Pediatric Ophthalmology, P.A. & The Center for Adult Strabismus

What is amblyopia?
What can a baby see?
What are the signs of poor vision in a child?
How do you know if a baby or young child needs glasses?
What is a blocked tear duct (Nasolacrimal duct obstruction)?
How is a blocked tear duct treated?
What are cataracts in children?
What is a chalazion and how is it treated?
Eye care facts and myths
What is retinopathy of prematurity (ROP)?
What is strabismus?

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”. 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 can a baby see?

Babies have poor vision at birth but can see faces at close range, even in the newborn nursery. At about six weeks a baby's eyes should follow objects, and by four months should work together. Over the first year or two, vision develops rapidly. A two-year-old usually sees around 20/30, nearly the same as an adult.

What are the signs of poor vision in a child?

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 uninterested in faces or age-appropriate toys, or if the eyes rove around or jiggle (nystagmus), poor vision should be suspected. Other signs to watch for are tilting the head and squinting. Babies and toddlers compensate for poor vision rather than complain about it.

How do you know if a baby or young child needs glasses?

Should a baby need glasses, the prescription can be determined accurately by dilating the pupil and analyzing the light reflected through the pupil from the back of the eye. Prescriptions for glasses can be measured in even the youngest and most uncooperative children by using a special instrument called a retinoscope to analyze light reflected through the pupil from the back of the eye.

What is a Blocked Tear Duct (Nasolacrimal duct obstruction)?

Obstruction of the tear duct will cause tearing or watering of the eye because the tears cannot drain properly. Symptoms of a blocked tear duct include eyelashes that are stuck together by mucus or an accumulation of tears in one or both eyes. The tears trapped within the duct may become infected, causing a painful swelling in the inner corner of the eyelid. In infants the membrane that causes the obstruction will usually open by six months of age. If this does not occur, your physician will often recommend treatment to open the blockage.

How is a blocked tear duct treated?

Initial treatment involves massaging the area over the affected tear sac (located under the skin between the eye and nose) to force the tears and mucus from the sac, hopefully pushing open the membrane causing the obstruction. In infants, this massage requires the active involvement of the parent, as it must occur frequently. Massage is generally continued until the tearing resolves. Antibiotic drops or ointments may also be prescribed by the physician in the event of infection. If the obstruction is still present, it may be necessary to open the tear duct by probing and irrigation. This is most commonly performed between six months and one year of age. The probing is done by passing a thin probe down the tear drainage system in an attempt to open the blockage. There is minimal pain associated with this procedure. After the probing, there may be some brief blood staining of the tears or a slight nosebleed. Antibiotic drops may be prescribed. This procedure is 90-95% effective after the first treatment. Unfortunately, blockages may recur in spite of probing. If the tearing persists, then a small tube may be placed down the duct to keep the tear draining system open. The tubes are tiny and generally imperceptible, and usually remain in place for six to twelve months to prevent the obstruction from recurring.

What are cataracts in children?

A cataract is a clouding of the eye's normally clear lens. The lens of the eye plays an important role in focusing images on the retina, the light-sensitive nerve cells lining the back of the eye. If the lens loses its clarity, light rays do not focus clearly and vision is blurry. Just as it is hard to see through a dirty window, it is hard to see through a cataract. Although most cataracts occur in older adults, they can appear in children, in one or both eyes, at birth with an incidence of one in one thousand births. They look like a white or gray spot in the pupil. Cataracts in children may be inherited or develop because of an infection or a disease acquired before birth, or as a result of an injury. In most cases, no specific cause is found. Children may lose vision permanently because of amblyopia (lazy eye) if a severe cataract is not removed quickly. The better eye will often require patching to strengthen the vision in the poorer seeing eye. Mild cataracts may not need treatment.

The focusing power of the original lens, removed during cataract surgery, must be replaced to restore vision. Intraocular lenses (IOLs), permanent plastic lenses placed inside the eye, are implanted in children and older babies as they are in adults. Regardless of the type of correction, children need follow-up exams to avoid possible complications, including glaucoma, scar tissue forming in the pupil, and amblyopia. Often, children will need eye muscle surgery because the eye turns or crosses.

Despite these problems, cataracts are the single most treatable cause of childhood blindness. After surgery, most children can see the blackboard in school (20/60-20/100). While some do not do as well, with appropriate correction, many children see almost normally.

What is a chalazion and how is it treated?

The term chalazion (pronounced chah la' ze on) is derived from the Greek word meaning small lump. It refers to a cystic swelling with chronic inflammation in an eyelid. A gradual enlargement can be felt near the margin of the lid due to the swelling in one of the eyelid oil glands (meibomian).

Treatment may involve any one or combinations of the following: antibiotic and/or steroid drops or injections, warm compresses, massage, or expression of the glandular secretions, surgical incision or excision.

Large chalazions which do not respond to other treatments can be surgically opened after the early inflammation is reduced. Surgical intervention in children is performed under general anesthesia.

Eye Care Facts and Myths.

Myth

Reading in dim light is harmful to your eyes.
It is not harmful to watch a welder or look at the sun if you squint, or look through narrowed eyelids.
Using a computer, or video display terminal (VDT), is harmful to the eyes.
If you use your eyes too much, you wear them out.
Wearing poorly-fit glasses damages your eyes.
Wearing poorly-fit contacts does not harm your eyes.
You do not need to have your eyes checked until you are in your 40s or 50s.
Safety goggles are more trouble than they're worth.
It's okay to swim while wearing soft contact lenses.
Children outgrow crossed eyes.
A cataract must be ripe before it can be removed.
Cataracts can be removed with lasers.
Eyes can be transplanted.
All eye care providers are the same.
Eye exercises help with learning or reading problems and cure most forms of strabismus.
All children with small amounts of farsightedness, astigmatism, and nearsightedness need glasses.
Adults with strabismus can’t be helped.

Fact

Although reading in dim light can make your eyes feel tired, it is not harmful.
Even if you squint, ultra-violet light still gets to your eyes, damaging the cornea, lens and retina. Never watch welding without wearing the proper protection. Never look directly at an eclipse.
Although using a VDT is associated with eyestrain or fatigue, it is not harmful to the eyes.
You can use your eyes as much as you wish-they do not wear out.
Although a good glasses fit is required for good vision, a poor fit does not damage your eyes
Poorly fit contact lenses can be harmful to your cornea (the window at the front of your eye). Make certain your eyes are checked regularly by your ophthalmologist if you wear contact lenses.
There are several asymptomatic, yet treatable, eye diseases (most notably glaucoma) that can begin prior to your 40s.
Safety goggles prevent many potentially blinding injuries every year. Keep goggles handy and use them!
Potentially blinding eye infections can result from swimming or using a hot tub while wearing contact lenses.
Children do not outgrow truly crossed eyes. A child whose eyes are misaligned has strabismus and can develop poor vision in one eye (a condition known as amblyopia) because the brain turns off the misaligned or "lazy" eye. The sooner crossed or misaligned eyes are treated, the less likely the child will have permanently impaired vision.
With modern cataract surgery, a cataract does not have to ripen before it is removed. When a cataract keeps you from doing the things you like or need to do, consider having it removed.
Cataracts cannot be removed with a laser. The cloudy lens must be removed through a surgical incision. However, after cataract surgery, behind the artificial lens may become cloudy. This membrane can be easily opened with laser surgery.
The eye cannot be transplanted. It is connected to the brain by the optic nerve, which cannot be reconnected once it has been severed. The cornea can be transplanted. Surgeons often use plastic intraocular lens implants (IOL’s) to replace natural lenses removed during cataract surgery.
An ophthalmologist is a medical doctor (M.D.) or doctor of osteopathy (D.O.), uniquely trained to diagnose and treat all disorders of the eye. An ophthalmologist is qualified to perform surgery, prescribe and adjust eyeglasses and contact lenses, and prescribe medication.
An optometrist (O.D.) is not a medical doctor, but is specially trained to diagnose eye abnormalities, and prescribe, supply and adjust eyeglasses and contact lenses. In most states, optometrists are qualified to treat certain eye disorders.
An optician fits, supplies, and adjusts eyeglasses and contact lenses. An optician cannot examine the eyes or prescribe eyeglasses or medication.
Eye exercises and tinted lenses do not help with learning or reading problems. In addition, eye exercises may help in only a few instances of eye alignment problems.
Eye glasses are necessary only when the vision of the eye(s) is significantly reduced or, in some cases, when the eyes cross due to excessive farsightedness.
Adults with strabismus have multiple options to improve or correct the alignment of their eyes. An ophthalmologist trained in Pediatric Ophthalmology in many cases will treat adults with strabismus.

What is Retinopathy of Prematurity (ROP)?

Retinopathy of Prematurity (ROP) damages premature babies' retinas, the layer of light-sensitive cells lining the back of the eye. ROP usually occurs in both eyes, though one may be more severely affected.

The last 12 weeks of a full-term pregnancy are an especially active time for the growth of the eye. When a baby is born prematurely, blood vessels are not ready to supply blood to the retina. At birth, abnormal new blood vessels form and cause scarring or detachment of the retina. The condition is especially common in very small babies. It is more likely to occur at one or two pounds than at three pounds.

Despite improved medical care, the disease is becoming more common because smaller and sicker infants are surviving. Supplemental oxygen given to premature babies may be part of the cause of ROP, but not the only factor, as once thought.

In severe cases, the retina may be extremely scarred and detached. Many cases get better without treatment and only a small number of children go blind. Freezing (cryotherapy) laser treatments can prevent progression of the disease.

Children with ROP are more likely to develop nearsightedness, strabismus, and amblyopia (lazy eye). Glasses, patching, and eye muscle surgery can help these associated problems. Follow-up exams of severely affected.

What is Strabismus?

Strabismus refers to misaligned eyes. If the eyes turn inward (crossed), it is called esotropia. If the eyes turn outward (wall-eyed), it is called exotropia. One eye can be higher than the other, which is called hypertropia (for the higher eye) or hypotropia (for the lower eye). Strabismus can be subtle, (occurring occasionally), or constant. It can affect one eye only or shift between the eyes.

Strabismus usually begins in infancy or childhood, but many adults develop strabismus often due to trauma or brain tumors. Some toddlers have accommodative esotropia. Their eyes cross because they need glasses for farsightedness. 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.

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. Often, the child’s brain learns to ignore or suppress the vision in the deviated eye. 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. Studies show school children with significant strabismus have self-image problems.

Amblyopia, or 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 the child alternates use of the deviated eyes. Adults do not develop amblyopia.

Strabismus is often treated by surgically adjusting the tension on the eye muscles. The goal of surgery is to straighten the eyes and allow them to move normally so that they will use the eyes together. Surgery is very successful at improving the condition, though a few patients (15-20%) will require additional surgery. Prisms and Botox injections of the eye muscles are alternatives to surgery in some cases. Eye exercises are rarely effective.