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Paediatric Ophthalmology Department |
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| Paediatric Ophthalmology Department |
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 Pediatric ophthalmology is a subspecialty of ophthalmology dealing with children's eye diseases. Vision in a newborn is very underdeveloped and develops as the brain matures taking about ten years to reach adult levels. Vision impairment in childhood has a dramatic impact not only on the social development of the child, but also on their learning capability and potential.
Since some serious eye disorders produce no early warning symptoms, it becomes all the more necessary to know when to get your child evaluated by a qualified professional. Quite often parents have no way of recognizing an eye problem unless the underdeveloped or affected eye looks obviously abnormal.
There are a number of eye disorders that affect infants and children. These include sight threatening disorders like strabismus or squint, amblyopia (lazy eye), high refractive errors, cataract, glaucoma, retinopathy of prematurity, tumors like retinoblastoma to name a few and other usually not so serious (to vision) conditions like simple conjunctivitis, allergies, and blocked tear ducts. The former need to be recognized and treated at the earliest, in order to provide the maximum attainable vision, before damage to sight becomes irreversible.
Some children or infants have visual disorders that are secondary to serious diseases in their brain or nervous system. Vision problems include cortical blindness, delayed visual maturation, optic nerve hypoplasia and optic nerve atrophy. The Paediatric Ophthalmology Department at ICARE treats about 5000 patients annually. |
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| Refractive Error: |
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| What is Refractive Error? |
| Refractive error is a condition wherein the rays of light do not form a focused image at the correct plane in the eye. They are focused either in front or behind the appropriate plane, leading to blurred images either for distance in myopia or for near in hypermetropia. In some, this defocused image may be only for a particular axis, what is commonly referred to as astigmatism or a cylindrical number. |
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| How common is it? |
| Myopia or ‘far sightedness’ is seen in about 30 out of every 100 persons in the population, with a much higher prevalence in school going children. Increased near work is a very important contributory factor to this disorder. Hypermetropia or ‘near sightedness’ is less common, but if not detected early it is more damaging to vision. Both show a familial tendency. So families with history of these disorders should get their children evaluated early. |
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| Why is it important to treat it at the earliest? |
| This is usually a minor disorder, as it can be easily rectified with the use of glasses. However, it can become a major and permanent cause for poor vision, if not detected and treated in early childhood. If undetected for long, as it is in a surprisingly large number, it can not only affect development of vision, but also have a dramatic impact on their learning capability. |
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| What is the treatment? |
As mentioned, constant use of spectacles is the simple answer in a vast majority. However, if it has been detected late in a child with either a ‘high number’ or a significant difference in the spectacle number between the two eyes, there may be a significant weakness in the vision of the eye with the larger number-the so called ‘lazy eye.’ This may need occlusion therapy.
 When should you suspect that your child has a refractive error?
If you find that your child is unable to see things that are at a distance clearly, rubs or squeezes his eyes often, has repeated styes’ in the eye, adopts a different head posture with tilting of the head or chin when focusing on anything intently, it is quite likely, that your child needs to be evaluated by the doctor to rule out a refractive error.
When should your child undergo a regular eye check-up to assess vision and the need for spectacles?
According to the guidelines laid down by American Academy of Ophthalmology, all children should have a comprehensive eye examination by their 4th birthday, if vision appears to be developing normally, and every 2 years thereafter. Certainly by pre-school your child should have regular eye examinations to maintain proper eye health. |
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| Squint |
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| What is Squint? |
| Squint or ‘crossed eyes’ is a misalignment of the eyes, wherein both the eyes point in different directions. While it could be an independent disorder, there are some in whom the basic problem is that of a cataract or corneal opacity blocking proper vision formation in the eye leading to a squint. |
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| How common is it? |
| About 4 in every hundred persons is detected to have a squint on evaluation. |
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| How do I suspect a squint in my child? |
While a squint could present with an obvious misalignment of the eyes, it could also show up in many other ways like an abnormal head posture with tilting of the head/chin or squinting of the eyes in bright sunlight.
It can manifest at any age, some presenting right at birth. |
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| When should I get my child for a check-up? |
| As soon as a squint is suspected, it is imperative that the child is examined by a pediatric ophthalmologist at the earliest. If there is a family history of squint, it is advisable to get an evaluation of the child even if there is no obvious misalignment. |
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| What if I decide to wait till my child is older before getting him for a check-up? |
There is a common misconception that a squint may disappear as the child grows. This leads to an unfortunate delay in seeking medical attention. Any such delay only limits the chances of attaining a normal or optimum vision. An uncorrected squint leads not only to the impairment of ‘reading vision’ with the development of a ‘lazy eye’, but also affects depth perception or 3 dimensional vision   permanently. |
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| What can I expect after the doctors evaluation? |
While some squints are completely corrected just with the use of glasses or eye muscle exercises, others need surgery.
In those children who develop a squint, because of a cataract or any other disorder that prevents the formation of normal images in the eye, the treatment would be to first tackle the primary cause and then the squint.
Your doctor may decide to go for occlusion therapy (see below), if it is indicated. This is done to strengthen a weaker eye prior to surgery, so as to ensure maintenance of alignment of the eyes after the operation. |
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| Lazy Eye/Amblyopia |
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| What is Amblyopia or “Lazy Eye”? |
Amblyopia or lazy eye is a weakness of one or both the eyes, seen in children with a high spectacle number or a significant difference in spectacle number between the two eyes. It is more common with ‘plus lenses’.
Another common cause of ‘lazy eye’ is a squint or misalignment of the eyes. The third important cause is an obstruction in the path of the light rays reaching the eyes, either due to cataract, opacities in the cornea or any other cause.
It affects approximately 2 or 3 of every 100 people. |
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| How can it present? |
| In some children it can be detected because the weakness in vision of one or both eyes is quite apparent. Unfortunately, however, quite often there is no obvious indicator to the parents that one eye is weaker. |
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| What you need to do? |
| Get your child evaluated at regular (See above) intervals by a pediatric oriented ophthalmologist. |
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| What is the treatment of this condition? |
 Those children who need high numbered glasses or who have a squint usually show a good response to occlusion therapy provided it is started early. However the squint would need to be treated surgically once the eyes gain optimal vision. If the ‘lazy eye’ is due to a cataract, corneal opacity etc. that needs to be tackled first. However, even in the latter, the amblyopia cannot be cured just by treating the cause. After surgery, occlusion treatment is needed to strengthen the weaker eye. All such children benefit enormously by occlusion treatment of the eyes done in a regulated manner at the appropriate time. |
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| What is Occlusion Therapy? |
There are various types of occlusion treatment. The basic purpose of all of them is to strengthen the weaker eye, by allowing that eye to see longer or preferentially and thus get stronger.
The occlusion can be either in the form of an adhesive patch worn over the stronger eye (see picture), contact lenses worn or eye drops instilled in the stronger eye to make the vision blurred in that eye. The commonest and most ideal type is occlusion with a patch. |
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| When should occlusion treatment be started? |
As soon as your ophthalmologist detects a lazy eye, he would decide to start with this treatment, whenever indicated. It is extremely important to detect and treat a lazy eye at the earliest, at the time of ‘plasticity’ or growth of the eye. This is generally accepted to be till about 9 years of age. After this age, though a trial of this therapy is still given till the teens, the results are less encouraging.
In general, success depends on the severity of the weakness, cause and most importantly, the age of the child at the time of detection. |
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| What if it is not detected or treated at an early age? |
| A delay in treatment would not only impair visual acuity, but also 3 dimensional vision or depth perception irreversibly. Left untreated, visual acuity in the amblyopic eye may be permanently reduced and a lifetime of poor and uncorrectable vision could result. |
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| Childhood Cataract |
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| Can cataract occur in young children? |
 Yes, while cataract (opacification of the lens in the eye) is one of the leading causes of childhood blindness in the western world, it is not uncommon in our country. |
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| How do I get to know that my child has a cataract? |
While an advanced cataract may be obvious with a white reflex from the pupil of the eye, an early cataract may be difficult to identify, unless the child is evaluated by an ophthalmologist.
In cases in which the cataract affects only one eye, it may be even more difficult to suspect, since the child carries out all his activities with the normal fellow eye. |
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| What is the treatment? If surgical, can I wait for my child to grow up before I consider getting him operated? |
 Treatment of cataract in children is mainly surgical. The surgeon would suggest the appropriate time and type of surgery depending on the type of catarct. Most children require the surgery at the earliest to prevent development of amblyopia (lazy eye). |
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| After surgery, will he need any further medical or surgical treatment? |
Yes. Some children with a cataract in one eye may need treatment for ‘lazy eye’ (described above). All children need to be regularly monitored for glaucoma and the need for change of glasses.
Further, at a later date, some may develop a membrane in the eye after the surgery, that may need to be removed by laser or surgery. |
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| Congenital Nasolacrimal Duct obstruction |
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| Retinopathy of Prematurity |
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| What is retinopathy of prematurity? |
| Retinopathy of prematurity (ROP) is a leading cause of childhood blindness in developed countries. Premature or low birth weight babies often need to receive oxygen until their immature lungs develop. Today, it is well accepted that exposure to high levels of oxygen over extended periods of time can trigger the disease in infants, causing the retina's tiny developing blood vessels to grow abnormally and lead to scarring of the retina. In some children, the retina is able to recover and damage is moderate. However, in severe cases, there is retinal detachment and, ultimately, blindness. |
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| When should such children be examined? |
| Any baby at risk for this condition should undergo a thorough screening of the retina at the earliest to detect the abnormality. Such infants can also have a misalignment of their eyes, which would need appropriate management. |
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| What is the treatment? |
| While the early stages of ROP resolve on their own spontaneously, advanced stages need laser treatment. The earlier it is detected the better the visual outcome. |
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| Retinoblastoma |
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| What is Retinoblastoma? |
Retinoblastoma (RB) is a rare form of cancer affecting the light-sensitive retinal cells that enable sight. Although the disease is very rare, it is the most common eye malignancy in children and the third most common cancer to affect children- occurring in one out of every 15,000 births. It tends to occur in families.
It is often detected by the caregivers, as a ‘white reflex’ in the pupil of the eye. |
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| What is the treatment? |
| The treatment of RB depends on the size and location of the tumor and whether one or both eyes are involved. With earlier detection and improved treatments, the prognosis for vision and life for RB patients has improved significantly in the past twenty years. However, because the disease is so rare, many pediatricians and primary care providers may not recognize the early signs, and parents rarely notice the subtle changes that may identify a tumor in their child’s eyes. Left untreated, RB tumor nodules grow rapidly, expanding to fill the eye and extending along the optic nerve to the brain, ultimately causing death. |
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| Childhood Glaucoma |
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