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However, higher degrees may result in amblyopia and should be corrected promptly. A healthy eye is able to focus all the light rays from a point source to a single point. In the presence of astigmatism, this focusing process to a single point is disrupted due to variations in the curvature of the cornea or lens at different meridians.

Most of the astigmatisms are the consequences of alterations in corneal curvatures. In other words, the refractive power of some part of the cornea is higher or lower than the rest of the cornea, so the astigmatism results.

If these regions of the cornea with different refractive power capacity are 90 degrees apart, the astigmatism is regular. If these regions are not 90 degrees apart, it is called irregular. Keratoconus is an important reason for irregular astigmatism. Refractive disorders place a significant economic and social burden on society. Spectacles continue to be the safest method of correction, whereas the interventional procedures are very rarely preferred in the pediatric population.

Anisometropia refers to a difference in the refractive status of the 2 eyes. If the difference is 2 diopters or more, either spherical or astigmatic, it is clinically significant.

Anisometropia should be managed with caution, since it is the most important risk factor for amblyopia. Amblyopia Amblyopia is the combination of two Greek words; amblyos — blunt and opia —vision.

The parents commonly 14 Complementary Pediatrics use the lazy eye terminology instead of ambloypia. Due to the suppression of the blurred vision from the diseased eye, the risk of development of unilateral amblyopia is much higher than the risk of bilateral amblyopia.

However, it may also develop bilaterally, if severe visual deprivation occurs in both eyes. A same ocular pathology that develops in a child may be an important etiology for a severe amblyopia, while the same pathology in the elderly decreases the visual acuity, but does not result in an amblyopia. This is very typical for the lens pathologies. Congenital cataracts are one of the important etiologies for amblyopia, while senile cataracts are the most common treatable cause of vision loss among the elderly.

Any pathology that results in abnormal visual experience in one or two eyes before the critical period of visual development may result in amblyopia. The amblyopia is the disease of the visual cortex and it only develops in children younger than years old.

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The critical period is the time of maximum neurological plasticity of the visual cortex cells. The visual acuity and binocular vision improves depending on the visual inputs until the end of the critical period.

There is no consensus on which visual acuity should be adopted for the clinical definition of amblyopia. The most common etiologies are eye deviations and refractive errors.

Anisometropia is a significant difference in the refractive status between the two eyes. The eye with more hypermetropia or more astigmatism is chronically blurred, so the risk of the development of amblyopia is high in that eye.

The pediatrician plays a crucial role in the early diagnosis of possible causes of amblyopia. The major determinants of success in amblyopia treatment are early recognition by the pediatrician, early referral to the pediatric ophthalmologist and prompt treatment. The initial step in the management is the correction of the underlying etiology, if possible.

Surgical treatment of the strabismus, or the congenital cataract, correction of the refractive errors by glasses or contact lenses are the main treatment modalities for the correction of the most common causes of amblyopia.

In some pathologies, such as nystagmus, retinoblastoma, it is not possible to eliminate the underlying cause of blurred vision totally. Therefore, the management of amblyopia due to such untreatable diseases is very difficult. After the correction of the underlying organic pathology, the most difficult aspect of the management starts; the occlusion of the sound eye in most cases or the alternate occlusion if the condition is bilateral. This is possible if the neurological plasticity of the visual cortex remains.

The best outcomes are achieved if the management starts before 5 years of age, but the patching may be tried up to 22 years of age Matta et al. If children cannot tolerate patching, the penalization, which is the impairment of vision in the sound eye by eye drops, can be preferred.

There is no consensus on the duration of patching per day and the total duration of the treatment. However, it is known that, it is long treatment frequently lasting more than years.

Well cooperation with the parents is crucial to obtain successful outcomes. It is commonly accepted that amblyopia cannot be treated beyond a certain age. However, some trials to manage amblyopia in adults gave promising results. Perceptual visual learning and levodepo are the possible new treatment modalities for amblyopia in the elderly. These may also be tried in elder children, if conventional treatments fail Astle et al.

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Pediatric eye deviations Under normal physiological conditions, the image of an object falls simultaneously on the fovea of each. This is possible if the eyes are properly aligned. This straight position of the eyes is called orthophoria. Any misalignment of the either eye is called strabismus or eye deviation in other words. There are 2 benefits of treating strabismus. The initial one is functional gain including the improvement of visual acuity and stereopsis.

The second one is the cosmetic improvement. Phoria is detected by the simple cover-uncover test. The test is performed while the patient fixates a distant object. The physician covers one eye for seconds and then the other eye.

If orthophoria is present, no movement is detected. If latent deviation exists movement of eyes towards the opposite of the deviation is observed. For example in a patient with inward latent deviation, the uncovered eye move from inwards to outwards.

Latent deviations may become manifest temporarily, when the child is tired or ill. It can also become permanently manifest during the follow-up. Horizontal deviations are the most commonly observed types of strabismus. Esotropia is the manifest inward deviation of eyes, while esophoria is the latent inward deviation of eyes. Exotropia is the manifest outward deviation of eyes, while exophoria is the latent outward deviation of eyes.

Esotropia is by far the most common form of strabismus. Infantile esotropia constitutes almost half of all cases of esotropia. Infantile esotropia is the inward deviation of eyes, which is diagnosed at 6 months of age.

The angle of deviation is usually large and surgery is usually indicated. Pseudo-strabismus is the illusion of deviation in a child with orthophoria. It is most commonly in the form of pseudo-esotropia. The most common reason for this false appearance of inward deviation is broad nasal bridge with prominent epicanthal folds.

Paralytic strabismus in children may be in form of third, fourth or sixth cranial nerve palsy. Cranial imaging must be ordered in all forms of acquired paralytic strabismus to exclude cranial masses Harley, The angle of deviation in eyes with all types of deviations is measured objectively by using special prisms. The prism cover test is preferred if the child cooperates. In severe amblyopia and in very young children prism reflex test Krimsky test is performed.

The patient fixates a light and the prism is placed in front of the deviating or bad eye to center the corneal reflex. Abnormal eye movements are frequently associated with pediatric eye deviations and they can influence the management of the cases. Accommodative types of esotropias may be completely cured with spectacles. Surgical correction is decided according to the angle of deviation, if the deviation is not corrected by the spectacles during follow-up.

All types of strabismus must be referred to an ophthalmologist, since early treatment by spectacles or surgery is important for normal binocular visual development.

Common eyelid and orbital diseases in children The most important issue in pediatric eyelid disorders is to identify whether the lesions affect the visual development or not. If it occludes the visual axis, the pathology must be treated promptly to prevent the development of amblyopia. Entropion, ectropion, distichiasis, epicanthal folds, and telecanthus increased distance between the medial canthus of each eye are common congenital anomalies of the eyelids. Although they are solely cosmetic problems in most cases, they may result in corneal changes secondary to corneal irritation and exposure due to mal-position of the eyelids.

Congenital ptosis is the most important disease of the eyelids in a child. It is usually unilateral and occurs sporadically in most cases.

The underlying pathology is the dysplasia of the levator palpebralis muscle. Surgical correction during the preschool years must be performed. If the disease is severe, early surgery to prevent amblyopia may be performed. The infections are mostly innocent and respond well to conservative therapies Hughes, The infections occur in two clinical forms; preseptal cellulitis or orbital cellulitis.

Orbital cellulitis is the most common cause of protrusion of the eyeball in children. It is a life-threatening disease of the tissues behind the orbital septum. On the other hand, preseptal cellulits involves tissues anterior to the orbital septum. Preseptal cellulitis usually responds to ampiric antibiotic treatment, whereas orbital cellulitis may be associated with serious complications requiring longer periods of treatment and surgical interventions Kanski, Protrusion of the eyeball, limitations of the eye movements and decreased visual acuity are signs of orbital cellulitis.

Skin trauma, sinusitis, lacrimal sac infections and rarely remote infections may be the source of preseptal or orbital cellulitis. Preseptal cellulitis rarely progresses to orbital cellulitis. Left orbital cellulitis Subperiosteal and orbital abscesses, intracranial complications meningitis, brain abscess and ocular complications such as optic neuropathy and endophthalmitis may complicate orbital cellulitis. Hospitalization and aggressive medical treatment to prevent lifethreatening complications is indicated in orbital cellulitis Sullivan, Any painful periorbital edema or pain associated with eye movements should raise the suspicion of serious orbital cellulitis and referral to an ophthalmologist is indicated.

Conjunctival diseases in children It is still a significant cause of blindness in underdeveloped countries. It can be bacterial, viral and chemical. The most serious form is caused by Neisseria gonorrhoeae. Onset is typically within the first days of life.

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It causes a severe purulent discharge. Treatment includes systemic 18 Complementary Pediatrics ceftriaxone and topical penicillin as well. Infection with herpes is rarer but requires prompt therapy with acyclovir.

Chemical cases are caused by silver nitrate and occur within 24 hours life. Tetracyclin, erythromyicin ointments or povidone-ioidine drops can be used for prophylaxis.

Majority of these infections are self-limited and does not require therapy. This section covers a variety of infectious conjunctival diseases that might be confronted in routine pediatrics practice.

Red eye is one of the most important ophthalmological emergencies. There are several causes such as conjunctivitis, keratitis, uveitis etc. Fortunately, majority of the red eye occurs due to conjunctivitis. The underlying etiology is almost always bacterial in children. However, it can be viral or allergic. During examination there are some key points that will help to differentiate the etiology: Symptoms: Allergic cases will always have prominent itching. Bacterial cases will always have discharge.

Presence and nature of discharge: Bacterial infections will have a purulent, yellow-green discharge. Viral cases will have a serous or mucoid discharge. Allergic cases will have serous discharge with excessive tearing. Laterality: Bacterial cases can be either unilateral or bilateral.

Viral and allergic conjunctivitis occur almost always bilateral. Cul-de-sac: Always pull the lower eyelid away from the globe to examine the cul-de-sac.

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Bacterial conjunctivitis will have tarsal papillae. Viral and allergic conjunctivitis will have tarsal follicles. Systemic associations: Viral conjunctivitis might be associated with upper respiratory infections. Allergic conjunctivitis might be seen with upper respiratory allergic symptoms. First-line therapy for bacterial conjunctivitis is topical flouroquinolone. Viral conjunctivitis is selflimited.

For allergic cases topical antihistaminic drops are effective. Corneal diseases in children The cornea is the anterior transparent, avascular anatomical structure of the human eye. There are many congenital and acquired corneal diseases, which may lead to blindness if left untreated. Corneal dystrophies, congenital anomalies, corneal ectasias, metabolic keratopathies and infectious diseases are the main corneal diseases that may be diagnosed in a child.

Most of the corneal pathologies disturb the transparency of the organ and should be referred to an ophthalmologist immediately. Microcornea, megalocornea, anophthalmos and microphthalmos are rare congenital anomalies that affect cornea.

Microphthalmos is defined as the developmental arrest of all ocular structures, while anophthalmos is the complete failure of the eye development. The treatment of the systemic disease is the mainstay treatment of these metabolic keratopathies. Corneal dystrophies and corneal ectasias are frequently diagnosed during puberty or later. They are structural diseases of the cornea and mostly genetically determined, but the clinical picture rarely occurs in childhood. Keratoconus is the most common corneal ectasia of the human eye.

It is typically diagnosed during puberty with unilateral impairment of vision. Corneal thinning and irregular astigmatism are the main features of the keratoconus. Bacterial keratitis usually occurs in patients with damaged corneal epithelial integrity. However, Neisseria gonorrhoeae, Corynebacterium diphteriae, Listeria and Haemophilus species may lead to keratitis in the presence of intact epithelium.

Bacterial keratitis is characterized by oval shaped corneal infiltrations surrounded by corneal edema, conjunctival hyperemia injection , ocular pain and photophobia. Gonococcal keratoconjunctivitis Pseudomonas aeruginosa keratitis tend be very severe and typically produces stromal necrosis with a shaggy surface and adherent mucopurulent exudates.

It is an infection usually seen in contact lens users with a damaged corneal epithelial surface. The infection may progress rapidly ending with corneal perforation. In the management of keratitis, ampiric broad-spectrum therapy is recommended until the offending microorganism is identified in the culture.

If the type of bacteria is identified from the stained diagnostic smear, then appropriate single drug therapy may be considered. Herpes simplex virus HSV infection is more commonly acquired in adolescence than in childhood. It can be transmitted to neonates as they pass through the birth canal of a mother with genital infection that can lead to serious systemic disorders in the newborns.

Primary ocular HSV infection is a form of HSV infection that typically manifests in children aged between 6 months and 5 years.

It causes unilateral blepharoconjunctivitis that has signs such 20 Complementary Pediatrics as cutaneous or eyelid marginal vesicles, or ulcers on the bulbar conjunctiva that can be rarely accompanied by dendritic epithelial keratitis. Primary ocular HSV infection is a self limited disease that usually resolves spontaneously. Oral antiviral therapy can speed up the resolution. Dendritic ulcers, stromal necrotizing keratitis and disciform keratitis are forms of recurrent ocular infection of HSV.

These may also occur in this age group. Topical and oral antiviral therapy can be used in the management of recurrent HSV keratitis. Adenoviruses are the most common viral pathogens that may cause viral keratitis in a child. Pharyngoconjunctival fever PCF and epidemic keratoconjunctivitis EPC are 2 different clinical pictures that are caused by different serotypes of adenoviruses. Corneal involvement is much more common and severe in EPC. Keratitis may persist for years in some cases.

PCF is the less severe form of the disease.

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Keratitis is usually mild and self limiting. Mild to moderate fever may accompany PCF. The management of adenoviral keratitis is usually conservative. Topical steroids and cyclosporine may be tried to reduce inflammation. Reduction of transmission risk by avoiding contact with infected patients during the initial days of the active disease and by good hygiene is much more important than its management. Ophthalmologists are well experienced about EKC, because unfortunately the eye clinics are usually the most common places to come in contact with the adenovirus and many ophthalmologists are infected once or more with adenoviruses.

Many outbreaks occur due to improperly disinfected diagnostic instruments Kanski, Symptoms include itching, photophobia, and mucoid discharge.

Corneal findings consist of Horner-Trantas dots degenerated eosinophils and epithelial cells in the limbal area, punctate epithelial erosions and shield ulcer an oval noninfectious epithelial ulcer. Corneal findings are generally accompanied by conjunctival ones which are hyperemia, conjunctival edema chemosis and papillary hypertrophy.

Topical antihistamines and mast-cell stabilizers can be used in the management of vernal conjunctivitis. Severe cases may require topical corticosteroid or topical immune-modulating agents such as cyclosporine. Atopic keratoconjunctivitis is a rare bilateral allergic eye disease that is most commonly diagnosed in young men, but also in children. Clinical picture is similar to vernal keratoconjunctivitis, but more severe.

The papillary hypertrophy are less developed compared to vernal keratoconjunctivitis. The history of allergy such as allergic asthma or atopic dermatitis is commonly associated. Keratopathy leading to total corneal neovascularization may occur.

Management is similar to vernalis keratoconjunctivitis, but the disease is less responsive. Corneal diseases usually respond to topical corticosteroids Kanski, Pediatric uveitis The uvea is a pigmented structure that primarily lies between the retina and the sclera and constitutes the vascular portion of the eye.

It comprises the iris, ciliary body and choroid. Uveitis, by strict definition implies an inflammation of the uveal tract. Uveitis is named according to the anatomical location of inflammation in the uvea. Anterior uveitis may be subdivided into: Iritis and iridocyclitis. Iritis is primarily the inflammation of the iris tissue. On the other hand, iridocyclitis involves both the iris and the pars plicata of the ciliary body.

Intermediate uveitis is defined as inflammation predominantly involving the pars plana, the peripheral retina and the vitreous. Posterior uveitis involves the fundus posterior to the vitreous base. Panuveitis implies involvement of the entire uveal tract without a predominant site of inflammation Kanski, Pediatric uveitis may be categorized into 4 types of uveitis based on the anatomical location of the inflammatory process. These are anterior non-granulomatous and granulomatous , intermediate and posterior uveitis.

Etiologic factors associated with these uvetis in children are as follows. Anterior non-granulomatous uveitis: Idiopathic, HLA-B27 associated, juvenile rheumatoid arthritis JRA , ankylosing spondylitis, Reiter's disease, psoriasis, inflammatory bowel disease, nephritis, systemic lupus erythematosus, Herpes Simplex virus HSV , Lyme disease, leukemia, drug-induced.

Anterior granulomatous uveitis: Sarcoidosis, inflammatory bowel disease, syphilis, Herpes simplex virus, tuberculosis, Behcet's disease, multiple sclerosis, fungal disease, Whipple's disease, leprosy. Anterior uveitis is the most common form of uveitis.

Features are typically with sudden onset of unilateral pain, photophobia and redness, which may be associated with lacrimation.

Occasionally patients may notice mild ocular discomfort a few days before the acute attack when clinical signs are absent.

Visual acuity is usually good. The presence of vitreal cells in an active vitritis are the main signs of pars planitis. Posterior uveitis encompasses retinitis, choroiditis and retinal vasculitis.

Some lesions may originate primarily in the retina or choroid but often there is involvement of both Sauberan, Special investigations such as skin tests, serology and radiology are indicated in posterior uveitis, granulomatous inflammation, recurrent uveitis and bilateral uveitis.

Treatment of the majority of uveitis involves predominantly the use of anti-inflammatory and immunosuppressive agents. Antibiotic therapy for infectious diseases may be 22 Complementary Pediatrics necessary. Topical steroids are the mainstay treatment for anterior uveitis, while systemic steroids are indicated in most cases of intermediate and posterior uveitis. Neutral countries in our sample fared distinctly better and, in fact, managed to grow throughout the conflict.

If the economic effect of the war was devastating, the speed of recovery was so impressive as to take by surprise informed observers, trade unions, entrepreneurs and policy-makers alike. In five years at most, Europe recovered the ground lost relative to the highest prewar income levels.

Not only were growth rates exceptionally high Table 1. Source: Data from Maddison Productivity growth is, obviously, the core phenomenon to be investigated in the present context: detailed measures and analyses of its determinants are, therefore, provided in the individual country studies included in this book. In the last column of Table 1. Although aggregation and index number problems make estimates in Table 1.

In other words, during we observe both a pronounced tendency for initially poorer countries to grow faster than richer ones and a decline in the cross-sectional scatter of per-capita output growth.

Postwar growth: an overview 5 Table 1. In most countries, the 'triumph of full employment' was a historically distinct feature of the period. While we leave a discussion of the above-mentioned features of the period to sections 5 and 6, dealing with the causes of growth, a brief quantification of the last three points might be in order here. A useful, if impressionistic, perception of the convergence processes may perhaps be drawn from Tables 1.

We observe both a strong tendency for initially poorer countries to grow faster than richer ones and a decline in the cross-sectional scatter of per-capita output. As a result, in the early s, the dispersion in levels of per-capita income among European countries was much less pronounced than it had been a quarter of a century earlier.

Moreover, the formation of a core of economies characterized by roughly similar standards of living was, by then, well under way. GDP per person in international dollars 1. Switzerland 2. Sweden 4. Denmark 5. Netherlands 6. Belgium 7. France 8. Norway 9. Germany Finland Austria Ireland Italy Spain Kuurne - Wikipedia ; Geschiedenis.

Optic nerve is surrounded by the vascular pia, arachnoid and dura mater. Ophthalmologists are well experienced about EKC, because unfortunately the eye clinics are usually the most common places to come in contact with the adenovirus and many ophthalmologists are infected once or more with adenoviruses. Majority of these infections are self-limited and does not require therapy. Amblyopia is the combination of two Greek words; amblyos — blunt and opia —vision.

It causes unilateral blepharoconjunctivitis that has signs such 20 Complementary Pediatrics as cutaneous or eyelid marginal vesicles, or ulcers on the bulbar conjunctiva that can be rarely accompanied by dendritic epithelial keratitis.

Statistiek Compendium. The retina is not completely vascularized at birth. Esotropia is by far the most common form of strabismus. Vind je statistiek een lastig onderwerp?

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