ROUTINE OPHTHALMIC EXAMINATION OF CHILDREN


If you started to read this article, it means you have at least one kid and you want to make sure when the ophthalmologist is supposed to see him or her! Let’s start in this way then… What does your pediatrician do during the routine check up and when does he or she want an ophthalmologist to get involved? One more step beyond, what is the purpose of routine ophthalmological assessment? What is the right time for routine ophthalmic assessment of your baby or child?

During routine examinations, your pediatrician examines eyes to determine whether there is strabismus, congenital anomalies or any other abnormal symptoms, and s/he refers you to ophthalmologist. However, there are some problems (such as hypermetropia and astigmatism) that cannot be diagnosed by pediatrician during routine physical examination. That is why you must get your child’s eyes routinely examined. We, as your child’s ophthalmologist, want to assess your child twice before your lovely one starts to attend school: your child should have routine ophthalmic assessment at age of about 12 months and 4-5 years irrespective of any complaint. The most important purpose of ophthalmic assessment is to prevent development of lazy eye. First several years of the life comprise the plastic period, as we refer. Vision is not completely mature at birth; full maturation is achieved when baby is almost 4 years old. In this period, any reason with temporary influence on quality of vision will result with permanent visual disorders in the future. The most common three underlying causes are refractive error, strabismus and opacity. If these conditions are early diagnosed, we can prevent development of lazy eye.

American Society of Pediatricians suggests first ophthalmic assessment to be made when child is 12 to 24 months, while other developed countries propose the age range of 6-36 months. This first assessment is largely comprised of medical history. Parental observation is very important at this age range, where baby cannot express herself/himself well. Your doctor asks you many questions including but not limited to if your child was prematurely delivered, whether you notice any abnormalities in her/his eyes or if you had ever noticed any abnormality in eyes, ptosis (drooping of lower or upper eyelid), signs of laziness, transient or permanent strabismus, and excess watering in either one or both eyes. Your physician will also want to be sure whether your child recognizes you at distance or if s/he gets objects closer to her/his face to see. Your physician may also question history of strabismus, hypermetropia or eye laziness in parents. Photoscreening is a test that gives quite reliable information about conditions which threat the vision by enabling physicians to locate the red reflections and their intensity in pupil. Although it is not the true alternative of vision assessment, it offers much useful information in children who may not talk. Photoscreening enables diagnosis of strabismus, refractive errors, retina abnormalities (particularly a pediatric retinal tumor, which is referred as retinoblastoma) and opacities (cataract). At this age range, visual assessment of the child is done for each eye separately with the ability to track objects and stare. During this examination, your doctor may question your baby’s visual ability using simple methods (Figure 1), or in suspected cases, more detailed methods are used.

Later, eyelids and eyes are evaluated with a light source and asymmetry of the eyelids, eye watering, eye gum and any abnormality of eyeballs are given particular attention. Next step is to evaluate the eye movements. Since the strabismus is the most important problem hindering the maturation of binocular vision, assessment of eye movements is of paramount importance. Your doctor will start assessment with two apparently easy diagnostic tests, namely alternate cover test and cover-uncover tests, which have strong diagnostic power; if required, other strabismus tests will be performed. Finally, symmetry of pupils, shape of pupils (round or not) and light reflex will be evaluated and pupils will be dilated with mydriatic eye drop and retina of your child will be assessed.

The second ophthalmic assessment of your child will be planned when s/he is 4 years old. In addition to tests of baseline assessment, visual acuity will be measured in this assessment. Since a 4 years old child does not know the letters or numbers, the assessment will be made with pictures, E cards, C cards or HOTV (a chart comprising of 4 letters). If visual acuity cannot be assessed in this baseline evaluation or resultant values are too low to match with findings of physical examination, an E Card is given to child to take to home and the parents are asked to return to clinic in a month. If fundus could not be examined whatsoever reason, it should be assessed in this control visit.

At school age, healthy children should be examined in every 2 years. At this age, children may express themselves, and accordingly, the examination will be similar to the examination of adults. The most important different is the need of mydriasis until child is 10-12 years old if a refractive error is suspected. At this age, dioptre values may change quickly. In addition to the routine examination, you should seek attention of ophthalmologist if any one of following conditions is faced:

  • If your child complains headache,
  • If your child complains difficulty in seeing chalkboard at school and if his grades goes down without a reason,
  • If your child complains eye pain,
  • If your child complains tiredness in eyes,
  • If your child blinks eyes very often,

Special Conditions

Prematurity

If you give birth to a baby at gestational age >32 weeks or a baby with birth weight <1500 g, your baby is under a serious risk for premature retinopathy. Such babies are monitored very closely (usually once a week) since the birth by a specialized ophthalmologist; if any condition threatening vision is found, the condition is eliminated with laser therapy or surgery. Mildly premature (gestational age is 32-36 weeks or birth weight is 1500-2500 g) babies are under slightly higher risk in comparison with term babies, and follow-up visit can be started at postnatal Month 1 if baseline examination (postnatal Week 1) indicates normal findings. Depending on gestational age at birth and the birth weight, a neonatologist will inform you about the follow-up visit schedule. Your compliance to the schedule is of paramount importance with respect to the vision of your baby in the future.

Nasolacrimal duct obstruction

In the first several months of the life, congenital nasolacrimal duct obstruction can be considered in babies who suffer from tearing in one eye and/or eye discharge. If your baby suffers from anyone of these conditions, you need to seek medical attention rather than waiting for routine assessment. We can overcome the problem using simple methods at early stages; however, pressure irrigation and probing may be required under general anesthesia after baby is 9 months old or even surgery when the child is 3 years old.

Strabismus

Strabismus is one of ophthalmic conditions, which require medical attention as soon as possible. Infants may have congenital strabismus; this condition will probably take attention of your pediatrician and you will be referred to an ophthalmologist. You should see your ophthalmologist even if strabismus is transient or induced by tiredness or sleepiness. Specified types of strabismus can be easily missed due to compliance of the child; they may be indicative of severe and / or unilateral refractive errors. Laziness does not develop if strabismus is treated at early stage and the child will achieve binocular vision.





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