 95% within
the first year; it has been suggested that early
epiphora with resolution may be regarded as a
normal variant.

11. SIGNS
• Epiphora and matting of eyelashes
– constant or intermittent,
– may be particularly noticeable when the child has an
upper respiratory tract infection.
• Gentle pressure over the lacrimal sac may cause
mucopurulent reflux.
• Acute dacryocystitis is very rare.
• The fluorescein disappearance test is highly
specific in this setting.

13. DIFFERENTIAL DIAGNOSES
 Punctal atresia,
 Congenital glaucoma,
 Chronic conjunctivitis (e.g. chlamydial),
 Keratitis,
 Uveitis.

14. MANAGEMENT
 Refer to ophthalmologist

15. LACRIMAL SAC MASSAGE
 Massage of the lacrimal sac has been suggested
as a means of rupturing a membranous
obstruction by hydrostatic pressure. The index
finger is initially placed over the common
canaliculus to block reflux, and then rolled over
the sac, massaging downwards.

17. PROBING
 Passage of a fine wire via the canalicular system
and nasolacrimal duct to disrupt the obstructive
membrane at the valve of Hasner.
 Usually regarded as the definitive treatment.
 Probing can be repeated if the first procedure is
unsuccessful.
 Can be combined with intubation of silastic tube.

19. CONGENITAL DACRYOCYSTOCOELE
 Collection of amniotic fluid or mucus in the
lacrimal sac caused by an imperforate Hasner
valve.
 It’s a complication of NLD obstruction.

21.  Present perinatally with a bluish cystic swelling at or
below the medial canthus accompanied by epiphora.

22. MANAGEMENT
 It may resolve with conservative treatment
 Risk of dacreocystitis is much higher than NLD
obstruction
 Usually needs probing & silastic tube implant.

23. CAPILLARY HEMANGIOMA

24.  The most common tumour of the orbit and
periorbital area in childhood
 5% of population
 Girls are affected more commonly than boys by
three folds.
 Strawberry birthmark
 Benign tumour

25.  Large or multiple lesions may have associated
visceral involvement, which can lead to serious
complications such as thrombocytopenia
(Kasabach– Merritt syndrome, with up to 50%
mortality) and high-output cardiac failure
 systemic investigation should be considered

26. PHACE SYNDROME
 Posterior fossa malformations
 Hemangiomas
 Arterial lesions
 Cardiac abnormalities
 Eye abnormalities

28. PRESENTATION
 30% present at birth
 The remainder within the first 6 months.
 Start to decrease in size after the first year
 30% resolve by the age of 3
 75% resolve by the age of 7

30. INDICATIONS FOR TREATMENT
 Refractive amblyopia
 Deprivation (occlusion) amblyopia
 Optic nerve compression
 Esxposure keratopathy
 Cosmesis

33. MANAGEMENT LINES
 Beta-blockers
 Steroid injection
 Laser
 Interferon alpha
 Local resection

34. VIGABATRIN

35.  Antiepileptic drug
 Inhibits the breakdown of γ-aminobutyric
acid (GABA)
 structural analog of GABA but doesn’t bind to
GABA receptors

36. OCULAR SIDE EFFECTS
 Bilateral concentric, predominantly nasal visual
field constriction.
 Uncommon except at high cumulative dose.
 The threshold for its prescription is generally
high due to the ocular toxicity. The risk is higher
in males than females

37. PRESENTATION
 Months or years after starting treatment.
 Asymptomatic unless scotoma at or near fixation.
 Bilateral concentric or binasal visual field
defects.
 Optic atrophy, arteriolar narrowing, abnormal
macular reflexes and surface wrinkling can be
seen.

38. PROGNOSIS
 Changes persist even if treatment is stopped, but
sometimes do not progress if continued.

39. SCREENING
 A baseline visual assessment, including visual
fields and OCT, is recommended prior to starting
treatment and thereafter every 3 months.
 In young children and others unable to perform
field or OCT testing, the optimal monitoring
modality is undetermined

40. NEUROFIBROMATOSIS SCREENING
GUIDELINES