Adult Strabismus

• >Strabismus is a condition in which the eyes are not aligned and point in different directions. This condition affects about 4% of adults.
• Strabismus may begin in childhood and persist, reoccur, or become symptomatic in adulthood. Strabismus also can result from certain medical problems. Graves’ disease (thyroid eye disease), diabetes, strokes, and trauma are some of the more common conditions that can lead to strabismus. Less common causes are diseases that affect the muscles such as myasthenia gravis, demyelinating diseases such as multiple sclerosis, or brain and orbit tumors. Occasionally strabismus can develop after eye surgery, such as cataract, retinal, or glaucoma surgery.
• Adults with strabismus may have double vision, loss of depth perception, confusion between images, eye fatigue, and reading difficulty. They often experience psychological or social problems because of the condition, and they may have problems interacting with others or securing employment because of the appearance of their eyes.
• Strabismus can be treated at any age. Occasionally, eye muscle exercises, prism eyeglasses, or botulinum toxin injections can improve certain types of strabismus if the misalignment is slight. Often surgery is required. Surgery is done on an outpatient basis and sometimes can be performed with a local anesthetic only. Strabismus surgery involves loosening, tightening, or repositioning the muscles to align the eyes. An adjustable suture may be used to fine-tune the end result. An ophthalmologist (Eye M.D.) can recommend treatment options.

Amblyopia

• Amblyopia is poor vision in an eye that did not develop normal sight during early childhood. This condition, sometimes referred to as “lazy eye,” can run in families. The main causes of amblyopia are strabismus, refractive errors, or cloudiness of the eye tissues.
• Amblyopia affects about three out of every 100 people. The best time to correct it is during infancy or early childhood, because after the first nine years of life, the visual system is normally fully developed and usually cannot be changed. It is recommended that children have their eyes and vision monitored by their primary care physician at their well-child visits. If there is a family history of amblyopia, children should be screened by an ophthalmologist (Eye M.D.).
• Strabismus, or misaligned eyes, is the most common cause of amblyopia. The eye that is misaligned is ignored by the brain and “turns off.” A refractive error (meaning an eye is nearsighted, farsighted, or has astigmatism) is another cause of amblyopia. If one eye has a very different refractive error from the other eye, or if both eyes have a very strong refractive error, amblyopia can develop in the eye or eyes that are out of focus. The most severe form of amblyopia occurs when cloudiness of the eye tissues prevents any clear image from being processed. This can happen in conditions such as infantile or developmental cataracts.
• Amblyopia is detected by finding a difference in vision between the two eyes or poor vision in both eyes. The ophthalmologist will also carefully examine the eyes to see if other eye conditions are causing decreased vision.
• Amblyopia is treated by forcing the brain to use the affected eye or eyes. If refractive errors are present, they are corrected with eyeglasses or, less commonly, with contact lenses or refractive surgery. If a cataract or other cloudiness is present, surgery may be necessary to clear the line of sight. Strabismus may require surgery before, during, or after the amblyopia treatment. Patching or blurring the sound eye is then used to improve the vision by forcing the brain to recognize and process information from the affected eye or eyes. Once maximum vision has been obtained, treatment often needs to be continued at least part time for months to years to maintain the recovered vision. The earlier the treatment is begun, the more successful it will be.

Babies' Vision

• Babies have poor vision at birth but can see faces at close range, even in the newborn nursery. At about 6 weeks of age, a baby should be able to fixate on an object (such as a face) and maintain eye contact. Over a child’s first few years, vision develops rapidly; 20/20 vision can be recorded by 2 or 3 years of age with some techniques.
• Parents should be aware of signals of poor vision. If one eye “turns” or “crosses,” that eye may not see as well as the other eye. If the child is not interested in faces or age-appropriate toys, or if the eyes rove around or jiggle (called nystagmus), you should suspect poor vision. Other signs to watch for are tilting the head and squinting. Babies and toddlers compensate for poor vision rather than complain about it.
• Should a baby need eyeglasses, the prescription can be determined fairly accurately by dilating the pupil and analyzing the light reflected through the pupil from the back of the eye.
• A baby’s vision can also be tested in a research laboratory, where the brainwaves are recorded as the child looks at patterns of stripes or checks on a television screen. This is called a visually evoked potential (VEP) test. Another test, called preferential looking or Teller acuity cards, uses simple, striped cards to attract the child’s attention. In both tests, as the stripes grow smaller and closer together, they become more difficult to see, and the child’s level of visual acuity can be assessed.

Childhood Reading Problems

• When children have difficulty reading, parents often think poor vision is the problem. If a visit to an ophthalmologist (Eye M.D.) rules out any medical or vision problems, your child may have a learning disability.
• A learning disability is a disparity between a person’s ability and performance in a certain area. It has nothing to do with intelligence or IQ. A learning disability can make it difficult to succeed in school and, if untreated, can get worse, causing a child to lose self-confidence and interest in school.
• Identifying the learning disability is the first step in treating it. Dyslexia, a reading disability that may involve reversing letters and words, is one of the many learning disorders that can affect reading.
• Exercises have been used to improve the coordination or focusing of the eyes. Since poor reading is not usually an eye problem, these exercises rarely prove helpful. Colored lenses, special diets or vitamins, jumping on trampolines, or walking on balance beams have also been prescribed without much success. Over time, these methods have tended to fall out of favor.
• Children with learning disabilities benefit from various educational programs, in or out of school. Parents also play a vital role. They can support their children by reading with them at home. Children with learning disabilities need to be encouraged to develop strengths and interests so they can fully develop their unique talents and abilities.
• Many people are confused about the importance of eyeglasses for children. Some believe that if children wear glasses when they are young, they will not need them later. Others think that wearing glasses as a child makes one dependent on them later. Neither is true. Some children need glasses because they are genetically nearsighted, farsighted, or astigmatic. These conditions generally do not go away nor do they get worse because they are not corrected. For people with refractive errors, eyeglasses or contacts are necessary throughout life for good vision.
• Nearsightedness (when distant objects appear blurry) typically begins between the ages of eight and fifteen but can start earlier. Farsightedness is actually normal in young children and not a problem as long as it is mild. If a child is too farsighted, vision is blurry or the eyes cross when looking closely at things. This is usually apparent around the age of two. Almost everyone has some amount of astigmatism (oval instead of round cornea). Eyeglasses are required only if the astigmatism is strong.
• Unlike adults, children who need glasses may develop a second problem, called amblyopia or lazy eye. Amblyopia means even with the right prescription, one eye (or sometimes both eyes) does not see normally. Amblyopia is more likely to occur if the prescription needed to correct one eye is stronger than the other or if the prescription in both eyes is very strong. Wearing eyeglasses can prevent amblyopia from developing or may treat amblyopia if already present.
• Children (and adults) who do not see well with one eye because of amblyopia, or because of any other medical problem that cannot be corrected, should wear safety glasses to protect the normal eye.

Childrens Eye Safety

• Accidents resulting in serious eye injury can happen to anyone, but are particularly common in children and young adults. More than 90% of all eye injuries can be prevented with appropriate supervision and protective eyewear. Goggles and face protection can prevent injuries in sports like baseball, basketball, racket sports, and hockey. It is more difficult to protect against injuries in boxing, although thumbless gloves help.
• Children with vision loss in one eye should wear polycarbonate safety glasses all the time and should wear safety goggles for sports and other dangerous activities. Choose frames and lenses that meet the American National Standards Institute (ANSI) standard for safety (Z87.1).
• Appropriate adult supervision is an essential part of preventing eye injuries. Children should never be allowed to play with fireworks or BB guns. Sharp and fast-moving objects such as darts, arrows, scissors, knives, and even pencils or pens can be dangerous. Special care should be taken when working around lawn mowers, which can throw rocks and debris, and when banging two pieces of metal together, which can dislodge small shards of metal. Chemicals such as toilet cleaners and drain openers are especially hazardous.
• A primary care physician or an emergency room physician can treat minor injuries, such as a foreign body or an abrasion (scratch) on the cornea. Any foreign material will be removed from the eye, an antibiotic eyedrop or ointment may be used, and an eye patch may be applied for comfort.
• More serious injuries, such as blood inside the eye (hyphema), a laceration (cut) of the eye, or rupture of the eye, require examination by an ophthalmologist (Eye M.D.). Both surgery and hospitalization may be necessary.
• Chemicals that burn should be rinsed from the eye immediately. Chemical burns can cause severe damage, so eyes should be flushed immediately. If sterile solutions or eyewashes are readily available, use them to flush the affected eye. If not, flush the eye with liberal amounts of water from the nearest sink, shower, or hose for ten minutes. Be sure water is getting under both the upper and lower eyelids. After they eyes have been flushed for ten minutes, bring the child to the emergency room immediately. The ultimate visual outcome after a chemical burn depends on the severity of the injury, which cannot always be identified in the initial examination.

Congenital Cataract

• Your eye works a lot like a camera. Light rays focus through the lens on the retina, a layer of light-sensitive cells at the back of the eye. Similar to photographic film, the retina allows the image to be “seen” by the brain.
• Over time, the lens of our eye can become cloudy, preventing light rays from passing clearly through the lens. The loss of transparency may be so mild that vision is barely affected, or it can be so severe that no shapes or movements are seen-only light and dark. When the lens becomes cloudy enough to obstruct vision to any significant degree, it is called a cataract. Eyeglasses or contact lenses can usually correct slight refractive errors caused by early cataracts, but they cannot sharpen your vision if a severe cataract is present.
• The most common cause of cataract is aging. Occasionally, babies are born with cataracts or develop them very early in life. This condition is called congenital cataract. There are many causes of congenital cataract. Certain diseases can cause the condition, and sometimes it can be inherited. However, in most cases, there is no identifiable cause.
• Treatment for cataract in infants varies depending on the nature of each patient’s condition. Surgery is usually recommended very early in life, but many factors affect this decision, including the infant’s health and whether there is a cataract in one or both eyes. If the child has a cataract in both eyes, it is possible that surgery may be delayed for years, or, depending on their severity, it may never become necessary. However, if only one eye is affected by cataract, the infant’s visual system can develop abnormally, and, if left untreated, serious vision problems and even vision loss can result.
• If surgery is necessary, the ophthalmologist (Eye M.D.) will remove the eye’s cloudy lens and part of the surrounding lens capsule. Usually, strong eyeglasses or contact lenses are prescribed for infants after surgery. For babies over one year of age, an artificial intraocular lens (IOL) may be recommended instead to replace the eye’s natural lens. The ophthalmologist can recommend which procedure and optical correction is best for your child.
• When only one eye has a cataract, amblyopia or “lazy eye” often is present or will develop even after the cloudy lens is removed. In this case, the eye is optically corrected with contact lenses, glasses, or an IOL. The amblyopia must be treated as well with patching or intentionally blurring the sound eye.

Congenital Glaucoma

• Glaucoma is a disease of the optic nerve, which transmits the images you see from the eye to the brain. The optic nerve is made up of many nerve fibers (like an electric cable with its numerous wires). Glaucoma damages these nerve fibers, which can cause blind spots and vision loss. When the condition is present at birth or develops at a very young age, it is called congenital glaucoma.
• Glaucoma develops when the pressure inside the eye, or intraocular pressure (IOP), is elevated. When the aqueous humor (the clear liquid that normally flows in and out of the eye) cannot drain properly, pressure builds up in the eye. The resulting increase in IOP can damage the optic nerve.
• Congenital glaucoma can be inherited and is also associated with a number of conditions and diseases, including neurofibromatosis, congenital rubella, Lowe’s syndrome, Sturge-Weber syndrome, homocystinuria, Marfan’s syndrome, Weill-Marchesani syndrome, Axenfeld- Rieger syndrome, Peter’s anomaly, aniridia, persistent hyperplastic primary vitreous (PHPV), nanophthalmos (small eye), and microcornea (small cornea).
• ymptoms of congenital glaucoma include an enlarged eye, cloudy cornea, photophobia, tearing, and lid spasms. It may be necessary for the ophthalmologist (Eye M.D.) to perform an exam under anesthesia to accurately examine the eyes and measure the intraocular pressure. If glaucoma is diagnosed, there are a number of surgical procedures that the ophthalmologist may recommend to help reduce IOP and prevent damage to the child’s vision.

Congenital Ptosis

• Ptosis is a condition in which the upper eyelid falls to a position that is lower than normal. The drooping eyelid can cover part or all of the pupil and interfere with vision, resulting in amblyopia. Ptosis can affect one eye or both eyes.
• Ptosis may be present at birth or develop later in life. If a droopy eyelid is present at birth or within the first year of life, the condition is called congenital ptosis. In most cases of moderate or severe congenital ptosis, surgery is required to tighten the eyelid muscles or suspend the eyelid from the brow so that the eyelid is not covering the line of sight. If the ptosis is severe, surgery may be recommended in infancy. Often surgery is delayed until a child is 3 or 4 years old.
• Amblyopia, or “lazy eye,” is decreased vision in one or both eyes caused by lack of use. This condition can occur with congenital ptosis. If amblyopia is present, treatment with patching, eyeglasses, or eyedrops may also be necessary. If left untreated, amblyopia may lead to permanent vision loss.

Esotropia

• One common form of strabismus, or misaligned eyes, is called esotropia. Esotropia, or “crossed” eyes, occurs when the eyes turn inward. Esotropia can be both congenital, when it occurs in infants, and accommodative, which is more likely to develop after two years of age.
• Young children with congenital esotropia cannot use their eyes together. In most cases, early surgery can align the eyes. With accommodative esotropia, when the child focuses the eyes to see clearly, the eyes turn inward. This “crossing” may occur when focusing at a distance, at close range, or both. Eyeglasses reduce the focusing effort and often straighten the eyes. Sometimes bifocals are needed for close work. If significant crossing of the eyes persists with glasses, surgery may be required.
• The main sign of esotropia is an eye that is not straight. Sometimes children will squint one eye in bright sunlight or tilt their head in order to use their eyes together.
• Amblyopia, or “lazy eye,” is closely related to esotropia. Children learn to suppress the double vision associated with esotropia so effectively that the deviating eye gradually loses vision. It may be necessary to patch the good eye and have the child wear eyeglasses before treating the esotropia.
• Esotropia is often treated by surgically adjusting the tension on the eye muscles under general anesthesia. The goal of surgery is to get the eyes close enough to perfectly straight so that it is hard to see any residual deviation. Surgery usually improves the condition, and though the results are rarely perfect, they are usually better in young children.
• The main sign of esotropia is an eye that is not straight. Sometimes children will squint one eye in bright sunlight or tilt their head in order to use their eyes together.

Eye Examination for Children

Children are examined for any rare congenital problems at birth and at each well-child examination by the primary care physician, who will check for problems that may not be apparent to the parent or child but that could have serious consequences for the child’s vision. When the child is old enough, the primary care physician will perform a more formal vision screening examination. If the parent or the child’s doctor has any concerns, or if there is a family history of strabismus, amblyopia, or other eye conditions, the child should be referred to an ophthalmologist (Eye M.D.) for evaluation. Conditions that the primary care physician will screen for include:

• strabismus (misaligned eyes);
• amblyopia (“lazy eye”);
• ptosis (drooping of the upper eyelid); and
• decreased vision.

If the child is referred to an ophthalmologist, he or she will conduct a physical examination of the eyes, using eye chart tests, pictures, or letters to test the child’s ability to see form and detail of objects, and to assess for any refractive error (nearsightedness, farsightedness, and astigmatism).
Vision problems in children can be serious, but if caught in time and treated early, the child’s good vision can be protected.

Eyeglasses for Infants and Children

• For years, children who have undergone cataract surgery to correct congenital cataract have been fitted with eyeglasses or contact lenses to correct their vision after surgery. These methods have worked well, but their success relies on parents making sure that their children wear their eyeglasses and contact lenses on a regular basis as prescribed. This is essential to preventing additional eye problems like amblyopia, which can cause poor vision and vision loss.
• Today, there is another option to correct children’s vision after cataract surgery. The use of intraocular lenses (IOLs) has become more common in children in recent years and has a distinct advantage over other forms of vision correction: IOLs provide continuous vision correction, preventing the vision problems that can develop if a child does not wear the prescribed glasses and lenses.
• The use of IOLs in children is still somewhat controversial, especially in children under 1 or 2 years of age. There is little data available to evaluate the long-term safety of IOLs implanted at a young age. Children can have an especially increased inflammatory response to the implants, which can often be controlled with steroid medications. However, in some cases, a fibrous membrane can develop, which will require further surgery to remove. Unlike glasses or contact lenses, the IOL prescription cannot be changed without surgery to replace the implants. This makes choosing the correct prescription especially important, which can be difficult in young children. In addition, a child’s eye may not be able to accommodate an IOL designed for an adult, so fit can be a problem. Finally, because IOLs do not correct astigmatism, and because the child’s eye will grow, which changes the refractive error (prescription), children with IOLs often need to wear eyeglasses in order to achieve good vision
• If your child requires cataract surgery, discuss all the options with your ophthalmologist (Eye M.D.) in order to make the best decision for your child.

Leukocoria

Leukocoria is a condition in which the eye’s normally black pupil appears white, especially under bright light. It is common to see “red eye” in photographs that were taken using flash photography. When the flash of a camera or another bright light produces the appearance of a white pupil, this is a sign of a serious underlying problem with the eye, and an ophthalmologist (Eye M.D.) should be consulted immediately. Primary care physicians often notice this sign when conducting a regular well-baby examination, and parents are frequently the first to notice it when looking at photographs of their children. Leukocoria is a sign of many diseases and conditions of infancy and childhood, including:

• congenital cataract;
• persistent hyperplastic primary vitreous (PHPV);
• retinoblastoma;
• retinopathy of prematurity; and
• toxocariasis.

Strabismus

• Strabismus refers to misaligned eyes. Esotropia (“crossed’ eyes) occurs when the eyes turn inward. Exotropia (“wall-eye”) occurs when the eyes turn outward. When one eye is higher than the other, it is called hypertropia (for the higher eye) or hypotropia (for the lower eye). Strabismus can be subtle or obvious, and can occur occasionally or constantly. It can affect one eye or shift between the eyes.
• Strabismus usually begins in infancy or childhood. Some toddlers have accommodative esotropia. Their eyes cross because they need glasses for farsightedness. But most cases of strabismus do not have a well-understood cause. It seems to develop because the eye muscles are uncoordinated and do not move the eyes together. Acquired strabismus can occasionally occur because of a problem in the brain, an injury to the eye socket, or thyroid eye disease.
• When young children develop strabismus, they typically have mild symptoms. They may hold their heads to one side if they can use their eyes together in that position. Or, they may close or cover one eye when it deviates, especially at first. Adults, on the other hand, have more symptoms when they develop strabismus. They have double vision (see a second image) and may lose depth perception. At all ages, strabismus is disturbing. Studies show school children with significant strabismus have self-image problems.
• Amblyopia (“lazy eye”) is closely related to strabismus. Children learn to suppress double vision so effectively that the deviating eye gradually loses vision. It may be necessary to patch the good eye and wear glasses before treating the strabismus. Amblyopia does not occur when alternate eyes deviate, and adults do not develop amblyopia.
• Strabismus is often treated by surgically adjusting the tension on the eye muscles. The goal of surgery is to get the eyes close enough to perfectly straight that it is hard to see any residual deviation. Surgery usually improves the conditions though the results are rarely perfect. Results are usually better in young children. Surgery can be done with local anesthesia in some adults, but requires general anesthesia in children, usually as an outpatient. Prisms and Botox injections of the eye muscles are alternatives to surgery in some cases. Eye exercises are rarely effective.

Tearing in Children

• Although it can be caused by wind, smoke, or pollen, an excess of tears in children is often caused by congenital nasolacrimal duct obstruction, a condition in which a baby’s tear duct is blocked instead of draining normally through the duct into the nose. The condition can be recognized by tears that build up on the surface of the eye and overflow onto the eyelashes, eyelids, and down the cheek. Because the tears are not draining normally, babies will sometimes get infections, which can cause red, swollen eyelids and yellowish-green discharge.
• Congenital nasolacrimal duct obstruction is usually caused by the failure of a thin tissue at the end of the tear duct to open properly when the child is born. It can also be caused by a lack of openings to the duct system at the eyelids, by infections, and by abnormal growth of the nasal bone, which pinches off the tear duct. Some infants may have excessive tearing due to narrow tear ducts rather than an obstruction. In this case, the tearing may be intermittent, occurring when the infant has a cold or during especially windy or cold weather. Finally, congenital glaucoma can cause tearing in children. This serious condition is often accompanied by other signs, including an enlarged eye, a cloudy cornea, and light sensitivity.
• Most babies born with blocked tear ducts do not need treatment. More than 90% of blocked tear ducts clear by themselves before the child turns 1 year old. If treatment is necessary, the first course of action is usually tear duct massage, along with topical antibiotics to treat infection. The tear sac is located between the inside corner of the eye and the side of the nose. The purpose of massage is to put pressure on the tear sac for a few seconds to pop open the membrane at the end of the tear duct. This is most easily done by putting your hands on each side of the baby’s head and using your index fingers to press on the tear sac. This should be done several times a day, such as at after feedings or diaper changes.
• In certain circumstances, tear duct probing, balloon tear duct dilation, or tear duct probing with tube placement may be necessary. Should your infant need treatment to remove a tear duct obstruction, ask your ophthalmologist (Eye M.D.) to discuss appropriate treatment options with you.