To paraphrase Ben Franklin: For want of early treatment, a child’s sight was lost.
Your children can naturally outgrow many things with or without your help: sibling rivalry, the need for a night-light, even puppy love. They will not, however, ever recover from amblyopia or strabismus—two serious childhood eye disorders—without help. If these problems are not caught and treated early in childhood, the conditions can last a lifetime—a lifetime of poor vision. On a brighter note, the earlier these problems are diagnosed and the earlier treatment starts, the earlier normal vision can be restored.
These and other eye problems can start early—as early as birth. In fact, one of the first things a doctor does to a baby after it is born—besides spanking it, of course—is put some drops of silver nitrate into its eyes to prevent the possibility of an eye infection from gonorrhea. If the mother were infected, the baby could pick up such an infection during delivery. Some states allow erythromycin ointment to be used as an alternative to silver nitrate. This antibiotic combats both gonorrhea and chlamydia, another common cause of neonatal eye infection.
Unlike puppies, which spend their first few days with their eyes closed, babies see the world as soon as they enter it. But even though they can see at birth, they don’t see all that well. Their eyes are still developing, as is their ability to use them.
A baby’s visual development actually starts in the womb during the fourth week of pregnancy. At that time, the clusters of cells that will develop into eyes are smaller than the head of a pin and are hidden behind a layer of tissue.
Sometimes people—especially expectant mothers—wonder whether a baby actually sees anything while in the womb. It all depends on how you define sight. There isn’t any light in the womb for the baby to use to see by, pressure on the eyeball itself can produce dots, spots, and flashes of color called phosphenes. In fact, the optic nerve translates pressure or the eyeball into all sorts of bizarre patterns.
But a baby doesn’t begin to see real objects in real light until it is out of the womb. Of course, it has no idea what it is seeing or what anything means, but both the baby’s vision and its understanding of what it is seeing will improve with age—provided there are no problems.
Shortly after birth, all babies should receive an eye screening in the nursery by a pediatrician, family doctor, or—in the case of an infant with a high risk of eye problems—an ophthalmologist. In a typical screening, the doctor looks at the eyes with a penlight, conducts a light reflex test, and checks the retinas with an ophthalmoscope.
High-risk babies, who receive a more careful screening by an ophthalmologist, are those with a family history of retinal problems, cataracts, or other diseases that could affect the eye. Premature children are at especially high risk. Another high-risk group are those children with a family history of retinoblastoma, a rare eye cancer that is often hereditary.
An Early Warning of Eye Cancer
Retinoblastoma is a rare eye cancer that is often hereditary. It strikes about 500 infants and children in the United States each year.
In the hereditary form, a retinoblastoma gene is passed from parent to child. But the disease can also be nonhereditary, occurring when a new mutation spontaneously occurs in the eyes of a child whose parents did not have the disease.
Fortunately, the hereditary form of the disease can be spotted early through genetic “fingerprinting.” If one of the parents had the disease, a blood test is taken and analyzed. The defective gene that caused the cancer can be spotted in the parent’s blood and then compared to the genes found in a sample of the baby’s blood. If there is a match, the child should be checked frequently for signs of emerging disease.
According to Thaddeus F. Dryja, M.D., associate professor of ophthalmology at Harvard Medical School, the defect in the gene causing the disease “can be as small as one wrong nucleotide, or gene subunit, in a gene that is 200,000 nucleotides long.”
If an eye tumor does develop, early treatment with radiation therapy, laser surgery, or cryotherapy may save both the baby’s eye and life.
Stages of Visual Development
Regardless of whether your child is a high-risk or normal-risk baby, you can expect certain levels of visual development during the first years of life.
A newborn, for example, usually prefers to look at objects that are close. Newborns also like to look at faces and brightly colored or moving objects.
A one month old’s ability to see is much more developed than that of a newborn. And by the time babies are three months old, their vision has developed to the point that they can smoothly follow a moving object, such as a rolling toy, and visually “hold on” to it even when it stops. This is also the time when they really begin to appreciate the colors and moving parts of crib toys such as mobiles. Such toys provide stimulation that may help a baby’s vision develop.
Somewhere between the third and sixth month of life, the retina becomes fairly well developed and the baby can actually see small details. The baby can also look from something close to something far away and then back again without getting visually “lost.” Depth perception, the ability to judge distances, also starts to develop at this time.
By six months, the eye is about two-thirds of its adult size. Both eyes are usually working together in tandem so the baby has good binocular vision and is developing better distance vision and depth perception. A baby’s routine physical at age six months should also include a vision screening to make sure everything is developing normally.
Young children naturally practice eye-hand coordination, and this is well under way by age one. Development of this skill can be enhanced and stimulated by games involving grasping, pointing, tossing, rolling, placing, and catching.
Between the ages of two and five, most children are eager to look at and study pictures, and they even like to draw their own. Picture books and anything else that tells them a story directly connected to what they are seeing helps children coordinate their hearing and vision.
The visual system continues to develop as the child grows, until about nine years of age. At that point, the system is completely developed.
Measles? Dim the Lights
Measles does more than make the skin break out in spots. It can also lead to a corneal infection that makes the eyes sore, teary, and very sensitive to light.
Being in bright light will not damage the eyes, but it will hurt and make the patient a lot more uncomfortable. So when you fluff your measles sufferer’s pillows, turn down the lights, too.
That’s why a child’s first complete eye examination should come before the third birthday. If a child has an eye problem such as strabismus or amblyopia—which we will look at in detail later in this chapter—correcting it could take years. And if it isn’t corrected while the child is still relatively young, it might be too late.
Signs That Signal Trouble
Quite often children don’t know that there is anything that needs to be corrected because they don’t have anything to compare their vision to. How, for example, could a person know that chocolate ice cream tastes better than radish ice cream if they’ve never had chocolate ice cream?
But it is usually possible to figure out if your child is developing eye problems. Here’s some advice from the National Society to Prevent Blindness, which says you should make an appointment with an eye doctor if your child does any of these things.
- Rubs eyes excessively
- Shuts one eye or keeps it covered
- Tilts head or thrusts head forward at an unnatural angle
- Has problems reading or doing other close work, or holds objects close to eyes
- Blinks frequently or is irritable when doing close work
- Is unable to see distant things clearly
- Squints eyelids together or frowns
You should also call the doctor if your child has:
- Crossed eyes
- Red-rimmed, encrusted, or swollen eyes
- Recurring sties of the eyelids
If your child complains of any of the following, a visit to the eye doctor is strongly recommended.
- Eyes itch, burn, or feel scratchy
- Inability to see well
- Dizziness, headaches, or nausea following close work
- Blurred or double vision
While you should always pay attention to any potential vision problems, you should pay special attention if your child is in one of the high-risk categories. These include:
- Children born prematurely
- Children with a family history of eye problems such as childhood cataracts, amblyopia, strabismus, or tumors
- Children whose mothers have health problems such as diabetes
- Children who have had any sort of eye injury, because complications from the injury might not appear until much, much later. Such complications may include glaucoma or cataracts
Leukokoria’s Many Causes
A leukokoria is a white pupil that some infants or children develop. When it occurs, it can indicate any of a number of conditions, some of which are life or sight threatening. Early diagnosis is the key to successful treatment.
The white pupil can be caused by a detached retina, hemorrhaging within the vitreous, or an intraocular inflammation, as well as a number of rare hereditary and developmental problems. Some of the more common and dangerous causes include the following.
Cataracts. This is the most common cause of leukokoria, affecting approximately 1 out of every 250 babies. While some cataracts are mild and pose little danger, others can require surgery within the first few weeks of life if the baby is to ever have a chance of normal vision.
Retinoblastoma. This cancer is the most dangerous cause of leukokoria, and the most common intraocular malignancy of childhood. It can lead to blindness and even death. It occurs in approximately 1 of every 20,000 live births. The prognosis is directly related to how far the cancer has spread throughout the eye—or beyond the eye—and how soon it is diagnosed and treated.
Retinopathy of prematurity (ROP). This disorder is usually associated with premature birth, low birth weight, and oxygen administration. While ROP disappears in 85 percent of all cases, it can also lead to blindness or other vision problems.
Persistent hyperplastic primary vitreous (PHPV). This is an abnormality in the development of the eye. The affected eye is usually smaller than the other eye. In some instances, prompt surgery must be performed to save the baby’s vision.
Discovering the Details
Like millions of other young children, Cathy didn’t know she had anything less than perfect vision until her teachers noticed that her work and classroom participation improved when she sat close to the blackboard. They recommended an eye examination, and the doctor prescribed glasses for her.
Her first day with her brand-new glasses, she came running into the house very excited. “Did you know, “she told her parents, “there are individual leaves on trees?”
“Lazy” Eye and Amblyopia
Technically, there is no such thing as an eye that is lazy, but the term is used loosely to refer to an eye that is weak. A “lazy” eye could be one that does not see as well as its fellow eye, that cannot be fully corrected with glasses to see 20/20, or that looks off to the side while its partner—the “good” eye—looks straight ahead.
A person with amblyopia has one eye that did not develop normal sight during early childhood. The weak or “lazy” eye is called amblyopic.
Amblyopia is a very common condition, affecting approximately 4 out of every 100 people. It must be treated early, or the baby’s vision can be permanently affected.
The most common cause is strabismus—misaligned or crossed eyes—which we will look at next. Other common causes include visual problems that can be corrected with glasses, such as nearsightedness, farsightedness, or astigmatism. Cataracts and other eye diseases can also cause amblyopia, but they are relatively rare in babies.
Because the average baby can’t be expected to read the letters on an eye chart—or even name the squares, circles, triangles, ducks, or other shapes on a child’s eye chart—it can be difficult to detect a weak eye.
An eye doctor will usually observe how a baby responds and looks at things when first one and then the other eye is covered. If the baby does have an amblyopic eye, he might try to look around or get rid of what is blocking the good eye when it is covered. An eye doctor can also look inside the eye for abnormalities such as cataracts, tumors, inflammations, or other problems.
Patching Takes Patience
If the doctor determines that the affected eye has potentially good vision, the child has to be taught to use the weak eye. This is usually done by patching the stronger eye to build up the weaker eye’s strength. In terms of what babies like to do, this is not a popular pastime. If a baby sees a bright and clear picture out of one eye and a dark or blurry picture out of the other, it is only natural to fight having the good eye covered.
Occasionally an eye doctor will use special eyedrops to blur the vision in the good eye or prescribe glasses that improve the vision in the bad eye and worsen the vision in the good one. This, however, is not done very often.
Patching must be done under a doctor’s supervision, and the instructions must be carefully followed, because it is possible to weaken the good eye through excessive patching.
The important thing to remember about amblyopia is that it can be corrected, but only if it is diagnosed and treated during infancy or early childhood—by age seven or eight. After that age, the imprint of blurred images is so fixed in the brain that treatment does not seem to help.
It’s as if the brain has decided that the amblyopic eye can never recover and refuses to even consider the possibility that it might.
Shiver Me Timbers, ‘Tis the Pirate Baby!
Patching is the most basic and helpful method of preventing or correcting amblyopia. And with a little imagination, effort, and investment in arts and crafts supplies, you can even add some fun to this treatment, if the doctor should prescribe it.
Because the stronger eye needs to be covered for weeks at a time, it is understandable that a child will fight having to wear the patch, no matter how persuasive or well intentioned your reasoning and eloquence might be. After all, if millions of adults can gleefully ignore all the medical evidence against smoking or drinking or eating too much, what makes you think a child will care about anything except the immediate need to have a clear view of the world?
That’s when the imagination, effort, and arts and crafts supplies come in. Decorate the patch.
Turn it into a pirate’s eyepatch, or a television screen, or anything that will make your child a little more willing to put up with the inconvenience of wearing it. Maybe everyone in the family can submit “designs” for the patch, and let the child choose from among them. Since the patch has to be changed on a regular basis, there is plenty of room—and need—for a wide variety of designs and any other props that can make patch wearing easier to put up with.
When decorating a patch, remember that the patch must cover the entire eye so that no light can get into it. Adhesive patches work best. Cloth patches, or those attached to the lens of the child’s eyeglasses, are too easy to cheat with by looking “around” them or just pulling them off.
The earlier patching starts, the more effective it will be. If patching does not begin before the child reaches the age of six or seven, it may be too late to correct the problem.
Regular eye tests are needed during the patching period to measure the progress of the weaker eye, and also to make sure that the stronger eye does not start to weaken from lack of visual stimulation.
Straightening Out Strabismus
Strabismus is the term used to describe any condition in which the eyes are not straight; people with strabismus may have crossed eyes, walleyes, or one eye that looks up while the other looks down.
While adults can sometimes develop strabismus, it usually occurs in children. In fact, 5 percent of all youngsters are affected.
A Grown-Up Problem
Although most adults with strabismus are people who did not have the problem corrected when they were children, it is possible for an adult to develop the condition.
The most common cause is eye muscle paralysis brought on by diabetes, thyroid disease, stroke, tumors, cataracts, or retinal diseases. Very often this kind of paralysis is only temporary; it gets better with time or with treatment of the underlying disease that caused it. For those who don’t get better, prisms can be incorporated into glasses, or surgery may be tried to straighten the eyes.
It is easy to be fooled by “false strabismus” in a baby. An infant’s nose is flat and undeveloped, and there may be an extra fold of skin on either side. This fold may cover up the inner white portion of the eye, the sclera, and make the eye appear to be crossed. As the child grows older, the bridge of the nose narrows and the skin is drawn up so that the fold disappears.
People with true strabismus might be bothered by it all the time, or only when they are tired, ill, or looking at an object close to their face. But no matter how or when it affects vision, the underlying cause is that the two eyes are not working together.
Baby’s First Home Eye Test
Infants often look as if they have crossed eyes. There is a simple test to find out if that’s really the case. Hold a penlight in front of your baby’s eyes so that the light reflects back from both of them.
If the reflection is centered in each pupil (the black center of the colored part of the eye), then your baby’s eyes are probably straight. If one of the reflections is off-center, make an appointment with an eye doctor.
There are six muscles attached to the outside of each eyeball that move the eye in all directions. Each eye is coordinated with the other through elaborate nerve connections in the brain. This mechanism normally keeps the eyes working together regardless of what they are staring at.
In strabismus, however, the two eyes do not work together. Rather, one eye—the “weak” one—will turn up, down, in, out, or follow slightly “behind” the “strong” one.
Why? We aren’t 100 percent sure. But we assume that it is caused by an imbalance in the nerve impulses to the muscles controlling the two eyes.
Making Faces Can’t Make Kids Cross-Eyed
Remember when your mom told you that if you crossed your eyes they’d get stuck in that position and not only would no one ever want to marry you, you would also look funny for the rest of your life?
Mom was wrong. And so was Dad, Grandpa, Aunt Adelaide, and anyone else who told you that if you crossed your eyes too long they would “stick” that way. There has never been a single case on record of a person whose eyes got “stuck” while they were being crossed or because they were being crossed.
When the two eyes work together properly, they view an object from slightly different positions. The two separate images travel through the optic nerve and are fused together in the brain.
But if the two eyes are looking in two different directions, they are seeing two very different objects at the same time. Instead of fusing the two views together, this can lead to double vision.
The brain hates double vision—absolutely hates it. Why? Because it can’t cope with it. So it takes the simple way out and just ignores one of the two images that is being transmitted to it—usually the more blurry of the two. It treats it as if it isn’t there and after a while, it isn’t.
The brain, in effect, fires the “bad” eye—permanently. And it can’t be forced to “rehire” it.
Because of the very real danger that vision will be lost in the weak eye, treatment should begin as early as possible. There are three important goals in treating strabismus.
- To preserve vision
- To make the eyes straight
- To make the eyes work together
Reaching these goals can require years of treatment, often difficult treatment that could require patching, eyeglasses, or even surgery.
Surgery That Balances the Eyes
Although wearing glasses or a patch might be adequate for treating mild strabismus, those tactics may not have much effect on more advanced cases. Many children need surgery on the muscles controlling the afflicted eye.
This is a safe and fairly simple operation in which the tension of the eye muscles is adjusted so that both eyes work together. Either one or both eyes may be operated on. Strabismus, after all, is a problem of balance between the eye muscles, and even though one eye may appear to be straight, both eyes might need adjusting.
The most common type of strabismus operation is done in a hospital and requires that the child be kept overnight. The child is put to sleep for the operation, in which the muscles controlling the two eyes are actually moved.
Why do the muscles have to be moved?
Take a 12-inch ruler and balance it on your finger. The balance point is in the middle, at the 6-inch mark. This can be compared to a well-balanced set of eye muscles. The balance point is in the center.
Now place two quarters on one end of the ruler. The balance is thrown off. The only way to rebalance it is to move your finger away from the middle of the ruler and closer to the two quarters.
A child with strabismus has eye muscles like the unbalanced ruler. Because the eye muscles are of different strengths, a new balance point must be found. If the muscles on the side surfaces of the eyeballs themselves are repositioned, they can exert either greater or lesser pressure to move the eyes in a balanced way.
There is a problem, however. When you tried to find the new balance point on the unbalanced ruler, you probably had to try several times. The same can be true with rebalancing the eyes. A second operation is often required, and sometimes a third. After all, each child’s muscular development is unique.
While the operation usually lessens the eyes’ degree of turn, glasses and patching might still be necessary. Sometimes eye exercises are also prescribed. Known as orthoptic exercises, these are intended to help the two eyes move together and to encourage the fusing of the two images seen by the eyes. These exercises are especially helpful after surgery for a child whose eyes are now almost straight.
Keep in mind that surgically straightening the eyes doesn’t always allow the child to use both eyes more effectively. Sometimes it just makes the eyes appear straight without helping the vision.
A Toxin That Treats
Surgery is not the only method of straightening eyes. Sometimes the doctor uses poison.
A potent nerve toxin, botulinum, can be injected into the stronger of the two eye muscles in minute amounts—usually starting with an injection of just one-billionth (0.000000001) of a gram. The toxin temporarily paralyzes and weakens the muscle, causing it to stretch. By injecting just the right amount, a turned eye can sometimes be made straight. Although not always as permanent as surgery, as many as one-third of strabismus patients are said to be helped by this treatment.
Surgeons have developed a procedure to do away with the need for a second—or third—strabismus operation. But it’s not for the squeamish.
It’s called “the adjustable suture technique,” because the surgeon leaves long sutures attached to the eye muscles after the initial surgery. These sutures, or strings, stick out of the eye socket next to the eyeball. When the strings are pulled, the eye muscles will move.
The day after the operation, the surgeon checks the eyes to see if they have been properly adjusted. The patient must be awake and alert for this test. If the eyes are not properly positioned, he pulls the strings attached to the eye muscles until they are, and then ties off the sutures and cuts away the excess string. (The sutures are the kind that will dissolve within the body in a few weeks.)
The procedure is not for everyone. Surgeons normally test their patients’ ability to withstand eye irritation before deciding who is a good candidate for it.
The Jumbled World of Dyslexia
Not all medical conditions or diseases act the way you think they should.
The first sign of heart trouble, for example, is often a tingling sensation in the left arm—not in the chest. Sometimes a pain in your hip means that you have a problem in your knee. And an inability to read or understand words because the letters appear to be all mixed up or reversed could mean that a child has a problem inside his brain, not inside his eyes.
Because dyslexia usually manifests as a problem with reading, it has traditionally been associated with the eyes. But although the disorder is not completely understood, current scientific thought treats it as a neurological or perceptual problem. The eyes are sending a clear picture to the brain, but the brain is somehow getting the picture confused.
There are three general classifications of dyslexia.
- Children with dysphonetic dyslexia cannot read or even sound out words phonetically. To them, words are secret coded messages, and each message has to be learned and memorized separately. A child with this type of dyslexia might “know” the words dog and wood, but be unable to read the word dogwood.
- Children with dyseidetic dyslexia, which is sometimes called gestalt-blind dyslexia, have trouble memorizing whole words and seeing the differences between similar-looking letters. They can use phonics to interpret the secret code we call writing, but they cannot remember the whole words they struggle to decode. A child with this condition might have to sound out the letters to “read” the word bicycle on page one of a story, and then have to struggle all over again when the word reappears on page two. The child might also spell the word as bysykul.
- The third category of dyslexic sufferers are those who suffer from both types, dysphonetic and dyseidetic dyslexia. They are the hardest to help.
Now even though logic would seem to insist that dyslexics must have something wrong with their eyes, no serious scientific studies have ever found any consistent difference between the eyes of dyslexics and nondyslexics. There are no anatomical differences, no chemical differences, no physical differences at all.
Reading specialists, often associated with the schools, help dyslexics “see” more clearly and let them untangle the mysteries of the written word. Different types of visual training have sometimes helped dyslexics overcome their problem. If these approaches work for you or your child, fine. Use them and rejoice.
There is no standard cure or aid that works for all dyslexics, or even for any one identifiable grouping of dyslexics. And when something does work for a specific dyslexic, there may be no scientifically acceptable explanation for why it works.
Look at it this way. Imagine that someone develops a remedy for the common cold. It’s given to 1,000 people with colds and all are cured overnight. Voila! A cure! But what if only 1 or 2 or 4 or 5 are cured? Sure, the treatment cures a few people, but it’s not a true cure for the condition. It’s something that will work on some of the people some of the time.
The same must be said about a “cure” for dyslexia.
There are a wide variety of aids, therapies, and training programs available. And you can’t rule them out, because some of them do work in specific cases. But because there is no way to say what will or won’t work in any given case—or why—you can’t count on them, either.
So if your child has a reading problem, first check to see if it’s a vision problem. If it’s not, find the experts who can tell you just what type of problem it is. And if it is dyslexia, keep looking until you find the aid or therapy that works. Read up on the subject and learn as much about it as you can.
But whatever you do, don’t give up. Your child’s future depends on it.