Pediatric Ophthalmology and Strabismus

A pediatric ophthalmologist is a medical and surgical doctor who specializes in the care of children’s eyes. They are trained to diagnose, treat, and manage all children’s eye problems, as well as prescribe eyeglasses and contact lenses. They are skilled at recognizing the subtle signs of an eye problem that a baby or young child cannot describe.

Good vision is important to help ensure children can be successful in life and in school. Neurologic development of vision occurs up until approximately age 12 years. Misalignment of the eyes or strabismus, uncorrected refractive errors (such as myopia), and asymmetry of refractive errors between the two eyes can negatively affect this development and cause amblyopia. If these conditions are diagnosed and treated early, good vision can develop and can be maintained. Therefore, it is important that children undergo vision screening more to identify these treatable conditions.

Our team of pediatric ophthalmologists provides the most advanced diagnostic consultations as well as medical and surgical management of children’s eye disorders. We diagnose and treat a wide range of eye conditions, including pediatric cataracts, pediatric glaucoma, tear duct problems, ocular trauma and injury.  Additionally, we treat adults with double vision and misalignment of the eyes.

A vision screening is a brief eye test that looks for potential vision problems and eye disorders. They are often first performed by the child's pediatrician. Vision screenings do not diagnose vision problems but if a problem is found, your child's provider will refer you to an eye specialist for diagnosis and treatment.

Your child’s vision can be screened by a:

• pediatrician
• family physician
• optometrist
• ophthalmologist
• or other properly trained health care provider

Screenings are also offered at schools, community health centers or community events.

The American Academy of Ophthalmology (AAO) recommends the following schedule:

Newborn 

A pediatrician, family physician, or other properly trained health care provider should examine a newborn's eyes for general eye health and perform a red reflex test in the newborn nursery. Any baby with an abnormal red reflex requires urgent consultation. An ophthalmologist should be asked to examine all high-risk infants (i.e., those at risk of developing retinopathy of prematurity (ROP); those with a family history of retinoblastoma, glaucoma, or cataracts in childhood; those with a family history of retinal dystrophy/degeneration; those with systemic diseases or neurodevelopmental delays associated with eye problems; those with any opacity of the ocular media; or those with nystagmus).

1 month to 4 years of age

From 1 month to 4 years of age, infants and toddlers should have their ocular health assessed at each routine well-child visit, including an external inspection, pupillary examination, corneal light reflection and assessment of fixation and following behavior. This assessment should address any concerns raised by the family or noted by the primary care provider.

3 ½  to 4 years of age

Emphasis should be placed on checking visual acuity as soon as a child is cooperative enough to complete the assessment. Generally, this occurs between ages 3 ½ and 4 years. This assessment can be performed by a pediatrician, family practitioner, ophthalmologist, optometrist, orthoptist, nurse, or other appropriately trained individual. Screeners should not have a vested interest in the screening outcome. A child who is referred from a vision screening or is uncooperative at a second attempt at vision testing should be referred for a comprehensive eye evaluation. It is essential that a formal testing of visual acuity be performed by the age of 5 years.

3 to 5 years

Photoscreening and handheld autorefraction may be electively performed in children 12 months to 3 years of age, allowing earlier detection of conditions that may lead to amblyopia. Photoscreening and handheld automated refraction are recommended as an alternative to visual acuity screening with vision charts (typically used for children 3 through 5 years of age) and in children who are unable or unwilling to cooperate with routine acuity screening with vision charts (but are not superior to vision chart testing for children able to participate). The use of vision charts to assess amblyopia in children 3 to 5 years of age remains a viable practice at the present time.

5 years and older

Additional screening on each child should be done at routine school checks or well-child visits every 1-2 years after age 5 years. Routine comprehensive professional eye examinations performed on normal asymptomatic children have no proven medical benefit.

Children with possible or diagnosed learning disabilities, such as dyslexia, should undergo a comprehensive eye examination so that any undiagnosed vision impairment can be identified and treated. Such children should be referred for appropriate medical, psychological, and educational evaluations and treatment of any learning disability. There is inadequate scientific evidence to suggest that “defective eye teaming” and “accommodative disorders” are common causes of educational impairment.2,3 Hence, routine screening for these conditions is not recommended.

What’s the difference between vision screening and a comprehensive eye exam?

A comprehensive eye exam diagnoses eye disease. Eye drops are used to dilate (widen) the pupil during the exam. This gives your ophthalmologist a fuller view inside the eyes. With dilation and other special testing, signs of eye disease are more evident. The American Academy of Ophthalmology advises parents to seek a comprehensive eye exam if:

• their child fails a vision screening
• a vision screening is inconclusive or cannot be done
• referred by a pediatrician or school nurse
• their child has a vision complaint or observed abnormal visual behavior
• is at risk for developing eye problems - children with medical conditions (such as Down syndrome, prematurity, juvenile idiopathic arthritis, neurofibromatosis) or a family history of amblyopia, strabismus, retinoblastoma, congenital cataracts or glaucoma are at higher risk for developing pediatric eye problems
• their child has a learning disability, developmental delay, neuropsychological condition, or behavioral issue

Amblyopia starts in childhood and is the most common cause of vision loss in kids. Up to 3 out of 100 children have it. The good news is that early treatment works well and usually prevents long-term vision problems. Untreated, lazy eye can cause permanent vision loss.

What is Amblyopia?

Amblyopia is when vision in one or both eyes does not develop properly during childhood as a result of eye misalignment, uncorrected high prescription, or an obstruction to light reaching the back of the eye like a cataract or droopy eyelid. It is also called lazy eye.

Risk Factors 

Risk factors associated with an increased risk of lazy eye include:

• Premature birth
• Small at birth
• Family history of misaligned eyes
• Developmental disabilities

Symptoms

Symptoms can be hard to notice. Parents may notice signs their child is struggling to see clearly. Some symptoms include:

• An eye that wanders inward or outward
• Poor depth perception
• Squinting
• Shutting one eye
• Tilting one's head to see an image clearly

Since it is generally difficult to notice, it is recommended for children to get a vision screening at least once between ages 3 and 5. 

Treatments

• Eyeglasses
• Covering the strong eye with a patch to stimulate the weaker eye
• Putting special eye drops in the stronger eye
• Surgery to realign the eyes in cases involving strabismus

It's important to start treating children with amblyopia early — the sooner, the better. Kids who grow up without treatment may have lifelong vision problems.

Strabismus is the misalignment of the eyes, in which one eye deviates inward toward the nose (esotropia), outward toward the ear (exotropia), upward (hypertropia), or downward (hypotropia) while the other eye remains looking straight ahead. Strabismus is relatively common. Between 2 and 4 percent of kids have esotropia and 1 to 1.5 percent have exotropia. Almost 1 out of 20 kids has strabismus.

Uncorrected strabismus can have far-reaching effects, including loss of vision and depth perception, as well as adverse effects on psychosocial development and gainful employment.

What causes strabismus?

Strabismus can be present at birth as well as develop during childhood or as an adult. In newborns, especially if they are tired, eye misalignment is common as the baby's eye muscles are developing and the baby is learning to focus. This is normal but they should outgrow it by 4-6 months of age. In children, strabismus is typically from a problem with the eye muscles and can have a genetic component. Uncorrected strabismus can lead to amblyopia, a condition in which the brain starts to ignore signals sent by the weaker, misaligned eye leading to vision problems.

Most adults with strabismus have had it since they were children. But at times, it starts later in life. In these situations, the adult usually has a problem that can affect eye muscles. Some of those problems may include:

• Health problems such as diabetes, thyroid disease (Graves' disease), Myasthenia gravis, brain tumors, or a stroke
• Accidents or head injury
• Damage to eye muscles during other kinds of eye surgery

Symptoms

Children do not necessarily realize there is a problem with their vision. Often it is another individual who notices the misalignment of the child's eyes. Occasionally a child may complain of double vision.

Adults, generally those with new strabismus and besides the most apparent symptom of having eyes that appear out of alignment, may experience:

• Weakness around their eyes or feeling like something is pulling around their eyes
• Double vision, loss of depth perception, or trouble reading
• Constantly tilting their head to see an image clearly

Treatments

• Eyeglasses for mild strabismus
• Vision Therapy
• Eye Muscle Surgery
• In cases of amblyopia, covering the strong eye with a patch to stimulate the weaker eye

Myopia (nearsightedness) is becoming increasingly prevalent worldwide. Myopia is associated with several pathological eye conditions, potentially leading to irreversible vision loss. Treatment for limiting myopia progression is critical early in life.

Several studies have associated myopia with the increase in near-work activities. Children are spending less time outdoors and more time in front of their phone, tablet, or computer. At a young age, this can impact the eyes' development, causing the eye to grow too long, which changes the focus of light in the eye and cause far away objects to appear blurry. As the eye grows longer the risk of the different pathological eye condition increases.

Treatments

• Generally myopia can be corrected with glasses and contacts
• To help prevent myopia, it is recommended for children to spend at least two hours per day outside.
• To help prevent progression, wearing correction (glasses or contacts) full-time is the first step. Uncorrected blurred vision research has shown myopic progression may increase
• When myopia continues to increase at an unexpected rate there are other options including drops and specific types of contact lenses
• There are other treatment options to help slow down myopia progression being currently studied. Our team at the Gavin Herbert Eye Institute are committed to staying up to date to be able to be able to provide the best treatment recommendation for each patient.