Overview of Eye Disorders in Children

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Congenital glaucoma and congenital cataracts (see Other Birth Defects

) are

uncommon disorders that can affect newborns and young children. Disorders that most often blur vision, such as nearsightedness, farsightedness, and astigmatism (all considered refractive errors), do occur in children and require prompt treatment to prevent amblyopia (a decrease in vision). Amblyopia affects about 2 to 3% of children and almost always develops before age 2. Misalignment of the eyes (strabismus) occurs in about 3% of children and can also cause loss of vision due to amblyopia.

In addition to doing a routine eye examination, doctors examine children at the earliest possible age for strabismus and refractive errors, which can cause amblyopia. Screening for this kind of visual problem should start by age 3 and continue during schooling.

Refractive Errors in Children Refractive errors, such as nearsightedness (inability to see distant objects clearly), farsightedness (inability to see close objects clearly), and astigmatism (an irregular curvature of the focusing surfaces of the eye--see Symptoms of Eye Disorders: What Is Astigmatism? ), result in blurring

of vision. Blurring occurs because the eye cannot focus images precisely on the retina. If uncorrected, a decrease in vision (amblyopia) may develop.

Children are often not able to make their vision problems known. Sometimes

a teacher or school nurse is the first to detect a vision problem.

All children should be screened for refractive errors and other eye problems. Children as young as 3 or 4 years old can view charts with pictures, figures, or letters used to test vision. Vision is tested in each eye separately to detect loss of vision that affects only one eye. The eye not being tested is covered.

Diagnosis is established by an eye examination and measurement of the refractive error. In young children, refractive errors are generally treated with eyeglasses. In older, more responsible children, refractive errors can be corrected with contact lenses. However, inadequate care and cleaning of contact lenses can lead to eye infections.

Amblyopia

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Amblyopia, a common cause of vision loss in children, is a decrease in vision that occurs because the brain ignores the image received from one eye. Vision loss may be irreversible if not diagnosed and treated before age 8.

Amblyopia can be caused by farsightedness, astigmatism, misalignment of the eyes, or cataracts.

Children can have no symptoms or symptoms that include squinting, covering one eye, or having one eye that does not look in the same direction as the other.

The diagnosis is based on the results of vision testing. If diagnosed and treated early, amblyopia can be corrected.

Treatment includes eyeglasses, an eye patch, or corrective surgery for cataracts.

Causes A child's visual pathways are not fully developed at birth. The vision system and the brain need to be stimulated by clear, focused, properly aligned, overlapping images from both eyes to develop normally. This development takes place mainly in the first 3 years of life but is not complete until about 8 years of age. If the brain does not receive proper visual stimulation from an eye during the development period, it learns to ignore (suppress) the image from that eye, resulting in vision loss. If the suppression persists long enough, vision loss can be permanent. There are several reasons for lack of proper visual stimulation, each of which can cause a type of amblyopia.

Refractive Amblyopia: Amblyopia may be caused by an uncorrected or unequal refractive error, usually farsightedness or astigmatism, particularly when there is a large difference between the two eyes.

Strabismic Amblyopia: Misalignment of the eyes (strabismus) can also cause amblyopia. The eyes produce two imagesone from each eyethat normally are fused or united into a single image in the brain and then integrated to produce three-dimensional images and high levels of depth perception. The ability to fuse images develops during early childhood. If the two images are so misaligned that they cannot be fused together, the brain suppresses an image, ignoring the input from that eye. The brain is unaware of the image from the affected eye even though the eye may be structurally normal. In adults, because the visual pathways are already developed, seeing two different images results in double vision (diplopia) rather than in loss of vision.

Deprivation Amblyopia: A third type of amblyopia develops when a clouding or opacity of the lens of the eye (cataract) or the cornea reduces or distorts the light entering an eye.

Did You Know...

Sometimes a teacher or school nurse is the first to notice a child has an eye disorder.

Symptoms and Diagnosis Children with amblyopia may be too young to describe symptoms. These children may squint, cover one eye, or have one eye that does not look in the same direction as the other, all of which may indicate a problem that requires examination. Children, however, often do not appear to have a problem. If one eye sees well and the other does not, children compensate well and do not seem to function differently from their peers. Thus, to detect problems in visual development, vision screening for all children should be started during early wellchild examinations and continued throughout childhood. In some areas, preschool children are screened by volunteers and local and regional agencies. Once children reach school age, screening is done in school by health practitioners. If a problem is found during screening, the child should see an eye doctor, either an ophthalmologist or an optometrist.

Prognosis and Treatment The sooner amblyopia or risk factors for amblyopia are detected, the more likely amblyopia can be prevented or corrected. For these reasons, vision screening

programs for children should be supported by the community.

Treating amblyopia involves forcing the brain to use the visual images from the problem eye. Sometimes this is accomplished simply by correcting refractive errors with eyeglasses. More often, doctors "handicap" the normal, stronger eye by putting a patch over it or using eye drops to blur its vision. If strabismus is the cause, it should be corrected (see see Eye Disorders in Children: Strabismus) after vision has been equalized between the eyes. A cataract or other opacity in the eye may require surgical treatment.

Treatment should be initiated promptly, preferably during the first 2 to 4 years of life. The earlier the treatment is initiated, the quicker the response will be. Regardless of the cause, amblyopia that has not been treated by age 8 usually cannot be fully reversed. Failure to effectively treat amblyopia may result in permanent blindness in the affected eye.

Strabismus

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Strabismus (also called squint, cross-eye, lazy eye, or wandering eye) is an intermittent or constant misalignment of an eye so that its line of vision is not pointed at the same object as the other eye. If untreated, strabismus can cause amblyopia (a decrease in vision) and permanent loss of vision. Strabismus is treated with correction of any refractive error, a patch to equalize vision, and, in some cases, surgery.

Strabismus is caused by an imbalance in the muscles that control the positioning of the eye.

Symptoms include misalignment of the eyes, double vision, and paralysis of eye muscles.

The diagnosis is based on an eye examination. Strabismus sometimes resolves on its own, but in most cases, eyeglasses, eye drops, or surgery is needed.

The causes of strabismus are varied and include an imbalance in the pull of muscles that control the position of the eyes and poor vision in one eye. Although not usually caused by a general medical or neurologic disorder, strabismus is a serious problem that should be evaluated and treated and not ignored or watched. Prompt examination by an eye doctor, either an ophthalmologist or an optometrist, is essential.

There are several types of strabismus. Some types are characterized by inward turning of the eye (esotropia or cross-eye) and some by outward turning of the eye (exotropia or walleye). Others are characterized by upward turning of the eye (hypertropia) or downward turning of the eye (hypotropia). The defect in alignment may be constant or intermittent and may be mild or severe.

Phoria is a tendency for misalignment of the eyes. The tendency is a minor defect that is easily corrected by the brain to maintain apparent alignment of the eyes and allow fusion of the images from both eyes. Thus, phorias usually do not cause symptoms and do not need treatment unless they are large and decompensate, producing double vision.

Tropia is a constant, visible deviation or misalignment of the eyes. An intermittent eye deviation that is frequent and poorly controlled by the brain is termed intermittent tropia.

Strabismus: A Misaligned Eye

There

are

several

types

of

strabismus. In the most common types, an eye turns inward

(esotropia or cross-eye) or outward (exotropia or walleye). In this

illustration, the child's right eye is affected. Strabismus may cause double vision (diplopia) in older children or amblyopia in younger children.

Parents sometimes notice strabismus because the child squints or covers one eye. The defect may be detected by observing that the child's eyes appear to be positioned abnormally or do not move in unison.

Children should be examined periodically to measure vision and to detect

strabismus starting at a few months of age. To examine an infant, a doctor shines a light into the eyes to see whether the light reflects back from the same location on each pupil.

Older children can be examined more thoroughly. Children may be asked to recognize objects or letters with one eye covered and to participate in tests to assess alignment of the eyes. All children with strabismus require examination by an eye doctor (ophthalmologist or optometrist).

If the defect is minor or intermittent, treatment may not be needed. However, if strabismus is severe or is progressing, treatment is required. Treatment depends on the characteristics of the strabismus.

Did You Know...

Children as young as 3 can have their vision screened.

Infantile Esotropia: Infantile esotropia is a constant inward turning of the eyes that develops before 6 months of age. It often runs in families and tends to be severe. The eyes often begin to turn inward by 3 months of age. The degree of turning is large and easily noticeable.

Surgery, which is done by altering the pull of the eye muscles, is usually needed to realign the eyes. Repeated operations may be necessary. Even with the best possible treatment, strabismus may not be fully corrected. Occasionally, amblyopia develops, but it usually responds to treatment.

Accommodative Esotropia: Accommodative esotropia is inward turning of the eyes that develops between the ages of 6 months and 7 years, most often in

children aged 2 to 3 years. It is related to optical focusing (accommodation) of the eyes.

The misalignment is the result of how the eyes move when focusing on nearby or distant objects. Children with accommodative esotropia are farsighted. Although everyone's eyes turn inward when focusing on very close objects, eyes that are farsighted also turn inward when looking at distant objects. In mild cases, the eyes may turn too far inward only when looking at nearby objects. In more severe cases, the eyes turn too far inward all the time. With treatment, accommodative esotropia can usually be corrected. Eyeglasses can help children focus on objects, reducing the tendency for the eyes to turn inward when viewing those objects. Many children outgrow farsightedness and eventually do not need eyeglasses.

Occasionally,

drugs

(such

as echothiophate

eye drops) are used to help the eyes to focus on nearby objects. If eyeglasses and eye drops fail to properly align the eyes, surgery may help. Amblyopia often develops in children with accommodative esotropia and sometimes in children with infantile esotropia.

Intermittent Exotropia: Intermittent exotropia is outward turning of the eyes that occurs intermittently, usually when the child is looking at distant objects or when the child is tired or ill. Intermittent exotropia is detectable after the age of 6 months.

Intermittent exotropia that is of small magnitude, occurs infrequently, and does not cause symptoms may not require treatment because amblyopia does not usually develop. If symptoms of eye strain due to an uncorrected refractive error become troublesome or if attempting to bring the eyes into alignment becomes troublesome, eyeglasses may be used. In more severe cases, surgery may be needed.

Paralytic Strabismus: In paralytic strabismus, one or more of the eye muscles that move the eye in different directions become paralyzed. As a result, the muscles no longer work in balance. The eye muscle paralysis is usually caused by a disorder that affects the nerves to the eye muscles, such as certain viral infections, brain injuries, or brain tumors that increase pressure within the skull and compress these nerves.

In children with paralytic strabismus, movement of the affected eye is impaired only when the eye tries to move in a specific direction, not in all directions. Amblyopia or double vision may develop. The double vision is made worse by looking in directions normally controlled by the paralyzed eye muscles.

Paralytic strabismus may resolve by itself over time. However, it may need to be corrected with eyeglasses and covering of the unaffected eye. Sometimes eyeglasses with prisms are used. Alternatively, surgery may be needed. If paralytic strabismus results from another condition affecting the nerves, such as a brain tumor, the other condition also needs to be treated.