Month: February 2018

This week’s blog on Paediatric Cataract has been contributed by Dr Syed M. Asad Ali, Consultant Paediatric Ophthalmologist, Strabismus and Cataract Surgery

What is Cataract?

Cloudiness or opacity in the natural crystalline lens of the eye is called cataract. It is also called ‘white water’ or ‘white pearl’ because of its white appearance. Cataract is very common in people over the age of 50 but – contrary to common belief – it can happen at any age. When a child is born with a Cataract it’s called Congenital Cataract and it affects the vision by preventing all the light reaching the retina at the back of the eye.

Causes of Cataract in the young

Cataract can occur in one eye (unilateral) or both eyes (bilateral). In Western countries, the incidence of Cataract affecting childhood vision is about 3-4 cases in 10,000 live births. The incidence is higher in Asia.

Bilateral Cataracts can be caused by genetic mutations; over 15 gene defects have now been discovered. There are also systemic associations with metabolic disorders such as galactosemia, Wilson disease and diabetes. It has been noticed in people with Trisomy 21 (down syndrome) as well. If a mother acquires an infection such as rubella, herpes, toxoplasmosis or syphilis, this can cause Cataracts at birth.

Unilateral Cataracts are sometimes associated with other eye diseases like small eye, abnormal front of the eye (anterior segment dysgenesis), inflammation, vitreous and retinal diseases.

Any significant trauma (impact with a sharp or blunt object) to the eye can cause Cataract.

Presentation

At a very early age, parents may notice a white area at the centre of the pupil or an abnormal reflection in the pupil. Some children develop squint due to lazy eye caused by Unilateral Cataract. Children are sometimes brought to the ophthalmologist after failing a school eye test. In the case of Unilateral Cataract, even older children may not realise that they are only seeing with one eye, as they are able to manage well.

Treatment

Treatment of Cataracts depends on a number of factors like age at diagnosis, presence of Unilateral or Bilateral, mild or dense cataract and the presence of lazy eye. Dense Bilateral Cataracts at birth are operated on at around 6-8 weeks of age because early surgery can pose a high risk of Glaucoma (blue water) and delaying surgery beyond 3 months of age can limit the vision improvement, due to the development of lazy eyes. Unilateral Dense Cataract at birth has a poor visual prognosis because of the early development of lazy eye.

Mild Cataracts do occur but significant Cataract treatment involves surgery and the removal of the Cataract. In children under 3-4 years of age, Cataract removal also removes the part of front jelly (vitreous) of the eye.

An intraocular lens (IOL) is usually implanted in children above 1 year of age but this can be done earlier in unilateral cases. The power of the IOL selected also allows for the growth of the eye.

After surgery care is very important and may involve regular eye drops for 4-6 weeks after surgery, regular wearing of glasses, contact lenses and patching (covering the one eye with better vision) for the prescribed number of hours. This requires a lot of support and involvement of the parents

In these cases, early diagnosis and prompt treatment can save children from lifelong sight impairment.

It is important for all children to have regular eye check-ups.

What is Glaucoma?

Glaucoma is an increase in pressure inside the eye and is a potentially blinding condition in childhood. Glaucoma has many potential causes.

Our eyes are filled with a fluid-like substance called aqueous humor, which moves around the eye and drains through tiny passages.

In children, the most common cause of Glaucoma is congenital malformation of these passages during the formation of the eye in the mother’s womb.

Testing your child for Glaucoma

Detecting Glaucoma at an early stage can prevent vision loss. All newborns, soon after birth, undergo a baby wellness check, which includes examining the eye for the presence of red reflex and to test the clarity of the cornea.

What is the cornea and red reflex?

The cornea is like the windshield of a car – if the windshield is clear, we are able to see very well. When the eye pressure increases, the cornea becomes cloudy and the red reflex is not seen. Red reflex can also be dull or absent in the presence of cataract or clouding of the lens. Both of these conditions require urgent intervention.

My child’s eyes are big! Should I be worried?

In many cultures, big eyes are a sign of beauty but unfortunately it is also one of the signs of developing Glaucoma. Since the fluid is trapped inside the eye and cannot drain properly, the eye gradually increases in size, just like filling a balloon with air makes it bigger. This increase in the size of the eye can damage the optic nerve at the back of the eye and which is the main nerve involved in vision.

What are the signs of Congenital Glaucoma?

• Large eyes
• Cloudy corneas
• Unequal size of eyes
• Constant watery or teary eyes
• Sensitivity to bright lights (‘Photophobic’)

Can Glaucoma be treated?

Yes, Congenital Glaucoma can be treated either medically or surgically. The success of any treatment depends on how early the treatment starts.

Who treats Glaucoma?

A trained Consultant Ophthalmologist with experience in dealing with Congenital Glaucoma should lead the treatment. It’s a condition that requires lifelong monitoring and treatment.

This week’s blog on Cosmetic Eyelid Surgery has been contributed by Dr. Qasiem Nasser, Specialist in Oculoplastic Surgery, Specialist in Cataract and Refractive Vision Correction Surgery

Cosmetic Eyelid Surgery

The eyelids are delicate structures and integral to protecting and maintaining the health of the eye. As we age, our entire skin thins out due to loss of collagen, tissue stretches and sags and the soft tissue loses volume. This collagen loss is accelerated by exposure to the sun. Often, the eyelids are the first place where this skin softening becomes obvious. Heavy upper eyelids may sag and interfere with vision affecting the patient’s superior field of vision causing the patient to frown the forehead constantly. Loss of elasticity of the skin and sagging may also cause lower eyelid ‘bags’, and cause protrusion of fat. This appearance may give the patient a ‘tired look’ and often seeks many non surgical treatments without a definite resolution.
Upper and lower eyelid surgery can help rejuvenate your appearance and is a common, safe and effective cosmetic surgical procedure when done by an experienced Oculoplastic surgeon. A scarless transconjunctival approach is usually done for selected lower eyelid blepharoplasty cases. In other cases, there may be asymmetrical upper eyelid skin folds for which upper eyelid blepharoplasty surgery could also rectify the asymmetry and achieve a nice aesthetic outcome.
Below are pre and post operation photos of patients to illustrate results:
Pre upper eyelid blepharoplasty
Post upper eyelid blepharoplasty
Pre upper eyelid blepharoplasty
Post upper eyelid blepharoplasty
Pre lower eyelid blepharoplasty
Post lower eyelid blepharoplasty Pre and post lower eyelid blepharoplasty

This week’s blog on Eye Tumours has been contributed by Dr. Mandeep S. Sagoo, Honorary Consultant Ophthalmologist in Ocular Oncology, oncologist in Dubai, Retino Blastoma and Medical Retina, Moorfields Eye Hospital & Barts Health NHS Trust, London.

Eye Tumours

Tumours inside and on the surface of the eye can be benign or malignant, and can also be primary or secondary tumours. Certain lesions in the eye such as naevi or moles are very common, and usually do not require treatment. Other lesions such as melanoma are rare, and require specialised treatment such as surgery or radiotherapy.

Naevus and Melanoma

Naevus is a benign mole on the eye. Some occur on the surface of the eye, in the conjunctiva, but others are found inside the eye, in the iris, ciliary body or choroid. An optometrist or ophthalmologist often finds these moles inside the eye, during an examination. Most moles should be monitored, although some may require treatment if they are causing vision problems. If moles show any sign of change, such as an increase in size or development of suspicious features, then treatment might be necessary. If they have become malignant – this is usually the diagnosis in adults – many malignant melanomas inside the eye can be treated by radiotherapy. Larger malignant melanomas may require radical surgery, such as removal of the eye.

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A Naevus or mole on the surface of the eye. This needs to be monitored.

A melanoma (type of eye cancer) inside the left eye that required treatment with radiotherapy.

Retinoblastoma

This is a childhood cancer of the developing retina and is rare, occurring in approximately 1 in 18,000 live births. It presents with a white-eye pupil reflex or a squint, though there are many other more common causes of these clinical signs. Retinoblastoma can occur in one or both eyes depending on the timing of the genetic mutation that causes tumour formation. Treatment is complex, ranging from chemotherapy to localised treatments such as laser, cryotherapy, localised chemotherapy, radiation, or eye removal.

The white pupil reflex on a photograph from this child’s right eye can be caused by many conditions, but one of the most serious is retinoblastoma, a type of rare eye cancer. Any child with this white reflex should be examined by an ophthalmologist within a week of onset.

A child with multiple retinoblastoma tumours in one eye (arrows). This is a type of eye cancer that requires specialist treatment.

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Vascular tumours of the eye

Haemangiomas and vasoproliferative tumours are benign vascular tumours and most are asymptomatic. Some types of vascular tumour can be part of generalised disorders, such as von Hippel Lindau syndrome or Sturge Weber syndrome, but other haemangiomas are not part of a syndrome. The type of treatment depends on the type of lesion and its features, such as the disturbance of surrounding tissues and its potential to cause future problems with sight or the eye. A range of treatments can be used, from laser to photodynamic therapy and radiotherapy.

Other tumours

Other tumours of the eye are very rare. Examples include osteomas, which can cause visual problems. Lymphoma of the eye (primary intraocular or vitreoretinal lymphoma) can affect the vitreous and retina, and usually requires extensive treatment by an oncologist in Dubai. Local treatments with intravitreal methotrexate injections are sometimes necessary to control ocular disease. Choroidal lymphomas may be primary and are often low grade, and usually respond well to radiotherapy treatment.

Secondary tumours

Cancers from other sites in the body can move into the eye. In many cases, the site of the primary cancer is already known but in about one third of cases, the first presentation of the cancer is in the eye itself and an extensive investigation is then required. Treatment would be directed towards the underlying cancer, as well as the eye condition, using radiotherapy, and in some cases local treatment to the eye may be necessary to preserve vision.

Conclusion

In summary, there are many different types of eye tumour occurring in tissues on, around or inside the eye. Many are only found on examination, as they may not cause any symptoms, highlighting the need for appropriate regular check-ups with a consultant (oncologist in Dubai).