Pediatric Ophthalmology

Pediatric ophthalmology is a subspecialty of ophthalmology dealing with children's eye diseases. The human visual system develops as the brain matures, a process that takes about ten years. Although a baby's eyes are optically capable of seeing, infant vision is limited to around 20/1500, in part because the brain has not learned how to process the visual messages it receives. As visual development proceeds, that same child will eventually be able to detect the finest details in an image.

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Some children or infants have visual disorders that are secondary to serious diseases in their brain or nervous system. At Bascom Palmer Eye Institute, these children receive the attention of a pediatric neuro-ophthalmologist who specializes in visual problems related to brain disorders. Vision problems include cortical blindness, delayed visual maturation, optic nerve hypoplasia, optic nerve atrophy and cranial neuropathies.

Pediatricians may refer infants to the Institute's neuro-ophthalmology clinic, usually after parents notice that their babies are not developing eye fixation. Children with brain tumors may also be referred in order to obtain base line visual examinations. When a child's visual disorder is not obvious diagnosis is difficult at best, depending less on diagnostic equipment than on the ophthalmologist's interpretation of every small finding during an examination.

The pediatric glaucoma specialists at Bascom Palmer Eye Institute treat all forms of glaucoma in children. A wide range of medical and surgical options are available to treat infants and children with these disorders. Sophisticated orthoptic diagnoses and therapies are utilized, including visual acuity testing in infants. Most patients require surgery which can include trabeculotomy or goniotomy.

What is amblyopia or "lazy eye"?

Common to about one in 25 to 50 people, amblyopia is a condition in which the visual function of one eye is underdeveloped, while vision for the other eye is normal, although, at times, it can affect both eyes. Amblyopia is most likely to be successfully corrected if detected and treated during infancy or early childhood.

This disorder, like others that affect the visual development, calls for early and regular visual examinations. Young children are not always aware of having one good eye and one impaired eye, and parents have no way of recognizing the problem unless the underdeveloped eye is obviously abnormal.

What causes amblyopia?
Any factor that prevents clear vision during infancy or childhood promotes amblyopia. The chief causes are:

• Strabismus (misaligned eyes).
• Unequal focus (an asymmetrical refractive error).
• Cloudiness in normally clear eye tissues such as corneal opacities and cataracts, which prevent the proper focus of light in the eye.

Because young children are often difficult to examine, pediatric ophthalmologists use a variety of unique methods to determine the existence of amblyopia and other visual problems.

What is the treatment for amblyopia?
Once amblyopia is detected, the brain must be encouraged to process visual information from the affected eye. This is frequently accomplished by applying a patch over the child's good eye. Eye drops are also sometimes used to treat amblyopia.

Left untreated, visual acuity in an amblyopic eye may be permanently reduced and a lifetime of poor and uncorrectable vision could result. This can become an ever more significant and disabling problem if the remaining healthy eye ever becomes diseased or injured. Unfortunately, once a child has reached roughly nine years of age, treatment rarely is successful.

http://www.nei.nih.gov/health/ambloypia/index.htm

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What is pediatric strabismus?

Strabismus is a visual defect in which the eyes are misaligned and point in different directions. The disorder is common among children, but is also present in approximately 1 to 2 percent of the adult population - usually as a condition that began in childhood.

Eye misalignment causes the brain to receive two different visual messages. In young children, the brain may begin to "ignore" the image sent by the deviating eye while highly detailed visual information may be processed from the straight eye. This results in amblyopia.

Strabismus is also frequently accompanied by defective or absent binocular vision, which is characterized by reduced 3-D vision, resulting in impaired depth perception.

Parents should realize that children usually do not outgrow strabismus and that treatment, whether glasses, eye drops, exercises, or eye muscle surgery, is most effective when initiated early in a child's development.

Once the visual system is developed, as in older children or adults, strabismus may produce double vision, eye strain, discomfort in reading, and headaches. Effective treatment is often available. Adults without a previous history of childhood strabismus should have a careful evaluation to rule out the possibility of medical or neurological causes, such as diabetes, thyroid disease, myasthenia gravis, brain tumor, or stroke.

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What is pediatric glaucoma?

Although it most commonly affects the elderly, primary infantile glaucoma occurs in about 1 in 25,000 babies born in the United States. Glaucoma may also develop in babies and children who have other types of eye disease. In both adults and children with glaucoma, the prevention of permanent blindness requires detection and proper treatment. Glaucoma may go undetected during childhood because the signs of the disease may not be obvious and the disorder can masquerade as other conditions.

What are the early signs of glaucoma in infants and children?

• Enlargement of one or both eyes (this may be subtle and can be mistaken for normal)
• Excessive tearing
• Cloudy corneas
• Sensitivity to light in one or both eyes
• Myopia (nearsightedness) in one or both eyes

How is pediatric glaucoma treated?

Pediatric glaucoma is treated differently than adult glaucoma. Most patients require surgery, and two operations for childhood glaucoma are trabeculotomy and goniotomy, which are almost never used in the treatment of adult glaucoma.
Because most eye doctors do not have experience treating infants or young children with glaucoma, patients usually are referred to specialists for treatment.

Approximately 80-90% of babies who receive prompt surgical treatment will do well, and may have normal or nearly normal vision for their lifetime. Most babies who have glaucoma and do not obtain appropriate care quickly will lose their vision.

Early detection and treatment can mean the difference between sight and blindness.

What advantage does Bascom Palmer offer?

The pediatric glaucoma specialists at Bascom Palmer Eye Institute treat all forms of glaucoma in children. A wide range of medical and surgical options are available to treat infants and children with these disorders. In conjunction with Bascom Palmer’s pediatric ophthalmologists and other eye care specialists, children receive short-term treatment of the immediate problem and long-term rehabilitative care and monitoring of their visual development.

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What is retinopathy of prematurity?

Retinopathy of prematurity (ROP) is the leading cause of childhood blindness in developed countries. Bascom Palmer physicians and scientists have earned international recognition for pioneering research into the cause and prevention of ROP. Studies conducted in cooperation with community neonatologists and ophthalmologists have led the way to a new understanding of ROP and to the identification of its potential victims.

Premature or low birth weight babies often need to receive oxygen until their immature lungs develop. Today, physicians know that exposure to high levels of oxygen over extended periods of time can trigger the disease in infants, causing the retina's tiny developing blood vessels to grow wildly and produce scars. In some children, the retina is able to recover and damage is moderate. However, in severe cases, there is retinal detachment and, ultimately, blindness.

Bascom Palmer Eye Institute has an established ROP protocol for premature babies who meet specific criteria (including birth weight). The ROP team conducts an extensive screening examination, including Retcam photography, ultrasound, and laser therapy to treat the rapid growth of blood vessels. In some cases, this treatment is quite successful.

In a multi-center, collaborative four-year study conducted at Bascom Palmer, physicians identified the level of oxygen dangerous to an infant's eyes. More importantly, the study revealed that a baby's exposure to oxygen in the first week after birth is less critical than exposure in the weeks that follow. In other words, low-birth-weight babies who remain on oxygen during the second through the fourth week are at greater risk of developing ROP and of developing its most severe form.

We hope the results of this study will generate new technology that more accurately monitors and controls the amount of oxygen that a baby's body absorbs while on life support. Because life support is often critical in preventing brain damage and death, the need for a solution, as soon as possible, is clear.

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What is retinoblastoma?

Retinoblastoma (RB) is a rare form of cancer affecting the light-sensitive retinal cells that enable sight. Although the disease is very rare, it is the most common ocular malignancy in children and the third most common cancer to affect children --- occurring in one out of every 15,000 births. In the United States, 250 to 350 new cases are diagnosed each year --- 90 percent of which occur in children under five years of age.

The treatment of RB depends on the size and location of the tumor and whether one or both eyes are involved. With earlier detection and improved treatments, the prognosis for vision and life for RB patients has improved significantly in the past twenty years. However, because the disease is so rare, many pediatricians and primary care providers may not recognize the early signs, and parents rarely notice the subtle changes that may identify a tumor in their child's eyes. Left untreated, RB tumor nodules grow rapidly, expanding to fill the eye and extending along the optic nerve to the brain, ultimately causing death.

Although the cancer is genetically determined, only 6 percent of newly diagnosed RB patients are found to have a positive family history of the disease. Forty percent of all children have a lifelong cancer risk from abnormality in the RB gene located in chromosome 13. In all cases, genetic counseling is important for children with a germ-line mutation.

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Why Bascom Palmer Eye Institute?

Following the recommendations of the American Academy of Ophthalmology, Bascom Palmer's pediatric ophthalmologists advise that all children have a vision examination by their fourth birthday if vision appears to be developing normally.

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Who are the Pediatric Ophthalmologists at Bascom Palmer Eye Institute?

Other Pediatric Ophthalmology Resources

American Academy of Ophthalmology
American Association of Pediatric Ophthalmology and Strabismus
Eye Resources on the Internet
National Eye Institute

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