Dobračina 27 - Beograd
Dobračina 27 - Beograd
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Pediatric Ophthalmology

CONGENITAL CATARACT

Congenital cataract is a burden for visual development and causes amblyopia. If the lens is completely opacified, light cannot enter the eye and there will be no vision.

 

Amblyopia develops very quickly, especially if cataract is only in one eye, and when the urgery is delayed.

Early cataract surgery in babies, aged a few months, gives the condition for visual development.

Adequate intraocular lens (IOL) which will correct the refractive error, will be implanted in the same eye, and will stay in the eye for the whole life.

 

The adequate IOL will be chosen concerning the age of a child at the time of operation, findings on examination and potential for high pseudophakic myopia development, which means that after cataract surgery it is possible to find myopia development, as the eye starts to be in use.

 

With IOL implanted (pseudophakia), better correction and visual development is achieved, than in the case of surgery without IOL implantation (aphakia) with postoperative correction of high dioptry with glasses (‘’thick’’ glasses).

In rare situations, the eye will stay without lens implant: small non-developed eye (nanophthalmus), anterior segment dysgenesis, inflammation.

 

After the operation, regular follow-ups are suggested, after a week, month, 3 and 6 months, then yearly, in order to perform the pleoptic treatment against amblyopia.

 

As the child is growing, after a few years will be necessary to recorrect the refractive error with glasses, contacts or laser. That is the age of already achieved improving in visual acuity and additional correction will even make it better. Of course, that is not as high refractive error as it might have been, if previously IOL had not been implanted during the cataract surgery.

 

If cataract is not dense and visual axes is clean, the light is able to pass through the lens, as it is a stimulus for visual development. That means that the danger for high amblyopia is less, and it is possible to wait for the operation till the moment when vision worsened.

The human lens in young has the role in accommodation, and that is why there is no need to hurry with operation.

 

In the case of traumatic cataract, the surgery should be done as soon as possible.

 

When planning the operation in cases with low level of amblyopia, multifocal implant should be an option. This implant might be the substitution for lost accommodation, giving acceptable near, intermediate and far vision.

Congenital cataract surgery in early age will give the chance for visual development, but intensive amblyopia treatment after the operation is a must!
Closing the better eye, or alternatively both eyes, will train the weaker eye to take the function and to develop binocular vision.

CONGENITAL GLAUCOMA

CONGENITAL GLAUCOMA is a serious eye disease for the whole life that will end in blindness, without appropriate operation and complete treatment, that will last for the whole life. It could be discovered immediately, on birth, or later. It is not rare that parents themselves, discover the ‘’big eye’’, eye ball is protruded and the cornea is very large and thin, but very soon opacity on cornea could be seen, what makes parents urgently asking for help.

The eye ball layers are very elastic in children, and in the case of high intraocular pressure (IOP) the enlargement of eye ball can compensate high IOP in some way, and it will somehow, for a while, protect the optic nerve.

The only treatment is surgery and drops, afterwards.


Congenital glaucoma very often goes with congenital cataract and some other anomalies of anterior segment of the eye (iridocorneal touch, iridocorneal dysgenesis, coloboma iridis, aniridia,…).

This is the disease for the whole life, despite the surgical procedure, requires constant follow-ups and possible medical or laser treatment, or another operation.

In congenital anomaly as dysgenesis of anterior segment, nanophthalmus (small eye), glaucoma is following risk, that makes the prognosis bad and requires frequent control for the whole life.

For patients with small eye (nanophthalmus) in late ages, when glaucoma risk becomes manifest (because of a shallow anterior chamber), surgery on the lens – phacoemulsification is the way to regulate the high intraocular pressure by making anterior chamber deeper.

STRABISMUS

STRABISMUS (CROSSED EYES) is very easy to recognize in children. It is the deviation in positioning of eye balls. The normal position of the eye balls is as important factor for binocular visual development and stereopsis, as good refractive error correction. 

If it is diagnosed immediately on the birth, or a few months after, then early treatment is of crucial value for better postoperative prognosis in development of visual acuity and binocular vision. Of course, before the strabismus operation, it is necessary to exclude the possible other causes of crossed eyes (neurological reasons, tumor, cataracts, etc.). 
After the operation, if there is a refractive error present, it should be corrected with glasses or with excimer laser, and pleoptic treatment is a must.

Strabismus could be classified in various subgroups, depending on the axes of eye ball position (horizontal, vertical, oblique misalignment). As congenital, it is often presented in paralythic, restrictive or special syndroms (Duan, Mebius, etc.).

Accommodative strabismus is a kind of eye misalignment that could be corrected with full refractive error correction, not with strabismus surgery. That is because of very strong accommodation, which makes the eyes crossed. The aim of refractive correction is to ‘’relax accommodation’’. That could be achieved with glasses or laser surgery, which is the better way for complete removal of refractive error.

PEDIATRIC REFRACTIVE SURGERY

UNDERSTANDING NEEDS

Refractive surgery in pediatric patients is in practice for many years. It is a right choice in special situations, when there is impending threat of high amblyopia in period of life crucial for visual development, when refractive error can not be corrected with conventional method. Often in ophthalmic practice one of the eyes is deliberately undercorrected to assimilate with „better eye“ , but this does not remove ambliogenic factors. It is impossible to manage cooperation with a small child to accept contact lens, besides the fact that lens itself can cause corneal problems. These challenges are overcome with refractive surgery. Years of experience showed effectiveness of refractive procedures in children, applied in early age, in the following indiacations for reducing amblyopia:
High myopia, hyperopia and astigmatism on both or only one eye. Large difference between both eyes is called anisometropia. In all of these situations is impossible to achieve good refractive correction on standard way, either because of non-compliant children, contact lens intolerance or limited abilities for glasses correction, in the most demanding period for visual development in early childhood.
Children with special needs and high myopia combined with other ocular (albinism, prematurely born, etc..) or medical problems (autism, Down Sy, cerebral palsy and other neuromuscular diseases, etc..), when the standard approach is ineffective or impossible to see through. In these situations, without laser correction these children remain “functionaly blind”, in fact with very limited visual function, what makes them non-cooperabile to perform important physical therapy.
Accommodative strabismus, has very high ambliogenic potential. This means that the eyes are not in regular position, due to strong accommodation, what makes them cross-sectioned. The aim is to give good refractive correction and ’’relax’’ accommodation. The laser is the best way to achieve that.
The aim of refractive procedure in children is not removal of spectacle and contact lens dependency, like in adults with already formed visual function. This is a chance in young age, to reduce anisometropy and achieve balance on both eyes and isometropy (balanced dioptry), to completely correct high refractive error, better than with standard treatment. This creates conditions for better visual development, visual acuity and binocular-stereo sight. This certainly improves compliance with a child which will now accept mandatory pleoptic treatments.

WHY IS THIS IMPORTANT?

At the age crucial for development of visual function (up to eight), full correction of refractive error is imperative. Some children achieve it with glasses, some with contact lenses (more seldom because of age or intollerance), and some of them will remain without adequate correction which will often turn into amblyopia and strabismus.

Great difference in dioptric value between the eyes is potentially amblyogenic defect, actually leading into amblyopia. It means when continuous and adequate correction is not achieved, the eye with high diopter will be „neglected” in comparison with „better ” eye, that fixates and will become dominant. Regarding the difficulties in correction of high diopters with glasses, the intollerance to contacts, or absence of collaboration, the only therapeutical approach that offers better and sharper image and improves the quality of life of these children is refractive surgery. Refractive surgery in pediatric age (especially under the age of 8), offers excellent possibility of establishing isometropic state (balanced diopters) on both eyes, in cases of anisometropy or bilateral high refractive errors leading into amblyopia.

It achieves better quality of image, binocular vision and stereopsis, because the ’’difference’’ in pictures from both eyes is less than gained with glasses correction. The brain starts to accept both pictures as one, comparing to two different images as in glasses correction. Nowadays, refractive surgery is performed as a therapeutical procedure.

In the indicated situations, using glasses is a waste of time, but the child is reffered to laser correction. Immediately after the laser procedure, the pleoptic treatment starts. This is the age of advanced laser technology with safety, predictability and precision of the procedures, that give good and sustainable outcomes.

These laser procedures are performed only in highly-specialized pediatric ophthalmic clinics in the world. Among them is Special Hospital SVETI VID, widely acclaimed and highly-honored for experience and surgical level, many times awarded in these fields. Professor Rudolf Autrata, who established here in SVETI VID pediatric ophthalmology, is one of the world’s pioneers in laser refractive surgery in children with many publications in Journals of pediatric ophthalmology.

EXCIMER LASER IN CHILDREN

Refractive pediatric surgery in SVETI VID reffers to strict medical indications: high anisometropy or high bilateral myopia, hyperopia and astigmatism, with high amblyogenic potential, when conventional treatment with glasses or contact lenses failed.
We use, for safety reasons, superficial laser ablation methods (T-PRK SmartSurfACE )
Refractive range is approximately from -13 up to +6 D, regarding the age, corneal characteristics and complete estimation. We do not recommend LASIK because of risk and potential complications, even not for adults. Laser procedures are performed on Schwind Amaris Excimer Laser. For children is recommended to do this procedure in general anesthesia (inhalation) and analgo-sedation. In compliant children, topical anesthesia is used. Surgical environment is well-equipped, with highly-educated and experienced staff.
Refractive procedures in children are done by Prof. Dr Rudolf Autrata.
He is one of the leaders in the world of ophthalmology, and one of the most cited person devoted to refractive procedures in children from early 90-ties of XX century. He published numerous articles in high-indexed journals and was honored for great contribution to development of pediatric ophthalmology. He is a chief of pediatric eye hospital in Brno, Masaryk University. He was many times awarded on international congresses for his work. In Special Hospital SVETI VID, he works as a chief of pediatric department.

HIGH MYOPIA

Razvoj visoke miopije (kratkovidosti) uglavnom nastaje zbog nekontrolisanog rasta očne jabučice, po aksijalnoj dužini. Normalno, kod mladih, oblik i krivina očnog sočiva kompenzuje ovaj porast očne jabučice. Taj proces se zove emetropizacija. Ponekad, to nije dovoljno i porast očne jabučice prevazilazi opseg emetropizacije, što rezultira određenom visinom kratkovidosti. Tkivo zida očne jabučice (ovojnice oka) se istanjuje, i izgled zadnjeg segmenta, mrežnjače, dobija poseban „miopni” izgled, istanjen i sklon oštećenjima, sa rizikom od nastanka ablacije mrežnjače.

Kao hirurska procedura, kojom bi se zaustavio progresivni rast aksijalne dužine oka i smanjio dalji razvoj kratkovidosti, sačuvalo tkivo ovojnica oka od daljeg istanjenja, ojačala struktura i time smanjio rizik nastanka ablacije, preporučuje se SKLEROPLASTIKA.

Procedura je u primeni godinama. Radi se u opštoj anesteziji, sada sa specijalnim biokompatibilnim implantima, koji se široko primenjuju i u drugim granama medicine (kardiohirurgija, abdominalna hirurgija, i sl). Nema potrebe za ostajanjem u bolnici, dete se otpušta kući istog dana, nekoliko sati nakon hirurgije.

Kontrola je za 3-4 nedelje nakon operacije. Potom sledi dalje praćenje, kontrole.

Razlozi nastanka visoke kratkovidosti su različiti: genetika, nakon operacije katarakte kod dece, zbog gubitka normalnog kompenzatornog mehanizma emetropizacije očnog sočiva, što je poznato i uzima se u obzir prilikom određivanja jačine intraokularnog sočiva koje će se ugraditi detetu pri operaciji katarakte, imajući u vidu starost deteta (nekoliko meseci, do 6 meseci, do godine dana, do 2 godine, i starije,…). Visoka kratkovidost se takođe očekuje u nekim sindromima, kao sto je Sy Down, ili kod prevremeno rođene dece, gde je došlo do regresije stadijuma retinopatije (ROP regresija).

CONGENITAL ANOMALIES ON EYE LIDS

PTOZA (SPUŠTEN KAPAK) u dečjem dobu operiše se ukoliko zatvara centralnu vidnu osovinu, i time stvara uslove za razvoj slabovidosti, ako postoji pre 4. godine života. Estetski momenat u dečjem uzrastu nije definitivan i rana operacija ima značaja sa aspekta otklanjanja smetnje za razvoj funkcije vida.

CHANGES ON CORNEA

UROĐENE I STEČENE PROMENE NA ROŽNJAČI

Danas se veliki broj površnih promena na rožnjači – zamućenja, ožiljci, ponavljajuće erozije sa otežanim zarastanjima, kako kod dece, tako i kod odraslih uspešno rešavaju laserskim tretmanom – PTK (fototerapeutska keratektomija).

Ova terapijska primena egzajmer lasera otklanja površni – loš epitel i olakšava njegovo zarastanje, ostavljajući finu, glatku površinu rožnjače. Time se smanjuju subjektivne smetnje (bol, iritacija, pojačano suzenje, fotofobija), a u kombinaciji sa PRK metodom (fotorefraktivna keratektomija) može istovremeno rešiti i dioptrijski problem ovakve rožnjače.

SURGERY ON LACRIMAL DUCTS

ZATVOREN NAZOLAKRIMALNI KANAL (suzni). Otkiriva se pojavom pojačanog suzenja oka i čestih infekcija (krmeljanja). Rešava se hirurškim putem sa implantacijom specijalnog drenažnog implanta, koji će omogućiti uspostavljanje normalne komunikacije.

Ovaj implant se lepo podnosi kod dece i nakon postignutog „ozdravljenja”, odnosno uspostavljanja komunikacije, ponovo se ukloni.

AMBLYOPIA IN CHILDREN

Amblyopia, poreklom grčka reč. Označava slab vid, odnosno smanjenu oštrinu vida, bez mogućnosti izoštravanja naočarima ili sočivima, a bez vidljivih morfoloških promena. To je funkcionalna slabovidost. Uslovi za funkcionalnu slabovidost postoje od ranog detinjstva, i ako se ne otklone, ostaje trajno.

Slabovidost se mora tretirati od najranijeg detinjstva, a da bi se pravilno tretirala, mora se na vreme otkriti. Od velikog je značaja za vidnu sposobnost, jer nema više mogućnosti tretmana, nakon uzrasta od 6, eventualno 8 godina, zavisno od uzroka. Otuda savremena oftalmologija insistira na strogim kontrolama vidne funkcije dece i ranom rešavanju slabovidosti.

NAJČEŠĆI RAZLOZI ZA NASTANAK AMBLIOPIJE SU:

Strabizam (može biti i posledica slabovidosti, i/ili njen razlog)

Anizometropija (razlika u dioptriji na oba oka) od ranog detinjstva netretirana

Refrakcijska greška (nekorigovana dioptrija) u ranom detinjstvu

Urođena (kongenitalna) katarakta, neoperisana u ranom detinjstvu

Okluzivni tretman

 

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