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Pediatrics

Amblyopia | Babies Vision | Esotropia | Exotropia | Eye Examination For Children | Eyeglasses for Infants & Children | Strabismus | Tearing in Children

Amblyopia

Amblyopia is poor vision in an eye that did not develop normal sight during early childhood. This condition, sometimes referred to as “lazy eye,” can run in families. The main causes of amblyopia are strabismus, refractive errors, or cloudiness of the eye tissues.

Amblyopia affects about three out of every 100 people. The best time to correct it is during infancy or early childhood, because after the first nine years of life, the visual system is normally fully developed and usually cannot be changed. It is recommended that children have their eyes and vision monitored by their primary care physician at their well-child visits. If there is a family history of amblyopia, children should be screened by an ophthalmologist (Eye M.D.).

Strabismus, or misaligned eyes, is the most common cause of amblyopia. The eye that is misaligned is ignored by the brain and “turns off.” A refractive error (meaning an eye is nearsighted, farsighted, or has astigmatism) is another cause of amblyopia. If one eye has a very different refractive error from the other eye, or if both eyes have a very strong refractive error, amblyopia can develop in the eye or eyes that are out of focus. The most severe form of amblyopia occurs when cloudiness of the eye tissues prevents any clear image from being processed. This can happen in conditions such as infantile or developmental cataracts.

Amblyopia is detected by finding a difference in vision between the two eyes or poor vision in both eyes. The ophthalmologist will also carefully examine the eyes to see if other eye conditions are causing decreased vision.

Amblyopia is treated by forcing the brain to use the affected eye or eyes. If refractive errors are present, they are corrected with eyeglasses or, less commonly, with contact lenses or refractive surgery. If a cataract or other cloudiness is present, surgery may be necessary to clear the line of sight. Strabismus may require surgery before, during, or after the amblyopia treatment. Patching or blurring the sound eye is then used to improve the vision by forcing the brain to recognize and process information from the affected eye or eyes. Once maximum vision has been obtained, treatment often needs to be continued at least part time for months to years to maintain the recovered vision. The earlier the treatment is begun, the more successful it will be.

Babies Vision

Babies have poor vision at birth but can see faces at close range, even in the newborn nursery. At about 6 weeks of age, a baby should be able to fixate on an object (such as a face) and maintain eye contact. Over a child’s first few years, vision develops rapidly; 20/20 vision can be recorded by 2 or 3 years of age with some techniques.

Parents should be aware of signals of poor vision. If one eye “turns” or “crosses,” that eye may not see as well as the other eye. If the child is not interested in faces or age-appropriate toys, or if the eyes rove around or jiggle (called nystagmus), you should suspect poor vision. Other signs to watch for are tilting the head and squinting. Babies and toddlers compensate for poor vision rather than complain about it.

Should a baby need eyeglasses, the prescription can be determined fairly accurately by dilating the pupil and analyzing the light reflected through the pupil from the back of the eye.

A baby’s vision can also be tested in a research laboratory, where the brainwaves are recorded as the child looks at patterns of stripes or checks on a television screen. This is called a visually evoked potential (VEP) test. Another test, called preferential looking or Teller acuity cards, uses simple, striped cards to attract the child’s attention. In both tests, as the stripes grow smaller and closer together, they become more difficult to see, and the child’s level of visual acuity can be assessed.

Esotropia

One common form of strabismus, or misaligned eyes, is called esotropia. Esotropia, or “crossed” eyes, occurs when the eyes turn inward. Esotropia can be both congenital, when it occurs in infants, and accommodative, which is more likely to develop after two years of age.

Young children with congenital esotropia cannot use their eyes together. In most cases, early surgery can align the eyes.

With accommodative esotropia, when the child focuses the eyes to see clearly, the eyes turn inward. This “crossing” may occur when focusing at a distance, at close range, or both. Eyeglasses reduce the focusing effort and often straighten the eyes. Sometimes bifocals are needed for close work. If significant crossing of the eyes persists with glasses, surgery may be required.

The main sign of esotropia is an eye that is not straight. Sometimes children will squint one eye in bright sunlight or tilt their head in order to use their eyes together.

Amblyopia, or “lazy eye,” is closely related to esotropia. Children learn to suppress the double vision associated with esotropia so effectively that the deviating eye gradually loses vision. It may be necessary to patch the good eye and have the child wear eyeglasses before treating the esotropia.

Esotropia is often treated by surgically adjusting the tension on the eye muscles under general anesthesia. The goal of surgery is to get the eyes close enough to perfectly straight so that it is hard to see any residual deviation. Surgery usually improves the condition, and though the results are rarely perfect, they are usually better in young children.

Exotropia

One common form of strabismus, or misaligned eyes, is called exotropia. Exotropia, or “walleye,” occurs when the eyes turn outward. This occurs most often when a child is focusing on distant objects.

The main sign of exotropia is an eye that is not straight. The exotropia may occur only from time to time, especially when the child is daydreaming, tired, or sick. Parents often notice that the child squints one eye in bright sunlight.

Amblyopia, or “lazy eye,” may develop with exotropia, although it is less common than with esotropia (“crossed” eyes), as the deviation is usually intermittent. Children learn to suppress the double vision associated with exotropia so effectively that the deviating eye gradually loses vision. It may be necessary to patch the good eye and have the child wear eyeglasses before treating the exotropia. Prisms and eye exercises may also help control the outward turning in some children.

Exotropia is often treated by surgically adjusting the tension on the eye muscles under general anesthesia. The goal of surgery is to get the eyes close enough to perfectly straight so that it is hard to see any residual deviation. Surgery is usually quite successful, since most children with the condition have binocular vision.

Eye Examination for Children

Children are examined for any rare congenital problems at birth and at each well-child examination by the primary care physician, who will check for problems that may not be apparent to the parent or child but that could have serious consequences for the child’s vision. When the child is old enough, the primary care physician will perform a more formal vision screening examination. If the parent or the child’s doctor has any concerns, or if there is a family history of strabismus, amblyopia, or other eye conditions, the child should be referred to an ophthalmologist (Eye M.D.) for evaluation.

Conditions that the primary care physician will screen for include:

  • strabismus (misaligned eyes);
  • amblyopia (“lazy eye”);
  • ptosis (drooping of the upper eyelid); and
  • decreased vision.

If the child is referred to an ophthalmologist, he or she will conduct a physical examination of the eyes, using eye chart tests, pictures, or letters to test the child’s ability to see form and detail of objects, and to assess for any refractive error (nearsightedness, farsightedness, and astigmatism).

Vision problems in children can be serious, but if caught in time and treated early, the chil

Eyeglasses for Infants and Children

Prescriptions for eyeglasses can be measured in even the youngest and most uncooperative children by using a special instrument called a retinoscope to analyze the light reflected through the pupil from the back of the eye.

Most lenses for children’s eyeglasses are made of polycarbonate lens material, which is stronger and lighter than glass. It is a good idea to request a scratch-resistant coating on children’s lenses. Children can be rough with glasses, and plastic lenses scratch easily.

Color tints or tints that respond to changes in light can be incorporated into eyeglass lenses. For children, the tint should not be so dark that the child has trouble seeing indoors.

Frames come in all shapes and sizes. Choose one that fits comfortably but securely. There are devices that keep eyeglasses securely in place, a good idea for active children and young children with flat nasal bridges. Cable temples, which wrap around the back of the ears, are good for toddlers. Infants may require a strap across the top and back of the head instead of earpieces. Flexible hinges hold the eyeglasses in position, allow the glasses to “grow” with the child, and prevent the side arms from breakage.

Often children do not like wearing their eyeglasses although the prescription is correct. Distraction, positive reinforcement, and incentives can help children develop the habit of wearing their glasses. If all else fails, your ophthalmologist can prescribe an eyedrop that blurs vision when the glasses are not in place. This often helps overcomes the child’s initial resistance to wearing glasses.

Strabismus

Strabismus refers to misaligned eyes. Esotropia (“crossed” eyes) occurs when the eyes turn inward. Exotropia (“wall-eye”) occurs when the eyes turn outward. When one eye is higher than the other, it is called hypertropia (for the higher eye) or hypotropia (for the lower eye). Strabismus can be subtle or obvious, and can occur occasionally or constantly. It can affect one eye or shift between the eyes.

Strabismus usually begins in infancy or childhood. Some toddlers have accommodative esotropia. Their eyes cross because they need glasses for farsightedness. But most cases of strabismus do not have a well-understood cause. It seems to develop because the eye muscles are uncoordinated and do not move the eyes together. Acquired strabismus can occasionally occur because of a problem in the brain, an injury to the eye socket, or thyroid eye disease.

When young children develop strabismus, they typically have mild symptoms. They may hold their heads to one side if they can use their eyes together in that position. Or, they may close or cover one eye when it deviates, especially at first. Adults, on the other hand, have more symptoms when they develop strabismus. They have double vision (see a second image) and may lose depth perception. At all ages, strabismus is disturbing. Studies show school children with significant strabismus have self-image problems.

Amblyopia (“lazy eye”) is closely related to strabismus. Children learn to suppress double vision so effectively that the deviating eye gradually loses vision. It may be necessary to patch the good eye and wear glasses before treating the strabismus. Amblyopia does not occur when alternate eyes deviate, and adults do not develop amblyopia.

Tearing in Children

Although it can be caused by wind, smoke, or pollen, an excess of tears in children is often caused by congenital nasolacrimal duct obstruction, a condition in which a baby’s tear duct is blocked instead of draining normally through the duct into the nose. The condition can be recognized by tears that build up on the surface of the eye and overflow onto the eyelashes, eyelids, and down the cheek. Because the tears are not draining normally, babies will sometimes get infections, which can cause red, swollen eyelids and yellowish-green discharge.

Congenital nasolacrimal duct obstruction is usually caused by the failure of a thin tissue at the end of the tear duct to open properly when the child is born. It can also be caused by a lack of openings to the duct system at the eyelids, by infections, and by abnormal growth of the nasal bone, which pinches off the tear duct. Some infants may have excessive tearing due to narrow tear ducts rather than an obstruction. In this case, the tearing may be intermittent, occurring when the infant has a cold or during especially windy or cold weather. Finally, congenital glaucoma can cause tearing in children. This serious condition is often accompanied by other signs, including an enlarged eye, a cloudy cornea, and light sensitivity.

Most babies born with blocked tear ducts do not need treatment. More than 90% of blocked tear ducts clear by themselves before the child turns 1 year old. If treatment is necessary, the first course of action is usually tear duct massage, along with topical antibiotics to treat infection. The tear sac is located between the inside corner of the eye and the side of the nose. The purpose of massage is to put pressure on the tear sac for a few seconds to pop open the membrane at the end of the tear duct. This is most easily done by putting your hands on each side of the baby’s head and using your index fingers to press on the tear sac. This should be done several times a day, such as at after feedings or diaper changes.

In certain circumstances, tear duct probing, balloon tear duct dilation, or tear duct probing with tube placement may be necessary. Should your infant need treatment to remove a tear duct obstruction, ask your ophthalmologist (Eye M.D.) to discuss appropriate treatment options with you.

 

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