No Child Too Young for Eye Exam

STANFORD, CALIF. – Myths about pediatric eye abnormalities often mislead parents into thinking an eye evaluation is not necessary, according to Dr. Deborah M. Alcorn, chief of pediatric ophthalmology at Lucile Packard Children’s Hospital, Stanford.

At a pediatric update sponsored by Stanford University, she debunked the top 10 myths about eye problems in children:

1. My child is too young for an eye exam. Dr. Alcorn said she frequently gets called to the neonatal unit to evaluate babies who are only a few months old. Infant eye exams are very objective. The child’s age is irrelevant, except that it’s better to treat a problem earlier rather than later, she said.

2. Tearing must be due to a blocked tear duct. Yes, epiphora is most likely to be secondary to a nasolacrimal duct obstruction, but the differential diagnosis includes corneal abrasion and glaucoma.

Placing yellow fluorescein dye in the eye can easily identify nasolacrimal duct obstruction; within 2-3 minutes, the dye will come out the child’s nose. In infants, treatment with warm compresses and massage will open 95% of lacrimal obstructions by 1 year of age.

Persistent, excessive tearing, especially in the first few weeks of life, may be a sign of an associated dacryocystocele. These blue-domed cysts deserve aggressive treatment with systemic antibiotics, warm compresses, and massage, Dr. Alcorn said. Nasolacrimal duct probing may be needed. If the color of the dacryocystocele changes from blue to very red with erythema, hospitalize the child to treat infection, she said.

Tearing and discharge may be due to congenital nasolacrimal duct obstructions. If you see a child with silicone tubing poking out of the tear duct, don’t pull it out – it’s a stent to enlarge the lacrimal duct. "We like to leave it in for 6 months," she said.

Courtesy of the National Eye Institute, National Institutes of Health

Tearing from corneal abrasion is accompanied by pain, discomfort, and often photophobia. If you use a topical anesthetic to make the eye exam easier, do not dispense it to parents, Dr. Alcorn said. Repeated use will break down the child’s cornea. Treat a corneal abrasion with a topical antibiotic; children usually prefer drops to ointment, which blurs vision, she noted.

You may see tearing from congenital glaucoma, which produces big eyes on the baby that seem beautiful but are abnormal. Unlike adult glaucoma, congenital glaucoma deserves emergency surgery, she said.

3. All red eyes are contagious. Viral conjunctivitis is highly contagious, but the causes of red eye are diverse. Subconjunctival hemorrhage usually is benign and spontaneously resolves. Episcleritis usually resolves with eye drop therapy. Eyes may be red from pinguecula or pterygium – hyperkeratotic reactions to the sun that are slow growing and not malignant. "We’re starting to see more of these because kids are not wearing sunglasses," Dr. Alcorn said.

Courtesy of the National Eye Institute, National Institutes of Health

Treat pinguecula and pterygium with sunglasses, artificial tears, and vasoconstrictors, and consider surgical removal if the lesion is interfering with wearing contact lenses or the pterygium involves the visual axis.

Conjunctivitis can be bacterial, viral, or allergic. The two main clues to differentiate the three kinds of conjunctivitis are the discharge (which is purulent in bacterial conjunctivitis and watery in viral or allergic conjunctivitis) and itching (which is marked in allergic conjunctivitis but minimal with the other two forms).

Viral conjunctivitis is so contagious that Dr. Alcorn said she tries to not let these patients into her examination room, in order to avoid having to wash the room with bleach afterward. These patients usually have bilateral red eyes, preauricular lymphadenopathy, conjunctival inflammation, and watery discharge. Upper respiratory infection, sore throat, and fever are common.

This has been one of the worst years for seasonal allergies causing acute allergic conjunctivitis, in Dr. Alcorn’s experience. Bilateral red eyes, profuse pruritus, chemosis, and ropy mucous discharge are typical.

A variety of topical medications in eye drops can be used to treat allergic conjunctivitis. However, do not prescribe a topical steroid or combination antibiotic-steroid without close follow-up, because steroids can cause glaucoma or cataracts or potentiate infection, she said.

4. Children outgrow crossed eyes. "I don’t care how cute your kids are, they should have straight eyes," she said. Refer any patients with constant strabismus before 12 weeks of age or any strabismus at older ages.

An eye cover test is easy to do to diagnose strabismus. With the patient looking straight ahead, cover one eye, peek behind the cover, and you’ll see the eye turn in or drift outward.

Courtesy Wikimedia/Dr. Sandra Brown, University of Michigan Kellogg Eye Center/Creative Commons

Children with a wide nasal bridge, prominent epicanthal folds, or an abnormally small interpupillary distance may seem to have a crossed eye, but really don’t. Dr. Alcorn usually reevaluates children with pseudostrabismus in 6 months "to be sure we didn’t miss something," she said.

Glasses can fix accommodative esotropia (one eye moving toward the other), but must be worn all the time, except when bathing, swimming, or sleeping. Surgery is not indicated.

If the child is unable to abduct the eye (look outward from the nose), there may be an intracranial process or infection. The eye that can’t turn out will always be turned in if there’s a sixth nerve palsy. In contrast, Duane’s syndrome, a congenital miswiring that prevents an eye from looking outward, allows both eyes to look straight ahead.

The cover test also is very valuable in diagnosing exotropia (outward deviation of an eye), which is much less common than esotropia. These patients may need glasses or another intervention, and should be evaluated.

5. A bump on an eye will go away. Sties often go away with treatment, but chalazia (chronic sties) may need surgical removal. Treat both with warm compresses, topical antibiotic ointment, light massage, and daily oral flaxseed oil (generally 1 tablespoon per 100 pounds of body weight). Eventually, if needed, consider incision and curettage or possibly a steroid injection, she said.

Courtesy Wikimedia/Dr. Sandra Brown, University of Michigan Kellogg Eye Center/Creative Commons

Not all lumps and bumps are sties. Capillary hemangiomas occur in 1%-2% of newborns, usually appear by 6 months of age, and involute spontaneously. Congenital hemangiomas can be treated with topical timolol or oral propranolol, and should be monitored regularly; 50% will resolve by 5 years of age and 70% by 7 years. Orbital dermoids will not go away on their own and usually require surgical excision at age 4 or 5 years. Lymphangiomas typically present in the first decade of life and will grow. Rhabdomyosarcomas deserve emergency care – they can double in size in a day.

6. One eye is bigger, but it’s a family trait. A child with one eye bigger than the other deserves evaluation to determine if this is truly globe asymmetry or if there’s another diagnosis, such as microphthalmia, ptosis, congenital glaucoma, or proptosis from a mass pushing the eye out.

7. Glasses worsen a child’s prescription. No one is too young to wear glasses, which will not worsen vision over time, Dr. Alcorn said. Myopia is becoming a worldwide epidemic, especially in Asian populations, according to a recent report (Lancet 2012;379:1739-48).

Other data suggest that myopia is starting at earlier ages and occurring more frequently, she said. There is some literature to support letting children play outside more often to prevent myopia, so they won’t always be looking at things up close. Laser treatment is not approved in the United States for people younger than 21 years because the eyes are still growing.

Myopia is a "major global health concern" because it increases the risk for blindness, glaucoma, retinal detachment, and other problems. "We’re hoping for a cure," she said.

8. Abnormal light reflexes are just a bad picture. When a child has refractive asymmetry on a vision-screening photograph, be concerned. The child may simply need glasses, or could have leukokoria, a cataract, retinoblastoma, or another problem.

9. Different-colored eyes are cute. Maybe they are, but you wouldn’t want to miss an infection or Horner syndrome, which can affect eye color, Dr. Alcorn said.

10. Parents don’t know best. "Listen to parents," she said. "They know their children!"

Dr. Alcorn reported having no relevant financial disclosures.

STANFORD, CALIF. – Myths about pediatric eye abnormalities often mislead parents into thinking an eye evaluation is not necessary, according to Dr. Deborah M. Alcorn, chief of pediatric ophthalmology at Lucile Packard Children’s Hospital, Stanford.

At a pediatric update sponsored by Stanford University, she debunked the top 10 myths about eye problems in children:

1. My child is too young for an eye exam. Dr. Alcorn said she frequently gets called to the neonatal unit to evaluate babies who are only a few months old. Infant eye exams are very objective. The child’s age is irrelevant, except that it’s better to treat a problem earlier rather than later, she said.

2. Tearing must be due to a blocked tear duct. Yes, epiphora is most likely to be secondary to a nasolacrimal duct obstruction, but the differential diagnosis includes corneal abrasion and glaucoma.

Placing yellow fluorescein dye in the eye can easily identify nasolacrimal duct obstruction; within 2-3 minutes, the dye will come out the child’s nose. In infants, treatment with warm compresses and massage will open 95% of lacrimal obstructions by 1 year of age.

Persistent, excessive tearing, especially in the first few weeks of life, may be a sign of an associated dacryocystocele. These blue-domed cysts deserve aggressive treatment with systemic antibiotics, warm compresses, and massage, Dr. Alcorn said. Nasolacrimal duct probing may be needed. If the color of the dacryocystocele changes from blue to very red with erythema, hospitalize the child to treat infection, she said.

Tearing and discharge may be due to congenital nasolacrimal duct obstructions. If you see a child with silicone tubing poking out of the tear duct, don’t pull it out – it’s a stent to enlarge the lacrimal duct. "We like to leave it in for 6 months," she said.

Courtesy of the National Eye Institute, National Institutes of Health

Tearing from corneal abrasion is accompanied by pain, discomfort, and often photophobia. If you use a topical anesthetic to make the eye exam easier, do not dispense it to parents, Dr. Alcorn said. Repeated use will break down the child’s cornea. Treat a corneal abrasion with a topical antibiotic; children usually prefer drops to ointment, which blurs vision, she noted.

You may see tearing from congenital glaucoma, which produces big eyes on the baby that seem beautiful but are abnormal. Unlike adult glaucoma, congenital glaucoma deserves emergency surgery, she said.

3. All red eyes are contagious. Viral conjunctivitis is highly contagious, but the causes of red eye are diverse. Subconjunctival hemorrhage usually is benign and spontaneously resolves. Episcleritis usually resolves with eye drop therapy. Eyes may be red from pinguecula or pterygium – hyperkeratotic reactions to the sun that are slow growing and not malignant. "We’re starting to see more of these because kids are not wearing sunglasses," Dr. Alcorn said.

Courtesy of the National Eye Institute, National Institutes of Health

Treat pinguecula and pterygium with sunglasses, artificial tears, and vasoconstrictors, and consider surgical removal if the lesion is interfering with wearing contact lenses or the pterygium involves the visual axis.

Conjunctivitis can be bacterial, viral, or allergic. The two main clues to differentiate the three kinds of conjunctivitis are the discharge (which is purulent in bacterial conjunctivitis and watery in viral or allergic conjunctivitis) and itching (which is marked in allergic conjunctivitis but minimal with the other two forms).

Viral conjunctivitis is so contagious that Dr. Alcorn said she tries to not let these patients into her examination room, in order to avoid having to wash the room with bleach afterward. These patients usually have bilateral red eyes, preauricular lymphadenopathy, conjunctival inflammation, and watery discharge. Upper respiratory infection, sore throat, and fever are common.

This has been one of the worst years for seasonal allergies causing acute allergic conjunctivitis, in Dr. Alcorn’s experience. Bilateral red eyes, profuse pruritus, chemosis, and ropy mucous discharge are typical.

A variety of topical medications in eye drops can be used to treat allergic conjunctivitis. However, do not prescribe a topical steroid or combination antibiotic-steroid without close follow-up, because steroids can cause glaucoma or cataracts or potentiate infection, she said.

4. Children outgrow crossed eyes. "I don’t care how cute your kids are, they should have straight eyes," she said. Refer any patients with constant strabismus before 12 weeks of age or any strabismus at older ages.

An eye cover test is easy to do to diagnose strabismus. With the patient looking straight ahead, cover one eye, peek behind the cover, and you’ll see the eye turn in or drift outward.

Courtesy Wikimedia/Dr. Sandra Brown, University of Michigan Kellogg Eye Center/Creative Commons

Children with a wide nasal bridge, prominent epicanthal folds, or an abnormally small interpupillary distance may seem to have a crossed eye, but really don’t. Dr. Alcorn usually reevaluates children with pseudostrabismus in 6 months "to be sure we didn’t miss something," she said.

Glasses can fix accommodative esotropia (one eye moving toward the other), but must be worn all the time, except when bathing, swimming, or sleeping. Surgery is not indicated.

If the child is unable to abduct the eye (look outward from the nose), there may be an intracranial process or infection. The eye that can’t turn out will always be turned in if there’s a sixth nerve palsy. In contrast, Duane’s syndrome, a congenital miswiring that prevents an eye from looking outward, allows both eyes to look straight ahead.

The cover test also is very valuable in diagnosing exotropia (outward deviation of an eye), which is much less common than esotropia. These patients may need glasses or another intervention, and should be evaluated.

5. A bump on an eye will go away. Sties often go away with treatment, but chalazia (chronic sties) may need surgical removal. Treat both with warm compresses, topical antibiotic ointment, light massage, and daily oral flaxseed oil (generally 1 tablespoon per 100 pounds of body weight). Eventually, if needed, consider incision and curettage or possibly a steroid injection, she said.

Courtesy Wikimedia/Dr. Sandra Brown, University of Michigan Kellogg Eye Center/Creative Commons

Not all lumps and bumps are sties. Capillary hemangiomas occur in 1%-2% of newborns, usually appear by 6 months of age, and involute spontaneously. Congenital hemangiomas can be treated with topical timolol or oral propranolol, and should be monitored regularly; 50% will resolve by 5 years of age and 70% by 7 years. Orbital dermoids will not go away on their own and usually require surgical excision at age 4 or 5 years. Lymphangiomas typically present in the first decade of life and will grow. Rhabdomyosarcomas deserve emergency care – they can double in size in a day.

6. One eye is bigger, but it’s a family trait. A child with one eye bigger than the other deserves evaluation to determine if this is truly globe asymmetry or if there’s another diagnosis, such as microphthalmia, ptosis, congenital glaucoma, or proptosis from a mass pushing the eye out.

7. Glasses worsen a child’s prescription. No one is too young to wear glasses, which will not worsen vision over time, Dr. Alcorn said. Myopia is becoming a worldwide epidemic, especially in Asian populations, according to a recent report (Lancet 2012;379:1739-48).

Other data suggest that myopia is starting at earlier ages and occurring more frequently, she said. There is some literature to support letting children play outside more often to prevent myopia, so they won’t always be looking at things up close. Laser treatment is not approved in the United States for people younger than 21 years because the eyes are still growing.

Myopia is a "major global health concern" because it increases the risk for blindness, glaucoma, retinal detachment, and other problems. "We’re hoping for a cure," she said.

8. Abnormal light reflexes are just a bad picture. When a child has refractive asymmetry on a vision-screening photograph, be concerned. The child may simply need glasses, or could have leukokoria, a cataract, retinoblastoma, or another problem.

9. Different-colored eyes are cute. Maybe they are, but you wouldn’t want to miss an infection or Horner syndrome, which can affect eye color, Dr. Alcorn said.

10. Parents don’t know best. "Listen to parents," she said. "They know their children!"

Dr. Alcorn reported having no relevant financial disclosures.

STANFORD, CALIF. – Myths about pediatric eye abnormalities often mislead parents into thinking an eye evaluation is not necessary, according to Dr. Deborah M. Alcorn, chief of pediatric ophthalmology at Lucile Packard Children’s Hospital, Stanford.

At a pediatric update sponsored by Stanford University, she debunked the top 10 myths about eye problems in children:

1. My child is too young for an eye exam. Dr. Alcorn said she frequently gets called to the neonatal unit to evaluate babies who are only a few months old. Infant eye exams are very objective. The child’s age is irrelevant, except that it’s better to treat a problem earlier rather than later, she said.

2. Tearing must be due to a blocked tear duct. Yes, epiphora is most likely to be secondary to a nasolacrimal duct obstruction, but the differential diagnosis includes corneal abrasion and glaucoma.

Placing yellow fluorescein dye in the eye can easily identify nasolacrimal duct obstruction; within 2-3 minutes, the dye will come out the child’s nose. In infants, treatment with warm compresses and massage will open 95% of lacrimal obstructions by 1 year of age.

Persistent, excessive tearing, especially in the first few weeks of life, may be a sign of an associated dacryocystocele. These blue-domed cysts deserve aggressive treatment with systemic antibiotics, warm compresses, and massage, Dr. Alcorn said. Nasolacrimal duct probing may be needed. If the color of the dacryocystocele changes from blue to very red with erythema, hospitalize the child to treat infection, she said.

Tearing and discharge may be due to congenital nasolacrimal duct obstructions. If you see a child with silicone tubing poking out of the tear duct, don’t pull it out – it’s a stent to enlarge the lacrimal duct. "We like to leave it in for 6 months," she said.

Courtesy of the National Eye Institute, National Institutes of Health

Tearing from corneal abrasion is accompanied by pain, discomfort, and often photophobia. If you use a topical anesthetic to make the eye exam easier, do not dispense it to parents, Dr. Alcorn said. Repeated use will break down the child’s cornea. Treat a corneal abrasion with a topical antibiotic; children usually prefer drops to ointment, which blurs vision, she noted.

You may see tearing from congenital glaucoma, which produces big eyes on the baby that seem beautiful but are abnormal. Unlike adult glaucoma, congenital glaucoma deserves emergency surgery, she said.

3. All red eyes are contagious. Viral conjunctivitis is highly contagious, but the causes of red eye are diverse. Subconjunctival hemorrhage usually is benign and spontaneously resolves. Episcleritis usually resolves with eye drop therapy. Eyes may be red from pinguecula or pterygium – hyperkeratotic reactions to the sun that are slow growing and not malignant. "We’re starting to see more of these because kids are not wearing sunglasses," Dr. Alcorn said.

Courtesy of the National Eye Institute, National Institutes of Health

Treat pinguecula and pterygium with sunglasses, artificial tears, and vasoconstrictors, and consider surgical removal if the lesion is interfering with wearing contact lenses or the pterygium involves the visual axis.

Conjunctivitis can be bacterial, viral, or allergic. The two main clues to differentiate the three kinds of conjunctivitis are the discharge (which is purulent in bacterial conjunctivitis and watery in viral or allergic conjunctivitis) and itching (which is marked in allergic conjunctivitis but minimal with the other two forms).

Viral conjunctivitis is so contagious that Dr. Alcorn said she tries to not let these patients into her examination room, in order to avoid having to wash the room with bleach afterward. These patients usually have bilateral red eyes, preauricular lymphadenopathy, conjunctival inflammation, and watery discharge. Upper respiratory infection, sore throat, and fever are common.

This has been one of the worst years for seasonal allergies causing acute allergic conjunctivitis, in Dr. Alcorn’s experience. Bilateral red eyes, profuse pruritus, chemosis, and ropy mucous discharge are typical.

A variety of topical medications in eye drops can be used to treat allergic conjunctivitis. However, do not prescribe a topical steroid or combination antibiotic-steroid without close follow-up, because steroids can cause glaucoma or cataracts or potentiate infection, she said.

4. Children outgrow crossed eyes. "I don’t care how cute your kids are, they should have straight eyes," she said. Refer any patients with constant strabismus before 12 weeks of age or any strabismus at older ages.

An eye cover test is easy to do to diagnose strabismus. With the patient looking straight ahead, cover one eye, peek behind the cover, and you’ll see the eye turn in or drift outward.

Courtesy Wikimedia/Dr. Sandra Brown, University of Michigan Kellogg Eye Center/Creative Commons

Children with a wide nasal bridge, prominent epicanthal folds, or an abnormally small interpupillary distance may seem to have a crossed eye, but really don’t. Dr. Alcorn usually reevaluates children with pseudostrabismus in 6 months "to be sure we didn’t miss something," she said.

Glasses can fix accommodative esotropia (one eye moving toward the other), but must be worn all the time, except when bathing, swimming, or sleeping. Surgery is not indicated.

If the child is unable to abduct the eye (look outward from the nose), there may be an intracranial process or infection. The eye that can’t turn out will always be turned in if there’s a sixth nerve palsy. In contrast, Duane’s syndrome, a congenital miswiring that prevents an eye from looking outward, allows both eyes to look straight ahead.

The cover test also is very valuable in diagnosing exotropia (outward deviation of an eye), which is much less common than esotropia. These patients may need glasses or another intervention, and should be evaluated.

5. A bump on an eye will go away. Sties often go away with treatment, but chalazia (chronic sties) may need surgical removal. Treat both with warm compresses, topical antibiotic ointment, light massage, and daily oral flaxseed oil (generally 1 tablespoon per 100 pounds of body weight). Eventually, if needed, consider incision and curettage or possibly a steroid injection, she said.

Courtesy Wikimedia/Dr. Sandra Brown, University of Michigan Kellogg Eye Center/Creative Commons

Not all lumps and bumps are sties. Capillary hemangiomas occur in 1%-2% of newborns, usually appear by 6 months of age, and involute spontaneously. Congenital hemangiomas can be treated with topical timolol or oral propranolol, and should be monitored regularly; 50% will resolve by 5 years of age and 70% by 7 years. Orbital dermoids will not go away on their own and usually require surgical excision at age 4 or 5 years. Lymphangiomas typically present in the first decade of life and will grow. Rhabdomyosarcomas deserve emergency care – they can double in size in a day.

6. One eye is bigger, but it’s a family trait. A child with one eye bigger than the other deserves evaluation to determine if this is truly globe asymmetry or if there’s another diagnosis, such as microphthalmia, ptosis, congenital glaucoma, or proptosis from a mass pushing the eye out.

7. Glasses worsen a child’s prescription. No one is too young to wear glasses, which will not worsen vision over time, Dr. Alcorn said. Myopia is becoming a worldwide epidemic, especially in Asian populations, according to a recent report (Lancet 2012;379:1739-48).

Other data suggest that myopia is starting at earlier ages and occurring more frequently, she said. There is some literature to support letting children play outside more often to prevent myopia, so they won’t always be looking at things up close. Laser treatment is not approved in the United States for people younger than 21 years because the eyes are still growing.

Myopia is a "major global health concern" because it increases the risk for blindness, glaucoma, retinal detachment, and other problems. "We’re hoping for a cure," she said.

8. Abnormal light reflexes are just a bad picture. When a child has refractive asymmetry on a vision-screening photograph, be concerned. The child may simply need glasses, or could have leukokoria, a cataract, retinoblastoma, or another problem.

9. Different-colored eyes are cute. Maybe they are, but you wouldn’t want to miss an infection or Horner syndrome, which can affect eye color, Dr. Alcorn said.

10. Parents don’t know best. "Listen to parents," she said. "They know their children!"

Dr. Alcorn reported having no relevant financial disclosures.