Children's Eye Health 101

When our kids are young, and even as they get older, it’s hard to gauge what they’re seeing (or not seeing). Eye problems are often asymptomatic, and even when a child does display symptoms, it doesn’t necessarily mean there’s a problem. Take the case of a boy whose best friend got eyeglasses – he decided he needed them too and started a “squinting campaign” to prove it! 


“Young children rarely complain of a decrease in vision. They tend to think that everyone else sees at the same level they do,” says Jennifer P. Mullon, M.D., pediatric ophthalmologist and president of Lexington Eye Associates, a Boston Parents Paper “Family Favorite” award winner. “Occasionally a toddler who seems clumsy, has a head tilt or poor attention will turn out to have a vision problem,” she says, but many eye issues are somewhat “fuzzy.” For example: 


• While vision problems can present as headaches, most children evaluated because of headaches turn out to have normal eye exams.


• Persistent eye blinking generally indicates an eye irritation or maybe a nervous tic and not a need for glasses.


• While a nearsighted child might sit close to the TV screen, many children with normal vision also do this.


That’s why vision screenings, done at well checkups in pediatricians’ offices as recommended by the American Academy of Pediatrics are “so important,” says Mullon.


It’s also why we consulted Mullon, as well as another local pediatric ophthalmology expert – Melanie Kazlas, M.D., medical director of Boston Children’s Hospital Ophthalmology at Massachusetts Eye and Ear Infirmary – for insight about caring for kids’ eyes at various stages. 


Red Reflex


An abnormal red reflex can signify a serious eye concern screened for in infants and young children. Kazlas explains, “The pupil is the ‘window’ to the back of the eye where the optic nerve and retina are. The retina, which can be compared to photographic film … [in a] camera, is highly vascular, which means it has many blood vessels to nourish this vital tissue. Since blood is red, the reflection seen through the pupil should be red.” If it is not, this may mean that there is something blocking the reflection of the blood vessels, such as a cataract, a corneal or retinal abnormality or, rarely, a tumor.


Retinoblastoma is the most common eye tumor in children, says Kazlas. Fortunately, there are only about 300 new cases a year in the U.S., and the condition has a more than 95 percent long-term survival rate if caught early.




Eye care begins at birth with ointment applied to a newborn’s eyes to prevent neonatal conjunctivitis, says Kazlas. 


During early critical stages of visual development, Mullon says, eye professionals look for:


• structural abnormalities in the eye, such as a congenital cataract, retinal and optic nerve disorders, and tear duct obstructions; and


• conditions affecting early visual development, such as high refractive errors, strabismus (misaligned eyes) or nystagmus (abnormal eye movements).


“Parents may see their infant’s eyes cross or wander occasionally for the first few weeks of life. This is normal,” says Kazlas. “If a crossed eye persists after 8 weeks of age or if a wandering eye persists after 16 weeks of age, this could indicate a problem.”  


Tear duct obstructions occur in about five percent of infants, notes Kazlas. “Tears may stream down the cheek even if the baby is not crying. The blockage, which is at the end of the ‘drainpipe’ – which begins at the corner of the eyelid near the nose and ends in the nostril – gets better on its own by12 months of age in more than 90 percent of cases.”




Make sure kids can see near and far by asking them to identify things in the environment at different distances, advises Kazlas.


Mullon recommends an initial eye exam between ages 3 and 5, or even earlier for children whose parents wore glasses at a young age.


Two common conditions affecting three percent of U.S. children, which can run in families, are:


Strabismus – a misalignment of the eyes. “If the eyes are not pointing in the same direction, for example, if one eye is pointed straight ahead and the other eye crosses in toward the nose or wanders out, the child will not develop proper depth perception or 3-D vision,” Kazlas explains. Strabismus, such as esotropia (crossed eyes) or exotropia (wandering eyes), can be constant or intermittent, she notes. Mullon adds that many of these children are at risk for amblyopia.


Amblyopia – poor vision in an eye (sometimes called a lazy eye). “‘Use it or lose it’ may be a helpful way to describe how vision develops in children,” says Kazlas. “If an eye is crossed, the visual part of the brain, which receives input from that eye, in essence shuts down and ‘forgets’ how to see clearly.”


Strabismus is often treated with glasses and sometimes surgery. Amblyopia is treated by patching or instilling a blurring drop, such as Atropine, to the better-seeing eye. With the child’s cooperation, Kazlas says she often sees improvement within six to 12 months, although maintenance may be needed. She adds that new research conducted in the Boston area about enhancing brain plasticity in adults may give hope to adults who failed amblyopia treatment as kids.


Elementary Schoolers & Up 


Children’s eyes are examined at ages 5 to 6 when they enter school.


“Visual development is felt to be nearly complete by about age 9 to 10,” says Mullon, “but the eyes continue to grow during the preteen and teenage years. During this time, the focus of the exam often shifts to detecting the onset of myopia.”


Getting Glasses


Most children aren’t born with myopia; they grow to become nearsighted as the eye grows larger. “Glasses are prescribed once the myopia is significant enough to affect school performance,” says Mullon. 


Becoming “dependent” on eyeglasses by wearing them all the time is a myth, says Kazlas. “Farsightedness, nearsightedness and astigmatism are all determined by the length and shape of the eyes. If the eye is relatively short (farsighted), relatively long (nearsighted) or if the front surface of the eye is shaped like a football or ellipse instead of a basketball or circle (astigmatism) then the image of what we are looking at can’t come into good focus unless we wear the proper lens to get the image into focus. There is no harm in wearing glasses all the time if the prescription is accurate.”


Getting Contacts


Even infants can wear contact lenses and do after cataract surgery, but that’s rare, says Kazlas. She recommends that parents “use their good parental wisdom” to determine when kids should get contacts. Kids need to be responsible enough to wash their hands when handling the lenses, store the lenses properly and be able to put them in and take them out by themselves. For most children, this is at the end of middle school or beginning of high school, says Kazlas, although she has seen younger kids whose parents wanted them to try contact lenses because they played sports.


Mullon adds, “Contact lenses are a medical device, and contact lens wearers are at increased risk for infections known as corneal ulcers. These infections can cause permanent scars on the cornea which can affect vision.” She stresses that parents and children need to understand the risk, and that the wearer should have an annual exam to monitor the cornea's health.


Are Contacts Best for Sports?


Not necessarily, Mullon answers. “Sports are often the motivating factor behind the desire to wear contact lenses. This is especially true for sports which require helmets which may make glasses fit challenging. What contacts do not provide, however, is protection for the eyes during sports. This is best achieved using sports goggles or glasses designed specifically for sports. Not only is the lens in these glasses shatterproof, but the frames are also built to withstand impact. A prescription correction can be put in these glasses, as well as in swim goggles.”


In such cases, experts say parents should trust their intuition and what they know about their kids to bring fuzzy issues into focus.

For more information about kids' eye infections, conditions and allergies, click here


Mary Alice Cookson is associate editor of Boston Parents Paper.

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07 Mar 2014

By Mary Alice Cookson