Pediatric ophthalmologists focus on the development of the visual system and the various diseases that disrupt visual development in children. Pediatric ophthalmologists also have expertise in managing the various ocular diseases that affect children. Pediatric ophthalmologists are qualified to perform complex eye surgery as well as to manage children’s eye problems using glasses and medications. Many ophthalmologists and other physicians refer pediatric patients to a pediatric ophthalmologist for examination and management of ocular problems due to children’s unique needs. In addition to children with obvious vision problems, children with head turns, head tilts, squinting of the eyes, or preferred head postures (torticollis) are typically referred to a pediatric ophthalmologist for evaluation. Pediatric ophthalmologists typically also manage adults with eye movement disorders (strabismus) due to their familiarity with strabismus conditions.

Children experience a variety of eye problems, many quite distinct from adult eye diseases. Pediatric ophthalmologists are specially trained to manage the following disorders:

• Infections (conjunctivitis).
• Strabismus is a misalignment of the eyes that affects 2-4% of the population; it is often associated with amblyopia. The inward turning gaze commonly referred to as “crossed-eyes” is an example of strabismus. The term strabismus applies to other types of misalignments, including an upward, downward, or outward turning eye.
• Amblyopia (aka lazy eye) occurs when the vision of one eye is significantly better than the other eye, and the brain begins to rely on the better eye and ignore the weaker one. Amblyopia affects 4% of the population and is clinically diagnosed when the refractive error of one eye is more than 1.5 diopters different than the other eye. The management of amblyopia involves correcting of significant refractive errors and using techniques that encourage the brain to pay attention to the weaker eye such as patching the stronger eye.
• Blocked tear ducts.
• Ptosis
• Retinopathy of prematurity
• Visual inattention
• Pediatric cataracts
• Pediatric glaucoma
• Abnormal vision development
• Genetic disorders often cause eye problems for affected children. Since approximately 30% of genetic syndromes affect the eyes, examination by a pediatric ophthalmologist can help with the diagnosis of genetic conditions. Many pediatric ophthalmologists participate with multi-disciplinary medical teams that treat children with genetic syndromes.
• Congenital malformations affecting vision or the tear drainage duct system can be evaluated and possibly surgically corrected by a pediatric ophthalmologist.
• Orbital tumours
• Refractive errors such as myopia (near-sightedness) and astigmatism can often be corrected with prescriptions for glasses or contacts.
• Accommodative insufficiency
• Convergence insufficiency and asthenopia
• Evaluation of visual issues in education, including dyslexia and attention deficit disorder.

Pediatric ophthalmologists often work in conjunction with orthoptists in the treatment of strabismus.

CLINICAL PEDIATRIC OPTHALMOLOGY   

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“Optometrists traditionally don’t prescribe contact lenses to children until they are at least 12 years old,” said Jeffrey Walline, an assistant professor of optometry at Ohio State University. “But we found that younger children are just as responsible with their lenses.”

He and his colleagues studied 169 children and teenagers who participated in the Contact Lens in Pediatrics (CLIP) study, which compares contact lens wear in children 8 to 12 with teens 13 to 17. About half the participants were in each group.

The researchers presented their findings from the month-long study on December 8 in Denver at the annual meeting of the American Academy of Optometry. The current findings confirm those of a much smaller study conducted by Walline and others, which suggested that children 8 to 12 could easily handle daily disposable contact lenses.

None of the children or teens in the current study had worn contact lenses prior to the study. The researchers gave each participant a three-month supply of disposable soft contact lenses, instructing the children and teens to take the lenses out each night and to throw each pair away after two weeks.

Each participant answered questions on the Pediatric Refractive Error Profile (PREP), a survey containing quality-of-life questions related to wearing contact lenses and glasses. The children and teens filled out the profile before they began to wear contact lenses, and again one month after wearing the lenses. PREP scores range from 100 (excellent quality of life) to 0 (poor quality of life.)

Questions included how much a child or teen liked wearing contact lenses or glasses, how clear her vision was while wearing the lenses or glasses, what her eyes physically felt like when wearing lenses or glasses, friends’ reactions to the change and how easy the contact lenses were to handle.

PREP scores suggested that the children and teens were more satisfied with wearing contact lenses than with wearing glasses: scores rose from 65 (pre-contact lens wear) to 74.5 for children, and from 63 (pre-contact lens wear) to 73 for teens.

“The biggest boosts were in terms of satisfaction with their correction and also with participation in activities,” Walline said. “Children and teens reported that it was much easier to engage in sports, dancing and other activities while wearing contact lenses.”

The researchers noted that there was little change in participants’ feelings toward their own appearance, nor did peer perceptions seem to change dramatically once a child or teen began wearing contact lenses.

“Vanity doesn’t seem to be a factor in children’s or teens’ satisfaction with switching to contact lenses,” Walline said.

Children wore their lenses almost as long as teens – parents reported that their children wore the contact lenses about 10.5 hours a day, while teens wore their lenses about 11.5 hours each day.

The soft disposable contact lenses used in this study, along with the necessary cleaning solutions, can cost roughly $260 a year, said Walline. Since children’s and teens’ vision can change very fast, such lenses are typically sold in a six-month supply. Adults can buy a one-year supply.

Walline and his colleagues are currently analyzing data gathered from the study participants after three months of wearing the contact lenses. Although that data isn’t included in this presentation, Walline said the findings are very similar to what he and his colleagues found at the one-month point.

“Children are very capable of taking care of contact lenses on their own,” he said.

In related work, Walline and his colleagues found that optometrists initially spend about 14 minutes longer fitting a child with contact lenses and teaching him how to insert and remove those lenses (total exam time was 110 minutes for children and 96 minutes for teens.)

“After the training is complete, children and teens both showed excellent understanding of contact lens care,” Walline said.

He conducted the study with Ohio State colleagues Lisa Jones, David Berntsen, Stacy Long and Monica Chitkara and with colleagues from the University of Houston and the New England College of Optometry.

The results suggest that nearsighted children as young as 8 years old reap social benefits from wearing contact lenses instead of glasses, researchers say.

In general, eye care practitioners in the United States tend to wait to prescribe contact lenses until children are in their early teens. But nearsighted children often are diagnosed with myopia and receive their first corrective lenses around age 8.

The study was designed to examine the effects of contact lenses vs. eyeglasses on a number of kids’ perceptions about themselves, especially what is called their global self-worth, or how valuable they think they are to society.

The research indicated that children’s global self-worth was not significantly affected by whether they wore contact lenses or eyeglasses. Similarly, the type of vision correction had no effect on how they felt they performed in school or how they perceived their own behavior.

“The effects really seem to be in areas that we would think made sense – how they feel about their appearance, athletic abilities and what their friends think of them,” said Jeffrey Walline, assistant professor of optometry at Ohio State University and lead author of the study.

The research is published in the March issue of the journal Optometry and Vision Science.

The study was conducted at five clinical centers in the United States that enrolled a total of 484 nearsighted children between the ages of 8 and 11. Of those, 237 were randomly assigned to wear eyeglasses and the other 247 were randomly assigned disposable soft contact lenses for the three-year duration of the trial.

Before assigning corrective lenses for the study, the researchers surveyed the participants to determine whether they had low or high satisfaction with the eyeglasses they had been wearing before the study began. This was done to determine whether previous unhappiness with eyeglasses might influence how the children with contact lenses perceived themselves.

“We thought kids who hated wearing glasses would have a lot greater benefit from contact lens wear than kids who thought glasses were perfectly fine,” Walline said. “Overall, across the scale, it didn’t seem to have much of an effect. But what that tells us is that, regardless of what kids think of their glasses, they seem to benefit from contact lens wear in these three specific areas.”

Though the participating children’s global self worth scores increased across the board over the course of the study, there was no significant difference in overall self-worth between the two treatment groups.

However, on average, contact lens wearers reported better perceptions about their own appearance than did kids wearing eyeglasses.

“The largest difference between the treatment groups was for physical appearance, regardless of whether they initially liked wearing glasses,” Walline said. “This indicates that children’s physical appearance self-perception is likely to improve with contact lens wear, even if they don’t mind wearing glasses.”

While children’s perceptions about their ability to play sports varied over the three years, over the duration of the study, in general, the kids with contact lenses felt better about their athletic competitiveness than did kids wearing eyeglasses.

The children with contact lenses also felt they were more accepted by their friends than did those wearing eyeglasses. But over the course of the trial, both treatment groups experienced an overall increase in their social acceptance scores.

One area that was affected by how kids previously felt about eyeglasses was scholastic competence. Children who had disliked their glasses and were then assigned contact lenses for the study ended up feeling more confident about their school performance.

Walline said the study suggests that even young children should be given the option to select contact lenses over glasses.

“Kids, in consultation with parents, should be able to choose what kind of vision correction they want,” he said. “Age should not be the determining factor for whether a child receives contact lenses or eyeglasses. Look at a child’s motivation, abilities, maturity, hygiene, eye size – lots of those factors – but don’t look at age. There are 6-year-olds who can wear contact lenses on their own and there are 25-year-olds who can’t.”

This work was supported by Johnson & Johnson Vision Care Inc. and The Vision Care Institute, a Johnson & Johnson company. The company supplied the contact lenses used in the study.

Co-authors of the paper were Lisa Jones, Loraine Sinnott and Monica Chitkara of Ohio State’s College of Optometry; Bradley Coffey of the Pacific University College of Optometry in Forest Grove, Oregon; John Mark Jackson of the Southern College of Optometry in Memphis; Ruth Manny of the University of Houston College of Optometry; Marjorie Rah of the New England College of Optometry in Boston; and Mitchell Prinstein of the University of North Carolina at Chapel Hill.

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Stephen Macknik, PhD, director of the Laboratory of Behavioral Neurophysiology; Susana Martinez-Conde, PhD, director of the Laboratory of Visual Neuroscience; Xoana G. Troncoso, PhD; and Jorge Otero-Millan; conducted a study based on the Enigma painting, a visual illusion in which rotational motion is seen within a stationary image. The artwork has been at the center of a debate over whether the brain or the eye is behind the perception of illusory motion.

Dr. Martinez-Conde’s laboratory recently discovered that microsaccades, a small, unconscious eye movement that occurs when humans fixate their eyes, are critical to normal vision. The team of scientists conducted the Enigma study to see if microsaccades are also behind the perception of this illusion. Based on their study, the hypothesis suggesting the illusion originates solely in the brain was ruled out.

Participants in the study observed the Enigma illusion while their eye movements were simultaneously recorded with high precision cameras. Microsaccade rates increased before the illusionary motion sped up and decreased before the motion slowed, revealing a direct link between the eye movements and the illusion.

“We have discovered that this illusion originates with eye movements and not solely the brain as previously thought,” says Dr. Martinez-Conde. “The findings from the study could help design future prosthetics for patients with brain damage or brain lesions that affect the perception of motion.”

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The retrospective study examined the medical records of 407 patients with strabismus (misaligned eyes) and compared them with records of children matched for age and sex but with normal eye alignment. Children with eyes that diverged (exotropia) were three times more likely to develop a psychiatric disorder than were the control subjects, while those with inward deviating eyes (esotropia) showed no increase in the incidence of mental illnesses.

Brian Mohney, M.D., the Mayo Clinic pediatric ophthalmologist who led the study, says the results can help alert physicians to potential problems in their pediatric patients. “Pediatricians and family practice physicians who see children with strabismus should be aware of the increased risk of mental illness,” says Dr. Mohney. “They can hopefully be alert to the earliest signs of psychiatric problems in patients with exotropia, so they can consider having them seen by a psychologist or psychiatrist.”

Strabismus is a misalignment of the eyes that affects three to five percent of children, and about 125,000 new cases are diagnosed each year in the United States.

“Intermittent exotropia occurs in approximately 1 percent of developmentally healthy children in the United States and, given its predominance over esodeviations [when the eye turns in] among Asian populations, it may be the most prevalent form of strabismus worldwide,” the authors write as background information in the article.

Jeff A. McKenzie, B.A., and colleagues at Mayo Clinic, Rochester, Minn., analyzed the medical records of 183 children younger than 19 in Olmsted County, Minn., who were diagnosed with intermittent exotropia between 1975 and 1994. For each patient, the researchers identified one control child who was the same age but did not have a diagnosis of any type of strabismus. Both groups were followed to an average age of 22.

During the 20-year study period, 97 of the children with intermittent exotropia (53 percent) were diagnosed with a mental health disorder, compared with 55 controls (30.1 percent)—meaning that patients with the condition had an increased risk of developing a psychiatric illness. Mental health disorders were diagnosed in 63 percent of boys (41 of 65) and 47 percent of girls (56 of 118) with intermittent exotropia, compared with 33 percent of boys (22 of 66) and 28 percent of girls (33 of 117) in the control group.

“Additionally, males with intermittent exotropia had a greater use of psychotropic medication, psychiatric emergency department visits, psychiatric hospital admissions, suicide attempts and suicidal ideation than controls, and females with intermittent exotropia had more suicidal ideation than controls,” the authors write.

The reasons underlying these associations remain unclear, the authors note. “Studies regarding the psychosocial impact of strabismus have reported that individuals with intermittent exotropia are not judged more poorly than individuals with orthotropia [the absence of strabismus] by adult observers. However, a negative bias toward people with strabismus has been demonstrated in children,” the authors write. “Although this study focused on mental illness that was diagnosed by early adulthood, there is also evidence to suggest that the social problems associated with strabismus persist and even intensify into adult life.”

“Further study is needed to determine whether interventions for intermittent exotropia can decrease or otherwise alter the future development of mental illness,” they conclude.

This study was supported in part by an unrestricted grant from Research to Prevent Blindness Inc., New York, New York.

Journal reference:

1. Jeff A. McKenzie; Jason A. Capo; Kevin J. Nusz; Nancy N. Diehl; Brian G. Mohney. Prevalence and Sex Differences of Psychiatric Disorders in Young Adults Who Had Intermittent Exotropia as Children. Archives of Ophthalmology, 2009; 127 (6): 743 DOI: 10.1001/archophthalmol.2009.68

Although genetic inheritance plays a role, the rapid rise of myopia suggests that environmental factors are driving the trend. Myopia usually begins and progresses during children’s school years, but research on the role of intensive reading or other “near work” has determined that this is a minor factor. A new study led by Kathryn A. Rose, MD, used data from the Sydney Myopia Study of more than 4,000 Australian school children to assess whether outdoor activity might be significant in controlling myopia.

Parents and their children, at age 6 or 12, reported on the children’s daily activities, which were classified as indoor or outdoor, and as near, medium or distance. Myopic refractive error, if any, was diagnosed for parents and children, and the children’s ethnicity was recorded. A key finding was that the lowest myopia rates in 12-year-olds were associated with high outdoor activity, independent of the level of near work activity.

In 12-year-old students myopia was most strongly associated with high levels of near work and low levels of outdoor activity. The findings suggest that it is the time spent outdoors rather than engagement in sports that is critical; the association between increased outdoor hours and lower myopia was found even if an outdoor sport was not included, while time spent on indoor sports, such as playing basketball in a gym, had no effect.

The researchers think the intensity of outdoor light may be an important factor. Myopic eyes are longer, measured front-to-back, than normal eyes; in response to intense light, the retina releases dopamine, a neurotransmitter that inhibits eye growth and may thus influence the development of myopia. Also, the pupils of the eyes constrict in intense outdoor light, which increases the visual depth of field, the distance at which objects can be clearly seen.

The researchers recommend further study to prove conclusively whether certain levels of time spent outdoors can control myopia and to define the mechanisms involved. The higher exposure to intense outdoor light may explain the lower prevalence of myopia in children in Australia, compared with ethnically matched peers in other countries, Dr. Rose says. She adds that “this protective effect suggests that a public health measure aimed at preventing development of myopia could be based on increasing the engagement of children in outdoor activity,” including family and school activities and sports.

This research was published in the August issue of Ophthalmology.

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Led by Dr. R. Michael Stiatkowski of Dean McGee Eye Institute/University of Oklahoma Department of Ophthalmology, the researchers evaluated the effects of pirenzepine in children with myopia. Myopia—sometimes called nearsightedness—is a condition in which focus on near objects is good, but distant objects appear blurry. Caused by a problem with the length of the eyeball or the curvature of the cornea, myopia gets worse over time in many children.

In the study, children with myopia were randomly assigned to treatment with pirenzepine gel or an inactive placebo gel. After a year of treatment, the average increase in myopia was significantly less for children using pirenzepine. The new study presents the final results in 84 patients who continued treatment for a total of two years: 53 with pirenzepine and 31 with placebo.

Although myopia worsened in both groups of children, the rate of progression was slower with pirenzepine. At the end of two years, myopia increased by an average of 0.58 diopters in children using pirenzepine versus 0.99 diopters with placebo. (All children initially had “moderate” myopia, with an average refractive error of about -2.00 diopters.)

New glasses are generally prescribed when myopia worsens by at least 0.75 diopters. During the study, 37 percent of children using pirenzepine met this cut-off point compared with 68 percent of the placebo group. With glasses, all children had about 20/20 vision at both the beginning and end of the study.

Pirenzepine treatment was generally safe, although eleven percent of children stopped using it because of side effects such as eye irritation. The drug also caused mild dilation of the pupils. The amount of change in the length of the eyeball was not significantly different between groups, although more research is needed to determine whether pirenzepine affects the growth of the eyes.

Myopia is the leading cause of loss of vision worldwide, affecting at least 25 percent of U.S. adults. Effective treatments to prevent or delay progressive myopia may reduce the risk of serious complications such as detached retina and glaucoma—even for children with moderate myopia, the risk of retinal detachment is increased by up to four times.

Treatments to slow worsening myopia could also have important quality-of-life benefits. For example, while children with -1.00 diopter of myopia may need glasses only part-time, those with -2.00 diopters will probably need glasses for all activities, including school and sports.

Previous studies have suggested that a drug called atropine can delay progression of myopia. The new results show that pirenzepine—a related drug with fewer side effects—is also safe and effective for this purpose.

More research will be needed before pirenzepine can be widely recommended for children with myopia. Key questions include the long-term effects and optimal length of pirenzepine treatment. In addition, more convenient and practical methods of drug administration may help to overcome some of the disadvantages of pirenzepine gel.

1. Siatkowski et al. Two-year multicenter, randomized, double-masked, placebo-controlled, parallel safety and efficacy study of 2% pirenzepine ophthalmic gel in children with myopia. Journal of American Association for Pediatric Ophthalmology and Strabismus, 2008; 12 (4): 332 DOI: 10.1016/j.jaapos.2007.10.014

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Children with convergence insufficiency tend to have blurred or double vision or headaches and corresponding issues in reading and concentrating, which ultimately impact learning. The findings show children improve faster with structured therapy sessions in a doctor’s office, with reinforcement eye exercises at home.

“This is good news for children and parents experiencing this fairly common condition,” says Brian Mohney, M.D., Mayo Clinic ophthalmologist and lead investigator for Mayo in the study. “Three different approaches were being used across the country and no one knew for certain which worked best. Now that’s settled. And only 12 weeks of treatment were necessary to demonstrate improvement.”

How they did it

The researchers followed 221 children nationally, ages 9 to 17, divided into four study groups, two of which received only home-based therapies. One group did simple daily exercises for 15 minutes, trying to focus on a moving pencil. A second home-based group performed a shorter version of the pencil exercise and a series of computer-based exercises using special software. A third group did an hour of supervised therapy in a clinical office each week along with 15 minutes of prescribed exercises at home five days a week. The fourth group, the placebo or control group, did office and home exercises designed to look like real therapy but that had no effect. Follow-up exams were held after the fourth and eighth weeks and at the end of the 12-week study.

Significance of the findings

Children in all three treatment groups experienced improvement, though it’s not clear from the research whether any improvement in the home groups was due to a placebo effect. About 75 percent of the children who had weekly office-based therapy coupled with 15 minutes of at-home exercise five days a week experienced either normalization (full correction) of their vision in 12 weeks or saw marked improvements, compared to roughly 40 percent in the two home treatment groups. Researchers say that the lower cost of home therapy may be a factor in its popularity, but they point to the high percentage of normalized vision in the office-based sample after 12 weeks as an indicator of quality outcome in the shortest period of time.

The National Eye Institute, part of the National Institutes of Health, sponsored the study. Others involved in the research from Mayo Clinic were Jonathan Holmes, M.D.; Melissa Rice, O.D.; Virginia Karlsson; Becky Nielsen; Jan Sease; and Tracee Shevlin.

1. . Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children. Archives of Ophthalmology, 2008;126(10):1336-1349 [link]

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Now Tel Aviv University’s eye and brain specialist Dr. Uri Polat of the Goldschleger Eye Research Institute has developed a computer therapy that could spare kids from the ugly eye patch, letting them enjoy themselves during therapy. The treatment, currently available for adults only, corrects the activity of the neurons in the brain, the main operator of eye function.

A leading expert in lazy eye syndrome recently assessed Dr. Polat’s invention and found that twenty hours in front of Dr. Polat’s computer treatment had the same effect as about 500 hours of wearing an eye patch. The review was published recently in Vision Research. Dr. Polat’s research group has also reported the new treatment’s efficacy in a number of scientific publications, including the Proceedings of the National Academy of Science (PNAS).

Not just any video game will work

In his carefully designed treatment, special and random objects appear, keeping the patient constantly alert and expecting the unexpected. A version of the therapy as a game is now in under development for children.

“As far as I know this is really a one-of-a-kind, non-invasive and effective way to treat lazy eye, without the use of an embarrassing eye patch,” says Dr. Polat. “This is probably the first treatment that attempts to correct lazy eyes in adults, something that doctors had previously given up on. Doctors don’t suggest intervention after the age of nine, because it usually doesn’t work.”

Making eye therapy fun

Taking it from the lab bench to a commercial product, Dr. Polat wants to make sure that the treatment will be as stimulating a regular video game. The existing game-like therapy he developed for the computer was “a bit boring,” he admits, making it hard for some kids to sit through an entire session of treatment, which can be administered by a parent or therapist at home or at school.

That’s why he’s now collaborating with researchers at Rochester University in New York, where gaming specialists plan to add more entertainment value to the new therapy while keeping all of its therapeutic power.

“You see these poor kids in kindergarten wearing the patch. Everyone hates it, especially the parents who know what it’s doing to their kid’s self-esteem,” says Dr. Polat. “My aim is to not only treat adults, but to treat kids using a computer two or three times a week, one hour each time, without the need for them having to wear a patch.”

Dr. Polat’s solution currently has the U.S. Food and Drug Administration seal of approval, Dr. Polat adds.

source : sciencedaily

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Clinical and Editor in Chief :

Widodo judarwanto, pediatrician

email : judarwanto@gmail.com,

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved