Eye cancer in children

Imagine the shock. You are playing with your child and as you look into their eyes, you catch sight of a white reflex. Similarly, it may be that you are looking at the photos in your phone and you start to see that one eye is again showing a white reflex. It is hard to imagine, let alone describe, the feelings that go through a parent’s mind when they realise there is something wrong with their child, particularly something that could affect their eyes and vision. This is especially so when we are talking about retinoblastoma which is one of the causes of a white reflex or white mass seen in an eye. This white mass or reflex is the result of a tumour being present in the back of the eye. Although this is a relatively rare condition, affecting approximately one in fifteen thousand live births, the seriousness of the diagnosis has led to recent publicity about the importance of following up on any potential concerns. A story on Channel Seven News in Sydney highlighted a new app that goes through the photographs in your phone, looking for a white reflex in your child’s eye. Fortunately, it is not always bad news and another more common cause of the white reflex can simply be that the light is bouncing off a healthy optic nerve head in the back of the eye. Of course, it is always appropriate for a child to be reviewed by an eye specialist if there is any cause for concern.

Retinoblastoma is the most common eye cancer in children. It does not discriminate in gender or race, and its incidence is the same in every population around the world. Although this is a unifying factor for all patients with retinoblastoma, the thing that sets populations apart across the world is inequality of access to health care and health professionals. In first world and high income countries such as Australia, we have healthcare in place which has led to an almost 100% survival rate for children with retinoblastoma. In low and middle income countries, the mortality rate is 70%. Given that retinoblastoma is a relatively rare condition and that care is very specialised around the world, considerable effort is put into trying to bridge this gap. Unfortunately, we are a long way from offering every child in the world the same outcome.

Retinoblastoma usually presents very early on in a child’s life, either in infancy or before four years of age. The tumour arises in the retina, which is like the film at the back of the eye, akin to the film in an old-fashioned camera. The film develops the image of light that enters the eye being focused by the cornea and lens, and then sends that via the optic nerve to the brain. There are millions of cells in the retina that are growing and dividing very early on in life and it is this massive cell division that leads to the potential for tumours arising. Retinoblastoma can happen in two distinct ways genetically. The tumour arises when you lose a copy of your tumour suppressor gene. Usually there are two in each cell, one from the father and one from the mother. It may simply be the case of extreme bad luck, that, as a cell was dividing, this gene was lost and then abnormal development or cancer grows as a result. This is a sporadic mutation which then leads to children presenting usually over two years of age. Conversely, you may have failed to have one tumour suppressor gene at conception and therefore every cell in the body is missing this vital defence mechanism. These children therefore present much younger with tumours typically in multiple locations and affecting both eyes.

The treatment for retinoblastoma is very specialised and requires a multi-disciplinary approach between the treating ophthalmologist, the paediatric oncologist and other disciplines that may be needed for treatment. Typically, the treatment involves chemotherapy which can be delivered systemically to the whole body or, at times, it can be delivered directly into the artery or via injection directly into the eye. Focal treatment can also be used, including freezing therapy to the tumour or laser therapy to physically destroy the tumour. Regardless, these children need intensive monitoring and frequent trips to theatre to have examinations under anaesthesia. Sometimes these treatments are not enough and the appropriate thing to do is to remove the eye itself. Although always a heart-wrenching decision to make for everyone involved, the prospect of saving a child’s life of course puts this into very sharp focus. Again, we are fortunate that we have the people and facilities in Australia to offer a positive outcome.

So, if you are worried that there could be something wrong with your child’s eye, and you notice a white reflex either directly or in a photograph, please make sure that you seek expert advice.

Dr Michael Jones
Head of the Department of Ophthalmology
The Children’s Hospital at Westmead
http://sosdoctors.com.au/

How are children’s eyes assessed?

Parents often ask “at what age can I have my child’s eyes checked?”. By using appropriate examination techniques, children’s eyes can be assessed at any age (and they should be checked every two years). In fact, every week I examine many preterm babies! Age is no barrier to having your child’s eyes assessed.

During their eye check, all children will have an assessment of their vision using a test that is appropriate for their age and development. There are specialised techniques for measuring vision in babies (observing their eye contact and visual reflexes), older babies and toddlers (using visual acuity measurement systems, which rely on the human brain’s preference to look at something rather than nothing), through to young children (using age-appropriate picture cards or by playing a matching game). For children aged four to five years and above, simplified versions of the usual adult vision test can be used.

Every child will also undergo an assessment of ocular alignment, which determines if the eyes are used together when looking into the distance or at objects nearby. The function of the muscles that control eye movements is assessed and the ability of the child to use their eyes together to see in 3D is measured. We do this using a series of interesting toys to take the child’s visual attention where it is needed for us to make our assessments. We also often use small prisms and special cards to measure 3D vision.

The anatomy of each eye is assessed and the child’s refraction (far- or near-sightedness, and astigmatism) is quantified. Both of these assessments require the child’s pupils to be dilated with specific eye drops. These drops take 20-30 minutes to have their full effect and will cause pupil enlargement and blurred vision for approximately three hours. The majority of children find the drops unpleasant (they sting for about 10 seconds when first put in) but it is a critical part of the assessment. An assessment without dilating drops is a partial assessment only.

Depending on the child’s signs and symptoms, other special assessments may be needed. These may include using the slit lamp, using the fluorescent yellow eye drops, having a patch put over one eye for a period of time or having photographs or scans performed.

Sometimes children are not interested in the games or strategies we use to assess their eyes or are unable to co-operate on that day. In these instances we gather as much information as we possibly can, but sometimes a second assessment is required for thoroughness. Whilst a visit to the ophthalmologist with your child has its challenges, your child should be treated with kindness and patience and the majority of children find it a fun, playful and interesting experience.

Dr Caroline Catt
General and Paediatric Ophthalmologist
Sydney Ophthalmic Specialists
http://sosdoctors.com.au

How do I know if my child has vision problems?

Having your child’s vision formally checked at regular intervals throughout their childhood is an important part of their routine preventative health care. Without a formal vision test by a qualified and experienced paediatric eye health professional, it can be impossible to know if your child has a problem with his or her vision. Children with reduced vision have nothing to compare their vision against (so often won’t complain of reduced vision, even if they have learned to talk) and will compensate for and find ways to manage with the vision they do have. Also, if one eye sees well and the other sees poorly, children will rely on the good vision coming from their better eye, ignoring their worse eye. Often it’s only when the child is school-aged and able to communicate well that they make reference to their ‘good eye’ and their ‘bad eye’, sometimes whilst covering one eye during a peek-a-boo game or playing dress-up with a pirate patch.

It is crucial that vision problems in children are diagnosed early because early diagnosis and treatment maximises the chance of your child having an excellent visual outcome. Delayed diagnosis and treatment may result in poor vision for life. In NSW, we are lucky to have the StEPS Vision Screening Program, where the vision of each and every four-year-old pre-school child is checked by a qualified orthoptist. If the child’s vision is abnormal, they will be referred for secondary screening or to a paediatric ophthalmologist for a comprehensive assessment. Frequently and understandably, parents are surprised by, and sometimes disbelieving of, an abnormal result because their child doesn’t seem to have any vision problems. It is ONLY through formal testing that a vision problem can be diagnosed in a young child.

There are, however, some signs in children that should prompt a review of your child’s vision, if noticed. These include squinting (screwing up their face or eyes when looking at an object of interest); exaggerated blinking; holding an object very close to the face; disinterest in books or drawing; rubbing the eyes; complaining of sore, or red eyes; adopting a particular head posture to see objects of interest; misalignment of the eyes (for example, an eye that turns inwards or outwards relative to the other eye); or nystagmus (shaking of the eyes or the appearance of rapid sidewards movements of the eyes).

In the absence of any concerns, we recommend a check every two years.

Dr Caroline Catt
General and Paediatric Ophthalmologist
Sydney Ophthalmic Specialists
http://sosdoctors.com.au

Tips for Keeping Children’s Eyes Healthy

We are so often bombarded with the Dos and Don’ts when it comes to caring for our children. Ensuring they are healthy and happy is arguably the most important role of the parent. Here are a few simple ways that you can help keep your child’s eyes and sight healthy:

1. Try to minimise screen time
Screens are a fact of life for both children and adults – for work, education and leisure. Although there is no hard evidence that screen time adversely affects children’s eyesight, it is important to exercise common sense with its use. The key to screen exposure in children is to set time limits, ensure age-appropriate content is being viewed, and balance it with other activities. There is no golden rule as to exactly how much screen time is too much. As a general rule, children should be spending most of their time away from screens, and only a small portion of their time in front of screens.

2. Spend plenty of outdoor time
There are well-known health benefits of time spent outdoors, such as Vitamin D exposure and physical exercise. We are also now learning about the benefits of sun exposure and outdoor time on the visual system. Recent studies have shown a link between sun exposure and a decrease in the prevalence of myopia (short-sightedness). We advise at least one hour of outdoor play each day.

3. Be sun smart
Remember that, along with protecting our skin, we need to protect our eyes from the harmful rays of the sun. As well as causing skin cancers, UV rays can cause growths on the surface of the eyes called pterygiums. UV exposure also plays a role in the development of eye diseases such as cataracts and macular degeneration in later life. The best way to protect your child’s eyes from the sun is to ensure they wear a broad-brimmed hat and sunglasses. There are a number of companies that now design children’s sunglasses in a range of colours and designs to suit every child, and there are even styles available for babies from as young as six months of age. Getting a child used to wear a hat and sunglasses early on in life will make it easier for them to tolerate these through those tricky toddler years and into later childhood.

4. Avoid eye injuries
Unfortunately, we see many preventable eye injuries in children each year. Most serious childhood eye injuries are caused by sharp implements such as pens, pencils, utensils, sticks, scissors and metal objects, and the most likely place for an eye injury to occur is at home. The best way to minimise the risk of eye injury is through supervision of your child in and around the home. Other tips for preventing eye injuries at home include removing objects that may cause harm (or placing them out of the child’s reach, or in a locked cupboard), cutting any trimmed tree branches right back to the tree trunk, allowing children to only observe an adult mowing the lawn from inside the house, ensuring that furniture has rounded edges, and not allowing children to play with laser pointers. Also, be careful around spring time when Magpies are nesting and become territorial as they may swoop. Wearing a hat and sunglasses will even protect the eyes from injuries associated with swooping magpies.

5. Have a healthy, balanced diet
We all know that maintaining a healthy diet has a positive impact on our general health. The foundations of a healthy diet and lifestyle are set in childhood, and are also modelled on the parent’s behaviours. Offering a varied diet including a range of vegetables and fish has been shown to reduce the impact and incidence of eye disease such as macular degeneration, glaucoma and cataracts in later life. As for getting the children to actually eat those vegetables – that’s another battle entirely!

6. Get to know your eye health professional
If you are concerned about anything to do with your child’s eyes or eyesight, seek help from an eye health professional. It is never too early to have your child’s eyes assessed, and it is important that a child has their eyesight checked prior to starting school. In some states, such as NSW, there is a preschool vision screening program called StEPS which offers a vision assessment to all four-year-olds at preschool. If your child does not have access to such a program, ask your GP to assess their vision around the age of four years old. If you have any concerns about your child’s eyes or vision, do not hesitate to ask your GP for a referral to an eye health professional. View the StEPS article in RANCZO’s magazine Eye2Eye for more information about the StEPS initiative.

Prof Frank Martin
Paediatric ophthalmologist
Sydney Ophthalmic Specialists

Sarita Beukes, MAOB
Head Orthoptist
Sydney Ophthalmic Specialists

For more information about the authors, please visit http://sosdoctors.com.au/

GUIDELINES FOR DONATION OF EQUIPMENT AND CONSUMABLES

TWO NEWLY UPDATED RESOURCES RELEASED TO HELP GUIDE PURCHASE AND DONATIONS OF EYE HEALTH EQUIPMENT AND CONSUMABLES

On October 14, The International Agency for the Prevention of Blindness (IAPB) has launched a new website dedicated to the latest IAPB Standard List, to coincide with World Sight Day. On the following day, RANZCO is releasing its updated Guidelines for Donation of Equipment and Consumables.

IAPB STANDARDS LIST

The IAPB’s Standard List is a database of eye health equipment. It collates information about diagnostic, medical and surgical equipment, including evaluations, comparisons for best-outcome and best-value equipment available. The parameters used for evaluating products include value for money; customer service; quality control; appropriateness for low and middle income countries; ease of use; and frequency of purchase. Based on the IAPB’s detailed analysis, the Standard List can guide the purchase as well as the donation of equipment and provide guidance on purchasing and maintaining eye health equipment.

To coincide with World Sight Day, the IAPB released a newly updated version of the Standard List website. The updated website also includes a ‘top-buys’ list of recommended products in each category of products. The evaluation criteria of appropriateness for low and middle income countries makes the IAPB Standard List of particular relevance for those planning international donations of ophthalmology equipment. Click here to visit the new website.

[Source: http://iapb.standardlist.org/about/]

RANZCO GUIDELINES FOR DONATION OF EQUIPMENT AND CONSUMABLES

In recent weeks, RANZCO has released updated versions of a number of its international development guidelines. Today, RANZCO is releasing its updated Guidelines for Donation of Equipment and Consumables.

The newly-updated guidelines can help ensure that any donation of equipment or consumables is appropriate and in-line with international best-practice standards for eye health equipment and consumables donations. The guidelines rely on a number of international guidelines and standards, including the IAPB Standard List, as well as relevant World Health Organisation guidelines, and 2016-updated guidelines by the Partnership for Quality Medical Donations.

Further international development guidelines have been reviewed and updated and will be released via the RANZCO website over the coming weeks. All development guidelines are available in the Policies section of the RANZCO website here.

For any information regarding RANZCO international development programs and international development guidelines, please email gvanheerden@ranzcodev.dev.nucleoserver.com.

RANZCO Policy and Programs team

The Asia-Pacific Eye Care Week

The 6th Asia-Pacific Eye Care Week organised by the Asia-Pacific Academy of Ophthalmology (APAO) will be held from 10–16 October 2016, in conjunction with World Sight Day on 13 October. Since 2012, APAO has organised its Asia-Pacific Eye Care Week in order to raise public awareness about eye care and eye health in the region. Additionally, the Asia-Pacific Eye Care Week is one way in which APAO supports the World Health Organization’s VISION 2020 initiative.

Each Asia-Pacific Eye Care week features two distinct ophthalmic themes chosen by the APAO Public Education Standing Committee and the APAO Central Secretariat. This year, the themes are ‘Cornea Infections in Asia’ and ‘Diabetic Macular Edema’.

Based on the selected themes, two of APAO’s Subspecialty Member Societies help prepare educational materials for the Asia-Pacific Eye Care Week, which are freely available online. This year, the Asia Cornea Society and the Asia-Pacific Vitreo-retina Society have generously prepared slideshows, explanatory notes and press releases, which can be found at http://www.apaophth.org/sixth-asia-pacific-eye-care-week/.

Over the years, the Asia-Pacific Eye Care Week has seen increased interest and participation. With the support of more and more individuals and organisations, APAO hopes to extend the right to sight to everyone in the Asia-Pacific region.

The APAO Secretariat will publish reports on activities held during the 6th Asia-Pacific Eye Care Week on its website, as well as via social media and other publications. Please send any details and photos of your events to Ms Sydney Stonner at sydneystonner@apaophth.org.

PHOTOS FROM THE 5TH ASIA-PACIFIC EYE CARE WEEK

Prof Ava Hossain spoke at a seminar during the 5th Asia-Pacific Eye Care Week organised by the Ophthalmological Society of Bangladesh.

In the Philippines, Prof Reynaldo Javate appeared on a celebrity news television show to promote the 5th Asia-Pacific Eye Care Week.

The Ophthalmological Society of Taiwan partnered with celebrity guides for the interactive traveling ‘Enhancing Sight, Enhancing Lives’ exhibit during the 5th Asia-Pacific Eye Care Week.