Children’s Eyecare

What is Pediatric Ophthalmology?
Pediatric Ophthalmology is a specialized branch of ophthalmology dedicated to diagnosing and treating eye disorders in children. Childrens’ eyes are not miniature adult eyes and a pediatric ophthalmologist has additional training, experience, and expertise in examining children, and has the greatest knowledge of possible conditions that affect the pediatric patient and his/her eyes.

Common eye problems affecting children include refractive errors (myopia, hyperopia, astigmatism), pink eye (conjunctivitis), eye rubbing, misalignment of eyes (squint), eye watering etc. Sometimes diseases elsewhere in the body can affect the eyes and a pediatric ophthalmologist manages these too.

Managing chidlrens’ eye disorders differs from that in adults because in children, eye sight related problems can affect the neurologic development of vision causing their eye to be “lazy” which is termed as amblyopia. Early diagnosis & treatment is necessary to ensure development of good vision in both the eyes and prevent lazy eyes.

What kinds of treatments do pediatric ophthalmologists provide?
Medical treatments:

• Prescriptions for spectacles and/or contact lenses
• Amblyopia (“lazy eye”) therapy including glasses, eye patching exercises or computer based exercises
• Topical (eyedrops) and or/systemic therapy for eye and lid infections, blocked tear ducts, raised eye pressure and inflammation in the eye

Surgical Procedures:

• Eye muscle surgery for squint and nystagmus (shaky eyes)
• Pediatric cataract extraction including use of intraocular lenses (IOLs)
• Probing and syringing for congenital nasolacrimal duct obstruction (blocked tear duct)

Additional treatments/surgeries performed by some include retinal examination and laser treatment of retinopathy of prematurity (ROP), surgical removal of pediatric orbital tumors/lesions, and surgery for glaucoma or ptosis (drooping eyelid) in the child based on their further training, experience and individual interest.

EYE PATCHING THERAPY - FACTS & MYTHS

In children with normal vision, the brain develops the ability to use both the right and left eye together starting as early as the first few months of life. This is called binocular vision i.e. image inputs from both eyes being fused in the brain as a single image.

In children with amblyopia or lazy eye the brain prefers to use the eye with good vision and starts ignoring or blocking inputs from the eye which has inferior quality of images. Because this happens very early in life, the brain does not learn to use the two eyes together and the lazy eye doesn’t get a chance to develop as it is ignored by the brain.

Patching therapy is a form of amblyopia therapy used to strengthen the weak or lazy eye.

Here are some of the common queries which parents have about eye patching and how it must be done.

How does patching therapy work?
In patching therapy, an occluder or patch is placed over the “good” eye to block its visual input, and in turn to force the brain to use the weak/amblyopic eye. With the normal eye covered, games or activities that demand vision or hand eye co-ordination are carried out by the lazy eye which slowly enhances it’s vision and development in the brain.

How should I patch my child’s eye?
The good eye may be patched with various techniques like ready eye patches which have self adhesive layer or using a tissue paper, folded and stuck over the eye with meditape or using a soft cloth occluder worn over the eye like a pirate eye patch etc. The method used may be different but it is important that the good eye is blocked completely and the child mustn’t be able to see from the sides or peep above the patch either.

How long do I generally need to patch my child’s eye?
Duration of patching and time to be spent daily with patching is generally determined by your eye doctor based on the child’d age, cause of amblyopia and how severe is the amblyopia. Therapy may be required for a few months to few years as well.

If my child has glasses does he/she need to wear glasses with patching?
Yes, patching therapy always works best when the appropriate spectacle correction is there in front the lazy eye. So glasses are to be given and the patch is preferably placed directly over the eye under the glass rather than covering the glass to prevent peeping from the sides.

What should my child do after wearing the patch?
Wearing an eye patch is not always enjoyable and it takes some time for the brain to adjust to having the dominant eye covered. Spending some fun time with your child or being close to your child during this time can make the transition easier.
Start with simple activities and then move to more challenging ones to help build your child's confidence. Reading, coloring, painting, crafts such as cutting and pasting, solving puzzles, playing catch are all fun activities that require good hand/eye coordination and will exercise the lazy eye well. Even if your child is too young to read, sit together looking at the pictures in children's books to make the weak eye work during patching.

Do I need to complete patching at a single stretch in a day?
Based on your and your child’s comfort patching may be done at once, or can be split in two sessions (for eg: if patching is prescribed for 2 hours daily, you can patch for an hour in the morning and an hour in the evening).

It’s a struggle to get patching done, so can I wait for my child to grow older and then start patching?
Unfortunately the answer is no. Our vision develops fatest in the early years of life and our brain has a sensitive period of upto 8-10 years of age during which it responds well to patching. Beyond this age and in still older children the response to patching may be slow to very minimal and there is a risk for the eye to have poor vision due to amblyopia through adulthood.

Are there any alternatives like medicines or surgery to improve vision instead of patching?
Other forms of therapy like penalisation of the better eye with eyedrops, systemic medication for amblyopia etc have been studied and tried. Certain eyedrops may be given in addition to patching or instead of patching in selected cases as decided by your treating doctor, but over all patching therapy has shown superior results. Surgery in the form of squint correction, removal of cataract etc may improve vision to some extent but these too need long term patching for vision improvement.

Are there any side effects of patching? Can it affect the eye being patched?
Sometimes while using adhesive patches or sticking tape children may develop localised reaction (redness/ itching/rashes) over the skin around the eye due to the adhesive material. This does not affect the eye from inside and can be treated by applying cooling lotion locally or changing the type of patch material used. A more serious side effect that one must be very cautious about is the amblyopic eye getting better than the initial “good eye” which we were patching and the good eye now becoming lazy or amblyopia. This is called as reverse amblyopia. In children with amblyopia due to squint in one eye we may see this change that squint now starts being manifested in the other eye too or alternates in both the eyes. While this is a good sign that both the eyes are now equally good, it is very important to follow up regularly when patching therapy is given to prevent the good eye from becoming amblyopic.

UNDERSTANDING REFRACTIVE ERRORS

Normally, in eyes without any refractive error, objects form a clear & focussed image on the retina, which is the innermost layer at the back of the eye. This is called as an emmetropic eye. Some of the important factors which determine this ability to focus include age of the individual, how far or close is the object to the eyes, general health and eye related factors like tear film health, curvature of the cornea (transparent layer in the front of eye), curvature & thickness of the lens inside the eye and the length of the eyeball.

If the front of the eye is more steep or the lens too thick or curved or the eyeball too long, images are then focused in front of the retina. In other words the focal point is too short for that eye and objects closer to that eye appear well focused while those at a distance are blurred. This is known as short-sightedness or myopia. Myopia can be corrected with minus lenses which give a clear image on the retina so things farther away come into focus.

However, if the front of the eye is more flat or the lens too thin or less curved or the eyeball too short, images are then focused behind the plane of the retina. In other words the focal point is too short for that eye and objects closer to that eye will appear more blurred than those at a distance.

This is known as long-sightedness or hypermetropia. Hypermetropia can be corrected with plus lenses which give a clear image on the retina.

Young children have a higher range of focusing powers and can adjust the shape of their lens to overcome small amounts of this hypermetropia. Hence, they do not always require a correction with glasses. However, as we age, this flexibility of lens shape adjustment reduces, causing eye strain for near work beyond 40 years of age requiring glasses for near work. This is termed as presbyopia.

In some eyes, the front of the eye is an oval shape instead of round or the lens may be slightly tilted in position. In these cases there are two planes of focus instead of one giving rise to image blur. This is termed as astigmatism and can be corrected with cylindrical lenses placed in a specific axis (given in degrees) to focus the image.

SCREEN TIME

"Screen time" refers to the amount of time a person spends staring at the digital displays of computers, tablets and smartphones.
Today, screens are used for work, education, communication and leisure. Small amounts of screen time can be useful and enjoyable for families as they enable us to connect with others, be creative and can be used for learning in children.

However, due to their multiple uses, a wide range of screen devices are now easily accessible to children and it is often difficult to control the amount of time spent on screens, instead of taking part in other important childhood activities. As a result, health care professionals are starting to see some effects on child health and research on this is still emerging.

The time spent in front of a screen, distance from the screen and the quality of the content on screen, has been linked to a number of positive and negative health outcomes.

Some of the positives of screen time include:

• Ability to keep in touch with family & friends
• Screen time can also play an important role in keeping children connected when they are sick or in hospital, or as a means of distraction.
• For children with a medical condition, social media platforms allow them to connect with others with similar conditions and provide opportunities for self-expression and for increasing awareness amongst peers about their condition.
• Older children’s use of the Internet helps develop their skills and interests.

Some of these include:
Weight gain due to inadequate physical activity, over eating or influence by junk food advertisements.
Sleep onset in children is delayed or prevented due to light emitted from screens when viewed in the evening or just before sleeping. Inadequate sleep is in turn linked to weight gain and behavioural disturbances.
Communication skills and ability to build healthy relationships/ friendships may get affected as screen usage isolates children from their environment and interactions with others.
Exposure to potentially harmful information especially hurtful messsages on social media platforms or watching violent content may cause children to behave aggresively as they perceive it to be normal behaviour.
Neck and back strain may develop due to the time spent leaning, or hunched over screens
Eye strain and fatigue may develop due to inadequate blinking while staring at the screen for a long time. Also research has shown that children who spend more time outdoors are less likely to develop short sightedness.

In view of all this, the American Academy of Pediatrics has set some guidelines for screen time viewing in children as follows:

• For children younger than 18 months, avoid use of screen media other than video-chatting. Parents of children 18 to 24 months of age who want to introduce digital media should choose high-quality programming, and watch it with their children to help them understand what they're seeing.
• For children ages 2 to 5 years, limit screen use to 1 hour per day of high-quality programs. Parents should co-view media with children to help them understand what they are seeing and apply it to the world around them.
• For children ages 6 and older, place consistent limits on the time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity and other behaviors essential to health. 
• Designate media-free times together, such as dinner or driving, as well as media-free locations at home, such as bedrooms.
• Have ongoing communication about online citizenship and safety, including treating others with respect online and offline.

Pediatric Cataracts

A cataract is any cloudiness or opacity of the natural lens of the eye, which is normally crystal clear. Commonly seen as an ageing process, cataracts can affect infants and young children as well. Sometimes these are caused by genetic defects or infections during pregnancy which present as cataract at, or soon after birth, while at times childhood cataracts can be acquired as a result of eye injuries, inflammation, tumours or systemic metabolic conditions like diabetes etc.

A cataract may stop light from reaching the retina (innermost layer of the eye) and thus prevent the eye from seeing. In order for a child to develop good vision, it is necessary that the brain receives a clear image from either eye. If there is a cataract, the brain receives blurry images from the eye and it limits the child’s visual development resulting in amblyopia or lazy eye.

Sometimes, presence of cataract in a child maybe the first sign or an important clue to an underlying systemic disorder which is not yet diagnosed.

Childhood cataracts can be of various types depending on the age of onset, the cause and the appearance of the cataract.
Cataracts which are small and not affecting vision can be closely monitored while cataracts which interfere with vision should be removed as soon as is safely possible to prevent permanent vision loss. Treatment involves surgical removal of cataract and replacing the natural lens with an artificial lens (if the internal condition of the eye is suitable). These children also require regular post-operative follow up to determine the appropriate glasses and to ensure good visual development without any complications.