The eyes are the child’s windows to the world. Visual disturbances can have far reaching consequences in a growing child. A quick eye exam at birth, checking external eye structures, eye movement and pupils can reveal gross abnormalities. The red reflex test is used to screen for abnormalities in the back of the eye. To be considered normal, the red reflex of the two eyes should be symmetrical. Thus, opacities in the visual axis, such as a cataract or corneal opacity can be detected early. Here we will discuss some of the common eye problems seen in paediatric practice.
- Cataract: Congenital cataract is a serious eye problem that should not be missed at birth. Bilateral congenital cataract is the most common cause of treatable childhood blindness. Surgery must be performed promptly in cases with dense congenital cataract; if not detected early, nystagmus, an involuntary eye movement may occur and may be followed by amblyopia (lazy eye), which may be irreversible. Surgery should be done preferably within two months of birth, with close follow up by an ophthalmologist.
- Retinopathy of prematurity: With advances in neonatal intensive care, we have more surviving very-low birth-weight babies and pre-terms. Those born less than 32 to 34 weeks of gestation and less than 1500 gms are prone to retinopathy of prematurity (ROP). This is a disease that affects immature vasculature in the eyes of premature babies. It can be mild with no visual defects, or it may become aggressive with new blood vessel formation (neovascularisation), which can progress to retinal detachment and blindness. Re-attachment of retina will not improve vision in these infants. At-risk neonates must be screened for ROP as a general rule at one month of life. Peripheral retinal ablation with laser under adequate analgesia and sedation by an ophthalmologist is the preferred method for treatment of severe ROP.
- Conjunctivitis: Known popularly as ‘Madras eye’, conjunctivitis is inflammation of the outermost covering of eyeball or inner surface of eyelid, usually caused by adeno viruses and occasionally by bacteria. It appears with pinkish colouration of eyes with copious eye discharge causing gumming of eyelids. Treatment is by instilling antibiotic drops in the eyes frequently, at least four to six times a day to prevent bacterial superinfection. It is spread through sharing objects with or close contact like shaking hands with the patient. During the season it is better to frequently wash hands and avoid touching eyes. Caution should be exercised when using swimming pools during the seasonal outbreaks. Keep the child from attending school, and other crowded places. Good response to treatment should usually be seen within two to three days, failing which it is better to see the doctor.
- Refractive errors: Since children do not report symptoms, it is better that all children have an eye check by three to four years to rule out short sight or long sight. Frequent tearing of eyes, squinting very closely at objects or while reading, sitting very close to the television, and headaches or eye pain after reading for long hours are all indirect pointers. A child referred for dyslexia because of poor school performance did very well when his myopia was identified and was prescribed glasses, much to the embarrassment of the school.
Myopia or short-sightedness is when near objects can be seen well but there is defective vision for distant ones. Children with hyperopia have difficulty in looking at distant objects and may present with squint or crossed eyes. Astigmatism is when the curve of the cornea is uneven and hence light does not focus to a single sharp point and causes blurred vision. Spectacles or contact lenses can sharpen vision. Loading children with refractive errors with vitamin A does not help. Instead, they should be encouraged to wear their spectacles or contact lenses regularly. This will help them see more clearly and help parts of the brain concerned with vision to grow and develop properly.
- Squint: A squint is a condition where the eyes look in different directions. The misalignment of the eyes can be caused by a problem with the eye muscles or by an uncorrected vision problem, such as short-sightedness or long-sightedness. Many babies occasionally squint up to three months of age as their vision develops. This is normal and nothing to worry about. If beyond this period the child still has a squint, he should be evaluated and treated promptly. In young children, a squint can cause blurred vision, double vision and lazy eye (amblyopia).
Treatment is most effective in very young children and can be done with glasses (to treat the refractive errors myopia, hyperopia, astigmatism), eye patch, eye exercises and corrective surgery. Glasses are used most commonly. An eye patch may be worn few hours a day for several weeks over the ‘good’ eye to encourage the eye with the squint to work harder. This will not correct the squint, but it can improve the vision in the lazy eye. Eye patches are most effective if they are worn before a child is seven or eight years of age. In some cases, it may be possible to treat a squint using special eye exercises that help the eyes work together. Surgery may be a treatment option if none of the above interventions work.
- Amblyopia: A clear picture conveyed to the visual cortex of the developing brain trains the brain to see. A squint, cataract or droopy eyelids may prevent light from an object from being focused sharply on to the back of the eye. The brain then ignores images from the affected eye leading to a ‘lazy’ eye, also known as amblyopia. This is more common in a child who has a squint. Treatment should be started early and if delayed beyond the age of eight, it is unlikely to be as successful. The main treatment options are treating or correcting any underlying eye problems and encouraging the use of the affected eye, so that vision can develop normally.
- Allergic conjunctivitis: Allergic conjunctivitis occurs when the eye has a reaction against an allergen such as dust, dander or pollen. This appears in the form of red eyes, watering, itching or burning in the eyes, puffy eyelids, especially in the morning and eye discharge. If the cause of the allergic reaction is identified, avoiding the allergen will help. Anti-inflammatory eye drops or steroid preparations are used for treatment, but have to be closely supervised by the doctor.
In the absence of specific complaints, it is our duty as caregivers to pick up potential problems and have a thorough eye check at the appropriate time.