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Iris colour is permanent at 1 year of age. Colour vision assessment can be performed by the Hardy-Rand- Rittler plates in children as young as 3 years of age Mollon et al. If the child cannot tolerate ophthalmic examination and detailed examination is indicated, sedation can be required. Routine intraocular pressure measurement in cases with congenital glaucoma is an example for such conditions.

Eye examinations after 3 years of age are more informative and more easily performed. Visual acuity assessment and the fundamental parts of eye examinations are similar with the adult patients. However, the physicians should keep in mind that, refractive status of the eye is very dynamic in preschool and school children, and preschool vision screening is recommended for all children. Refractive disorders Ametropia includes the hyperopia, myopia and astigmatism.

The most common refractive error in the pediatric population is myopia. The prevalence is found to be much higher in the Far East. The prevalence decreases rapidly during the process of emmetropization.

Only few children develop astigmatism greater than 1 diopter by 6 years of age Maida et al. The cornea provides two thirds of this total power and the lens provides the remaining 20 D. The normal eye creates clear images by focusing the images on the retina.

If the unaccommodated eye focuses the images behind the retina, hperopia farsightedness develops. On the other hand myopia nearsightedness is the state in which the unaccommodated eye focuses the images in front of the retina.

The hyperopia and myopia may be due to altered total refractive power of the eye, but the axial length changes instead of that is the most common reason in most of the cases.

Reduced axial length results in hyerpopia and the reverse in myopia Riordan-Eva, The parental history of myopia, genetic predisposition and various environmental factors are associated with the development of myopia in a child.

Familial predisposition also exists in hyperopia, which is much less common in the pediatric population. The children can tolerate low amounts of hyperopia by accommodation, so most of the low amounts of hyperopia are unrecognized in this population.

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.

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. 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. 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. 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. 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.

Kuurne - Wikipedia ; Geschiedenis. De lijst sp. Google ; Search the world's information, including webpages, images, videos and more. Google has many special features to help you find exactly what you're looking for. Boek: Statistiek voor Dummies - Boekenbestellen. Vind je statistiek een lastig onderwerp? Geen nood,deze tweede editie van Statistiek voor Dummies Deborah Rumsey. Pearson Education, - pages. Antwoord op vele vragen die dagelijks afkomen op degene die beroepshalve Introductie tot de statistiek - Logos Foundation ; 1 Basisbegrippen en beschrijvende statistiek 1.

Achter de computer, tot in de late uurtjes, vele weekends was ik er zoet mee. Studieboeken online downloaden - bookboon. Skip navigation. This work should be seen as complementary to the present volume, in terms of providing further interpretation of postwar economic history and also factual material for reference, and it is to be published as B.

Crafts eds. Pedersen University of Aarhus Albrecht O. Kuznets, 23 We still refer to the past fifty years as the 'postwar': this is perhaps the best tribute to the fact that the 'second Thirty Years War' marked a major watershed in the history of mankind.

So much so that it proved to be a major intellectual watershed as well. In fact, until fairly recently, often marked the borderline of historical research, more recent decades being considered as the playing ground for journalists, political scientists and sociologists. Only the boldest, or most inconsiderate, scholars entered thefield,and they did so at their own risk.

The same can be said of economic historians: with few exceptions, they have been reluctant to apply the tools of their trade to the 'postwar' period, more often than not leaving it as the domain of applied economists.

Things are changing, however, and the half century following the end of the Second World War is now increasingly seen as being ripe for historical investigation, much beyond the Marshall Plan years that have attracted much recent attention.

This chapter aims at reviewing the performance of the European economy since in a longer-run perspective, which sees the period from to as being an exceptional one in the history of 'modern economic growth', in that it departed from the secular trendfirst by under- and then by overperforming. In this chapter, the European economy is tentatively seen as an aggregate, at least in fieri.

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If the interwar years of slow and volatile growth were characterized by nationalism and wars that crystallized national economic peculiarities, the subsequent period of high growth resulted in a convergence of per-capita incomes that can be seen and understood as being both the cause and the effect of a broader social and institutional convergence.

European growth, average annual growth Period Real GDP 1 2. Countries are those for which col. Some of them, the pioneers, had already proceeded a long way along the road leading to ever increasing material welfare; others, the late-comers, were just taking their first steps. The secular trend fits well with Kuznets' definition of'modern economic growth' as a process characterized by 'rates of growth in per capita income rang[ing] mostly from about 10 percent to over 20 percent per decade' Kuznets, While the long-run trends follow the steady quantitative change predicted by such authors as Colin Clark, Kuznets, Abramovitz and Chenery, Table 1.

The perspective of secular trends in 'modern economic growth' is a useful starting point in considering the economic history of Europe during the half century following the end of the Second World War. In particular, such a perspective is helpful when considering the standard subdivision into two distinct periods, the first, to about , being characterized by very high growth rates and near-full employment, the second showing a rather sluggish performance in terms both of output and employment.

Here, the longer-run view conveys two messages: 1 the period was truly exceptional in the process of'modern economic growth', 2 the subsequent growth record can hardly be regarded as unsatisfactory. The exceptional character of the 'high-growth years' is better judged in the light of the poor European performance during the previous three decades.

Whether or not one agrees with Kuznets2 that major wars are somehow endogenous to the process of modern economic growth, they certainly coincide with a considerable slowdown in European growth between and , plausibly not unrelated to the boom of Postwar growth: an overview 3 the following two decades.

As we shall see, the catch-up for ground lost in two world wars and in the most severe economic depression to date is one of the reasons explaining the much above average growth rates of the s and s: other reasons, discussed in section 6, relate to domestic and international factors likely to be exceptional in the history of modern economic growth. Post growth looked uncomfortably low in the light of expectations created during the previous quarter of a century.

However, if both the longer run and the predictions of the then-prevailing theory are taken into account, the picture looks considerably less dismal.

Having assessed the postwar European performance against the longer-run background of'modern economic growth', we may now turn to a brief appraisal of some quantitative features of the main subperiods. Table 1.

In the GDP of France, of the three Axis countries and of the Netherlands had fallen back to late nineteenth-century or early twentieth-century levels. One or two generations of work and accumulation had been lost.

Belgium fared a little better.De lijst sp. It may be genetically proven in some cases. The parents commonly 14 Complementary Pediatrics use the lazy eye terminology instead of ambloypia.

Gratis studieboeken in samenwerking met Bookboon - Gratis. The infection may progress rapidly ending with corneal perforation.

Babies born at or before 31 weeks of gestational age, or weighing grams or less are under high risk for ROP. Therefore all ROP cases must be routinely referred to an ophthalmologist to screen for these possible associations. In a significant proportion of the patients, the diagnosis is made by chance during a routine eye examination or by noticing leukocoria. Familial predisposition also exists in hyperopia, which is much less common in the pediatric population.

Ocular abnormalities include high myopia, empty vitreous with membranes and bands.

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