Indian Journal of Ophthalmology

: 1983  |  Volume : 31  |  Issue : 5  |  Page : 517--520

Ocular changes in infants and children treated for hyperbilirubinaemia with phototherapy in the neonatal period

Mathew Krishnan, VK Khanna, Indra Narayanan, Rajini Kantha 
 Department of Ophthalmology, Lady Harding Medical College, New Delhi, India

Correspondence Address:
Mathew Krishnan
Head of the Department of Ophthalmology, Medical College, New Delhi

How to cite this article:
Krishnan M, Khanna V K, Narayanan I, Kantha R. Ocular changes in infants and children treated for hyperbilirubinaemia with phototherapy in the neonatal period.Indian J Ophthalmol 1983;31:517-520

How to cite this URL:
Krishnan M, Khanna V K, Narayanan I, Kantha R. Ocular changes in infants and children treated for hyperbilirubinaemia with phototherapy in the neonatal period. Indian J Ophthalmol [serial online] 1983 [cited 2020 Aug 15 ];31:517-520
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Full Text

Jaundice is observed in about 50% of the term and 80% of the pre term infants. Exchange transfusion and phototherapy are considered the best methods of treating neo­natal hyperbilirubinaemia.

Conflicting reports have been published in the literature, about the various ocular changes due to hyperbilirubinaemia and phototherapy. Damage to the retinal photoreceptor cells of experimental animals, exposed to high intensity illumination has been reported by various authors.

This fact prompted us to do a complete analysis of the ocular hazards due to hyperbili­rubinaemia and phototherapy.

 Material and Methods

114 infants and children who were admitted to the neonatal unit of Kalawati Saran Children's Hospital of Lady Hardinge Medical College Delhi, from September 1972-August 1979, were taken up for this study. Premature babies, asphyxia, prolonged labour etc were estimated in order to avoid the possible subsequent neurological deficits which may occur in these cases.

These infants were divided into two groups:­

(i) Group 1-56 cases with peak bilirubin levels of more than 15 mg%.

(ii) Group 11-58 normal control cases. They had either very mild physiological jaundice or none at all. Each was matched for infants in the test group for sex, birth weight (± 200 gms) and date of birth (± 15 days).

A thorough eye examination was done including ocular movements, Hirschberg test, cover test, synoptophore, convergence, accommodation test, Maddox rod test, and Worth's four dot test. Dyslexia tests were also done to detect minimal brain damage.

Visual acuity was estimated by the Snellen's chart. Where this method was impossible gross vision was tested by showing light and toys and watching the eye and head movements. Similarly colour vision was also tested by using objects of different colours. Refraction and fundus examination were done after dilatation of the pupil with atropine. Sedation was given wherever necessary.


The results of orthoptic check up is shown in [Table 1].

6 out of 56 cases (19.71%) in the test group had squint as compared to 2 out of 58 cases (3.45%) in the control. Out of these 6 cases, one child had paralytic convergent squint associated with severe neurological deficits, while the remaining 5 cases were concomittant divergent squint. The serum bilirubin levels in squint cases is shown in [Table 2].

All the squint cases had serum bilirubin levels of more than 19 mg%. The case with bilateral 4 Nerve paralysis had the highest bilirubin level in this series (53 mg%).

Neurological deficit-Delayed milestones and speech retardation were seen in 8 and 13 cases of group I and one each in group 2. Severe neurological deficits like chorioathetosis and mental retardation, were seen in two cases with high bilirubin levels (43.8 mgm% and 53 mg%), and both these cases had squint.

No definite relationship could be established between the incidence of squint and duration of phototherapy as seen in [Table 3].

The convergence test was possible in 48 cases. Convergence was 6 cm (normal) in all cases except for cases with divergent squint in which it ranged between 10-14 cms. Accommo­dation could be judged in 16 cases only, and it was found to be normal.

Visual acuity and colour vision did not reveal any abnormality in any group.

Retinoscopy could be done in 52 of 56 case in group I and 51 of 58 cases in group 2. Retinoscopy findings are shown in [Table 4].

Hypermetropia was found in 36 cases in t test and 39 cases in the control group. Myopia was seen in 6 cases in the test and 4 cases the control group. A family history of myopia could be obtained in 4 out of 6 cases of group I and 2 out of 4 cases of group 4.

No relationship could be found between the peak serum bilirubin level and the refractive error as seen in [Table 5].

Fundus examination revealed large discs in 6 cases, small discs in one case and marked temporal pallor in 3 cases in group I. In group II large discs were seen in 6 cases and pale discs in 2 cases. In one case each from group I and II, dull macular reflex with mottling were observed. These two patients were too young for visual assessment by the Snellen's chart.


Killander et al [1] and Hymen et al [2] found an increased incidence of squint in cases of hyperbilirubinaemia. Drew et al [3] in a series of 300 infants found squint in 5 cases, after exposure to phototherapy. We found 6 cases of squint in group I as compared to 2 in the controls. It is possible that squint could be due to high levels of bilirubin or phototherapy or both, as all of them received phototherapy. However, our study suggests that this complica­tion is more likely due to hyperbilirubinaemia rather than phototherapy as all cases of squint Dyslexia tests were done in 17 cases of the test group and 15 cases of the control group. Findings were normal in all these cases. had high serum bilirubin levels of over 19 mg% and there was no relationship between the duration of phototherapy and squint. Further, none of the cases with low serum bilirubin levels showed this defect even though they had received phototherapy.

The major pathological changes in Kernicterus includes demyelinization, loss of neurons and gliosis of various parts of the brain

The case of bilateral VI Nerve paralysis had 53 mg% serum bilirubin level and also chorioathetosis, mental retardation, loss of hearing and delayed milestones. Another case with serum bilirubin level of 43.8 mg% had the same neurological deficits with a concornittant squint. Whether this too was a paralytic squint now manifesting as a concomitant squint, was difficult to assess in this child.

Optic atrophy in Kernicterus has been reported by Malamud [4] Marked pallor of the disc seen in 3 cases of test group could be an early manifestation of optic atrophy. A long term follow up in these cases is necessary for final assessment.

 Summary and Conclusion

1. 56 cases of hyperbilirubinaemia, treated with phototherapy were studied for ocular changes.

2. A high incidence of squint (10.71%) was seen in these cases and the probable cause is hyperbilirubinaemia.

3. Optic disc pallor seen in cases could be due to early optic atrophy.


1Killander, A., Michaelson, M., and Eberhard, V. M., Acta. Pediatr., 52, 481, 1963.
2Hymen, C.B., Keaster, J., Henson, V., Harris, I., Sedwick, R., Wursten, H., and Wright, A.R., Am. J. Dis. Child., 117, 395, 1969.
3Drew, J.H., Marriage, K.J., Nayle, V.V., Bajraszewaki, E., and Mc Namara, J.M., Arch. Dis. Child., 51, 454,1976­
4Malamud, N., Pathogenesis of Kernicterus in light of the sequelae. Kernicterus and its import­ance in cerebral palsy. Eleventh Annual Meeting, and Charles, Nomas publishers, 1961.