PEDIATRIC CARE

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PEDIATRIC OPHTHALMOLOGY

Pediatric ophthalmology is a subspecialty of medical doctors

This child is nearsighted and requires glasses to see clearly in the distance.

who are trained to diagnose and treat infant, childhood and adolescent eye diseases. These disorders range from the common condition of pink eye to life threatening disorders of the retina called retinoblastoma. It takes the expertise of a pediatric ophthalmologist to diagnose the vast range of conditions that fall between these two extremes. The pediatric ophthalmologist is trained in general adult ophthalmology before subspecializing in pediatrics. They can diagnose and treat childhood eye diseases as well as diseases found in adults.

Ophthalmologists are medical doctors (MD) who have completed four years of medical school plus a year of internship. This is followed by at least three years of hospital based residency training in ophthalmology. Ophthalmologists give total eye care. They examine the eyes for glasses, prescribe oral, injectable or topical medications, and perform all types of eye surgery. Pediatric ophthalmologists have chosen to specialize in eye disorders of infants, children, and adolescents. To do so requires one year of additional fellowship training.

 

Increase of Information Needed for Proper Diagnosis and Treatment

Dr. Grendahl uses a special device to check an older child for glasses.

In recent years, there has been a tremendous increase in the amount of information available to physicians who diagnose and treat eye disorders. New topical and systemic medications plus new surgical technologies (including laser and microsurgery) are part of an explosive growth of knowledge. This deluge of scientific discovery has given rise to subspecialization. It is difficult for a general ophthalmologist to master all of the information or surgical techniques that are now available. Pediatric ophthalmology evolved over the past forty years in response to an exponential growth of information about children's eye

A non threatening office environment helps children look forward to coming to the eye doctor.

problems. By concentrating their attention to one area, pediatric ophthalmologists are best trained to diagnose and treat children's eye problems, no matter how difficult or unusual that problem might be.

Providing the proper office environment, non-threatening equipment along with a friendly examination is the role of the pediatric ophthalmologist.

The specialty of pediatrics, along with the other pediatric subspecialties, (like pediatric cardiology and pediatric endocrinology), evolved in order to provide children with understanding physicians specifically trained to give children compassionate and accurate medical care.

 

Children's Eye Problems Often Differ from Those Seen in Adults

Children are not small adults. This statement seems obvious to parents, but the medical implications of this difference are not so apparent. Children's eye problems are often quite different from those of a fully-grown individual. Children have eyes that are still developing. Additionally, the potential impact of uncorrected eye problems during childhood may lead to visual loss for the rest of a person's life.

 

How Children Can Best Be Examined

	Dr. Grendahl checks a baby's vision using a small toy. If the baby sees the toy, he will follow the toy with his eyes.
	Fixation toys and cartoons in the exam room.
	A Teller acuity test helps us check your child's eyesight even if your child can't talk. This test involves using striped cards behind a puppet stage to determine if your child sees finer and finer stripes.

Children approach their physicians differently than adults do. Both groups of patients are apprehensive, but they often manifest their fear in different ways. Further, young folks have difficulty describing their symptoms, they do not answer medical questions accurately, and they may lose patience with the medical examination. They must be approached with gentleness and kindness so they will not be frightened. The examination room and even the equipment used must be modified to help allay anxiety.

As you can imagine, it is sometimes quite difficult to examine infants or children. Our pediatric ophthalmologist utilizes toys to attract the visual attention of an infant or child. Dr. Grendahl often uses cartoons to hold the visual attention of a child just long enough to gather necessary information to help make a diagnosis. Even in the non-verbal infant or child, measurement of visual acuity can be obtained by using toys, pictures, or a Teller acuity tester. Children need a few examinations in order to obtain valuable information to make an accurate diagnosis. Rarely, it is necessary to put a child to sleep to acquire additional information. We call this an exam under general anesthesia or EUA. This is performed only if it is absolutely necessary. We perform this procedure in the hospital under the care of an anesthesiologist. With the advent of small portable equipment, we find that we can bring the entire examination room equipment into the hospital when the EUA is done.

Strabismus is one of the most common conditions seen by pediatric ophthalmologists. Strabismus is a generic term for any misalignment of the two eyes. One form of strabismus is the condition when one eye is turned in relative to the other eye. This crossing of the eyes is called esotropia. Eso is Greek for 'in' and tropia is Greek for 'to turn'. It literally means to turn in. The term strabismus is also applied to the condition when one of the eyes turns out relative to the other.

	A. Estropia-one eye "turned in" B. Extropia-one eye "turned out" C. Hypertropia-one eye "turned up" D. Hypotropia-one eye "turned down"
	Dr. Grendahl checks a child for strabismus

This condition is called 'wall eyed' or exotropia. Exo is Greek for 'out' and tropia is Greek 'to turn'. It literally means turned out. Sometimes one of the eyes turns up or down relative to the other eye. This is another form of strabismus called hypertropia or hypotropia, respectively. Sometimes giving glasses will straighten the eye alignment. Sometimes it is necessary to do eye muscle surgery to realign the eyes.

Another common disorder treated by a pediatric ophthalmologist is amblyopia. Amblyopia is an abnormal development of the area of the brain responsible for vision. With this condition one or both eyes may see poorly. There are many reasons for amblyopia. Amblyopia, or lazy eye, affects 2% of the general population and causes loss of vision in more young people than all eye diseases and trauma combined.

Amblyopia develops in childhood, when the connections between the eyes and the brain are developing. The brain must learn how to put together information sent from two eyes and make one picture. If the image from one eye is clear and the other blurry, or if the eyes are misaligned and send two different pictures, the brain will ignore the picture sent from one eye. Amblyopia results when the brain consistently ignores the information from the one eye. The appearance of the affected eye may be perfectly normal, yet its vision will be abnormal. Using the analogy of the eye as a camera and the brain as the photo-processing machinery, the problem causing amblyopia is not that the camera (eye) is defective, but that the photo processor (brain) is not properly developing the "film" it receives.

Even small babies sometimes need glasses in order to develop normal vision.

With early detection and treatment, visual loss from amblyopia can be minimized or even completely reversed. Treatment usually involves patching the better seeing eye, forcing the brain to "pay attention" to the eye with poor vision. Glasses or surgically realigning the eyes also may be required. The important thing to remember is that amblyopia can only be successfully treated in childhood, the earlier it is detected, the better chance for success. After age 9, it is unusual for intervention to significantly improve visual acuity in this condition. Therefore, early vision screening is very important, since often there are no clues that amblyopia is present. As long as one eye sees well, you may not learn that the other sees poorly until it's too late.

	Tears are made in the tear gland under the upper lid. Tears drain through the puncta into the lacrimal sac and eventually drain into the nose. The nasolacrimal duct is often blocked at birth.
	A small probe is passed through the tear duct system to open up the blockage.
	Occasionally a silicone tube is placed in the tear duct system to hold the duct open.

It is often necessary to patch the good eye so that the partially sighted eye is used. This is called occlusion therapy or patching therapy. This is an attempt to stimulate that part of the brain that has been suppressed or "turned off" by a blurred image. Below you will find a partial list of causes of Amblyopia:

1. Strabismus (eye misalignment)
2. Untreated refractive errors (a need for glasses)
3. Cataracts
4. Corneal scars or opacities
5. Malformation of the retina or film of the eye
6. Drooping Eyelid (ptosis)
7. Malformation of the optic nerve (the cable that connects the eye to the brain)
8. Tumors of the eye.
9. Glaucoma

Another common pediatric eye disorder is a blocked tear duct. It is surprisingly common for infants to be born with a partially developed or plugged tear duct. Normally functioning tear ducts are necessary to drain the tears from the eyes. Frequently it is necessary to put the child to sleep to probe the tear ducts and establish drainage. It is sometimes necessary to put in temporary tear duct tubes to promote drainage.

While it is true that cataracts are more common in older adults, infants and children can have cataracts as well. The treatment of pediatric cataracts is a little different from the adult cataracts. Children often have amblyopia associated with the cataract. After surgery many children require patching treatment in order to treat the amblyopia. If cataract surgery is performed when a child is less than 1 year we usually do not put an artificial lens back in the eye. A contact lens is required to replace the power of the lens that was removed. Children older than 1 year can often have the lens power replaced with an artificial or intraocular lens.

Dr. Grendahl performs retinoscopy to check a baby for glasses

It is quite common for children to develop refractive errors (a need for glasses). The refractive errors seen are myopia (near sightedness), hyperopia (far sightedness), and astigmatism. The pediatric ophthalmologist uses a special tool called a retinoscope. In this way we can find the true refractive error of an infant or child. Retinoscopy is often the only way to determine if a child has a need for glasses, and can even be performed on a newborn.

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