Eyedolatry: children's vision

An Introduction to InfantSEE

The first time I heard about InfantSEE I was still a student at the Southern College of Optometry. One of my staff doctors, the lauded Dr. "Bubba" Steele, is a co-founder of the program. Training with Dr. Steele was a huge asset to my career, and I can't express enough what a huge benefit it was that I was able to work under both him and Dr. W.C. Maples, two of the most well-known names in Pediatric Optometry. But to get back on track, the InfantSEE program is a great initiative dedicated towards promoting ocular health for infants between 6 months and a year old. Providers in the InfantSEE program offer FREE eye exams for infants, so every new parent should consider finding a provider in their area!

Infants will readily follow lights, so checking eye muscle movement and alignment is relatively easy for your doctor. To get a complete look at the back of the eye, dilation will be needed. Rest assured, there will be no damage to your child's eyes from these drops. Photo from The Eye Care Center in Royal Falls, Virginia.

Why is an infant exam important?
Most children don't get visual screenings until they enter kindergarten, but the eyes are developing from the time your child opens them for the first time. Remember, the eyes have to transfer information to the brain in order for you to see, so there are a multitude of important connections developing in newborns. The retinal photoreceptors respond to light, the optic nerve delivers this information to the brain, and the brain processes and interprets the information. Not to mention the eye muscles that have to work together for eye movements and binocular vision (using both eyes together, creating depth perception). If there is any breakdown in the flow of information, permanent vision loss results. Detecting problems early (WAY before your child is being asked to learn to read) is obviously essential!

Retinoblastoma is a dangerous cancer that quickly passes
from the eye to the brain. It can best be detected with
a dilated eye exam.

What conditions will be screened for?

Retinoblastoma or other ocular tumors
Congenital cataracts. Yes, you can be born with cataracts! If you notice a white reflection in photos of your child's eyes, take them to a doctor immediately. A red reflex is normal, but a white reflex could be evidence of cataracts or even more dangerous cancerous growths.
Strabismus (Eye Turns) Sometimes a child's eyes can look like they are turning, but are actually normally aligned due to the poorly developed nasal bridge of an infant. Your eye doctor will be able to differentiate a real eye turn from a "pseudo" strabismus.
Amblyopia (Lazy Eye) In order to see depth, both eyes have to work together equally. If prescriptions are greatly different between the eyes or an eye turn exists, the child will ignore that eye's blurry image. The risk is that the brain connections to that eye will NEVER develop. That means even with the best pair of glasses or contact lenses, if this condition is not caught early the child will NEVER have good vision out of the "lazy" eye. The earlier amblyopia is caught, the better chance of getting the vision of the lazy eye back to normal.

Leukocoria is an ominous white reflex indicating a vision threatening (and sometimes life threatening) ocular condition.

These are just a few of the main conditions being screened for, but you can tell from the list above how important detection of these problems can be!

Finding an InfantSEE Doctor

If you go to their website, you can search for a provider by zip code. Then just contact the doctor's office and schedule your FREE exam. I would allot around 30 minutes for the appointment. Your doctor may want to dilate your child's eyes, which the child may not especially like, but lets the doctor fully check the eye's health. It's a great idea to schedule the appointment around nap time. Believe it or not, if your child is sleepy it is really a lot easier for the doctor to look into the eye!

In the future I plan to devote another post to new OD's joining InfantSEE. I just signed up today and it was unbelievably fast and easy! More information to come soon.

PS: Check out my good friend's interview with her local newspaper. The next generation of ODs are devoted to getting the word out about children's vision!

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Accommodative Insufficiency: A Guide for New ODs

accommodation 13:51

Let me set the stage with a classic patient presentation.

10 year old patient complains of distance blur at school. When you ask a few more questions, they also state that sometimes when they are reading they have headaches or blurry vision. Sometimes they even tell you that their distance vision is blurry after they read (though it is rare for a young child to be this perceptive).

When vision is checked, acuity is typically 20/25 to 20/40 unaided. Usually worse at distance than near, but they read the 20/20 line really slowly up close. Their ending prescription is anywhere from +0.50 (low hyperopia or far sightedness) to -0.50 (low myopia or near sightedness), but the 20/20 line is still hard for them to read. Note: I know ODs out there know what I mean when I say myopia or hyperopia, but I am including the other terms for all other readers to the blog!

Kids and the phoropter: not exactly a match made in heaven. Best to not confuse things too much with subjective testing that is difficult to understand (like phorias or fused cross cylinder).

Then you switch to near testing. Depending on the patient, only certain tests yield good results. Cover test is normal (most kids don't do well with phorias and vergences!). You might be able to get a binocular fused cross cylinder on older children if you are lucky. The responses vary. My two best tests are NRA/PRA and near retinoscopy (such as MEM). Classic NRA/PRA readings are low usually on both plus and minus blur points. They typically do very poorly with PRA (the minus blur points). You can of course also do an accommodative facility test (with the +2.00/-2.00 flippers and a timer), but in the real world this test is very time consuming to perform in a routine exam.

Near Retinoscopy: I should do it more that I do -- lots of great information can be gleaned. But I don't have these cards in every exam room, so I typically rely on NRA/PRA results and then trialing loose lenses at near subjectively.

Then I like to demonstrate with loose lenses to the patient. Get them out of the phoropter as soon as possible! Let them hold a near card or reading material. Hold up a +0.75 lens and see their response. It is usually quite dramatic. Now sometimes the kid just wants glasses, so hold up a -0.75 or -1.00 and see what happens. If they are really having accommodative issues, they aren't going to like this at all. I will often show the patient what happens when they switch from near to distance with the lens to demonstrate that the glasses are only good for up close.

Prescription wise, I typically Rx +0.75 to +1.25 depending on the patient's distance prescription. The hardest part in all of this, of course, is telling the patient's parents why they need glasses. I always talk about Vision Therapy as an option too, but in my area, it is very expensive and of course not covered by insurances. I always explain that the glasses are for reading only (any near activity they are going to perform for longer than 10 minutes). A near activity I define as anything they are holding closer than arm's length. That means they are going to have to take the glasses on and off at school, but believe me this goes over much better than telling them they need bifocals. Here is my general discussion:

The focusing system of the eyes is made up of the eye muscles and a structure called the lens that the eye muscles control. When you do near work like reading, the eye muscles have to work to bring the image clear. Sometimes those eye muscles get tired, especially with so much near work at school like reading and math worksheets or tests. If you are straining those muscles up close, then they can get locked up in that position, so when you look across the room at the board, it will appear blurry too! The glasses I am prescribing are to relax how hard your eye muscles are having to work up close. Your child doesn't have bad vision, and doesn't need glasses all the time. They only need these glasses for near activities to reduce strain. In most cases, as the eyes continue to develop, they will no longer need these glasses over time. We will check the prescription and their need for near glasses every year at their annual exam.

I hope this helps. Telling a parent their child needs glasses is difficult in any situation, but when you tell them they need glasses for near when they have been complaining to mom and dad for months their distance vision is blurry, it is even harder. Most parents only know myopia (or near sightedness), so any other use of glasses seems strange. Again, especially when their child is coming home complaining of distance blur! I always like to tell parents that studies have shown myopia can be related to eyes being over-strained at near, so hopefully the use of these glasses can help with delaying myopia onset. If the parent is near sighted, they will appreciate any efforts to prevent their child from having a large myopic prescription. In a future post I will detail a patient's guide to accommodative dysfunction to hopefully make things easier for parents to understand!

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The Patient's Guide to Refractive Error Part 2: Hyperopia

accommodation 21:29

Hyperopia, or "far sightedness" can be a more difficult concept to grasp than myopia. Myopes need their glasses to see clearly, but it is not that straightforward for hyperopes. When you think about someone that wears glasses, the classic image is a "Mr. Magoo" type that is bumbling around blind without their glasses. The thing is, hyperopes (in most cases) can see pretty well most of the time. People with only mild amounts of hyperopia generally never even know they have refractive error until their focusing system begins to decline in a condition called presbyopia (more on that later) that occurs around age 40.

Mr. Magoo: a man sorely in need of contact lenses

In simple terms, hyperopes see better in the distance than they do up close (the opposite of myopes if you recall from this post). Opposite from myopes, light entering the eye falls behind the retina in hyperopia. The focusing system (accommodation) must be used to bring the image back to lie clearly on the retinal cells. Basically, hyperopes have to use their focusing system all the time, distance and near. Known as accommodation, the focusing system must overcome the patient's prescription at distance to see clearly, as well as the prescription AND the near demand of a target when something is held up close. This is why vision is more blurry at near to the patient; their focusing system is just too overwhelmed by the demand.

Why does light fall behind the retina? Well, a patient with hyperopia has either:

flatter cornea that doesn't bend light as much as an average cornea
or a shorter eyeball

Hyperopes are corrected by "plus" lenses which act to move the image back to the retina, and thus to relax how hard the focusing system must work to see things clearly.

My biggest challenge as an optometrist with hyperopic patients that still have a functioning accommodative system? Convincing them to wear glasses! Especially if they are children with an active and healthy focusing system. When low hyperopes wear their glasses, they aren't going to see any clearer with their glasses on for most distances. What they will notice is that things look magnified, and this relaxes how hard their eyes have to work for activities especially at near.

What to do if your child is hyperopic? Children through early elementary school are normally hyperopic, and most do not suffer from any visual discomfort do to their healthy focusing system. If your child is getting frequent headaches at school, suffering from discomfort when reading, or seeing double/expressing an eye turn, these are all reasons that a hyperopic prescription would be necessary. Typically these glasses are worn at school and for near activities, and an emphasis is made on balancing the prescription so both eyes are using the same amount of accommodation (or focusing effort). Again, your child may tell you that their glasses don't help them see any more clearly if they are hyperopic and this is normal! The glasses are to ensure that their focusing system does not become overloaded and can continue to provide clear vision to the wearer.

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What is a Cataract?

cataract surgery 11:25

Cataract extraction is one of the most commonly performed surgeries in the United States, but based on my experience in patient care, a large percentage of people are unsure of what a cataract actually is. To explore this topic further, let’s address some common misconceptions:

1) Cataracts are NOT a film over the surface of your eye. This is a very common misconception, but cataracts actually develop inside your eye in a structure called the lens (see picture below). The lens functions just like a lens on a camera – it changes shape to focus and create a clear image. Over time this lens can harden and become cloudy, which is the development of a cataract. Just as you would expect, clouding and yellowing of the structure responsible for focusing a clear image results in constant blurry vision.

This picture shows a cross-section of your eye, diagramming the lens which has developed a cataract in this case. The lens is located INSIDE the eye, sitting behind the iris (or the colored part of the eye). Picture courtesy seewithlasik

2) Cataracts are NOT a disease. Most often they are a result of the normal aging process the lens. While aging is the predominant factor for developing cataracts, certain medical conditions like diabetes can predispose someone to developing cataracts sooner than usual. Prolonged use of steroids can also cause cataract formation. It is also possible to born with cataracts which can cause substantial deficiencies in the development on the visual system, so having a comprehensive eye exam is important even for children!

This patient has a nuclear cataract, characterized by yellowing of the lens. This is one of the most common types of cataracts caused by aging, smoking, and UV damage. Picture courtesy drhlis.com

3) I know it is a scary concept to some, but the ophthalmologist performing your cataract surgery will have to enter the eye to remove it. Remember that the lens where the cataract forms is inside of your eye, behind the iris (the colored part of your eye). The surgeon uses very small instruments to enter the eye and remove the cataractous lens. With today’s technical advancements, you don't even have to be put to sleep to have this procedure performed.

4) Once a cataract is removed it can NOT grow back. That’s a relief, right? It is possible that a film can grow over the back of the intraocular implant (a small device that surgeons insert to replace your lens to allow you to focus a clear image again). This film may reduce vision, but you will not have to have a second surgery to remove it. All it takes is a quick laser procedure.

5) Most people DO still need to wear glasses after cataract surgery. While in most cases the goal of surgery is to fully correct your distance vision, the standard intraocular implant inserted to replace your lens is not able to focus for near distances. That means that you will continue to need reading glasses. Depending on your eyes and the surgical outcome, some people may also have left-over astigmatism (which causes blur at all distances) that must be corrected with glasses. There are more expensive intraocular lens devices available that can help focus for both distance and near, but the technology has not been entirely perfected at this time. Researchers are actively exploring this idea though, so expect future breakthroughs.

6) There is NOTHING you can do to entirely prevent yourself from getting cataracts. Yes, that is 100% a true statement. To use the words of a fellow optometrist, “ everyone will get cataracts if they live long enough.” Some people get them younger; some people’s progress more rapidly to reduce vision; some people will never have the cataract bother them enough to want surgery. There ARE some things you can do to slow down the onset and progression of your cataracts, however. Some suggestions:

A) DO wear sunglasses outside. UV light can damage the lens and lead to cataract formation. Studies show that more Americans are applying sunscreen because of the risk UV damage to the skin, but much fewer people responded to wearing sunglasses for UV protection. Your eyes need protection too, and there are a lot of stylish options out there!

Wearing sunglasses is not just a fashion statement , but protects your ocular health and vision. Choose 100% UVA/UVB blocking sunglasses for maximum protection. Plus, there are so many stylish options out there like Gucci 3164 in tortoise above!

B) DON’T smoke. Like you needed any more reasons. Smoking increases the rate and progression of cataracts.

C) DO have yearly eye exams. Tell your doctor about medical conditions like diabetes, Wilson’s disease, and myotonic dystrophy that predispose you to cataracts. Be aware that certain medications (especially steroids) also increase your risk. If you are having blurry vision, it is always best to get it checked out. Cataract surgery is a relatively easy procedure, but in conditions like diabetes, having the cataracts removed earlier may help decrease the surgical risk and improve the outcome of your vision! You don’t want to wait until your vision is drastically impaired.

D) If you are a parent, your children DO need to have their eyes checked as well! Some children are born with vision-threatening conditions like cataracts, and the earlier these problems are caught, the better chance your child has for developing normal vision. Because a child's eyes and visual pathway to the brain are still developing, a cataract in a child can cause permanent vision loss, even after the cataract is removed! Programs like InfantSEE allow free eye exams for children between 6 months and 1 year of age. This is a great way to screen for blinding conditions, so please seek out local providers to see if they are participants!

This child's parents are truly protecting them from dangerous UV damage by using a brimmed hat and sunglasses! You can purchase sunglasses for children and babies through companies like Baby Banz.

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