All children should have an initial eye evaluation by a pediatrician within the first week of life. “A newborn’s vision is 20/200 to 20/400,” explains David B. Granet, MD, Director of the Division of Pediatric Ophthalmology & Ocular Motility, and Associate Professor at the Departments of Opthamology and Pediatrics at the University of California, San Diego. In layman, equivalent terms, “This is only the big E on the eye chart. Newborns also do not see color until they are a few months old.”
At around three months of age, babies begin to smile. “This is the time when the visual system really starts to kick in and they interact more in the world. When a babies sees their parents smile, they begin to smile back.”
By six months of age, a child’s vision improves, and by age one, becomes comparable to that of an adult. “At this time they are focusing on things, right around the time they start walking,” Granet says. During each well-baby examination, babies undergo a brief screening evaluation. Between ages one and three, the pediatrician will do a more extensive, age-appropriate screening.
“If a child has a serious issue such as cataracts or glaucoma, which should be detected by the pediatrician in the first couple of weeks of life, they need to be taken care of quickly,” says Granet. “If not treated early, any blockage of vision early on in life can have permanent consequences on the developing brain, which may not allow the child to ever see.”
Two other urgent concerns are corneal opacities, glaucoma and an eyelid that completely blocks the eye.
Common Eye Concerns
Parents are often concerned that their newborn’s eyes do not look straight, yet occasional misalignment is normal in infants.
“We don’t expect children’s eyes to look straight or to be used perfectly until about three or four months of age. However, if a child’s eyes are persistently, insistently, and consistently crossed, it is worthwhile to have a pediatrician and perhaps a pediatric eye specialist do an evaluation,” says Granet.
Blockages in the tear drainage system, known as nasal lacrimal duct obstruction, are also fairly common in infants. Parents may recognize this problem when a child’s eyes secrete a goopy discharge.
Fortunately, as the child grows, this conditions tends to disappear spontaneously and the drainage pipe opens naturally. “An estimated 90 percent of tear blockages clear up by the age of one, although some specialists may decide to perform an in-office procedure earlier to make life a little easier for the child and parents,” says Granet.
If a blockage occurs, parents can attempt to clear it by gently massaging the nasal lacrimal system. Antibiotic drops may be prescribed to treat an infection, which can occur when tears do not fully drain, but because the drops do not open the blockage, infections may recur.
“Pediatric ophthalmologists can use special drops to make an independent assessment of a child’s need for glasses at any age,” says Dr. Granet.
- Nearsightedness (myopia) is when objects that are close appear clear while objects that are far away, do not. Glasses are not always prescribed for young children with myopia.
- Farsightedness (hyperopia) is sight that is better at a distance than at a closer range. Large amounts of farsightedness can induce eyestrain, which can lead to crossing of the eyes. “Glasses are often prescribed to help a child who is struggling to see better,” Granet says.
- Astigmatism, a condition where the eye is not completely round, causes a distortion of the optical image coming into the eye. A prescription lens balances out the curvature. “Going to a doctor who can appropriately and carefully check the prescription without overcorrecting the child is important,” says Granet.
- A child whose eyes start to wiggle or bounce back and forth, a condition technically known as nystagmus, should be evaluated by a specialist.
Children who need eyeglasses require a special fitting that goes beyond using smaller versions of adult eyeglasses. For example, some lens materials, such as polycarbonate, can protect children who face a higher risk of having their lenses shatter, and children’s frames require specific designs. “Any child who is having developmental signs of decreased vision should see a pediatrician and perhaps have an eye exam to see if an ocular problem is the issue,” Granet says.
Strabismus represents any misalignment of the eyes. Crossed eyes, also called esotropia, occurs when either eye looks straight ahead and the other eye turns inward toward the nose. “It is the act of focusing that is causing the eyes to cross,” says Granet. Generally, this condition develops in early infancy or childhood.
Parents should consult an eye specialist if their child’s eye is consistently crossed beyond the age of four to six months. If not properly treated, crossed eyes can lead to permanent loss of vision. “If glasses are not indicated, there is a high likelihood that surgery will be needed to align the muscles,” Granet explains.
A few specialists will use Botox to treat strabismus; however, most ophthalmologists will intervene with surgery in children. The best results for congenital crossing of the eyes are at one year of life or younger, he adds. If a child becomes cross-eyed between the ages of two and five, glasses are usually indicated.
A more serious underlying condition, such as a tumor or neurological problem, may be the cause for eye crossing in a very small percentage of children.
Amblyopia (Lazy Eye)
Amblyopia, or “lazy eye,” results in poor vision without any obvious injury or disease to the eyeball. “Amblyopia can result from an eye that is turned, or an eye that has a different need for glasses, or if an eye is blocked by an eyelid or cataract,” explains Granet.
In some cases glasses may be prescribed. In other cases, one eye needs to be forced to see better with a patch or other method. Says Granet: “I frequently use a method known as Atropine penalization. A drop is instilled in the “good” eye on a regular basis that blurs the vision and makes it slightly worse that in the other eye. This forces the child to use the other (weaker) eye without the use of a patch.”
Recently, a study compared the use of a patch to the drop and found that both yield virtually equal results. Another study compared two hours and six hours of patching in children who have mild amblyopia, and found that in that case also, essentially equal results were achieved.
Physicians individualize treatment to best fit each family and child’s needs. “I use the drops while the child is in school and recommend the patch for at home,” says Dr. Granet. “The treatments are extremely powerful and can literally restore sight to a blind eye.”
Untreated amblyopia will result in a permanent decrease in vision, to the extent of causing functional blindness.
Conjunctivitis, or pink eye, is an inflammation of the conjunctiva, the thin, transparent membrane lining the eyelids and front of the eyeball. Allergies, environmental irritants, or an infection can cause pink eye. Symptoms may include eye swelling, redness, irritation, and a yellow, sticky discharge that causes the eyelids to stick together.
If the conjunctivitis is viral or bacterial, it can be highly contagious. Special precautions, such as washing hands frequently and keeping fingers away from the eyes, should be taken. In addition, the bacterial infection is usually treated with prescription antibiotic drops or ointment.