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How to Treat PULL-OUT SECTION www.australiandoctor.com.au COMPLETE HOW TO TREAT QUIZZES ONLINE www.australiandoctor.com.au/cpd to earn CPD or PDP points. INSIDE Retinopathy of prematurity Congenital cataract Congenital glaucoma Congenital nasolacrimal duct obstruction Ophthalmia neonatorum Strabismus Retinoblastoma Birth marks and lid lesions Delayed visual maturation The blind baby Case studies Paediatric eye — the first 12 months THE AUTHOR Introduction ‘PAEDIATRIC eye’ and ‘the first 12 months’ are statements that generate fear in many primary care physicians. This is because the chal- lenges are significant: the patient can’t give a history, nor is there much past history to guide diag- nosis and management; and it can be difficult (sometimes impossible) to measure vision and perform a full assessment without specialist equipment. In addition, the major differen- tial diagnoses for the most common conditions presenting to general practice are serious conditions that can cause long-term vision impair- ment if the diagnosis is missed. However, with an understand- ing of the normal in terms of visual development, awareness of the ‘red flag’ features on history and clinical assessment (see box 1), and with an appreciation that it is always appropriate to refer any concerns to an ophthalmologist, who has the resources and equipment to under- Box 1. ‘Red flags’ on history and examination • Visually unresponsive child • A ‘glint’ or white spot inside the eye • ‘Photoleukocoria’ (a white reflex in the eye on flash photography) • Asymmetry of the red reflex Box 2. Normal visual response milestones • Blink to bright light within a few days of birth DR CAROLINE CATT adult and paediatric ophthalmologist, Sydney Ophthalmic Specialists, the Children’s Hospital at Westmead, Sydney, and Sydney Eye Hospital. • Fix on faces by six weeks • Fix and follow objects of interest by three months • A ‘squint’ or ocular misalignment • Roving eye movements or nystagmus • Good ocular alignment without strabismus by four months • Watering with photophobia • Large eyes • Corneal clouding • Conjunctivitis in a newborn • A birthmark involving the eyelid Visual development – what is normal? We are born with an immature visual system that requires visual input to fully develop. The normal visual response milestones of babies are listed in box 2 (note: there is a wide spectrum) take a full ophthalmic assessment, these presentations need not be frightening. In this How to Treat, we review normal visual development, and the common and the serious ophthalmic conditions that present within the first year of life. The majority of babies are born with hypermetropia (far sighted- ness), which gradually diminishes throughout childhood. Children www.australiandoctor.com.au also have strong accommodative responses, which is why most chil- dren with normal levels of hyper- metropia do not require spectacles — they are able to pull near objects into sharp focus via their accommo- dative reflex. In the first few months of life before a baby has learned to accommodate, its vision is quite blurry compared with what we con- sider to be normal adult visual acu- ity. Visual acuity improves rapidly in the first six months of life in a normally developing child. cont’d next page Copyright © 2017 Australian Doctor All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the publisher. For permission requests, email: [email protected] 28 July 2017 | Australian Doctor | 17