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Schnall Pediatric Ophthalmology

A Child's Eye Exam: An Outline

Why Worry About A Child's Eyes?

Babies are able to see as soon as they are born. For the visual system to continue to develop properly, children need clear input from both eyes to the brain. If there is a problem which interferes with vision in either eye or both, the connections from the eye to the brain can become weak or not develop properly. Crossed or turned eyes or an imbalance in the way each eye focuses can interfere with this normal development of the visual system.

Because of the importance of maintaining normal vision in infants, and because an ophthalmologist (medical eye doctor) is able to recognize and treat problems early, we are interested in examining very young children. This is especially true if the parents or the child's doctor feels that there may be some problems or if there is a family history of eye problems.

What Are Common Eye Problems in Childhood?

Four percent of children have ocular problems that can diminish vision in one or both eyes. The three most common types of problems that occur are strabismus (misaligned eyes), amblyopia (lazy eye), and refractive errors (focusing problems).

When should I have my child's eyes checked?

Most physicians examine many parts of the eye during a child's medical examination. However, they may refer to an ophthalmologist if there is difficulty in measuring vision, any sign of amblyopia or if they suspect an abnormality of the eye alignment or structure. It is recommended that all children have their vision checked by three years of age or sooner (around six months to one year) if there is a family history of problems. Fortunately, the ophthalmologist can perform complete eye exams on children of any age.

What Questions Are Asked At The Eye Exam?

A child's eye examination begins by discussing any problems the parents recognize. It is important to find out if there were problems with the pregnancy or with the child's birth, or if the child's growth and development are proceeding normally. A history of eye problems in the family is important. The ophthalmologist needs to know about the child's health in general. Are there other medical problems? Has the child had any treatment with medications or surgical procedures?

If your child has been treated with medications, glasses or contact lenses, these should be brought to the eye examination. The names and addresses of other physicians who may be treating the child should be supplied so that they may be informed of the findings of the eye exam.

How Do Ophthalmologist Examine a Baby's Eyes?

Many parents are quite surprised to find that a complete eye exam can be performed on young children. A skilled ophthalmologist can get a good idea of how well a child can see based on the way a child uses his eyes to look at and follow attractive toys or lights.

No matter how the vision is tested, it is important to check each eye separately. Two to five percent of children have one eye which does not see as well as the other, a condition called amblyopia or "lazy eye".

For older children who can talk but who do not yet know their numbers or the alphabet, special charts are used that have pictures of common items such as birds, birthday cakes, and stars. Some tests may require the child to point to a letter matching the letters on a chart. All of these tests show a child smaller and smaller items in order to get an idea of the child's best visual acuity.

Testing for binocular vision (the ability to use both eyes together) and depth perception can both be done early in childhood. In some special situations, measurements may be made of a young child's vision based on brain wave measurements while the child watches striped patterns or by observing the way the child looks at black and white stripes on flashcards.

Lights, Lights, Lights!

Lights are used to examine the pupils to see if the eyes are working properly. During this portion of the examination, the areas around the eyes such as the eyelids and the tear canals are also examined. The tiny flashlight can also be used to see if a child's eyes are straight or turned. If a child is looking straight at the light, it will reflect off the front of the child's eyes in a way that allows the ophthalmologist to tell whether the eyes are turned or straight. This is important in infants because their wide noses may make their straight eyes appear crossed. Sometimes one eye is covered and then the other. If the eyes are not aligned properly, they will jump back and forth when looking at the light or toy. Wedge-shaped pieces of clear plastic called prisms can be used to measure the amount of misalignment of the eyes.

Why are Eye drops Needed?

One of the less enjoyable but most essential portions of the eye exam is the dilation of the pupil. This not only allows the ophthalmologist to view the inside of the eye, but the dilating drops temporarily relax the child's focusing power so that nearsightedness, farsightedness or astigmatism (all referred to as refractive errors) can be accurately measured. Most doctors have preferences for which dilating drops they use. Some drops are given once, some are given multiple times and all take about 20 - 30 minutes to be effective. For some children's revisit exams, it may be necessary to have a special drops or ointment put in the eyes at home before coming to the examination.

What Happens After the Drops?

Whether your child is attentive or not at this point, or even if he/she is asleep, it can be determined if your child's eyes are out of focus, using small lenses and a special flashlight called a retinoscope. By shining a beam of light into the eye, the ophthalmologist can see the back of the eye reflecting lights and by holding lenses in the path of this reflection see whether the child is nearsighted, farsighted, or has astigmatism. It is a somewhat different technique from that which ophthalmologists use to fit glasses for adults, but it is, nonetheless, very accurate. This tells us if your child needs glasses.

How Are The Inside of the Eyes Checked?

Once your child's pupils are dilated, your ophthalmologist can get a very good look at the inner eye structure to make sure the eye is healthy. The inside of the eye holds the retina, which functions similar to film in a camera. It processes the visual information into signals, which are sent down the optic nerve to the brain. The optic nerve itself, as well as the blood vessels which supply the retina, can be seen in the back of the eye. Special instruments allow the inside of the eye to be seen in great detail.

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