Pediatric Eye Health

There is no specific age for an eye examination. Any child with complaints can be examined regardless of age. In cases where a child does not cooperate with the examination, sedative or calming medications may be used, and if these methods do not yield satisfactory results, general anesthesia may be administered to complete the examination. Even if a child has no complaints, they should undergo at least one eye examination by the age of 3-4.

One of the main concerns families have during the examination is whether their child can see. In children under three years old, vision can be detected using non-accommodative methods or a rough estimate of vision can be made by combining all examination findings. Children over three years old can learn the letter E with proper attention, and their vision can be tested by asking which direction the ends of the letter point. Additionally, shapes can be asked. For older children, visual acuity is assessed by asking them to identify letters, similar to adults. A special aspect of children’s eye examinations compared to adults is the assessment of glasses. In particular, for infants, young children, and non-cooperative older children, glasses prescriptions can be determined using a special instrument called a skiaskopi or a computerized measurement device with the use of eye drops. Drug-based examinations also help evaluate the back parts of the eye.

White Pupils

The pupil is the black circle in the center of the colored part of the eye. If the pupil turns white, gray, or yellow, it indicates serious conditions:

– Cataract: This can be congenital or arise later due to injuries, metabolic disorders, and infections. It is one of the most common causes of white pupils. If not detected early and treated, it can lead to permanent vision loss, strabismus, and uncontrolled eye movements.

– Tumors: Besides many benign tumors, malignant tumors such as retinoblastoma can cause the pupil to turn white. Treatment is crucial for preserving vision and health.

– Infectious and inflammatory conditions: Various bacterial, viral, or parasitic infections can turn the pupil white. Many inflammatory conditions, known or unknown, can also cause this.

– Developmental disorders: The eye develops through specific stages in the womb to reach its shape at birth. Any interruption in development due to drugs, infections, metabolic disorders, injury, or premature birth can cause serious abnormalities.

– Others: Conditions such as retinal detachment, blood vessel disorders, nerve abnormalities, or bleeding inside the eye can turn the pupil white. It is undesirable for a disease to be detected after the pupil has turned white. Early treatment yields better results. Once the pupil has turned white, even if action is taken quickly, the success will be limited.

Strabismus

Both eyes should look at the same point together. If one eye is looking at the intended target while the other looks in a different direction, the person has strabismus. Strabismus can occur at any age but is more common in childhood. It is not a single disease but has various types. In childhood strabismus, the child usually favors one eye to prevent double vision. The non-preferred eye may develop amblyopia (lazy eye). Amblyopia is a serious disorder that can only be treated during childhood. The most common type of strabismus in children is when the eyes deviate toward the nose. Strabismus where the eyes deviate outward, upward, or downward is less common. Not all types of strabismus are noticeable to parents or relatives, and some may not be detected even with a simple examination, requiring further investigation.

Sometimes, conditions that mimic strabismus are observed. These are called pseudo-strabismus. Pseudo-strabismus can occur due to abnormalities in the eye sockets, asymmetry, eyelid disorders, and a flat nasal bridge. After differential diagnosis of these conditions, some may require treatment targeting the cause, while others may only require monitoring of the child’s development. Another common term in our society is latent strabismus or hidden strabismus. Medically, latent strabismus can be described as deviations that are not present under normal conditions but can be revealed through specific tests. Deviations may also appear during stressful or ill times when the child is otherwise healthy. Regardless of the type, any strabismus is significant and requires early diagnosis, treatment, and follow-up.

Amblyopia (Lazy Eye)

Amblyopia is a commonly discussed but less well-known condition. It is difficult to detect and often goes unnoticed until the treatment phase has passed. Amblyopia can be defined as the inability to improve vision despite the absence of any prominent disease affecting the eye’s nerve layer and pathways. The mechanism of development involves the underutilization of the nerve. If the image from the eye’s front refractive components does not reach the nerve layer or reaches it blurry, amblyopia develops. The causes of amblyopia should be promptly addressed, and the visual nerve must be stimulated. The causes include:

1. Strabismus: When the eyes look in different directions, two separate images are sent to the brain, causing double vision. The brain suppresses the image from one eye, leading to single-eye vision, while amblyopia develops in the suppressed eye.

2. Refractive errors: If there is a significant refractive error difference between the two eyes or high astigmatism, myopia, or hyperopia in each eye, amblyopia can develop.

3. Other eye diseases: Conditions that obstruct the visual axis, such as opacity or abnormal positioning of the cornea, iris, lens, or vitreous body, can cause amblyopia. Cataracts are a common type. Eyelid disorders can also obstruct the visual axis and cause amblyopia.

Amblyopia treatment should be started before the age of 10. The earlier the treatment begins, the more successful the outcome will be. Treatment involves two steps: addressing the underlying factor causing amblyopia and treating the amblyopia itself.

Eye Discharge and Redness

Complaints such as burning, stinging, itching, redness, and discharge in the eyes typically indicate inflammation of the conjunctiva, the thin transparent membrane covering the eye surface. Sometimes, inflammation of the cornea can also cause these symptoms, and both conjunctival and corneal inflammations may occur simultaneously. Eyelid issues can also cause similar complaints. Conjunctival inflammation can be infectious, allergic, immunological, toxic, or traumatic. Infectious types are caused by bacteria, viruses, and parasites and usually occur when hygiene rules are not followed or when infected individuals’ items are shared. Additionally, a weakened immune system increases susceptibility to infections. Conjunctivitis in infants can be very severe.

Allergic conjunctivitis typically occurs in spring but can happen in all seasons. It is characterized by itching and tearing, and some allergic conditions can be severe enough to impair vision. Although treatment can be challenging, it should not be neglected. Immunological (autoimmune) conjunctivitis is more common in the elderly but can also occur in children and be severe. Toxic and traumatic conjunctivitis result from exposure to drugs and chemicals.

Corneal inflammations are called keratitis or keratopathy. These can also be infectious, immunological, allergic, toxic, or traumatic. The unique aspect of corneal inflammations is that if not treated appropriately and promptly, they can lead to opacity, affecting central vision and complicating treatment. Advanced corneal diseases may require severe surgeries, such as corneal transplants, where a clear cornea from a donor is stitched into the patient’s opaque cornea. This surgery, while providing a solution, is not without complications and requires addressing any resulting or potential amblyopia.

Finally, eyelid inflammations can cause symptoms like burning, stinging, redness, and discharge. They are characterized by scaling at the base of the eyelashes, eyelash loss, and redness at the eyelid edges. These conditions can also cause secondary issues on the eye surface.

Eye Tearing

In children, especially infants, conditions like conjunctivitis, corneal and eyelid diseases, foreign bodies, and congenital glaucoma can cause tearing. However, tearing is primarily a typical sign of blockage or narrowing of the tear ducts. Sometimes, tearing can become infectious and lead to discharge. Pressing the nasal bridge may release inflammatory fluids. This situation can be distressing for parents during the first year, but usually, the duct opens by the end of this period, and the child’s symptoms disappear. To facilitate duct opening, massage of the nasal bridge may be recommended. In cases with significant discharge, antibiotic drops may be used. If the infection increases, more intensive treatment may be necessary.

If the duct remains blocked after the first year, probing under general anesthesia may be performed. This procedure may need to be repeated if unsuccessful. If the duct still does not open, surgical intervention similar to adults’ procedures may be required after age 3-4. This involves making an incision from the nasal bridge, locating the tear sac, removing some bone tissue, and opening the sac to the nose. A tube may sometimes be placed to maintain this opening.

Congenital Intraocular Pressure Elevation

This is a serious disorder that can lead to permanent blindness if not addressed early. It causes symptoms such as light sensitivity, tearing, squinting, and red eyes in infancy. The transparent structure in the center of the eye, the cornea, enlarges and becomes opaque. If intraocular pressure is elevated unilaterally, the corneal enlargement is more pronounced. Persistent high intraocular pressure can cause cracks in the cornea and cupping of the optic nerve, leading to irreversible nerve cell death and loss of function.

Several abnormalities can mimic or accompany intraocular pressure elevation in infants. To diagnose these conditions, the child may need to be examined under general anesthesia. If high intraocular pressure is confirmed, surgical treatment is necessary.

Visually Impaired Children

The term “visually impaired child” refers to children with congenital or acquired visual disorders. The visual impairment may involve decreased or no vision and can be either unilateral or bilateral. Visual impairment may include conditions like amblyopia, strabismus, color blindness, retinal and corneal diseases, and optic nerve disorders. Vision loss or blindness can occur if these conditions are not addressed appropriately.

The degree of visual impairment is classified into various stages:

1. Severe Visual Impairment: This involves very limited vision or visual field and may require assistance for daily activities.
2. Moderate Visual Impairment: This involves reduced vision that still allows some ability to perform daily activities but with difficulty.
3. Mild Visual Impairment: This involves reduced vision that may affect reading, detailed work, or other activities, but the child can still perform many tasks with support.

These conditions can significantly impact a child’s development, educational opportunities, and daily activities. Early intervention, including educational support, rehabilitation, and medical treatment, is crucial for managing visual impairment and improving quality of life.