Today’s Topic – Eye Problems of Childhood! Childhood blindness is a devastating social and economic problem.
When a child is born blind or becomes blind, the loss of considerable man years of productivity compounds the magnitude of the economic loss, even surpassing the man years lost due to age-related cataract.
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The Child’s Eye
Of all human organs, the eye is the most fully developed one at birth. Though many changes occur with maturity, the absolute dimensions of the eye are closer to adult size than nearly any other organ of the body. “Why Are The Whites of My Eyes Yellow? Info Here“
The human eye grows rapidly during the first year of life. During the first six weeks of life the cornea flattens, the axial length increases and the power of the lens decreases.
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The Normal Visual Milestones
A child can start fixing (focusing on an object) a week after birth. However, fixation is fully developed by around 6 to 8 weeks. By around 4 months, the fovea in the retina is completely developed. By 6 months of age, visual acuity develops to a normal adult level of 6/6. At around 3 years of age, contrast sensitivity is well developed while depth perception is fully developed around 6 years of age.
Obviously the visual acuity in very young children cannot be measured using a regular vision chart. There are special methods like play charts and identification of colorful objects to record the vision.
Eye Diseases of Children
The various sight threatening conditions of childhood are as follows:
- Cataract in Children
- Congenital Rubella
- Management of Congenital Cataract
- Contact Lenses
- Intraocular Lenses
- Refractive Errors
- Management 01
- Management 02
- Retinopathy of Prematurity (ROP)
- Pediatric Glaucoma
01. Cataract in Children
The word cataract is often associated with old age. However, children can be born with cataract (congenital cataract) or may develop the disease during their first few years of life (developmental cataract).
The reasons for this development of cataract in children can be ascertained in about half the number of cases and include:
- Congenital rubella
- Hereditary diseases, for example, galactosemia, an inborn disease of milk intolerance
- Chromosomal anomalies
Of these, congenital rubella deserves special mention.
02. Congenital Rubella
An estimated 238,000 children in developing countries are born with congenital rubella syndrome (CRS) every year. In a hospital-based study performed at Aravind Eye Hospital, 25 percent of infantile cataracts were found to be associated with congenital rubella.
Rubella cataract is a part of a highly destructive congenital syndrome caused by maternal infection by the rubella virus (commonly called German measles) contracted during the first or early second trimester of pregnancy.
The syndrome includes malformations of the heart, deafness, mental retardation, dental defects and ocular disturbances such as cataracts (which are bilateral in 75 percent of the cases), congenital glaucoma, retinal disease, and abnormally small eyes.
The cataract is obvious at birth as white opacities in the pupil. These white opacities are called leukocoria or cat’s eye reflex.
03. Management of Congenital Cataract
The treatment of congenital cataract depends on three major factors:
- The presence of associated ocular abnormalities
- Whether the cataract is total or partial
Unilateral or one-sided cataracts often carry a poor prognosis because of complications like severe amblyopic (described later) and associated squint of the involved eye. This type of cataract can be removed by surgery.
Bilateral complete cataracts have a more favorable prognosis. The treatment entails prompt surgical removal of cataracts and rehabilitation of the residual errors with spectacles or intraocular lenses.
Since the child cannot perceive its problem, the cataract must first be recognized by someone else, usually a member of the family, sometimes a teacher or a trained health worker. Cataract in children is very different from cataract in adults. The surgery is more complex and the postoperative follow-up care much more demanding.
Children’s eyes react differently from adult eyes after cataract surgery. Severe intraocular inflammation and posterior capsular opacification are more common. The eye grows until the child is two years old. This leads to frequent changes in the refractive state of the eye.
In children above two years of age, extracapsular cataract extraction is done and an IOL implanted.
Below two years of age, it is better not to insert an IOL for the following reasons:
- The eyeball grows in the first two years of life and since the eye is increasing in size the power may change after a few years
- The IOL is of a particular size and may become unstable due to the increased space available with the growth of the eye
If an IOL is not implanted, the eye is said to be aphakic. This condition can be corrected by means of spectacles or contact lenses.
Spectacles can be used following bilateral cataract surgery but are not very useful for uniocular aphakia because of the discrepancy in image size between the two eyes.
This causes intolerable double vision.
06. Contact Lenses
Contact lenses are useful for compliant children who can handle them. They cause less distortion of images when compared to spectacles and are more effective in combating amblyopia.
The major problems with contact lenses are cleanliness and hygiene. A dry and dusty environment is not suitable for contact lens. In addition, wearing them and taking them out can be a problem for very young children.
Although tolerance is much better with the newer lenses, allergy, itching, and discomfort are common in children.
07. Intraocular Lenses
They are the best solution to aphakia. A few important features, however, are to be considered:
- IOL surgery should be done by an experienced surgeon since the chances of postoperative inflammation are high.
- The power of IOL is to be individualized as the eye is still in the growing phase.
- The commitment is for a longer period because of the postoperative care involved.
Amblyopia is to be treated aggressively.
If IOL has not been done in the primary setting, the surgeon has to do it in a secondary setting.
People with congenital cataracts develop posterior capsular opacification within a few months, and so a second surgery for membranectomy has to be considered.
08. Refractive Errors
Refractive error is the most common complaint for which a child is brought to the ophthalmologist. Since children have a strong tendency to accommodate, refraction should be performed after dilating the pupil fully.
There is a general perception that refractive errors and wearing spectacles are becoming more common in recent times. Actually, demanding visual needs and awareness in seeking eye care may have played a major part in this apparent increase.
A child with an uncorrected refractive error is restricted to the limits of his vision. The frustrated child becomes an introvert, keeping away from the other children of his age, and avoids outdoor activities.
Incidentally, the child may not be aware of this problem and it is usually the parent or the observant class teachers who refer the problem to the eye doctor.
Hence, it is very important that visual acuity testing should be performed for all children and each eye should be tested individually.
This is particularly important since, in some instances, refractive errors can be present only in one eye, and if we do not check each eye individually, we may not be able to detect unilateral refractive errors.
Failure to do so may cause one eye to dominate the other, resulting in a condition called amblyopia, which is also termed lazy eye.
With normal binocular vision, both eyes are aimed at the same target. The visual portion of the brain fuses the two pictures into a single three-dimensional image.
When one eye is misaligned, as in strabismus, or in uncorrected unilateral refractive error, two different pictures are sent to the brain. In a young child, the brain learns to ignore the image of the misaligned eye and sees only the image from the straight or better-seeing eye.
This causes a loss of depth perception and binocular vision. The misaligned eye becomes lazy or it is said to develop amblyopia. Any condition which causes a significant difference in the visual power of the two eyes can result in amblyopia of the weaker eye.
The controlling visual area of the right eye is present on the left side of the brain and vice versa. When normal vision is present in both eyes, the brain centers on both sides are equally stimulated and hence equally developed.
When the image of one eye is unclear, the brain starts suppressing that eye’s image and gradually it leads to permanent uniocular loss of vision.
When vision is impaired in both eyes, the child may get amblyopia, that is, decreased vision in both the eyes, if spectacles are not prescribed. Amblyopia is a significant problem and can be averted by screening all children for refractive errors.
This is possible by recruiting the efforts of public institutions like schools to screen their students systematically and periodically.
10. Management 01
Amblyopia can be treated by patching (obstructing the view) of the better eye to strengthen and improve the vision in the weaker eye. If amblyopia is detected in the first few years of life, treatment is often successful. As a rule, the earlier the amblyopia is treated, the better the visual result, because the child will be able to develop binocular vision and depth perception.
Strabismus is commonly called squint or cross-eye. In this condition, the eyes are not aligned to the Centre and may point in different directions.
Inward turning of the eye is called esotropia and outward turning of the eye is called exotropia. Often, the squinting is constant.
Sometimes, squinting can be noticed, when the child is tired and fatigued. Treatment of this condition should be initiated as soon as possible to prevent amblyopia. If surgery is delayed, only the cosmetic benefit will be obtained.
12. Management 02
The treatment goals for strabismus are to preserve vision, to straighten the eyes and to restore binocular vision. Depending on the cause, the treatment may involve repositioning of the eye, removing a cataract or correcting other conditions which are causing the eyes to turn.
In accommodative esotropia, spectacles reduce the focusing effort and can straighten the eyes. Sometimes bifocals are necessary for close work. Eye drops, ointments or special lenses called prisms can also be used to straighten the eyes. People with strabismus should be checked for refractive errors and the power should be recorded.
Strabismus surgery involves making a small incision in the tissue covering the eye and repositioning the muscles.
13. Retinopathy of Prematurity (ROP)
Retinopathy of prematurity (ROP) occurs in preterm babies that may have received intensive neonatal care. The blood vessels in the retina are not fully developed at birth and are susceptible to damage due to outside agents including excess oxygen.
The ‘first epidemic’ of ROP occurred in the West during the 1940s and 1950s and was the single commonest cause of blindness in many industrialized countries. ROP is an important part of Eye Problems of Childhood topic.
These countries are now witnessing a ‘second epidemic’ of blindness in children due to ROP. The re-emergence of the condition has come about paradoxically in the survival of extremely premature, low birth weight babies.
It is important that a qualified vitreo-retinal surgeon screens all preterm or low birth weight babies that have received intensive care immediately after delivery.
14. Pediatric Glaucoma
Glaucoma is a condition where the optic nerve is progressively damaged because of various causes, chief among them being increased intraocular pressure. It is mainly a disease of the aged but it can also occur in pediatric patients.
Its incidence is 1 in 10,000 live births. It has been classified into congenital, infantile and juvenile glaucoma. Pediatric Glaucoma is the also important part of Eye Problems of Childhood topic.
Congenital glaucoma (up to 1 year of age): In addition to optic nerve damage, the eyeball enlarges because the sclera in the eye of the baby is distensible. The corneas of these babies are, therefore, large. The layers of the cornea, which are not elastic, may get torn, resulting in opacification. Diagnostic features are tearing, photophobia (avoidance of light) and enlarged eyes.
Infantile glaucoma (between 1-3 years of age) and juvenile glaucoma (between 3-16 years of age): The eyes are not enlarged and symptoms like watering and corneal enlargement are absent. These types of glaucoma are diagnosed during routine screening or when the child is examined because of a family history of glaucoma.
The treatment of congenital glaucoma is mainly surgical and involves creating a new drainage channel for a free outflow of aqueous humour.
Some other information for Child Eye Care:
- Precautionary Measures
- Children should wear protective goggles when participating in science labs.
- Prevent children from playing dangerous games like Bow & arrow and Gulli Danda, which poses risk of serious eye injury
- Avoid playing with fire crackers, Holi etc.
- Provide adequate supervision and instruction when children are handing Pencils
- Scissors, they should be held away from the eye
- When playing children should not throw stones at other
This Article Source: Kalinga Eye Hospital and Wikipedia
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