Eyes on Peds: Ophthalmology Advice For Your Pediatrics Rotations

With nearly 50 available fellowship programs specific to pediatric ophthalmology in the United States, it should be no surprise that your pediatrics rotation as a medical student offers ample opportunity to fuel your interest in ophthalmology.

This rotation can be overwhelming as you try to handle all the challenges that come with working with patients that range from just minutes old to teenagers. Putting your passion for ophthalmology on the back burner can be easy. Still, I feel your pediatrics rotation is a perfect opportunity to grow your skills and knowledge in ophthalmology.

Here, I will break down the common ocular pathologies and clinical situations you may encounter during your pediatrics rotation and how you can utilize this rotation to its fullest as you continue your journey towards ophthalmology.

Learn a pediatric ophthalmologic exam

A pediatric rotation can look different depending on what setting your rotation is in. For example, I spent my time in a pediatric emergency department (ED) and a neonatal intensive care unit (NICU). Others will spend their time in outpatient clinics, and others still are in large inpatient pediatric care centers. Regardless of your location, your rotation will likely expose you to some component of a pediatric ophthalmologic exam.

Throughout a child’s life, they should receive frequent vision screening to identify possible pathologies early on. This is vital to a child's development, as undetected ocular issues can cause patients to fall behind in development and even cause permanent blindness. Some studies have shown that 80% of a child’s learning comes through visual means.¹

As a student interested in ophthalmology, take advantage of your pediatrics rotation and the screening guidelines to learn a proper pediatric eye examination.² It shouldn’t surprise you that kids don’t love having their eyes examined, so do your best and remain patient, ask for help from a parent/caregiver, and you’ll improve as time goes on!

As with most examinations, you’ll want to start by taking a thorough history. This will likely come from a parent or guardian rather than the child, but the goal remains to identify patients at higher risk for pathology. Eliciting a proper family history should include asking about any history of strabismus, congenital cataracts, retinoblastoma, or if they are aware of any genetic diseases in the family.

There are about 350 hereditary diseases affecting the eye.³ Parents and/or guardians should also be asked about premature birth, cerebral palsy, or down syndrome, which increases the patient’s risk of ocular pathologies.⁴

How to check for a red reflex

Next up, you must learn how to check a red reflex. A red reflex is currently recommended by the academy of pediatrics to be performed before discharge from the neonatal nursery and in every subsequent visit.⁵ That means you have ample opportunity to learn to check a red reflex during your pediatric rotation.

This procedure is done noninvasively, making it ideal for children, and is a vital part of screening in the pediatric population as it can identify several dangerous issues early on. It is performed by shining a light with a direct ophthalmoscope into the eye; the direct ophthalmoscope will likely be on the wall in nearly all pediatric settings. The light will travel through the clear portion of the eye and reflect towards the examiner after hitting the ocular fundus. Anything that impedes light flow through the eye will result in an abnormal red reflex.⁵

A normal red reflex is symmetric, and both eyes should be equal in color and intensity of the reflex. Some possible abnormal findings to look out for include:⁴

Leukocoria or a white-colored pupil can be caused by congenital cataracts, retinopathy of prematurity, retinoblastoma, and pediatric glaucoma.
Refractive errors like astigmatism can cause asymmetric red reflex.
Abnormal size or shape red reflex can be caused by aniridia (born without iris), coloboma (hole/missing area in the iris), or trauma.

Your next step after identifying an abnormal red reflex depends on the underlying pathology, but an ophthalmology consult is a definite must. I’ll go into further depth on some of the pathologies more likely to come up on exams and during your rotation later in this piece.

Screening for strabismus is recommended before 6 months and between 3-5 years of age.⁶ Strabismus, or misalignment of the eyes, can be classified by how the eye turns and the frequency of turning. As your career progresses, you’ll learn the intricacies of identifying which muscle or muscles are responsible for causing the misalignment.

For your purpose as a student on a pediatrics rotation, just learning to identify strabismus is a great step and can prevent a patient from developing amblyopia. For a brief review, amblyopia occurs from strabismus because the brain receives two different images from the eyes. Eventually, the brain irreversibly ignores images from one eye, significantly reducing or eliminating vision potential in that (misaligned) eye.⁶ You can imagine why it’s so important to identify this early in your pediatric patients.

So how can you identify strabismus as a student on your peds rotation? One super useful test is the corneal light reflex, also known as the Hirshberg test. You can have the child fixate on a target (this is where throwing a fun toy in your backpack pays off!), and then you shine a light from about 3 feet away at the child’s eyes. You should see the light reflection coming off the cornea equally in both eyes, with the reflection being slightly nasal and in the pupil. Any deviation from this suggests strabismus.

Another useful exam technique is the cover, uncover test. Like the corneal light reflex, you’ll have the child fixate on a target and then cover one eye. If the uncovered eye moves to fixate on the target, that eye may be misaligned.

So even though there isn’t a slit lamp to sit down at, be sure to take the opportunity, grab that direct ophthalmoscope, and check a red reflex. Screen your patient for strabismus by checking a corneal reflex or attempting a cover test. Doing this will make you a stronger ophthalmologist in the future and show the pediatric team you’re willing to go the extra mile to screen your patients properly.

Some common pathologies in clinic and shelf exams

Conjunctivitis

Commonly, a young child is brought into pediatric EDs or clinics by parents who state the patient’s eyes have been red and have been bothering them for a few days. Conjunctivitis can come from three main etiologies in this situation; viral, allergic, or bacterial, and it’s your job as a student to tease out the answer.

Three main etiologies of conjunctivitis

Allergic

The presentation is bilateral, usually with serous discharge. Itching is a major clue, and the patient may have classic “allergic shiners” (think: dark undereye circles) from rubbing their eyes. You can ask about a family or personal history of atopy and any possible new allergen exposures. Treatment is antihistamine drops, topical mast cell stabilizers, oral antihistamines, and cold compresses as needed for symptomatic relief. In severe cases, steroid eye drops may be used as well.⁷

Bacterial

This presentation can be unilateral or bilateral, often with thick, non-remitting mucopurulent discharge. Often the eye is stuck shut in the morning due to dry discharge. Neisseria Gonococcal or Chlamydial conjunctivitis in a newborn is a favorite of test writers, so be sure to know how to differentiate the two. Briefly, newborn gonococcal conjunctivitis usually occurs in the first 3-5 days of life. It presents with thick mucopurulent discharge, while chlamydial occurs later, up to 14 days after birth, and has a more watery discharge. In terms of prevention, topical erythromycin ointment at birth is given to prevent gonococcal eye disease.

Treatment includes an intramuscular cephalosporin injection for gonococcal and topical and oral erythromycin for chlamydial infection. Treatment for simpler bacterial infections is usually topical antibiotics like erythromycin, gentamicin, or ciprofloxacin (in older patients—fluoroquinolones are generally contraindicated in very young patients).

Viral

This will be the most common presentation! Adenovirus is the biggest culprit here. Patients can have unilateral or bilateral erythema with scant watery discharge. Often, the presentation will have accompanying viral upper respiratory infection symptoms (e.g., sore throat, cough, swollen preauricular lymph nodes). (Morrow) Treatment is supportive of things like a cold compress.

It is important to note that early cases of cellulitis, both pre-septal and orbital, can masquerade as conjunctivitis, but don’t confuse them! To rule out the more dangerous orbital cellulitis, your attending will want to know if extraocular movement is intact, if there is pain with EOM or if any proptosis is present. This will help them rule out an immediate emergency. If there is any doubt, recommend ophthalmology consult and STAT imaging (CT Orbits).

Retinoblastoma

While you’ll hopefully never diagnose this pathology in the clinic, it is a favorite of test writers and worth knowing. Retinoblastoma is a neuroblastic tumor arising from the retinal tissue, usually occurring in children between 1 to 2 years old. Loss of the tumor suppressor gene RB is responsible, and roughly 60% of cases arise from somatic non-hereditary mutations, with the remaining 40% occurring from hereditary forms. In terms of diagnosis, the most common presentation is leukocoria followed by strabismus, so even more reason to be able to identify those two issues on the exam! If suspected, an ultrasound or CT scan can confirm the diagnosis.

Treatment varies based on the severity at presentation, ranging from laser therapy to complete enucleation.⁸ Outcomes are generally good, with a 93% 5-year survival rate in the US, but metastasis to the brain can occur within a year, so early detection is essential.

Retinopathy of prematurity

Another favorite of test takers, retinopathy of prematurity is important to understand heading into your pediatrics rotation. The retinal vasculature develops around 15-18 weeks and doesn’t complete until between 36-40 weeks gestation.⁹ Problems arise when a child is born prematurely, and the retina is forced to work before fully developing. Other risk factors include low birth weight, birth at 28 weeks or less, and the need for oxygen supplementation.

The underdeveloped and overworked retina becomes ischemic, causing neovascularization which leads to a host of issues, including bleeding, retinal traction, and retinal detachment. This usually takes some time to develop, which is why it’s so important for you to know that you and your attending should check for ROP in premature infants. Treatment is similar to neovascularization from other causes, with laser coagulation and anti-VEGF treatments being the mainstay.¹⁰

Shaken baby syndrome (SBS)

This pathology is not easy to learn about or discuss but is incredibly important to learn about before heading into your pediatric rotation. Nearly 2 million children are abused annually, and 6% of all child abuse cases are identified by ophthalmologists.¹¹ This is because SBS produces telltale multi-retinal hemorrhaging highly suggestive of child abuse.

Children with SBS may also have other signs of child abuse, such as fractures or subdural hemorrhages. Any child with signs of abuse should get a dilated fundus exam to look for retinal hemorrhages.¹² Outcomes are generally poor, and Child Protective Services should be contacted in all situations.

Congenital cataracts

As mentioned before, congenital cataracts cause leukocoria. But what causes congenital cataracts? As a student, you should be very familiar with a few possible culprits. First, see if it's bilateral or unilateral. Bilateral cataracts often don’t have an identifiable underlying cause, with some genetic cause most likely. Other causes of bilateral cataracts and favorites of test takers include Wilson disease, galactosemia, TORCH infections, or trisomy 21.

Unilateral congenital cataracts are usually idiopathic or traumatic.¹³ Keep an eye out for congenital cataracts during your pediatric rotation, and be sure to know the possible causes for your exams.

Conclusions

Pediatrics and ophthalmology truly are intertwined specialties. Throughout the residency and your career as an ophthalmologist, you will undoubtedly be tasked with providing ocular care to children. Your pediatrics rotation is a fantastic opportunity to build foundational knowledge that can help to guide you throughout all the pediatric ophthalmology experiences to follow. Do your best to learn what has been discussed during this piece, apply it during your day-to-day, and most importantly, enjoy your pediatrics rotation.

References

Lee E. BSc, Nirojini Sivachandran, MD PhD, Gloria Isaza, MD, Five steps to: Paediatric vision screening, Paediatrics & Child Health, Volume 24, Issue 1, February 2019, Pages 39–41, https://doi.org/10.1093/pch/pxy044
Gudgel D. “Eye Screening for Children.” American Academy of Ophthalmology, 4 Nov. 2021, https://www.aao.org/eye-health/tips-prevention/children-eye-screening.
“Hereditary Ocular Disease.” Research to Prevent Blindness, https://www.rpbusa.org/rpb/resources-and-advocacy/resources/rpb-vision-resources/hereditary-ocular-disease/#:~:text=There%20are%20more%20than%20350,to%20name%20just%20a%20few.
Nguyen M, Blair K. Red Reflex. [Updated 2021 Sep 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553139/
Pediatrics, American Academy Of. “Red Reflex Examination in Neonates, Infants, and Children.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Dec. 2008, https://publications.aap.org/pediatrics/article/122/6/1401/68818/Red-Reflex-Examination-in-Neonates-Infants-and?autologincheck=redirected.
“Strabismus (Crossed Eyes).” AOA.org, https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/strabismus?sso=y.
Morrow GL. and Richard L. Abbott. “Conjunctivitis.” American Family Physician, 15 Feb. 1998, https://www.aafp.org/pubs/afp/issues/1998/0215/p735.html.
Melamud A. et al. “Retinoblastoma.” American Family Physician, 15 Mar. 2006, https://www.aafp.org/pubs/afp/issues/2006/0315/p1039.html.
Aaron W. and Bunya V. “Embryology of the Eye and Ocular Adnexa.” EyeWiki, 30 Nov. 2021,
Boyd K. “What Is Retinopathy of Prematurity (ROP)?” American Academy of Ophthalmology, 11 May 2022, https://www.aao.org/eye-health/diseases/what-is-retinopathy-prematurity.
Friendly DS. Ocular manifestations of physical child abuse. Trans Am Acad Ophthalmol Otolaryngol 1971; 75: 318-332.
Stelton C. “Shaken Baby Syndrome.” EyeWiki, 28 July 2022, https://eyewiki.org/Shaken_Baby_Syndrome#cite_note-2.
Heidar K. “Cataracts in Children, Congenital and Acquired.” EyeWiki, 30 Nov. 2021, https://eyewiki.org/Cataracts_in_Children,_Congenital_and_Acquired#Etiology.
https://eewiki.aao.org/Embryology_of_the_Eye_and_Ocular_Adnexa#Retina.