Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

Many years ago, when I was a student at the Cornell Medical College we had as one of our Professors of Pediatrics a well-known pediatrician in New York City. He was a vigorous person, physically and in his manner of speaking. He was somewhat of a maverick and had his own ideas on modes of treatment. For instance, he felt the shining of colored lights on a sick child could be a beneficial therapeutic approach - for, he said, it made the parents feel that something was being done for the child more than the usual treatment of aspirin and tincture of time. Antibiotics had not as yet been discovered.

But there was another side to this opinionated teacher. In the right pocket of his coat he always carried a magnifying glass sheathed in a removable leather cover. He loved to look through this at the eyes of children. "There is nothing more beautiful in the whole world." he said, "the blues and browns and greens and grays in so many arrangements and designs." It reminded me of the thrill I had as a boy collecting colored glass marbles (immys) which to a child's eye were as beautiful as anything in the universe.

So often during my years as a practicing pediatrician I thought of Dr. Louis Schroeder when I examined the eyes of children and spent a little extra time to enjoy their beauty.

It was in the early 1960s that pediatric ophthalmology suddenly was recognized as a real and important entity. Within a period of six years during that decade, four textbooks devoted to the subject were published. Today, in the field of ophthalmology, the period of infancy and childhood is recognized as a very important if not the most important ophthalmological period in the life of a human being.

Some of the former hazards have already been conquered. Many of us still remember vividly the mysterious episode of retrolental fibroplasia, a condition which baffled all of us in the early 50s. Today it is very rarely seen.

Maternal rubella as a cause of congenital cataracts in infants was discovered by Dr. Norman Gregg in Australia in 1941. In spite of this, it was not until the use of rubella vaccine was perfected in the late 1960s that this cause of eye defects has been gradually overcome. It is interesting to note that after the rubella outbreak in the US in 1964 more than 20,000 babies were born with birth defects.

But there are still ophthalmological conditions in infancy and childhood, which if not treated and corrected may lead to blindness or. as in the case of retinoblastomas, even to death.

This, then, throws the burden of skillful observation and preventive care upon the shoulders of the practicing pediatrician.

The most common abnormality seen by all pediatricians is, of course, strabismus. Strabismus, as all of us know, if not treated in its early stages may lead to amblyopia with permanent atrophy of the optic nerve in the unused eye.

On the other hand, one of the most uncommon defects, but an extremely dangerous one, is the development of a retinoblastoma. The average age of diagnosis is 13 months, and 90% of the cases are diagnosed before four years of age. This makes the condition essentially a pediatric problem for early diagnosis. It is most important that the appearance of a white pupillary reflex be detected as soon as possible for, if left undiagnosed too long, the tumor would prove fatal.

The pediatrician should also be responsible for detecting vision defects such as myopia, hyperopia and astigmatism as early…

Many years ago, when I was a student at the Cornell Medical College we had as one of our Professors of Pediatrics a well-known pediatrician in New York City. He was a vigorous person, physically and in his manner of speaking. He was somewhat of a maverick and had his own ideas on modes of treatment. For instance, he felt the shining of colored lights on a sick child could be a beneficial therapeutic approach - for, he said, it made the parents feel that something was being done for the child more than the usual treatment of aspirin and tincture of time. Antibiotics had not as yet been discovered.

But there was another side to this opinionated teacher. In the right pocket of his coat he always carried a magnifying glass sheathed in a removable leather cover. He loved to look through this at the eyes of children. "There is nothing more beautiful in the whole world." he said, "the blues and browns and greens and grays in so many arrangements and designs." It reminded me of the thrill I had as a boy collecting colored glass marbles (immys) which to a child's eye were as beautiful as anything in the universe.

So often during my years as a practicing pediatrician I thought of Dr. Louis Schroeder when I examined the eyes of children and spent a little extra time to enjoy their beauty.

It was in the early 1960s that pediatric ophthalmology suddenly was recognized as a real and important entity. Within a period of six years during that decade, four textbooks devoted to the subject were published. Today, in the field of ophthalmology, the period of infancy and childhood is recognized as a very important if not the most important ophthalmological period in the life of a human being.

Some of the former hazards have already been conquered. Many of us still remember vividly the mysterious episode of retrolental fibroplasia, a condition which baffled all of us in the early 50s. Today it is very rarely seen.

Maternal rubella as a cause of congenital cataracts in infants was discovered by Dr. Norman Gregg in Australia in 1941. In spite of this, it was not until the use of rubella vaccine was perfected in the late 1960s that this cause of eye defects has been gradually overcome. It is interesting to note that after the rubella outbreak in the US in 1964 more than 20,000 babies were born with birth defects.

But there are still ophthalmological conditions in infancy and childhood, which if not treated and corrected may lead to blindness or. as in the case of retinoblastomas, even to death.

This, then, throws the burden of skillful observation and preventive care upon the shoulders of the practicing pediatrician.

The most common abnormality seen by all pediatricians is, of course, strabismus. Strabismus, as all of us know, if not treated in its early stages may lead to amblyopia with permanent atrophy of the optic nerve in the unused eye.

On the other hand, one of the most uncommon defects, but an extremely dangerous one, is the development of a retinoblastoma. The average age of diagnosis is 13 months, and 90% of the cases are diagnosed before four years of age. This makes the condition essentially a pediatric problem for early diagnosis. It is most important that the appearance of a white pupillary reflex be detected as soon as possible for, if left undiagnosed too long, the tumor would prove fatal.

The pediatrician should also be responsible for detecting vision defects such as myopia, hyperopia and astigmatism as early as possible.

I remember when some years ago I was the pediatrician at a well-known nursery school. There was one little boy who stood out from the group for he appeared to be mentally retarded. He did not enter into the activities but would stand up in the class yelling and paying little or no attention to the other children. On examination we found him to be highly myopic - almost shut out from his surrounding world. Once he was given adequate glasses he was immediately a different child. He became greatly interested in everything, and did very well in his studies in school, high school and college.

Generally it is difficult for the practicing pediatrician to detect vision defects on the child under three years of age. But we can ask questions:

* How close does a child get to a book when he or she looks at a picture?

* Is there excessive sensitivity to light?

* Does the child tilt the head to one side when looking at a book or television?

* Is there frequent blinking or rubbing of eyes?

* Does the child often attempt to brush away blurriness in front of one or both eyes?

If glasses are necessary, the pediatrician should always insist that safety lenses be used. There are two types - highly tempered glass, which can be finely cracked but does not splinter or break, and the plastic type, which is unbreakable but scratches rather easily. Contact lenses, which are the safest of all. can be used in children as young as seven years of age. as a rule.

There will be two issues of Pediatric Annals devoted to ophthalmology. Both will be under the Guest Editorship of Dr. J. Denis Catalano, Chief of the Department of Pediatric Ophthalmology at the St. Louis Eye Hospital in St. Louis, Missouri. Dr. Catalano has one great advantage over most physicians in this field for he is a trained pediatrician who decided to specialize in ophthalmology.

The first paper in this present symposium is on "Pediatric Eye Trauma, " and has been contributed by Dr. Thomas Frey, Assistant Clinical Professor of Ophthalmology at George Washington University, Washington, D. C. This is undoubtedly one of the most common eye complaints brought to pediatricians. A child with sand thrown in his or her eyes by a playmate, burns of the eyes with various cleaners, as well as direct blows to the eye from a thrown or hit ball or some other object all of these are commonly encountered.

Dr. Frey, in an excellent review of the whole subject deals first with the evaluation of the child with eye injury, reminding us not to overlook the possibility of child abuse. Then, in turn, he covers the evaluation and treatment of chemical burns, abrasions, foreign bodies, penetrating wounds, blunt trauma, and the eye defects following head trauma. The newer methods of examination such as the CT scan and ultrasonography are noted. as is the information to be obtained from their use. This article should be read by all practicing pediatricians as it contains much information of value in handling these frequent cases of eye injury.

The second paper is by Dr. Catalano and discusses "Leukokoria The Differential Diagnosis of a White Pupil." This is a most important diagnosis since in certain cases the need for diagnosis is urgent, and delay may lead to a fatal result. In my own experience I saw a good many cases of retrolental fibroplasia before we realized the cause. Strangely enough, I diagnosed two cases of congenital glaucoma within six months and never saw another case among my patients. Also, I observed a few cases of cataracts during the German measles epidemic in the 1960s. In more than 50 years of practice none of my patients ever developed a retinoblastoma, which is the most dangerous of the conditions causing leukokoria.

In his article Dr. Catalano lists 26 conditions which may cause a "white pupil." Of these, cataracts are still the most common cause, and retinoblastomas the most dangerous. Both of these are fully discussed. The less common abnormalities are described and the latest treatments noted. Dr. Catalano closes his discussion by recommending ophthalmic examination of newborn infants. Besides the advantage it offers a child with a correctable abnormality, he states this "is of importance also to prevent unwarranted legal entanglements."

The third contribution to this symposium is by Dr. Anwar Shah, the Medical Director of the St. Louis Eye Hospital, St. Louis, Missouri and speaks of "Retinal Diseases in Children." This very informative article discusses numerous conditions affecting the retina in infants and children. There is, as there must be, some repetition of certain conditions causing leukokoria, as discussed in the previous paper. However, there are many retinal abnormalities which a pediatrician should be aware of. Among these are the pigmentary retinopathy found in 70% to 75% of the cases of congenital rubella, the chorioretinal scars of toxoplasmosis in the newborn child, the appearance of the retina affected by toxocara, and the eye findings of phakomatosis which include neurofibromatosis and tuberous sclerosis. The practicing pediatrician will, in all probability, see very few children with retinal diseases, but awareness and knowledge and the ability to examine carefully will make the great difference when rare conditions are present.

The final paper discusses "The Red Eye" and has been written by Dr. Flavius G. Pernoud III, Chief of the Corneal Service at the St. Louis Eye Hospital. Conjunctivitis and trauma of the eye are the most common eye defects seen by the pediatrician among his daily patients. Most of us have the experience to treat the majority of such cases without the need to refer to an ophthalmologist.

Dr. Pernoud, in his article, recognizes the abilities and the needs of the pediatric practitioner. He gives us excellent directions on the examination of a traumatized eye, even suggesting anesthetic eye drops that will stain scratches of the cornea at the same time. An important section of this paper deals with infections of the eye. The author notes at the outset that there is relatively poor immune response of the eye to infection, as well as poor penetration by antibiotics. Both viral and bacterial conjunctivitis are discussed, with a consideration of the organisms usually found and the antibiotics most effective in treatment. Dr. Pernoud draws attention to the fact that organisms which usually do not cause infection elsewhere in the healthy human being may infect the eyes. The urgency of prompt diagnosis and treatment of ophthalmic neonatorum is emphasized.

10.3928/0090-4481-19830701-01

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