Dizzy Child in Opthalmic Practice

Dizzy Child in Ophthalmologic Practice : 

Dizzy Child in Ophthalmologic Practice Ahmed Awadein, MD, FRCS Assistant Professor of Ophthalmology, Cairo University Fellow of Johns Hopkins Hospital, USA Dizzy Child in Ophthalmology

Is the child really dizzy? : 

Is the child really dizzy? Dizzy Child in Ophthalmology

Slide 3: 

The patient's history is critical in the evaluation of the patient with dizziness. Ask the patient to describe their symptoms by using words other than "dizzy." The rationale for using other words is that patients may use dizzy nonspecifically to describe, unsteadiness, generalized weakness, syncope, inability to see, or falling. Dizzy Child in Ophthalmology

Case number 1 : 

Case number 1 Dizzy Child in Ophthalmology

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A 4-year old child Parents started to complain about hitting objects and falling while he is walking Dizzy Child in Ophthalmology

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On examination, there was no nystagmus Fixation was unsteady and unmaintained on both sides Dizzy Child in Ophthalmology

Fundus Examination : 

Fundus Examination Dizzy Child in Ophthalmology

What is the cause of dizziness? : 

What is the cause of dizziness? Dizzy Child in Ophthalmology

Slide 9: 

Poor vision Children with SEVERE BILATERAL VISUAL LOSS may confuse the parents and cause the parents to describe the child complaints as being dizzy rather not able to see especially if the visual loss is recent-onset Dizzy Child in Ophthalmology

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Associated sensorineural deafness or vestibular affection Usher syndrome Kearns-Sayer Alport Stickler Noorie’s disease Dizzy Child in Ophthalmology

Case 2 : 

Case 2 Dizzy Child in Ophthalmology

Slide 12: 

A 6-year old child complaining of dizziness Child has high refractive error (myopia, astigmatism) He was told he needs glasses Dizzy Child in Ophthalmology

Can high refractive error cause dizziness : 

Can high refractive error cause dizziness Dizzy Child in Ophthalmology

Slide 14: 

Uncorrected refractive error by itself rarely cause dizziness Patients would usually complain about unable to see clearly in the class or sitting close to the TV set Dizzy Child in Ophthalmology

Slide 15: 

Glasses themselves can cause true dizziness Wrong prescription: Children may be unable to judge that they are wearing “over-correction” or “totally wrong prescription” especially if the prescription was done without cycloplegic drugs Children must have full cycloplegic before prescribing them glasses Wrong spectacles done by the optician Right/Left Dizzy Child in Ophthalmology

Slide 16: 

High cylindrical correction (for correction of astigmatism) can cause dizziness especially if Recently started wearing them Wears them inconsistently Why? High cylindrical correction cause a lot of ocular aberration that would result in seeing straight surfaces slanting or sloping People would describe that the floor does not look straight when look down Straight edges appear curved Dizzy Child in Ophthalmology

Case number 3 : 

Case number 3 Dizzy Child in Ophthalmology

Slide 18: 

A 4-year old child Presenting with alternating convergent squint Child started to complain about being dizzy at school Dizzy Child in Ophthalmology

Can strabismus cause dizziness? : 

Can strabismus cause dizziness? Dizzy Child in Ophthalmology

Strabismus : 

Strabismus Most forms of strabismus in children do not result in dizziness Children with strabismus develop sensory adaptive mechanisms that prevent them from seeing double Suppression: brain temporarily neglects the image of the squinting eye Amblyopia: diminished visual acuity in the squinting eye Abnormal retinal correspondence: re-organizination of the corresponding retinal points of the two eyes Dizzy Child in Ophthalmology

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Only a recent-onset paralytic squint would result in abrupt onset of double vision and may cause sensory complaints This would be evident by Recent onset Limitation of movement in direction of paralyzed muscle Face turn to direction of paralyzed muscle Dizzy Child in Ophthalmology

Case number 4 : 

Case number 4 Dizzy Child in Ophthalmology

Slide 23: 

A 3-years old child Started going to the nursery Child has bilateral nystagmus Child has occasional complaints about being unable to focus Dizzy Child in Ophthalmology

Congenital nystagmus : 

Congenital nystagmus Dizzy Child in Ophthalmology

Slide 25: 

Children with congenital nystagmus rarely complain of oscillopsia coexistent afferent visual defects might decrease the threshold for oscillopsia. visual information might only be accessed during foveation periods (when there is minimal retinal image motion) and at other times would be "suppressed." Extraretinal signal could be used by the brain to cancel out those effects on vision due to the oscillations Elevated central threshold for the detection of motion might help to suppress oscillopsia. Presence of quick phases may, like voluntary saccades, reduce the perceptual threshold for detecting target movement. Dizzy Child in Ophthalmology

Recent onset nystagmus : 

Recent onset nystagmus Dizzy Child in Ophthalmology

Role of ophthalmic examination : 

Role of ophthalmic examination Visual acuity DIE testing (Dynamic illegible E testing) Oculomotor examination Range Saccadic movement Pursuit movement Gaze testing: limitation, end-gaze nystagmus, rebound nystagmus Doll’s head maneuver: Vestibulocular reflex Here comes your footer  Page 27 Dizzy Child in Ophthalmology

Role of ophthalmic examination : 

Role of ophthalmic examination Nystagmus Are the eye movements that bring the eyes back to the target? Slow eye movements (nystagmus) Saccades (saccadic oscillations) Is the nystagmus jerky or pendular? Is the nystagmus unilateral or bilateral? What is the direction of nystagmus? What is the effect of blocking fixation? Increase nystagmus intensity: vestibular nystagmus Decrease nystagmus intensity: congenital nystagmus Here comes your footer  Page 28 Dizzy Child in Ophthalmology

Role of ophthalmic examination : 

Role of ophthalmic examination Nystagmus What is the effect of different gaze positions? What is the effect of eccentric gaze? What is the effect of posture? provocative factors latency, fatigability, suppression by visual fixation, accompanying sensation of dizziness. Here comes your footer  Page 29 Dizzy Child in Ophthalmology

Ocular Nystagmus : 

Ocular Nystagmus Pendular and horizontal May be jerky in side gaze May be vertical or rotatory Severity depends on severity of visual loss Decrease with convergence Increase on abduction May be associated with abnormal head posture Here comes your footer  Page 30 Dizzy Child in Ophthalmology

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Frenzel goggles Video nystagmography Here comes your footer  Page 31 Dizzy Child in Ophthalmology

Thank You : 

Thank You Here comes your footer  Page 32 Dizzy Child in Ophthalmology