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Pediatric Ophthalmology

Routine Eye Care For Kids

Vision problems in children are uncommon but when they do occur, they often go undetected. Young children may not realize or be able to communicate that their vision is impaired, and even older children may not notice if the vision in only one eye is affected. Every parent wants their child to have perfect vision, so how often should children have eye examinations to make sure their eyes are healthy?

Every newborn undergoes a brief eye examination shortly after birth, mainly to ensure that no birth defects of the eye are present. This is usually performed by a pediatrician, family physician, nurse practitioner, or a physician’s assistant. A similar examination should take place between six and twelve months of age, usually during a well-child check-up with a pediatrician or family physician. A primary goal of this second examination is to ensure that light can enter the eye unobstructed, so that vision will develop normally. This is evaluated by shining a light into the eye and observing a red or orange glow, called a red reflecx, in the pupil of the eye – similar to the red eye often seen in photographs taken using a flash. Any problems that prevent light from entering the eye – such as extreme far-sightedness, crossed eyes (strabismus), or even a cataract – can prevent normal vision development. This results in a condition called amblyopia, or lazy eye. Many conditions, if left undetected, can cause amblyopia, which can be treated if it is identified during the critical vision development period that lasts until children are about 8 years old.

Once a child reaches age 2 ½ to 3 ½, and certainly by the age of 5, a vision screening should take place to make sure that vision is developing normally. Children in this age group are preparing to enter pre-school or kindergarten, and this examination is a good check for school readiness. This examination can be done during a well-child visit to the pediatrician or family physician, but should include some measurement of the child’s vision. Most children this age cannot read the letters on the eye chart, but special vision-testing charts – including some with easy-to-recognize pictures – are available for children this age. Because vision is vulnerable to amblyopiain this age group, a formal examination by an eye care specialist should take place if the pediatrician is unable to perform testing, or if the test results are in any way abnormal. Some children in this age group have high degrees of near-sightedness or far-sightedness, and need glasses to help their vision develop normally.

If they are passing all screening exams and no problems are noted by parents, we still recommend that all children have a baseline eye examination by an ophthalmologist once before age 5 years. Thereafter, most children will undergo one or more vision screenings in elementary school, providing additional opportunities to identify vision problems.

If a child fails any screening exam or problems are noted, by parents, physicians, or school personnel, an immediate eye exam is recommended. Otherwise, normal children need routine eye exams every 3-5 years.

Amblyopia

*What is amblyopia?*

Amblyopia is poor vision in an eye that did not develop normal sight during early childhood. It is sometimes called 'lazy eye.” Newborn infants are able to see, but as they use their eyes during the first months of life, vision improves. During early childhood years, the visual system changes quickly and vision continues to develop. If a child cannot use his or her eyes normally, vision does not develop properly and may even decrease. After the first nine years of life, the visual system is normally fully developed and usually cannot be changed. The development of equal vision in both eyes is necessary for normal vision. When one eye develops good vision while the other does not, the eye with poorer vision is called amblyopic. Usually, only one eye is affected by amblyopia, but it is possible for both eyes to be 'lazy.' The condition is common, affecting approximately two or three out of every 100 people. The best time to correct amblyopia is during infancy or early childhood.

*What causes amblyopia?*

Amblyopia is caused by any condition that affects normal use of the eyes and visual development. In many cases, the conditions associated with amblyopia may be inherited. Amblyopia has three major causes:

• Strabismus (misaligned eyes)
  Amblyopia occurs most commonly with misaligned or crossed eyes. The crossed eye 'turns off' to avoid double vision, and the child uses only the better eye. The misaligned eye then fails to develop good vision.
• Unequal Focus / Refractive Error
  Refractive errors are eye conditions that are corrected by wearing glasses. Amblyopia occurs when one eye is out of focus because it is more nearsighted, farsighted or astigmatic than the other. The unfocused (blurred) eye 'turns off' and becomes amblyopic. The20eyes can look normal, but one eye has poor vision. This is the most difficult type of amblyopia to detect since the child appears to have normal vision when both eyes are open. Amblyopia also can occur in both eyes if both eyes are very blurred. This can happen when there is a high amount of nearsightedness, farsightedness or astigmatism. This is called bilateral refractive amblyopia.
• Cloudiness in the Normally Clear Eye Tissues
  An eye disease such as a cataract (a clouding of the eye's naturally clear lens) may lead to amblyopia. Any factor that prevents a clear image from being focused inside the eye can lead to the development of amblyopia in a child. This is often the most severe form of amblyopia.

*How is amblyopia diagnosed?*
It is not easy to recognize amblyopia. A child may not be aware of having one strong eye and one weak eye. Unless the child has a misaligned eye or other obvious abnormality, there is often no way for parents to tell that something is wrong. Amblyopia is detected by finding a difference in vision between the two eyes or poor vision in both eyes. Since it is difficult to measure vision in young children, your ophthalmologist often estimates visual acuity by watching how well a baby follows objects with one eye when the other eye is covered. Using a variety of tests, the ophthalmologist observes the reactions of the baby when one eye is covered. If one eye is amblyopic and the good eye is covered, the baby may attempt to look around the patch, try to pull it off, or cry.

Poor vision in one eye does not always mean that a child has amblyopia. Vision can often be improved by prescribing glasses for a child. Your ophthalmologist will also carefully examine the interior of the eye to see if other eye diseases may be causing decreased vision. These diseases include:

• Cataracts
• Inflammations
• Tumors
• Other disorders of the inner eye
  

*How is amblyopia treated?*
To correct amblyopia, a child must be made to use the weak eye. This is usually done by patching or covering the strong eye, often for weeks or months. Even after vision has been restored in the weak eye, part-time patching may be required over a period of years to maintain the improvement. Glasses may be prescribed to correct errors in focusing. If glasses alone do not improve vision, then patching is necessary. Amblyopia also may be treated by blurring the vision in the good eye with special eyedrops or lenses to force the child to use the amblyopic eye. Amblyopia is usually treated before surgery to correct misaligned eyes, and patching is often continued after surgery as well.

If your ophthalmologist finds a cataract or other abnormality, surgery may be required to correct the problem. An intraocular lens may be implanted. After surgery, glasses or contact lenses can be used to restore focusing while patching improves vision.

Amblyopia cannot usually be cured by treating the cause alone. The weaker eye must be made stronger in order to see normally. Prescribing glasses or performing surgery can correct the cause of amblyopia, but your ophthalmologist must also treat the amblyopia itself.

A common treatment for amblyopia is to patch the strong eye; the weak eye is strengthened because the child is forced to use it. If amblyopia is not treated, several problems may occur:

• The amblyopic eye may develop a serious and permanent visual defect
• Depth perception (seeing in three dimensions) may be lost
• If the good eye becomes diseased or injured, a lifetime of poor vision may be the result
  

Your ophthalmologist can give you instructions on how to treat amblyopia and can help you and your child to carry out this treatment. Children do not like to have their eyes patched. But as a parent, you must convince your child to do what is best for him or her. Your interest and involvement will be necessary for successful treatment.

*Loss of Vision Is Preventable*
Success in the treatment of amblyopia also depends upon:

• How severe the amblyopia is; and
• How old the child is when treatment is begun.

If the problem is detected and treated early, vision can improve for most children. Amblyopia caused by strabismus or unequal refractive errors may be treated successfully during the first nine years of age. After this time, amblyopia usually does not recur.

If amblyopia is not detected until after early childhood, treatment may not be successful. Amblyopia caused by cloudiness of the eye tissues needs to be detected and treated extremely early - within the first two months of life - in order to be treated successfully.