Pediatric Ophthalmology
Blocked Tear Ducts
Approximately one-third of newborns tear excessively. It occurs when a membrane (a skin-like tissue) in the nose fails to open before birth, blocking part of the tear drainage system. If tears do not drain properly, they can collect inside the tear drainage system and spill over the eyelid onto the cheek. Rarely, the tear duct itself may become infected, leading to a serious infection called dacryocystitis. If a child’s inner eye appears red, swollen, and difficult to open, immediate medical attention is required for emergent antibiotic treatment.
Tears are produced to keep your eyes moist. As new tears are produced, old tears drain from the eye through two small holes called the upper and lower punctum. These holes are located at the corner of your upper and lower eyelids near the nose. The tears then move through the canaliculus passage and into the lacrimal sac. From the sac, the tears drop down the tear duct (also known as the nasolacrimal duct), which drains into the back of your nose and throat. That is why your nose runs when you cry. In infants with overflow tearing, the membrane blocking the tear duct prevents tears from draining into the back of the nose and throat.
Tearing can also be caused by wind, smoke or allergies, or other environmental irritants. A very rare condition called congenital glaucoma can also cause excessive tears. With congenital glaucoma, other signs and symptoms, such as an enlarged eye, a cloudy cornea, high eye pressure, light sensitivity, and eye irritation, will accompany tearing.
Treatment of Blocked Tear Ducts
Blocked tear ducts can initially be treated by applying massage over the lacrimal sac. This is followed by applying antibiotic eye drops or ointment to the eye and cleaning the eyelids with warm water. To massage the tear ducts, place your finger under the inner corner of the infant’s eye next to the nose. Roll your finger over the bony ridge while pressing down on the bony side of the nose. This movement squeezes tears and mucus out of the sac.
The blocked tear duct often spontaneously opens six to twelve months after birth. If overflow tearing persists, your ophthalmologist may need to open the obstruction surgically by passing a probe through the tear duct.
Tear Duct Surgery
Dr. Adams performs tear duct surgery as an outpatient surgical procedure. Surgery is usually performed at the approximate age of 1-year-old after all conservative measures such as massage and antibiotic drops fail to resolve the condition.
Under sedation, a thin metal probe is gently inserted through the tear drainage system to open the obstruction. The drainage system is flushed with fluid to ensure the pathway is open. The procedure is usually completed in minutes.
Your child should soon be able to resume normal activities upon discharge from the surgical center. Clear liquids in small amounts are advised for the first few hours following surgery. A normal diet may be resumed as soon as the anesthesia effects subsided. You may bathe the child, and the child may resume all usual activities the day after surgery. Swimming should be avoided for two weeks.
Following surgery, your child will be on antibiotic drops twice daily. Parents may see blood-tinged tears or nasal discharge. Tearing may persist for a time after the procedure due to normal post-operative swelling. All of these should be resolved quickly after surgery. Your child will return to see Dr. Adams in 1-2 weeks following the procedure.
In a small percentage of patients, tearing may persist despite surgery. In these cases, an additional probing procedure is required, often with the placement of tubes within the tear drainage system. This is to stent the tear ducts open.
Focus Effort & Eye Crossing
In children, there are different types of eye crossing, but one of the most common is related to the ability of the far-sighted child to focus at close range. Children with far-sightedness have more difficulty seeing objects up close than in the distance and thus require more effort to focus on objects near. The ability to focus on a near object also requires the eyes to turn inward to remain focused on the object. Since eye crossing and focus effort are linked together, children can develop crossed eyes when they use too much effort to focus on objects of interest.
To see better and reduce focus effort, children with large amounts of far-sightedness and eye crossing will require glasses. As glasses decrease the amount of effort the child needs to focus on objects it also reduces the amount of eye crossing. This condition is called accommodating esotropia.
Some children may have additional crossing only near and can benefit from bifocals. This provides extra assistance in focusing at close distances. If these measures do not work the child may require surgery to realign the eyes.
What if glasses straighten the child’s eyes?
A child whose eyes are held straight by glasses will be closely monitored to ensure that proper visual development is taking place. As the child grows older it is possible to eventually wean them out of glasses once visual development is completed. Children whose eye alignment improves, but is not satisfactory may need surgery in addition to glasses.
Parents of children with this condition often notice that the eyes continue to cross when the glasses are removed. Crossing of the eyes upon removal of the glasses suggests only that the glasses are helping. This emphasizes the need to keep glasses on the child at all times. This crossing may continue until the child outgrows farsightedness or readjusts the relationship between focus effort and convergence. Most children whose crossed eyes are straight with glasses begin to maintain good alignment without glasses at eight or nine years old. Children with significant farsightedness or other significant optical problems may never be able to maintain good eye alignment without glasses or contacts.
What if glasses do not straighten the eyes?
When glasses completely realign the eyes and equal vision is achieved nothing further is required. However, when glasses do not completely realign a child’s eyes, surgery may be necessary. Strabismus, like so many other conditions, requires an individualized treatment plan. Treatment goals, briefly stated are to make your child see well with each eye individually, to make the eyes as straight as possible so that they can function as a pair, and to improve appearance. Dr. Adams tries to reach these goals by the safest, fastest, and most effective means. Surgery is always held as the last resort by our physicians.
Special thanks to Pediatric Ophthalmology Consultants for providing the original Focus Effort and Its Relationship to Crossing of the Eye.
Amblyopia or Lazy Eye
Approximately 5% of all children will develop an eye condition that can result in permanent visual loss if not detected and treated early. Often, this decrease in vision can remain unnoticed by the most observant of parents because children usually will not exhibit any change in behavior. Children can play and interact without showing any signs that one eye is not seeing as well as the other. Children sometimes do not realize that their vision is abnormal because they have not grown to know the difference.
Children are not born with completely developed vision. Nerve connections and visual processing are still incomplete until eight years old. At this age, the eyes still learn to see. Normal visual development requires that both eyes of a child receive a focused image and remain straight. Any condition that blurs a child’s vision during this period, such as a need for glasses, eye misalignment, or a drooping eyelid, can interfere with normal vision development. Because the brain becomes confused with the vision of a blurred or crossed eye, it will ignore this eye and only use the good eye. Like a muscle that weakens with disuse, the eye that is not being used will also weaken, resulting in visual loss. Decreased vision from this disruption of visual development is called amblyopia or “lazy eye.” The longer this remains undetected, the more difficult it is to treat.
As a child approaches eight years old, the eye learning process is complete and cannot be changed. What vision a child has developed at this age, whether good or bad is what he or she will have for the rest of his life. This is why it is imperative to identify these children as early as possible, ideally at three years old. This allows for treatment to be started early and for better visual outcomes.
Treatment depends on the condition, which blurs the child’s eye or causes a misalignment, but usually involves patching therapy. An eye patch covers the normal seeing eye to force the weaker eye to be used. With time, and if initiated early enough, this can strengthen the eye and improve vision.
Dr. Adams has years of experience working with children and treating pediatric eye disorders. If you suspect that your child has a visual problem or you have a family history of childhood eye disease, please contact our office or your pediatrician for an evaluation.
Patching Instructions
What Is Patching?
Patching is a technique for treating amblyopia (lazy eye). The better-seeing eye is covered to encourage vision development in the weaker eye. Amblyopia can be caused by unequal eyeglass prescriptions, crossed eyes, or other abnormalities that affect vision in young children.
How Long Will A Child Need to Wear the Patch?
This will vary for each child. As a general rule, the younger the age of the child and the shorter the time the eye has been affected the less time it will take for treatment. Young children’s vision may change rapidly. Occasionally, vision in the good eye may be decreased when the patch is removed, but will usually return to normal as soon as that eye is used again.
To ensure that a child is given the best chance to develop normal vision, patching may be continued for a few weeks or months after vision stabilizes. Once vision has improved in the weak eye there is a small chance of worsening again. Because of this, close monitoring is necessary throughout childhood. If vision does not improve after a reasonable period of effective patching, your ophthalmologist may recommend discontinuing this treatment.
At first, your child may not want to wear the patch. Keep encouraging your child to wear the patch to improve their vision. If you are having trouble, try placing the patch on the eye before your child wakes up. TV, video games, or another favorite activity may help pass the time wearing the patch. It is crucial that your child wears the patch while awake as the patch will not improve vision if the child is asleep. Avoid using the patch when your child is engaged in dangerous activities such as sports, bicycle riding, etc.
What Kind of Patch Should Be Used?
The patch should be comfortable. It should remain firmly in place and should not allow any peeking around the edges. Commercial patches come in “regular” and “junior” sizes and are available at Eye Surgery Associates and most drug stores. Eye patches with elastic and occluders that clip onto glasses are not recommended as they may allow peeking. The patch should be attached directly to the skin around the eye for best results.
Retinoblastoma
Retinoblastoma is the most common pediatric eye tumor inside the eye. This tumor usually develops by eighteen months of age, and over 90% of patients are diagnosed before three. The tumor occurs at a rate of 1 in 15,000 to 1 in 30,000 live births. The gene responsible for this tumor has been identified and studied in great detail. Years ago, retinoblastoma was uniformly fatal, but now, with early intervention, we can preserve both life and vision.
The retinoblastoma tumor originates in the retina, the light-sensitive area of the eye that enables us to see. The tumor will normally present as an abnormal red reflex (commonly known as a “red eye” in photographs) in which the pupil of one eye appears whiter. These abnormal red reflexes can also occur from other conditions such as strabismus (or crossed eyes), cataracts, or, most commonly due to the angle at which the photo was taken. All pediatricians screen for retinoblastoma during your infant’s well-baby visits. However, despite proper screening, the tumor can still go undetected. In 2002, during Dr. Dorfman’s, (Dr. Adams’ colleague) presidency at the Florida Society of Ophthalmology, we began a public awareness campaign to promote early detection of this tumor. The campaign is aimed at teaching parents how to recognize an abnormal red reflex. We want parents to recognize that both eyes should have an equal and symmetric red reflection in childhood photographs. An asymmetric reflection, especially a white reflex, can be a sign of retinoblastoma. Recognizing the abnormal appearance of a child’s red reflex in photographs obtained at home can lead to early diagnosis, and the ability to save your child’s life.
Fortunately, the overall survival rate is more than 95%, and our goal is to continue to promote early detection of this life-threatening disease. Most retinoblastoma symptoms will first be detected by a parent. Please look at the red reflex in your child’s photograph. If you are uncertain, please take your child to an ophthalmologist as soon as possible for a comprehensive examination. We also encourage you to emphasize the importance of this condition to your friends and family.
Early diagnosis and intervention are critical to this disease’s successful treatment..
Retinopathy of Prematurity
Many premature babies develop an eye condition known as retinopathy of prematurity (ROP). This results from an abnormal growth of blood vessels in the retina at the back of the eye. Most cases of ROP are mild and cause no serious problems, but sometimes a more severe disease develops that must be treated (usually with a laser) to prevent blindness. Dr. Adams screens and performs laser surgery on premature infants in neonatal intensive care units in Palm Beach County. They are one of only a few ophthalmologists in South Florida who provide this service.
ROP does not develop until a month or more after birth. For this reason, every small premature infant must have an eye examination at 6 weeks. The risk is higher and lasts longer for very small infants, very premature infants, and infants exposed to high oxygen concentrations.
When a baby is found to have ROP, an examination of its eyes must be repeated every 1 to 3 weeks. This is until it is clear whether treatment will be necessary or the condition improves.
Because ROP can cause blindness, and because this can usually be prevented if treatment is given at the proper time, it is extremely critical for all eye examinations to be done exactly when they are supposed to be. If the baby still needs eye care following discharge from the hospital, appointments for an outpatient examination will be made. You must keep these appointments.
Examination of a premature baby’s eyes to look for ROP is done in a special way. This is quite different from the way an older person’s eyes are usually examined. In most cases, it is necessary to place instruments in the eye that allow one to see the entire retina. This upsets the baby, but it is not painful because an anesthetic drop is given before starting. Sometimes, the white part of the eye appears red following examination.
When no ROP develops, or when mild ROP clears, the baby’s eyes usually are normal. Sometimes though, glasses are needed at an early age, or problems such as crossing of the eyes may be seen. For this reason, it is a wise idea for any baby who was born prematurely to have its eyes examined again at the age of one. This is sooner if you notice anything unusual about the way the eye looks.
When severe ROP develops, even if it is treated properly, the baby’s retinas may become scarred so that vision is reduced in a way that cannot be helped by glasses. If your baby begins to show signs of severe ROP, Dr. Adams will explain to you in detail what you should expect.
