Myopia Profile

Clinical

Retinal detachment in children

 Posted on August 3rd 2021 by Connie Gan

High myopes have 5-6 times higher risk of developing retinal detachments compared to low myopes.1 They also happen in adult myopes, right? Wrong! Retinal detachments can happen at any age, including in children. KG shared detail of a patient who was diagnosed with a retinal detachment at 12 years of age. Here is the case.

KG This (see below for full sized photos) is the WHY of myopia control. A 12 year old patient of mine, -7.00, with what my local friendly retinal surgeon has diagnosed as an 'old detachment' (OLD!! He's 12!!!!!!!!) with distal retinal hole which he lasered. He will need to be monitored for uptake of the laser, which if poor could indicate active subretinal fluid (requiring laser of the whole area) - after two months it appears to be taking well, but my Ophthal friend says this patient needs to be monitored in the long term as the detached area can become atrophic and prone to further breaks. This child has a lifetime of retinal drama ahead. And he's only 12. :( We're managing him with a partial OK treatment with around -2.00 residual in specs, and he's been refractively stable since this management was first commenced with an interstate colleague in 2014, and continued by us this past year. His mother presents his refractive history, before partial OK treatment, as being -4.50 before his 6th birthday; -5.50 before his 7th and -7.00 by his 8th birthday. His axial length is R 26.6mm and L 26.3mm R&L- greater than 26mm has been associated with an 82% frequency of myopic retinal changes (Varma et al, ARVO abstract 2014); and a cumulative risk of vision impairment of 25% (Tideman et al, JAMA Ophthalmol 2016). If only we'd seen him earlier. :(KG No symptom and no significant known injury or event either.Retina combined.png

Retinal detachment in children

Paediatric retinal detachment (PRD) is rare and challenging. It accounts for 3%-7% of all retinal detachment cases.2 The causative factors 2 include:

  • Trauma
  • An associated condition (Morbus Stickler, Marfan Syndrome, Coat disease etc)
  • High myopia
  • Retinopathy of prematurity (ROP)
  • Previous intraocular surgery
  • Idiopathic

Early diagnosis can be difficult as children may not necessarily recognize or appreciate the symptoms such as a sudden increase in floaters, flashes of light, or changes in their field of vision. As a result, they may not raise the alarm that something in their vision has changed. The average age of onset of PRD is usually between 9-12 years old.3 The most common types of PRDs include: 4

  • Tractional retinal detachments (29%, causes include retinopathy of prematurity, persistent fetal vasculature or familial exudative vitreoretinopathy)
  • Traumatic retinal detachments (26%)
  • Rhegmatogenous retinal detachments (22%, causes include myopia, X-linked retinoschisis or Stickler's syndrome)

The prognosis varies with different type of PRDs. Rhegmatogenous retinal detachments have better visual outcome whereas tractional retinal detachments have poorer visual outcome.4 In addition, late diagnosis and macular involvement also affect the outcome.

Considering the best management path

RC Would you consider adding .01% atropine?KG Definitely, if he doesn't get good enough control with the partial OK treatment, but it seems to have done the job beautifully over the past 2.5 years. If we forget for a second that he's a progressing myope (even though this is the point of the post!) he still needs refractive correction and most -7.00's are going to do best with CL correction. So my approach is that if we get a good myopia management result with optical corrections, there's no need to add atropine as first line combo therapy. Perhaps in future we'll get an understanding of those for whom a combo therapy should be first line treatment - in this case you'd think such fast progression at such a young age would have led to still seeing some progression in OK wear, but he's responded remarkably well. And while we don't want to wait to see a child progress, jumping straight on progression of -0.50 or more in less than a year is a good indicator for needing better control options.HO Is there a reason you couldn't correct the total -7.00?KG Yes, flat corneae.

This particular child has an axial length of 26.6mm and 26.3mm in his right and left eyes respectively. As KG mentions in the original post, eyes with an axial length exceeding 26mm have an 82% frequency of retinal changes attributed to myopia, and at least a 25% cumulative risk of vision impairment across their lifetime.5,6

Attempting to control myopia as much as possible is important to reduce the continued axial growth of the patient's eyes - the mechanical impact of stretching is likely responsible for the stronger link between axial length and ocular health risk in myopia than between myopic refractive error and risk.6

Does this patient need additional myopia control intervention? The case indicates that partial correction orthokeratology has provided effective myopia control over the past 2.5 years. One commenter mentions adding 0.01% atropine, which has shown an additive effect for myopia control with orthokeratology, although this may be more in children with lower (less than 3D) than moderate myopia.7

Does this patient need additional ocular health monitoring? The answer to this is of course yes - annual retinal health examinations through dilated pupils are recommended for high myopes by the International Myopia Institute.8

Since this patient is now being co-managed between an optometrist and ophthalmologist, ongoing communication between eye care practitioners is crucial to ensure the best vision and eye health outcomes for the patient. Highly myopic patients, young or old, should be advised of the symptoms of retinal tears and detachments so that expedient clinical review is possible.

Take home messages:

  1. Paediatric retinal detachment may be challenging to diagnose as the symptoms are painless and children may not identify these symptoms as abnormal.
  2. It is important to be vigilant and perform thorough ocular health checks on all high myopes regardless of age. Retinal health examination through dilated pupils is recommended annually for high myopes, young and old.

Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

Read Connie's work in many of the case studies published on MyopiaProfile.com. Connie also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on MyopiaProfile.com. Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

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