Eye Advice for All Ages

11 Sep

by Jill R. Wells, M.D.

Hi Parents,

I am a comprehensive ophthalmologist and I would like to give a few tips and recommendations regarding your kids’ ocular health. While the American Academy of Ophthalmology does not recommend routine eye exams by ophthalmologists for all children, vision screening evaluations are extremely important. Eye and vision evaluations begin in the newborn period and should continue at all pediatric visits. In addition, you can perform simple tests at home to help determine if your child has any significant vision loss.

In the newborn and infant stages, your pediatrician will focus on inspecting the anatomy of the eye, the pupil reaction, and most importantly, the “red reflex”. The red reflex is the reddish-orange color coming from the retina- the same concept as ‘red eye’ in photographs. If the reflex is white or dull compared to the other eye, this could indicate a number of eye diseases including cataract or even worse, cancer in the eye called retinoblastoma. Retinoblastoma is extremely rare with only about 300 new cases in the United States each year. I have seen quite a few cases of retinoblastoma because I work at a major referral center and parents will often say they noticed a “white discoloration” of the eye on a photograph. So remember to inspect photos of your kids’ eyes and if you see a white reflex make an appointment with an ophthalmologist as soon as possible. 

As your child ages, vision screening focuses on strabismus and amblyopia. Strabismus is a misalignment of the eyes. If your child’s eye turns in or out or does not move appropriately in all directions of gaze, see an ophthalmologist. Amblyopia, or “lazy eye” refers to decreased vision in the eye even when no structural problem is found in the eye. If amblyopia goes untreated, there may be permanent vision loss. Amblyopia can be caused by an opacity in the eye, a droopy lid blocking the vision in one eye, near-sightedness, far-sightedness, astigmatism or a difference in the refractive error between the two eyes. If your child is not yet talking, you can try to completely cover one eye and see if she can follow a toy or object with the other eye. If the vision is decreased she may become fussy and try to move your hand away. Then do the same test to the other eye. Once your child talks and understands symbols (around age 3) her vision can be measured in the pediatrician’s office. Each eye will be checked individually and the most important thing you can do is to make sure that the eye not being tested is completely covered. Kids don’t like to ‘fail’ tests so they may be embarrassed if they do not see the symbols on the chart. If they can peek with the other eye to get the right answer, they will. Do not let the kids cover their own eye with their hands- too easy to peek through fingers. And don’t count on the technician checking to see that your child isn’t peeking- it doesn’t always happen. It is not uncommon that we kids with decreased vision in one eye who passed screening exams in the past.

If your child fails any screening exam, an exam by an ophthalmologist is needed. The table below shows the recommended ages and methods for pediatric eye screening exams taken from the Preferred Practice Pattern Guidelines of the American Academy of Ophthalmology.

 

Recommended Age

 

Method

 

Indications for Referral to an Ophthalmologist

 

Newborn to 3 months

 

Red reflex

 

Absent, white, dull, opacity, or asymmetric

 

External inspection

 

Structural abnormality

 

Pupil examination

 

Irregular shape, unequal size, poor or unequal reaction

 

3 to 6 months (approximately)

 

Fix and follow

 

Failure to fix and follow in a cooperative infant

 

Red reflex

 

Absent, white, dull, opacity, or asymmetric

 

External inspection

 

Structural abnormality

 

Pupil examination

 

Irregular shape, unequal size, poor or unequal reaction

 

6 to 12 months and until child is able to cooperate for verbal visual acuity

 

Fix and follow with each eye

 

Failure to fix and follow

 

Alternate occlusion

 

Failure to object equally to covering each eye

 

Corneal light reflection

 

Asymmetric or displaced

 

Red reflex

 

Absent, white, dull, opacity, or asymmetric

 

External inspection

 

Structural abnormality

 

Pupil examination

 

Irregular shape, unequal size, poor or unequal reaction

 

3 years and 4 years (approximately)

 

Visual acuity* (monocular)

 

20/50 or worse, or 2 lines of difference between the eyes

 

Corneal light reflection/ cover- uncover

 

Asymmetric/ocular refixation movements

 

Red reflex

 

Absent, white, dull, opacity, or asymmetric

 

External inspection

 

Structural abnormality

 

Pupil examination

 

Irregular shape, unequal size, poor or unequal reaction

 

5 years (approximately)

 

Visual acuity* (monocular)

 

20/40 or worse, or 2 lines of difference between the eyes

 

All other tests and referral

indications are as in age 3 and

age 4 years

 
 

Every 1 to 2 years after age 5

 

Visual acuity* (monocular)

 

20/30 or worse, or 2 lines of difference between the eyes

 

All other tests and referral

indications are as in age 3 and

age 4 years

 

I would also like to say a few words about contact lenses. Contact lenses should only be used as directed by an optometrist or ophthalmologist. Teens and adults are now able to purchase colored contact lenses at beauty parlors to change the color of their eyes. These are not FDA approved and I have seen serious complications from these lenses. Contact lens hygiene is also very important for lenses that are prescribed. Do not let your kids store contact lenses in water or homemade solutions. I also recommend NEVER sleeping in contact lenses. The risk of corneal ulcers is much higher in patients who sleep in their contact lenses.

An excellent resource for parents who want to read about pediatric ophthalmology can be found at www.aapos.org. There is a tab “Info for Patients” which provides explanations of many eye conditions found in the pediatric population.

Dr. Wells is an opthalmologist at Emory University.

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