2nd Global Pediatric Ophthalmology Congress June 05-06, 2017 Milan, Italy

Pedro Mattar is a Consultant at the Pediatric Ophthalmology and Strabismus Division at King Khaled Eye Specialist Hospital in Saudi Arabia. He has studied Pediatric Ophthalmology at University of Colorado, Denver, USA, Ophthalmology from AVAO Venezuela, and Medicine from Universidad Central de Venezuela. He is a member of American Association of Pediatric Ophthalmology and Strabismus, American Society of Cataract and Refractive Surgery, Venezuelan Society Ophthalmology, Pan American Association of Ophthalmology, Latin-American Pediatric Ophthalmology Society and Pan American Society of Retinopathy of Prematurity.

Ocular motor nerve palsies includes third, fourth and sixth nerve palsies. Congenital or acquire, can affect the adult and pediatric population; moderately or severely disturbs the position and movements of the eyes. Compensatory head posture, amblyopia and diplopia are among the clinical manifestation. High percentage is associated with systemic and neurological disease. After an intensive workup and a concise diagnosis a pediatric and strabismus specialist has the challenge to offer surgical treatment for alignment and diplopia free field in these patients. We present different surgical approaches in the management of ocular motor nerve palsies.

Serap Azizoglu has completed her PhD from La Trobe University and currently works at Deakin University, School of Medicine, Deakin Optometry as Associate Lecturer in Optometric Clinical Skills.

Access to general health and eye care is related to an individual’s socioeconomic status (SES). We aimed to examine the prevalence of oculo-visual disorders in children in Istanbul Turkey, drawn from schools at SES extremes but geographically nearby. Three school-based vision screenings (presenting distance visual acuity, cover test, eye assessment history, color vision, gross stereopsis and non-cycloplegic autorefraction) were conducted on 81% of a potential 1014 primary-school children aged 4-10 years from a government (low SES) and two nearby private (high SES) schools in central Istanbul. Of the 823 children, mean age was 6.7±2.2 years; approximately 10% of all children were referred for a full eye examination (8.2% and 16.3% of private/government schools, respectively). Nearly 65% and 22% in the government/private schools respectively had never been previously examined. Of all children, 94.5% and 86.6% were able to read/identify with each eye the 6/9.5 or the 6/6 line of letters/shapes respectively, 7.9% presented wearing spectacles, 3.8% had impaired color vision, 1.5% had grossly impaired stereo-vision, 1.5% exhibited strabismus, 1.8% were suspected to have amblyopia and 0.5% reduced acuity of likely organic origin. Of the 804 without the latter three conditions, 6.0% were myopic ≤-0.50 DS, 0.6% hyperopic ≥2.00 DS, 7.7% astigmatic ≥1.00 DC and 6.2% anisometropic ≥1.00 DS. The results highlight the different pattern of visual problems associated with lifestyle differences in two populations raised in the same urban locale but drawn from different socioeconomic background and the need for general vision screenings prior to school entry .

Mikhail G Kataev is involved in Oculoplastic Surgery since 1978 after graduating from the 2nd Moscow Medical Institute. The beginning of ophthalmic surgery practice was set in Moscow Helmholtz Research Institute of Ophthalmology. In 2015, he became the Head of the Oculoplastic department at the Fyodorov Eye Microsurgery Complex, Russia. The range of surgical interest includes congenital, traumatic, senile, postmorbid pathology and aesthetic surgery as well. He has also supervised PhD theses related to ultrasonic surgery, carbon implants, surgical expanders, oriental eyelids and primary reconstruction in severe eyelids trauma. He is a member of the European Society of Plastic and Reconstructive Surgery since 1994.

Background: Normal morphology and function of ocular adnexa and orbit are critical in maintaining perfect vision. Early age is a most vulnerable period for developing vision function in children. Impairment of vision due to external ocular problems can be caused by epicorneal opacity or by the lack of seeing because of irritation, blepharospasm, epiphora, ptosis or strabismus.

Materials & Method: The whole cohort of more than 7000 pediatric oculoplastic patients in our data base contains about 4000 individuals susceptible to vision impairs. Oculoplastic surgery was indicated in cryptophthalmos, congenital symblepharon, and epicorneal opacity after burn, SJS, toxic epidermal necrolysis (TEN) causes direct blurring of the vision field. Potential risk of low vision (amblyopia) was an indication for surgery in strabismus, ptosis, and secondary blepharospasm, caused by conjunctival metaplasia, trichiasis, distichiasis, and entropion. The third indication was lagophthalmos due to eyelids skin deficit, ectropion or coloboma. All possible types of surgery were used to solve adnexal problems. Percent distribution in this specific group showed as follows: ptosis surgery 57%, strabismus surgery 17%, reconstruction of eyelids and fornices 21%, trichiasis 3% and orbital surgery 3%.

Results: The effect of treatment was evaluated by eyelids shape, proper mucous lining of the fornices, sufficient opening and closure of the eye fissure. In 98% of patients, anticipated result was achieved. Multistep surgery was often needed as a normal way of treatment. No serious complications were observed.

Conclusion: The effect of oculoplastic procedures corresponds differently with regaining of vision function. The correlation depends on the type of pathology. Ptosis and common strabismus repair leads to good outcome. Elimination of trichiasis and dysplasia of the conjunctiva facilitates vision and improvement in function. Meanwhile, restoration of the fornices in TEN patients suffering from dry type of lesion may stay poor. Nevertheless high rate oculoplastic surgery is a powerful tool for restoration of ocular adnexa and providing proper background enabling function repair.

Ayad Shafiq began his training as a Paediatrician and changed specialisations to train as an Ophthalmologist with a special interest in Children s eye conditions, and inherited eye problems. Special interests include; Childrens eye problems from birth, Adult cataract surgery (approximately 450 operations per year for cataract) and Adult squint or strabismus.

Statement of the Problem: Systemic absorption of bevacizumab is a major concern in premature babies whose developing organs and brain may be adversely affected by suppression of vascular growth factors.

Rationale: We assessed the contralateral effect on the untreated eye by documenting serial images of the retinal vessels. Could even a micro-dose of bevacizumab have a demonstrable effect on the untreated eye by systemic vascular absorption? Most babies with APROP have simultaneous bilateral treatment. The asymmetry in this case allowed a short period of careful observation which could provide important qualitative evidence of systemic drug effect.

Type of Study: This was an observational study of a single case.

Methodology: Both eyes were photographed prior injection, at day 5 and at day 12. Images were compared to assess dilatation and tortuosity in both treated and untreated eyes.

Results: Both eyes responded to injection of one eye. A smaller but lesser reduction was noted in the untreated eye in vascular tortuosity and dilatation of posterior pole vessels.

Conclusion: Even a micro-dose of 0.16 mg bevacizumab injected in one eye, has a qualitative effect on retinopathy of prematurity in the untreated eye. Systemically absorbed bevacizumab appears to be absorbed adequately to have an end organ effect. The 'standard' dose currently used in premature babies is 0.625 mg, four times greater dose than that used in this baby. We treat APROP in all cases with a micro-dose of bevacizumab. This is effective in a case series of bilateral primary treatment. Systemic absorption has been pharmacologically proven for a larger standard dose of bevacizumab. This study adds evidence to the suggestion that even a micro-dose has systemic end organ effects. In view of the unknown potential systemic effects, research should be directed at identifying the smallest dose which is effective at preventing blindness in APROP.

Elias F Jarade, MD. is the director of the Corneal, External Disease, and Refractive Surgery Services at Beirut Eye Specialist Hospital. Dr. Elias is a graduate of Harvard Medical School with 2 certificates of fellowship in cornea and refractive surgery from the Eye Center and Eye Foundation for Research, and The Massachusetts Eye and Ear Infirmary, Harvard Medical School. Dr. Elias is heavily involved in the practice and research of cornea, cataract, refractive surgery for the past 15 years with main interest in keratoconus. Has to his record more than 50 peer reviewed scientific papers and chapters. Also, presenter and invited faculty in the field of cornea and refractive surgery at international meetings. Board member for the “Journal of Refractive Surgery” “International Journal of Ophthalmology”, “International Advisory Board for the Saudi Journal of Ophthalmology”, Founder-general secretary of the Emirates Cornea and Refractive Surgery (ECRS) club, Guest editor for the “Journal of Ophthalmology”.

Purpose: To report the incidence, clinical presentation, risk factors, and treatment outcome of pediatric keratoconus in a tertiary referral eye hospital in Beirut, Lebanon.

Methods: In this retrospective study, the authors evaluated all patients with keratoconus 14 years or younger newly diagnosed at the Beirut Eye Specialist Hospital, Beirut, Lebanon, between January 2010 and December 2014. The incidence of pediatric keratoconus among all pediatric patients and among patients with keratoconus of all ages was assessed. Patients with pediatric keratoconus were evaluated for keratoconus stage, initial presentation, uncorrected distance visual acuity, corrected distance visual acuity (CDVA), corneal topography, and pachymetry. Patients were classified according to different treatment regimen groups and different follow-up visits were evaluated. 

Results: During 5 years, 16,808 patients were examined, of whom 2,972 were 14 years or younger. A total of 541 patients were diagnosed as having keratoconus; of those, 16 were 14 years or younger at the time of diagnosis. Hence, the incidence of keratoconus was 0.53% among pediatric patients and 3.78% among adult patients (>14 years). Initial presentation was during routine checkup (1 of 16) for allergic conjunctivitis (3 of 16), reduced vision (10 of 16), and corneal hydrops (mimicking keratitis) (2 of 16). Except for 2 patients lost to follow-up, all eyes received corneal cross-linking treatment and 16 eyes received additional intracorneal ring segment implantation.

Conclusions: The incidence of pediatric keratoconus indicates that increased awareness for keratoconus among children is needed, mainly in cases of family history of keratoconus, ocular allergy/pruritus, poor CDVA, corneal hydrops, and/or high astigmatism.

Lelio Sabetti is an Ophthalmologist who is in charge of the Pediatric Ophthalmology and Strabismus Unit at the Department of Biotechnological and Applied Clinical Sciences of the University of L’Aquila, Italy. Most of his efforts have concentrated on strabismus in children and adults, and treatment of amblyopia. He is also a Fellow of the Italian Strabismus Association (AIA) and of the European Strabismological Association (ESA).

Aim: To investigate the effects of choline combined with Bangerter filter in the treatment of amblyopia and to evaluate increase in visual acuity. The evaluation was conducted in comparison to patients undergoing treatment with Bangerter filters alone.

Methods: A sample of 80 amblyopic subjects with initial average visual acuity of 0.63 with follow-up at 12 months was studied. All subjects were assigned to use a Bangerter filter placed on the corrective spectacle lens all waking hours and alternating the eye (1 day over the left eye, 1 day over the right eye). Choline was administered orally to 39 patients once daily, five days per week for the entire study period. Patients underwent ophthalmic examination of the anterior and posterior segment of the eye to assess the acuity vision in LogMar and refraction in cyclopegia, orthoptic examination with ocular motility study, cover/ uncover test with prism and fusion range.

Results: All patients demonstrated an increase in visual acuity. The patients with exodeviation associated with the administration of choline showed a 50% improvement of vision at 12 months and a 44.79% improvement was observed in patients with esodeviation. The subjects assigned to the Bangerter group experienced improvement in vision at 12 months, specifically a 28% improvement in patients with exodeviation and a 34% improvement in subjects with esodeviation was observed.

Conclusions: The filter is an effective amblyopia treatment; however these effects are markedly enhanced when coupled with the administration of choline. Findings suggest that the effects are particularly relevant in the more severe amblyopic cases.

Antonella Vecchies has done her Master’s degree in Vision Science from the University of Padua. She is an Optometrist and has done her specialization in contact lenses for the irregular cornea and in pediatric population. She has also worked at the Children's Hospital Burlo Garofolo (Trieste-Italy).

Scleral lenses are large diameter rigid gas permeable lenses that range from 14 mm to over 20 mm in diameter. Scleral lenses completely cover the cornea and extend onto the sclera and are supported by the conjunctival tissue. Pediatric patients with keratoconus, pellucid marginal degeneration, post-penetrating keratoplasty, corneal scarring or ocular surface disorders are most appreciative of the benefits of scleral lenses. In cases of ocular surface disease or persistent epithelial defects, scleral lens wear can facilitate healing and corneal health. The goals of scleral lenses fitting in pediatric age are visual rehabilitation for refractive errors, protection the ocular surface and reducing symptoms in severe ocular surface disease. The benefits of scleral lenses are a great stability and centration on ocular surface without any touch in the cornea. To obtain corneal clearance the recommended overall lens diameter is at least 2 mm larger than the corneal diameter. It is necessary that the sagittal depth of the initial lens selected be greater than the sagittal height of the cornea. The elevation of an individual cornea may be measured using topographical elevation data, anterior segment OCT imaging. The OCT permits to evaluate with a great precision central corneal clearance, limbal clearance and haptic zone.

He is an Orthoptist of the European Reference Network Center for Low Vision. In 2005, he got general certificate of Education State Secondary School Lyceum specializing in scientific and technological studies “G. B. Quadri” of Vicenza from Italy. In 2008, he completed his degree in Orthoptics and Opththalmologic Assistence from School of Medicine, University of Padua, Italy and from 2009 – 2010 Study Course and Master in Optometry from Institute B. Zaccagnini – Bologna, Italy. In 2017 he Study Course and Training Program entitled: “Visual Training in Educational, Dyslexia and Sport Vision” from Scientific Institute Intervision – Milan, Italy.

Learning disabilities are a common problem in the pediatric population and are generally associated to memory dysfunction or mathematical calculations. Efficient reading is accomplished through complex and interrelated processes, one of which is vision. Determining the relationships between vision and learning involves more than evaluating eye health and visual acuity it is a multidisciplinary approach (ophthalmologist, orthoptist/optometrist, posturologist and logopedist) in which all appropriate areas of function are assessed and managed. Current research indicates that some people with reading difficulties, such as difficulties related to dyslexia, have co-existing visual and language processing deficits. Unresolved visual deficits can impair the ability to respond fully to educational instruction. To identify learning related vision problems we need to fully evaluate the three interrelated areas of visual function: 1) Visual pathway integrity including eye health, visual acuity and refractive status; 2) Visual efficiency including accommodation (focusing), binocular vision (eye teaming) and eye movements; and 3) Visual information processing including identification and discrimination, spatial awareness, and integration with other senses. Efficient reading requires accurate eye movements and continuous brain integration of the information obtained from each eye. The full diagnosis and management of many oculomotor anomalies (ocular dominance, fixation, vergence amplitude, saccade and smooth pursuit) helped by automatic computerized tests are necessary to increase learning ability simply by identifying the one missing micro-skill. Visual training is a method attempting to correct or improve presumed ocular disorders, visual processing, and perceptual disorders. Vision therapy can be broadly divided into two categories. In the first category, classic orthoptic techniques are used to correct accommodative (focusing) and convergence dysfunctions as well as heterophorias (latent misaligned eyes) and refractive errors (need for glasses) that might be responsible for asthenopic symptoms (eye fatigue and discomfort often aggravated by close work). In the second category, often referred to as behavioral vision therapy, eye movement and hand-eye coordination training techniques are used to improve visual processing skills, learning efficiency, and visual-motor integration. Behavioral vision therapy is based on the premise that differences in children’s visual perceptual motor abilities exist and that these perceptual motor abilities influence cognitive and adaptive skills such as reading, writing, and motor activities used in activities of daily living. Behavioral vision therapy has been recommended to improve visual skills and processing in the belief that this will improve learning disabilities, including speech and language disorders, and nonverbal learning disorders. In conclusion, the management plan of patient with dyslexia and learning disabilities include treatment, guidance and appropriate referral. The expected outcome is an improvement in visual function with the alleviation of associated signs and symptoms. Vision therapy does not directly treat learning disabilities or dyslexia but improve visual efficiency and visual processing, becoming a part of a multidisciplinary approach thereby allowing the person to be more responsive to educational instruction.

Oscar Orjeda is a Medical Ophthalmologist, graduated from the Universidad Mayor de San Marcos and is a Ophthalmology Specialist at the Cayetano Heredia University. He has done his specialization in Pediatric Ophthalmology in Pittsburgh, and in Glaucoma from Argentina. He is a Doctor at the Children's Hospital, Peru. He is the Medical Director and General Manager of the Optima Vision Clinic, Peru. He is also a Principal Investigator of Glaucoma in Children at Parexel International, USA.

In the present study we evaluated the phenotype of the Peruvian inhabitant and compared it in relation to childhood glaucoma. The study was carried out from May 1997 to May 2015. We evaluated 94 patients that were equivalent to 169 eyes where 52% were primary childhood glaucoma and 48% were secondary childhood glaucoma. We compared the cases of Vander Helm (1965), Sampaolesi (1991) and ours both in gender and bilaterality, concluding that in relation to gender, unlike the two authors mentioned that give a ratio of 70% for men and 30% for women, we found a ratio of 55% for men and 45% for women; with respect to present symptoms, 100% of cases present photophobia, with 5% of cases of rhinorrhea. The type of camerular angle that the patient presents according to Sampaolesi, which finds a Type I angle in 70% of cases and Type II in 30%, we found 60% of cases for an angle Type I and 40% of cases for a Type II angle. In the use of anti-metabolites, we found that 5 fluorouracil produces small and highly vascularized blisters unlike the blisters produced by mitomycin which are flat avascular blisters. In relation to valve implants, we found that adult Ahmed implants could be used without any problem in children's eyes. We conclude that ocular pathology is closely related to the ethnology of each region.

Elias F Jarade, MD. is the director of the Corneal, External Disease, and Refractive Surgery Services at Beirut Eye Specialist Hospital. Dr. Elias is a graduate of Harvard Medical School with 2 certificates of fellowship in cornea and refractive surgery from the Eye Center and Eye Foundation for Research, and The Massachusetts Eye and Ear Infirmary, Harvard Medical School. Dr. Elias is heavily involved in the practice and research of cornea, cataract, refractive surgery for the past 15 years with main interest in keratoconus. Has to his record more than 50 peer reviewed scientific papers and chapters. Also, presenter and invited faculty in the field of cornea and refractive surgery at international meetings. Board member for the “Journal of Refractive Surgery” “International Journal of Ophthalmology”, “International Advisory Board for the Saudi Journal of Ophthalmology”, Founder-general secretary of the Emirates Cornea and Refractive Surgery (ECRS) club, Guest editor for the “Journal of Ophthalmology”.

Purpose: To evaluate the safety and visual outcome of intracorneal ring segment (ICRS) implantation followed by crosslinking in pediatric keratoconus patients.

Design: Retrospective interventional case series

Methods: This retrospective study included pediatric patients (≤14 years) with keratoconus and poor corrected distance visual acuity (CDVA) that underwent ICRS implantation and crosslinking (CXL). ICRS were inserted under topical anesthesia after creating a corneal tunnel with an Intralase femtosecond laser. Crosslinking was performed 1 month subsequently. Records were reviewed and data collected preoperatively, at 6 months, at 1 year, 2 years and 4 years postoperatively. Additionally, an 8-year follow-up of a 9-year old patient with ICRS implantation is reported, but is not included into the statistical analysis, since CXL was performed only 7 years later. For this patient ICRS were inserted manually under general anesthesia.

Results: 12 patients (17 eyes; 10 males, 2 females) aged 9-14 years (mean age 12.3 years) received ICRS implantation followed by CXL. Follow-up times ranged from 6 months to 8 years after surgery. At the 6-month follow-up all eyes were evaluated, at the 1-year, the 2-year and the 4-year follow-up 11, 10 and 7 eyes were evaluated, respectively. At the 6-month follow-up, mean CDVA in comparison to preoperative levels improved significantly (p=0.001) from 0.300.19logMAR to 0.120.1logMAR, mean uncorrected distance visual acuity (UDVA) also improved significantly from 0.900.50logMAR to 0.430.31logMAR. A significant decrease in both keratometry readings and spherical equivalence (from -4.0D to -1.56D) was also noted after ICRS insertion. At the 1-year, the 2-year and the 4-year follow-up refractive values remained relatively stable in comparison to the 6-month follow-up, except for a minor but significant improvement in cylinder and, at 4 years, in UDVA. The patient with the 8-year follow-up also showed visual improvement and a stable cornea. All patients tolerated the surgery well and no intraoperative or postoperative complications were reported, except for one ring segment that had to be removed after two years due to vascularization and corneal thinning.

Conclusion: ICRS implantation is a safe and effective procedure for visual rehabilitation in children with keratoconus and poor CDVA.

Introduction: Anisometropic amblyopia is the second most common cause of amblyopia. Anisometropic amblyopia can occur when there is a difference in refractive error between the two eyes.

Purpose: The purpose of this study is to evaluate factors predicting success in the treatment of anisometropic amblyopia.

Materials & Method: The records of 18 children from 3-8 years old, treated successfully for anisometropic amblyopia were reviewed. Optimal refractive correction was provided. Age, initial visual acuity and stereoacuity of anisometropia were analyzed. The time course of improvement in visual acuity and the factors related to amblyopia resolution were assessed. Patching or atropine penalization was considered in additional to optical management if patients show no improvement with glasses alone after 3 months.

Results: 18 children with a mean age of 5.6 years were included. Mean time to amblyopia resolution was 5.8 months (range 2 to 15 months). Worse best corrected initial visual acuity was associated with longer time to resolution. Seven (38.9%) of the hyperopic patients achieved visual acuity of 20/20 in the investigated period. Better initial stereoacuity predicted good final stereoacuity. Treatment outcome was not related to age, but was related to better baseline visual acuity and lesser amounts of anisometropia.

Conclusion: Compliance with treatment has major effect on response to therapy. Treatment of anisometropic amblyopia with glasses alone can be a successful option. Patching or pharmacological penalization can be added if there is no improvement in visual acuity only with glasses after 3 months.