Learn more about pediatric eye care

1. My child will not wear the glasses! – Getting used to the glasses is the most difficult part. The first two weeks are critical. Your child must wear glasses at all times. It is important to be gentle but firm with your child during this period. Cable temples which wrap around the back of the ear will encourage your child not to remove the glasses. Putting toy glasses on your child’s favorite stuffed animal or doll also helps. Keep it up! When your child gets used to the glasses wearing them will become routine. Please do not be discouraged. The difficulties are temporary, but the results are lifelong. An uncomfortable fit is the most common reason children refuse to wear their glasses. You should obtain a child’s frame which fits comfortably. Frequent adjustments are required. As your child grows the earpiece may become too short and may need to be adjusted or replaced. Of course, if you are concerned that the glasses are not the correct prescription or that they do not fit well, we will be happy to re-check them for you.
2. My child’s eyes are straight while wearing the glasses but cross when we remove the glasses for bedtime! – Glasses do not cure your child’s farsightedness; they simply straighten your child’s eyes by relaxing the focusing reflex. When your child removes the glasses, he or she again has to focus in order to see clearly. In fact, after wearing glasses your child will be used to seeing clearly at all times. Therefore, your child probably will make a strong focusing effort in order to see clearly without their glasses. This focusing effort results in crossing. The only cure is for your child to outgrow the problem (see question 3).
3. Will my child outgrow this condition? – Some children do indeed outgrow accommodative esotropia. However, it takes several years and usually not before 9-12 years of age or older. Children do not outgrow accommodative esotropia in only a few months. It is difficult to predict which children will outgrow their need for glasses. Most children who are very farsighted will always require glasses, even if the glasses are only used to improve vision and not to correct esotropia. Contact lenses can be substituted for glasses when your child becomes a teenager. About half the children who require bifocals eventually outgrow the need for these bifocals.
4. Why hasn’t the doctor recommended surgery to get rid of these glasses and cure my child? – All children with esotropia are not alike. Surgery may be right for some children with esotropia but may not be the right option for your child. We avoid surgery in a child whose eyes are always straight while wearing their glasses. Surgery is avoided because there is a real risk of your child’s eyes turning out or becoming “wall-eyed” as they grow older and become less far-sighted.

Convergence insufficiency (CI) is a common eye muscle coordination problem. When reading or doing close work, a person’s eyes must turn in (converge) for the words to be clear and single. In CI, the eyes do not turn in easily and, as a result, extra convergence effort must be used to force the eyes to turn in. This additional effort can cause a number of symptoms such as eyestrain, headaches, blurred vision and double vision.

Amblyopia is also known as “lazy eye.” Amblyopia typically begins during infancy and early childhood. In most cases, only one eye is affected. But in some cases, amblyopia can occur in both eyes. The most common treatment is patching.

Patching is done to improve vision in the amblyopic or “lazy” eye by forcing the child to use the eye which is not covered. Patching is the most effective way, and often the only way, to improve the vision of an eye with amblyopia. If not treated, amblyopia or “lazy eye” may result in permanent visual loss!!

The sticky patch should be placed on the child’s face and not the glasses as the child will peek around a patch which is placed on the glasses. Opticlude® and Coverlet® are two brands of adhesive patches which are available. The patches may be purchased at a drug store.

A cloth patch which fits around the front and sides of your child’s glasses also works well. Cloth patches are available for purchase at Lor-Ron Optical or at many drug stores, or, if you like to sew, you can make one yourself. Important: Do not use a “pirate patch” which is held on by string or elastic. Your child will peek around this type of patch. Do not put a patch, tape, or nail polish on a spectacle lens, as the child will look around it.

Common Problems with patching

There are three common complaints about patching as a treatment for amblyopia. Please do not be discouraged. Patching is often the most important treatment for your child’s vision. The difficulties are temporary but the benefits are lifelong.

Initial Adjustment: Getting used to the patch is the most difficult part. The worse the vision in the amblyopic or “lazy” eye, the harder will be the adjustment. The first 24 hours are critical!! It is extremely important that the patch not be removed during this time. It is important to be gentle but firm with your child during this period. You may have the child draw a picture on the patch, place a sticker on the patch, or place a patch on the child’s favorite stuffed animal or doll in order to encourage your child to wear the patch. Try rewarding your child for wearing the patch for an hour, a day, and a week. Keep it up! As your child’s vision improves patching will be easier and will eventually become routine

Skin Irritation – The adhesive on the patch may irritate your child’s skin, especially during the summer. If the skin becomes irritated the adhesive area can be trimmed so that less adhesive contacts the face. The patch should also be moved slightly each time it is applied. In that way the same part of the skin is not always under the adhesive.

If skin irritation continues then lotion with Aloe Vera may be applied to the irritated areas at times when the patch is not being worn.

Tincture of Benzoin may be obtained at a drug store and will effectively protect your child’s skin from the adhesive. Tincture of Benzoin may be applied to the skin and left to dry for a minute before applying the patch (please be very careful that you do not get it in your child’s eye).

If skin irritation becomes worse, please do not stop patching. Instead, you may use gauze eye pads and strips of medical tape, avoiding the irritated areas of skin. If your child wears glasses, a cloth patch may be obtained which fits around the front and sides of the glasses.

Crossing of the eye under the patch – Occasionally, during patching an underlying misalignment between the eyes may worsen. This means the patching program is making the underlying condition more obvious and DOES NOT necessarily mean the patching is causing damage. However, please call the doctor if you feel your child’s eyes are crossing more.

Actually, patching is intended to allow your child to see well enough to use the previously “lazy” eye. In children with misaligned eyes the previously preferred eye might turn while your child now uses his or her “lazy” eye.

Your child has been diagnosed with exotropia. This condition occurs in approximately 1% of children and develops between 6 months and 5 years of age.

Symptoms

Exotropia means an eye is turned outward relative to the other eye.

Most children with exotropia have intermittent exotropia. Intermittent indicates that your child’s eyes are not always turned outward. At certain times your child’s eyes may be straight and at other times an eye may drift outward. The outward drifting is often most apparent when your child is tired or inattentive, particularly in the evening.

In the majority of children, this outward drifting occurs primarily on distance viewing. Therefore, when your child looks directly at you up close the outward turning of the eye may not be visible.

Your child may develop double vision when his/her eye drifts outward. At first, your child may close the drifting eye to prevent double vision. This double vision may also induce your child to straighten his/her eyes. As your child’s eye drifts outward more frequently he/she will become used to this misalignment. In effect, your child will “turn off” the drifting eye to prevent double vision. This will lead to more frequent outward drifting of the eyes. Finally, your child may completely loose the ability to use the eyes together and become constantly exotropic.

In contrast, some children have an eye which drifts out more while reading. This may cause various symptoms such as eyestrain, headaches, difficulty with prolonged periods of reading, and blurred vision.

Prognosis

Without treatment, 75% of children with exotropia will worsen over time. 15% of children will improve without therapy. 10% of children will remain the same.

Treatment

Glasses, exercises and surgery are the most common treatments. An important observation: If your child’s eyes only turn outward occasionally, no treatment may be necessary. It is important that you notice how often your child’s eyes turn out. If this outward turning begins to occur more frequently, further treatment may be indicated.

Glasses – Glasses will be prescribed if your child is nearsighted. By improving your child’s distance vision, glasses will often improve your child’s control of his/her ocular misalignment.

Children who are very farsighted or astigmatic are also given glasses. Again, by improving your child’s vision the exotropia will often improve. In certain unusual circumstances bifocal glasses may be prescribed.
Patching:

If your child has amblyopia, or a “lazy eye,” the eye with good vision will be patched in order to improve the vision in the eye with poor vision. The treatment of amblyopia is very important. Children with untreated amblyopia will always have difficulty using their eyes together.

Older children may refuse to wear a patch. If your older child refuses to wear a patch, drops may be given. These drops blur the vision in the better seeing eye and are a substitute for a patch. Both treatments will improve the vision in the amblyopic eye.

Exercises – Eye exercises, properly called orthoptic therapy, may be indicated in certain cases of exotropia. Orthoptic therapy is often used in children who cannot turn their eyes inward normally while looking at close objects. Orthoptic therapy may also be used in children who have small amounts of exotropia. To learn more about orthoptic therapy, click here.

Surgery – Many children with intermittent exotropia will eventually require surgery. Strabismus surgery may be indicated if your child’s eyes frequently turn outward. Surgery would also be indicated if your child’s control over his/her ocular misalignment is clearly worsening.

During surgery the extraocular muscles, which control the position of the eyes, are weakened or strengthened.

Strabismus surgery is usually successful. In fact, approximately 70% of children will require only one operation to obtain a satisfactory result.

After surgery it is frequent and often desirable for your child’s eyes to be turned inwards slightly. This will usually resolve after a few weeks or months. Sometimes drops or glasses will be used to straighten eyes that are turned inwards after surgery.

Please note that in some children an eye may begin to drift outward again months or years after an initially successful surgical procedure. Therefore, it is important to continue to observe your child’s eye position.

Alternate Occlusion

If your child’s eyes turn out frequently, treatment may be indicated to prevent further worsening of your child’s control over his/her deviation.

Alternate occlusion attempts to prevent your child from learning to “ignore” an eye by forcing your child to use each eye individually. In many cases, alternate patching can decrease how often your child’s eyes turn outward.

To perform alternate occlusion, an eye is patched for a few hours per day. One eye is patched one day and the other eye is patched the next day. For example, the right eye might be patched for three hours on Monday, the left eye is patched for three hours on Tuesday, the right eye is again patched for three hours on Wednesday and so on.

Some children prefer to let one eye drift more than the other eye. If this is the case, the eye which your child prefers to look with might be patched more frequently. This patching will prevent your child from ignoring the eye which drifts. Your doctor will customize a patching regimen for your child.

Your child has an obstruction of his/her nasolacrimal duct. This is a very common condition in the first few months of life and is usually not serious.

Normally, tears drain from the eye into the nose through the nasolacrimal or “tear” duct. Any blockage between the eye and the nose will cause tearing. In most infants the blockage is at the end of the tube which opens into the nose. However, in some children the entire tear duct is narrow. In other cases, small bones inside the nose may obstruct the opening of the tear duct.

Symptoms

When the tear duct is blocked the tears do not drain properly. Because of this the child’s eye is always wet with tears that “well up” and may run down the face. Often, there is a mucus buildup in the corner of the eye closest to the nose.

In addition, the tears stagnate in the tear sac. This may result in repeated mild infections. You may notice that your child frequently develops cloudy mucus or pus in the inside corner of the eye.

Treatment

There are two options for treatment for Nasolacrimal Duct Obstruction: medical and probing.

Medical – The vast majority of infants with tear duct obstruction get better all by themselves. If the obstruction persists massage and antibiotic eye drops may be necessary. Massage should be done daily. Massage is performed by firmly pressing on the side of the nose next to the eye and then rubbing downwards. Massage is an attempt to force open the thin membrane blocking the tear duct.

Probing – If the obstruction persists or is very bothersome, tear duct probing should be considered. Tear duct probing is usually done under general anesthesia. During the probing a fine wire is passed through the tear duct in order to open the blockage. No incisions are made.

Bleeding or infection are possible complications. Every effort is made to minimize these very unusual occurrences.

Recovery time is usually very quick. Most children are back to normal soon after surgery. Activity is not restricted after the procedure.

Probing of nasolacrimal duct obstruction is successful 90 percent of the time. However, sometimes the obstruction does not resolve or reoccurs. Additional procedures may be necessary. In some cases, a small plastic tube is temporarily inserted into the tear duct to keep it open. Tubes are usually effective but do require removal.

Strabismus is a condition in which the eyes are not aligned correctly. While one eye looks at the target, the other eye is looking in a different direction. Esotropia is a type of strabismus where the straying eye is crossed inwards. Exotropia is another type of strabismus where the straying eye is drifting outwards. Hypertropia describes a straying eye which looking upwards or downwards instead of at the target.

Strabismus surgery seeks to readjust the alignment of the eyes. The goals of surgery include:

1. Enabling the brain to use the eyes together
2. Cosmetically improving eye position and movement

There are six muscles responsible for moving each eye. During surgery, these muscles can be weakened or tightened. By adjusting the muscles, the surgeon aligns the eyes. The patient’s brain must then learn to use the eyes together. The success of the surgery depends on how difficult it is to re-align the eyes and how well the patient’s brain adjusts to using the eyes together.

Pre-operative Evaluation

The pre-operative evaluation is a very important part of strabismus surgery. During the pre-operative evaluation, Dr. Goldberg will measure the misalignment of the eyes in different gaze positions. The patient’s ability to move the eyes will be evaluated. Dr. Goldberg will consider optical and visual factors which might influence the results of surgery. In almost all cases, Dr. Goldberg will measure the mis-alignment on at least two separate occasions before surgery. If your child is very young or difficult to examine, it may take several visits until accurate and stable measurements can be obtained.

Incomitance

In some patients, their strabismus is incomitant. Incomitant means that the amount of misalignment varies on up, down, or side gaze. Surgery is planned to achieve alignment in all gaze positions. However, it is most important to have the eyes aligned when looking straight ahead. In some cases, there will still be some mis-alignment on side gaze even after surgery. In children, there may still be some drifting of the eyes when your child looks up or to the side. Adults may still have double vision when looking to the side or down.

Surgery

During strabismus surgery, the muscles which move the eyeball can be weakened or strengthened. The position of the muscles can also be moved. To weaken the muscle, a suture is placed in the muscle. The muscle is then removed from the eyeball and reattached farther back. To strengthen the muscle, the muscle is shortened to increase its ability to pull the eye.

The eyes always move together. While it appears that either the right or left eye is misaligned, the problem is actually the balance between the eyes. Therefore, surgery can be performed on either one eye or both eyes in order to balance and straighten the eyes. Strabismus surgery is performed as an outpatient, usually under general anesthesia. During the surgery, incisions are made in the conjunctiva. The conjunctiva is the thin covering over the eye. In children, the incisions are usually made in the pocket between the eyelid and eyeball to hide the scars.

In older patients and patients with previous surgeries the incisions may be made where the iris touches the white part (the limbus). In most cases the scar is not visible. After the surgery, the white of the eye will be very red in the area of the incision. This is a blood spot. The blood spot will dissolve in about two weeks. However, the white of the eye may stay inflamed and red for several more weeks. In some cases, particularly if there is scarring from a previous surgery, the area may always stay a little red. If surgery is performed in both eyes, then both eyes will not be patched.

Surgical Risks

The risks associated with strabismus surgery include:

Continued misalignment– Overcorrections and undercorrections are by far the most common complications of strabismus surgery. After surgery for esotropia (cross-eyes) the eyes will initially appear a little turned out. This will usually resolve. However, the eyes may become significantly turned out either soon after surgery or many years later.After surgery for exotropia, the eyes may cross inwards causing double vision. More commonly, the eyes are straight for months or years but eventually drift outwards again. Overcorrections and undercorrections may require treatment with glasses, prisms, or patching. Further strabismus surgery may be needed in many cases.

Infection – The eyes will look red in the area of the incision. If an infection develops the entire white of the eye may look red. There may be pus and the eyelids may become red or swollen. Children may develop fever or become sleepy. Infections usually can be treated with eye drops, oral antibiotics, or intravenous antibiotics. Rarely a serious infection can occur inside the eyeball. This would cause decreased vision and pain. To prevent infection, please do not have the patient play in a playground or work in the yard, or in any dirty environment. You may shower, bathe, or wash your hair the day after surgery.

Loss of vision – Loss of vision may occur if an infection occurs inside the eyeball. In addition, the needles used in surgery may damage the retina, the film inside the eye. If the retina is damaged, laser or freezing treatment may be needed.