You’ve probably taken your kids for their back-to-school physicals. Maybe they’ve been to the dentist. But what about the eye doctor? Have you taken your kids to get their eyes examined?
If you have worn glasses yourself since childhood, you probably know the drill. But if you haven’t required vision correction or haven’t had regular eye exams, it can be confusing to know the who, when, where, and why of your child’s eyecare. Here are the answers to some common questions parents have about eye care, as well as a glossary of some common childhood eye conditions.
When should my child have his first eye exam? How often should he have eye exams after that?
The American Optometric Association (AOA) recommends that infants have a comprehensive eye exam between the ages of 6 and 12 months. After that, the AOA recommends a complete exam between the ages of 3 and 5 years and then annually, starting at age 6.
The AOA has a program called infantSEE which provides a comprehensive infant eye exam between 6 and 12 months of age, free of charge regardless of family income or access to insurance coverage. You can find an infantSEE provider here. There are 20+ optometrists in the Corridor who provide this service!
The American Academy of Ophthalmology (AAO) recommends screenings (i.e., a health professional checking for specific eye conditions but not a complete eye exam) for newborns, infants between 6 and 12 months old, preschoolers between 3 and 3 1/2 years old, and as needed during school age. If a child fails a vision screening or a problem is suspected, the child should have a comprehensive eye exam.
Here in Iowa we are lucky to have another resource for vision screening. IowaKidSight is a collaboration between the Lions Clubs of Iowa and the Department of Ophthalmology and Visual Sciences at the University of Iowa Stead Family Children’s Hospital. Free vision screenings are offered to children ages 6 months through kindergarten in all 99 Iowa counties. Screenings are done by Lions Club members using a specialized camera, and photos are then interpreted by specialists at the Children’s Hospital. If a screening detects a problem, you will receive a letter and a list of local optometrists and ophthalmologists who can complete a full exam on your child.
How can an eye doctor even check the vision on my child? She can’t read or respond to, “Which is better, 1 or 2?”
As with many fields of healthcare, eyecare has both subjective tests (which require patient input, for example: “Which is better, 1 or 2?” “Does your knee hurt when I bend it like this?”) and objective tests (through which the doctor can test things without input from the patient, such as x-rays, blood pressure, etc.). One of the main tests to determine whether an infant or toddler may need glasses is called retinoscopy. A retinoscope is a hand-held instrument with a light that an eye doctor moves back and forth to see the reflection off the child’s retina (back layer of the eye with the rods and cones). The eye doctor will hold up lenses in front of your child’s eye and shine the light through the lens. Not only can this test help determine a glasses prescription, but it can detect an eye turn or “wandering” eye and even help detect some types of tumors that can occur in infancy.
Why does my child need an eye exam? The pediatrician always checks his vision at well child visits.
While pediatricians can look into the child’s eye with an ophthalmoscope and have older children read an eye chart, this routine vision screening is not a substitute for a comprehensive eye exam in which the eyes are dilated. Dilating a child’s eyes (using eye drops to make the pupil or black center of the eye open widely) not only allows the eye doctor to get a good view of the health inside the eye, it can also assist in determining the most accurate prescription.
Often an eye doctor will use the retinoscope (described above) both before and after the dilating drops. Kids have amazing powers of focus and can sometimes focus so hard they are able to see things clearly even if their vision needs correction. This isn’t the best situation for their eyes, however, so checking for a prescription after the eyes are dilated gives a more full picture of what is going on. If you’ve had your eyes dilated and remember not being able to see clearly up close for a few hours, this is the reason why: the dilating drops temporarily “paralyze” the focusing system of the eye. By eliminating that focusing ability to make additional measurements, the best prescription can be reached.
Who is the best doctor to see your child?
For a complete dilated eye exam, you can take your child to an optometrist or an ophthalmologist. Both of these specialties also have doctors who sub-specialize in pediatrics. An optometrist will check the health of your child’s eyes, prescribe glasses as needed, undertake vision therapy with your child for certain issues, and fit your child with contact lenses. An ophthalmologist will also check the health of your child’s eye and prescribe glasses, but they are also the ones who will perform surgery on your child’s eye if needed. An optometrist can make a referral to an ophthalmologist if it turns out your child needs surgery. An ophthalmologist may make a referral to an optometrist for vision therapy or a contact lens fit.
Speaking of contact lenses, at what age can a child get contact lenses?
While there are medical reasons for children to get specialty contact lenses as early as a few months after birth, the typical kid will get contacts as a tween. There’s no “magical age” that a child can get contacts; my rule of thumb ties into maturity of the child. You may have a 10- or 11-year-old girl who is ready for contact lenses, but a boy may not be ready until 13 or 14 (not to stereotype, but this is what I’ve seen most often). As the parent, your input about whether your child is ready is very important. Additionally, I believe that a child needs to be able to insert, remove, and care for contact lenses independently and not rely on a parent’s help.
What should you do if you suspect your child has an eye condition?
If you suspect that your child has a problem with her eyes, take her to an optometrist or ophthalmologist. While you could start with your pediatrician, you may just end up being referred to an eye doctor anyway. I would also recommend going straight to an eye doctor for things like “pink eye” (see conjunctivitis below), swelling around the eye, or any eye injury. And pretty much without exception, I recommend against taking anyone (adult or child!) to the emergency room for any eye problem, largely because most ERs just don’t have the best equipment and supplies to diagnose and treat ophthalmic issues.
There are a number of childhood eye issues that are relatively common but often poorly understood. Hopefully this glossory will help!
Glossary of some common childhood eye concerns:
Ambylopia – sometimes called “lazy eye.”
This is when one eye can’t see as well as the other. This happens for a couple of main reasons. The worse-seeing eye may have a stronger refractive error (i.e., need glasses or a stronger power of glasses) or be turned inward or outward (see strabismus). Because the images your child sees from each eye are not the same, the brain has a hard time figuring out what its seeing, and the vision doesn’t develop the same in the two eyes. The result is amblyopia. Usually treatment is glasses and/or patching and sometimes vision therapy. If the amblyopia is due to an eye turn, surgery may be indicated in some cases.
A refractive error which may occur alone or with near- or far-sightedness (see myopia and hyperopia). When light hits an eye with astigmatism, it doesn’t all come into focus in the same spot on the retina (back layer of the eye). This results in a blurry image. You may have heard an often-used analogy that an astigmatic eye is shaped more like a football (long flatter curve and short steeper curve) than a baseball (uniform curve all over).
A cloudiness of the lens (the focusing mechanism) of the eye. While typically associated with aging, cataracts can also occur in children. Some children are born with congenital cataracts in one or both eyes and require surgery to remove the lens(es) of the eye in order to let light enter and the child’s vision to develop properly. Following cataract surgery, your child will be fit with contact lenses or glasses or both to provide the best vision possible.
The time until about age 8-10 is called the “critical period” for vision development. After this time it is much harder for the vision to develop normally, so it really is critical that any vision issue (not just cataracts) is addressed as soon as identified. Another time we see cataracts in children is when there has been trauma or injury to the eye. Typically this is just in the injured eye. If a child is older, the surgeon may consider placement of an artifical lens called an intraocular lens or IOL. This lens would then allow light to be focused on the child’s retina, forming a clear image.
An infection and inflammation of the tissues around the eye causing the eyelid and surrounding area to be red, swollen, and warm to the touch. Preseptal (“in front of the eyelid”) cellulitis is most commonly seen in children under age 2 and usually requires antibiotic treatment. The usual culprits in cellulitis are often the normal bacteria from the skin making their way inside through a scratch or bug bite, although sometimes there is no readily visible break in the skin. Cellulitis is not pink eye and is rarely contagious. Another variation of cellulitis, orbital cellulitis, is actually an infection in the eye socket and can be very dangerous. However, preseptal cellulitis is more commonly seen in children.
Conjunctivitis – aka “pink eye”
Conjunctivitis is a redness of the white part of the eye caused by bacteria or virus and may often occur with a cold or other upper respiratory infection. It may be accompanied by watering/tearing, discharge from the eye, matted eyelashes, blurred vision, and burning. According to the CDC, between 65% and 90% of all cases of conjunctivitis are viral. This means that the majority of cases of pink eye do NOT need to be treated with antibiotic eye drops. Many doctors prescribe antibiotics regardless of the cause of conjunctivitis, but viral conjunctivitis, especially, is self-limiting and will go away on its own, usually in under a week.
Conjunctivitis is very contagious, but there are preventive measures you can take. The best way to prevent its spread is to avoid touching your child’s eyes/face and discourage him from doing so as much as possible, wash hands frequently, don’t re-use washcloths, etc. And if your child wears contact lenses, no contacts should be worn until the conjunctivitis is resolved.
Increased pressure inside the eye(s). Thankfully, congenital (or infantile) glaucoma is relatively rare, affecting about 1 in 10,000 births. The increased pressure inside the eye can lead to damage of the optic nerve, the main information highway taking visual information to the brain for processing. Although generally slow progressing, glaucoma can lead to severe vision loss. Congenital glaucoma is usually identified in the first year or two of life and is treated with pressure-lowering eye drops and/or surgery. While you may see a bulging of your child’s eye(s) as a result of glaucoma, it can often go undetected, making those early eye exams all the more critical.
Hyperopia – farsightedness.
This is a refractive error in which a person can see better far away than up close (different than when you hit your 40’s and all of a sudden seem to need longer arms!). In hyperopia, light entering the eye doesn’t come to its focus before it reaches your retina, thereby leaving you to see a blurry image. Contact lenses and glasses can correct hyperopia, and you may notice someone’s eye looking larger behind the lenses for farsightedness. It is normal for babies and young children to have some degree of hyperopia, and glasses are usually not prescribed for these normal, low amounts.
Myopia – nearsightedness.
This is a refractive error in which a person can see better up close than far away. In myopia, the light entering your eye comes into focus before it gets to your retina, so you see images as blurry. Like hyperopia and astigmatism, glasses and contact lenses can correct myopia. In contrast to farsightedness, lenses that correct nearsightedness may make someone’s eye appear smaller behind their glasses. It is not uncommon for myopia to be discovered in the early school years when a child realizes he can’t see the board in his school classroom.
Nasolacrimal duct obstruction (blocked tear duct)
A blockage of the tiny opening that drain tears from the eye. This is fairly common in infants and may result in swelling and/or redness around the eye. Once diagnosed, the easiest solution is to use warm compresses and gentle massage to try to get the blocked duct to re-open. In rare cases, this is not sufficient, and the duct may need to be probed or surgically opened.
An eye misalignment in which one or both eyes turn inward or outward. It is not uncommon for babies’ eyes to drift and wander a bit, but if you start to notice a consistent turning of your child’s eye, it’s time to get it checked out. Depending on the type, strabismus can be treated with glasses, patching, vision therapy, or surgery. Strabismus can be due to a focusing issue or a muscle issue, and this will help determine the best course of treatment. Again, it is important to address the problem before the “critical period” ends around age 8-10.
A bump on the eyelid near the edge of the lid. It may be red, swollen, and painful and can be found on the outside (external hordeolum) or inside (internal hordeolum) of the eyelid. It is typically caused by bacteria and may look like a pimple on the eyelid. It is important to get a proper diagnosis because a stye and cellulitis may appear somewhat the same. The treatment for a stye is usually to start with warm compresses and gentle massage. Sometimes an antibiotic is prescribed. If your child wears contact lenses, they should be removed until the stye goes away.
Remember, your kids only have the set of eyes they were born with. Make sure you take good care of their peepers!
** This post is not intended as medical advice or to replace care by a licensed health care provider. **