Recognising Vision Problems in Children

Children typically have no idea when they have vision problems. Vision problems typically onset gradually, and children tend to believe that everyone sees similar to them, even when they have vision problems. As a result, you will rarely hear a child say any of the following: “My vision doesn’t seem to be as clear as it used to be.” “I started seeing double when reading two weeks ago.” “My eyes are feel uncomfortable when I read.”

It has been estimated that 80% of what we know is learned through vision. Therefore, children with vision problems may struggle at school simply due to correctable vision issues. Because children rarely complain of vision problems, and vision problems can lead to learning difficulties, it is recommended by the American Optometric Association that children undergo annual comprehensive eye examinations if they are at risk for visual impairment. To determine if your child may be at risk, please go here.

Seeing Vision Problems in Children

Because children don’t often tell you that they have problems with their eyes, there are some signs for which you should watch. The most common vision-related problems differ by age. Beginning with the youngest children, we will provide things to consider that may portend vision issues. Infants’s eyes frequently wander because they have not yet developed the ability to control their eye movements at all times. One eye occasionally pointing in or out is common and should not be considered a problem unless the child continues to do this after eight months of age, unless it is always the same eye, or unless it is constant. A visit to the optometrist is warranted if any of those conditions exist. If the child’s eye crosses most or all of the time, then the child may have congenital esotropia, and surgery in combination with vision therapy may be necessary to correct the problem.

If the child’s eyes begin to cross frequently at around age two years, especially when the child looks at close objects, then the most likely problem is accommodative esotropia. If this is the case, wearing glasses will help to eliminate most or all of the crossed eyes.

Nearsightedness (myopia) is the most common vision problem in children. It typically onsets between the ages of 8 and 10 years, although that may vary dramatically. Nearsighted children can see clearly at near, but have difficulty seeing distant objects. These children tend to squint when looking at distance objects, and may complain of headaches around their eyes, as a result of squinting. Nearsighted children are frequently detected during school vision screenings or recognized by teachers, and glasses or contact lenses can easily clear up their vision and reduce symptoms.

It is also important to remember that even children who can see details far away may have vision problems. Farsighted children may be able to read distance vision charts, but their eyes must strain to do so. Their eyes must strain even more to see up close. While a child may pass a vision screening at school by reading the bottom line on the chart across the room, he or she may struggle visually. These children often complain of headaches during the week, but less often during the weekend. They may fall asleep after a very short period of reading or struggle to maintain attention because their eyes become strained. Their headaches are typically over the eyes or on the side of the head, and they rarely wake up with a headache. They frequently try to avoid reading because it makes their eyes uncomfortable, although they rarely say that.

Another problem with similar symptoms is convergence insufficiency, which means that children have difficulty bringing their eyes toward the nose when looking at close objects. The symptoms of convergence insufficiency have frequently been misdiagnosed as attention deficit disorder because children find it difficult to attend to any single near task for even a relatively short period of time. Headaches, eye strain, double vision, and tiredness while reading are some of the main symptoms that children will exhibit. Vision therapy frequently reduces or eliminates the symptoms related to convergence insufficiency, and may improve a child’s attention during learning-related tasks.

Teachers are commonly the first people to suspect a vision problem in children because of the demanding visual environment at school. Children rarely complain at home, although homework time is an excellent time to watch your child for potential vision problems. Children with vision problems may rub their eyes frequently, fall asleep after reading for five minutes, perform better when narrating than when writing, cover an eye or close an eye when reading, or simply refuse to read. If your child exhibits these symptoms, then a visit to the eye doctor is warranted and may result in improved attitude and aptitude.

6/11/15

Jeffrey J. Walline, OD, PhD
The Ohio State University
Associate Professor
Chair, Research and Graduate Studies

Vision and Special Needs Children

In the United States, special needs is a term used in clinical diagnostic and functional development to describe individuals who require assistance for disabilities that may be medical, mental, or psychological. Different types of special needs vary in severity. People with autism, Down syndrome, dyslexia, blindness, ADHD, or cerebral palsy, for example, may be considered to have special needs. Statistics tell us that among children ages 3 to 17, nearly 15 percent have one or more developmental disabilities. For many of these children, the kinds of disabilities they experience may require special approaches to providing care, education and/or other accommodations.

The way a special needs child behaves or reacts can sometimes be unexpected because he/she processes sensory information differently than other children. Having the right cues in our environment can mean the difference between participation and non-participation in medical care for many of these children. Our work environment should always be arranged in a way to achieve physical and emotional comfort for the child. Patience, attentive listening, caring, and building a trusting relationship with a family and child who may be undervalued in other settings are all critical to providing good medical care.

Vision and Special Needs Children

Children with special needs are referred to pediatric ophthalmologists on a regular basis. Many of these children do not respond appropriately to standard vision screening procedures. Unidentified vision problems in this special population can further impact growth and development. The role of pediatric ophthalmologists is to ensure that the child does not have any eye conditions that could potentially interfere with his/her learning opportunities, personal development and/or overall wellbeing.

Down syndrome:
Down syndrome continues to be the most common chromosomal disorder. Each year, about 6,000 babies are born with Down syndrome, which is about 1 in every 700 babies born. It is estimated that more than 80% of these patients have some clinically significant ocular pathology. Such conditions include refractive error requiring glasses (70%), strabismus (45%), and nystagmus (35%). Other common eye problems include blepharitis, blocked tear duct, eyelid ptosis, cataracts, and keratoconus (irregularly shaped cornea). The improved quality of medical care and educational resources have allowed for a more productive life and a longer life expectancy for people with Down syndrome. Their quality of life can be further enhanced by the proper assessment and correction of eye problems.

Autism:
In 2014, the Centers for Disease Control and Prevention (CDC) released new data on the prevalence of autism in the United States. This surveillance study identified 1 in 68 children (1 in 42 boys and 1 in 189 girls) as having autism spectrum disorder (ASD). Autistic behaviors may include visual components such as lack of eye contact, starring at light or spinning objects, fleeting peripheral glances, side viewing and difficulty attending visually. An eye examination is essential in order to detect an eye condition that could potentially explain these visual behaviors. According to a study published in the June 2013 issue of Strabismus, more than 40 percent of children with autism have strabismus, or crossed eyes. This work is limited in that the researchers did not use a representative sample of children with autism. Still, the prevalence of eye problems in autism appears to be several times higher than that of the general population.

Learning Disabilities:
Dyslexia is the most common neurobehavioral disorder affecting children. Visual abnormalities have not been found to affect the brain’s ability to process visual stimuli and children with learning disabilities have no increased incidence of ophthalmologic disease. However, ophthalmologic consultation should be provided to children who fail vision screening tests. This allows for diagnosis and therapy of treatable ocular conditions such as refractive errors and eye muscle imbalances.

Children with ADHD, cerebral palsy, or any other neurodevelopmental disorders should also have periodic vision screenings. Children who do not pass the vision screening should be referred to an ophthalmologist with experience in the care of children.

Physicians are not the only adults involved in the care of special needs children. At increasing rates, children with special needs are being provided with the same life experiences as their non-disabled peers. Taking part in a sport or joining a group like the Scouts, are popular activities for children. Children with disabilities are encouraged to join in such activities to help improve their health and give them opportunities to make friends. As a result, more and more adults in the community are finding themselves working with these children on a regular basis.

When considering ways to work with special needs children, we have to keep in mind that every child is different. A positive attitude and patience are probably the two most important qualities for anyone who works with these children. Parents of special needs children focus on helping their child to be “the best he/she can be”. The devotion and care these parents provide for their child have been an inspiration, and I always look forward to my visits with them.

4/2/15

Chantal Boisvert, OD, MD
Assistant Clinical Professor
Gavin Herbert Eye Institute, UC Irvine
Pediatric Ophthalmology & Strabismus
Neuro-Ophthalmology

Hadley’s Online Education for the Blind and Visually Impaired

12/4/14

The Hadley School for the Blind (www.hadley.edu) is the world’s largest educator of people who are blind or visually impaired as well as the world’s largest Braille educator. The school’s curriculum has always been delivered completely through online education, meaning students can study from anywhere at any time. Hadley serves nearly 10,000 students in all 50 states and approximately 100 countries. Hadley serves adult students, age 14 and over. Our mission is to promote independent living through lifelong, distance education programs for individuals who are blind or visually impaired, their families and blindness service providers.

Hadley courses are tuition-free for people who are blind or visually impaired and their family members; there is modest tuition for professionals. Students study at their own pace and receive personalized, one-on-one instruction from their instructor by phone, email, virtual “office hours” or mail.

Students can take courses in four formats: large print, Braille, audio or online. Since we began offering courses in an online format in 2002 as part of our eHadley initiative, more than 13,000 students have completed one or more online courses. 89 of our approximately 100 courses are offered in an online format, and 20 new online courses were introduced in 2014. Most of our online courses also are now accessible on mobile devices, so that students can literally study on the go if they choose.

If you’re not familiar with blindness, you may be asking yourself how a blind person can take courses online. The answer is through adaptive technology, such as screen magnifiers or screen readers. A screen reader is a software application that converts text on a screen to speech. One of the most popular is called JAWS. If a student doesn’t know how to use a screen reader, Hadley has a series of courses to teach them how to use this technology!

While many students come to us to learn to read and write Braille, we offer much more than just Braille education. In addition to Braille, some of our most popular areas of study include access technology, independent living skills, employment skills and recreation. These courses fall within Hadley’s Adult Continuing Education Program, which represents the largest number of students at Hadley. Some examples of ACE courses include:

Independent Living Series: This series of two-lesson courses focuses on a variety of topics central to the tasks of daily living. When individuals lose their sight, it can be overwhelming. They must relearn key daily living skills, such as cooking, dressing themselves and getting around. These courses give our students the tools they need to retain their independence and lead productive lives. The individual course topics include: orientation and mobility basics; clothing care and dressing confidently; socializing and dining; and cooking.

Self-Esteem and Adjusting with Blindness: Whether a student was born visually impaired or lost vision later in life, this course will help them understand the adjustment to life’s demands. Maintaining self-esteem with the changes and adaptations that come with blindness are discussed in-depth and illustrated with quotes from many blind persons.

Human Eye 1 and 2: These courses explain the parts of the human eye, how it works and how corrective lenses work. They enable the student to describe the basic anatomy, routine examination procedures and some common conditions of the human eye. Hadley also offers courses on some of the specific conditions that can lead to vision impairment, including: macular degeneration, diabetes and glaucoma. These courses are designed to help students living with these conditions to better understand them and how to manage them.

Developing Your Technology Toolkit: Technology plays a significant role in how people interact with each other, and most will likely encounter some aspect of technology in their everyday life. This course presents a variety of prominent desktop and mobile solutions. It also discusses how adaptive technology solutions provide access to mainstream hardware and software. In addition, it focuses on proprietary, adaptive technology products designed to be used specifically by persons who are visually impaired.

Enjoying Bird Songs: Listening to birdsongs helps people reduce stress, improve cognition and memory, interact with nature and even have spiritual experiences. This course guides students through the many bird songs presented in Hadley student John Neville’s audio CD set Beginner’s Guide to Bird Songs of North America. This course helps students become able to appreciate nature and birdsongs, as well as reflect on their experiences with birdsong.

Also part of the ACE program is the Forsythe Center for Employment and Entrepreneurship (FCE), designed to address the 70 – 80% un- and underemployment rate among people who are blind or visually impaired. The FCE is not an academic, college-level business program, but instead was designed to provide the requisite computer training; relevant social security, tax, accounting, legal, marketing, management and communications information; and content specific to the needs and concerns of visually impaired individuals who want to launch and grown their own businesses. All FCE courses are online, and many are just one-lesson modules, which makes learning quick and easy. Some examples of modules include: The Marketing Plan, The Business Plan, Forms of Ownership and Networking Skills.

Since the 1930s, The Hadley School for the Blind also has offered a nationally-recognized, accredited High School Program, available to students with visual impairments age 14 and up who live in the United States. Students may transfer credits from courses taken at Hadley to their high school to graduate locally. Students may also earn their high school diploma directly through Hadley. Frustration with local schools not offering quality vision services or accessible formats, difficulties passing the state-required exit exam for graduation or inability to travel long distances have prevented many of our students from earning their diploma in the past, so the Hadley High School Program is a much-needed “second chance.”

Courses are supplemented by Seminars@Hadley, free 60 to 90-minute webinars that are available to the public. These seminars are designed to bring together our blind and visually impaired students from around the world to discuss various topics in a virtual conference room with a panel, moderator and guest speakers. Participants listen to the seminar from their computer and post questions electronically. They also ask questions and/or make comments using a microphone. Seminar topics are timely, practical and determined by what our students tell us they need. Some of our most popular seminars include: Learning to Put the “You” in YouTube, Simplifying Internet Searching and Crafting with Vision Loss. Some seminars are approved for Continuing Education Credits (CEUs).

Hadley also offer a series of instructional videos on YouTube called iFocus (www.youtube.com/hadleyschool). These videos explain how to use the vision accessibility features on iDevices (Apple products such as the iPhone and iPad). Each video focuses on a specific task on iDevices, such as sending a text message or creating a calendar event . There are now 25 videos in the series, and they have been viewed nearly 10,000 times!

For more information about Hadley or to enroll, visit our website at www.hadley.edu, call our Student Services Department at 800-526-9909 or send an email to student_services@hadley.edu.

Kate Streit
Media and Marketing Specialist
The Hadley School for the Blind

Our Thanks to Guest Bloggers Continues

10/7/14

More Amazing Guest Bloggers

Last week I took the opportunity to thank our very first guest bloggers for helping us launch the Discovery Eye Foundation Blog. We are pleased that so many people appreciate the wide range of eye-related information from eye care professionals, as well as the stories from people that live with eye disease on a daily basis.

Here is a round-up of guest bloggers since June 2014 that shared their time, experience and/or expertise to provide you with the best eye-related information.

Sumit “Sam“ Garg, MD – what you should know about cataracts

Randall V. Wong, MD – floaters, causes and treatments

Roy Kennedy – his personal experiences with the miniature telescope implant

Sandra Young, OD – the importance of getting vitamins and minerals from your food and not just supplements

Jeanette Hasseman – living with keratoconus

Greg Shane – theater for the blind

Caitlin Hernandez – blind actress and playwright

Jullia A. Rosdahl, MD, PhD – lasers for glaucoma and genetics and glaucoma

Maureen A. Duffy, CVRT – ways to reduce harmful effects of sun glare

Kooshay Malek – what is it like to lose your vision and being a blind therapist

Jeffrey J. Walline, OD PhD – children and contact lenses

Robert Mahoney – choosing a home care agency

Robert W. Lingua, MD – nystagmus in children

Buddy Russell, FCLSA, COMT – common pediatric eye diseases, treatment options for children and pediatric contact lenses

NIH (National Institute of Health) – telemedicine for ROP diagnosis

Harriet A. Hall, MD – evaluating online treatment claims

Patty Gadjewski – the life-changing effects of a telescopic implant

Michael A. Ward, MMSc, FAAO – proper contact lens care and wearing contacts and using cosmetics

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Our First Three Months Of Eye Care

9/30/14

Discovery Eye Foundation Blog’s First Three Months

It is hard to believe, but this blog has been providing information and insights into eye disease, treatment options, personal experiences of living with vision loss, and other eye-related information for seven months.

All of this would not have been possible without the expertise of remarkable eye care professionals who took time out of their busy schedules to share information to help you cope with vision loss through a better understanding of your eye condition and practical tips. Since so much information was shared in the seven months, here is a look at the first three months, with the additional four months to be reviewed next Tuesday.

I am very thankful to these caring eye professionals and those with vision loss who were willing to share their stories:

Marjan Farid, MD – corneal transplants and new hope for corneal scarring

Bill Takeshita, OD, FAAO, FCOVD – proper lighting to get the most out of your vision and reduce eyestrain

Maureen A. Duffy, CVRT – low vision resources

M. Cristina Kenney, MD, PhD – the differences in the immune system of a person with age-related macular degeneration

Bezalel Schendowich, OD – blinking and dealing with eyestrain

Jason Marsack, PhD – using wavefront technology with custom contact lenses

S. Barry Eiden, OD, FAAO – contact lens fitting for keratoconus

Arthur B. Epstein, OD, FAAO – dry eye and tear dysfunction

Jeffrey Sonsino, OD, FAAO – using OCT to evaluate contact lenses

Lylas G. Mogk, MD – Charles Bonnet Syndrome

Dean Lloyd, Esq – living with the Argus II

Gil Johnson – employment for seniors with aging eyes

We would like to extend our thanks to these eye care professionals, and to you, the reader, for helping to make this blog a success. Please subscribe to the blog and share it with your family, friends and doctors.

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Telemedicine For Diagnosing Retinopathy Of Prematurity

8/28/14

Technology now allows patients access to highly-qualified, specialized care, no matter where they live. This potential is demonstrated in the sight-saving treatments that can be used to help children lead normal healthy lives. The following article is posted with the permission of the National Institute of Health (NIH).

Telemedicine is an effective strategy to screen for the potentially blinding disease known as retinopathy of prematurity, according to a study funded by the National Eye Institute (NEI). The investigators say that the approach, if adopted broadly, could help ease the strain on hospitals with limited access to ophthalmologists and lead to better care for infants in underserved areas of the country. NEI is a part of the National Institutes of Health.

The telemedicine strategy consisted of electronically sending photos of babies’ eyes to a distant image reading center for evaluation. Staff at the image reading center, who were trained to recognize signs of severe ROP, identified whether infants should be referred to an ophthalmologist for evaluation and potential treatment. The study tested how accurately the telemedicine approach reproduced the conclusions of ophthalmologists who examined the babies onsite.

“This study provides validation for a telemedicine approach to ROP screening and could help save thousands of infants from going blind,” said Graham E. Quinn, MD, professor of ophthalmology at the Children’s Hospital of Philadelphia and the lead investigator for the study, which is reported today in JAMA Ophthalmology. The study was conducted by the e-ROP Cooperative Group, a collaboration that includes 12 clinics in the United States and one in Canada.

Some degree of ROP appears in more than half of all infants born at 30 weeks pregnancy or younger — a full-term pregnancy is 40 weeks — but only about 5 to 8 percent of cases become severe enough to require treatment. In ROP, blood vessels in the tissue in the back of the eye called the retina begin to grow abnormally, which can lead to scarring and detachment of the retina. Treatment involves destroying the abnormal blood vessels with lasers or freezing them using a technique called cryoablation. Early diagnosis and prompt treatment is the best prevention for vision loss from ROP, which is why the American Academy of Ophthalmology recommends routine screening for all babies who are born at gestational age 30 weeks or younger or who weigh less than 3.3 pounds at birth.

The study evaluated telemedicine for ROP screening during the usual care of 1,257 premature infants who were born, on average, 13 weeks early. About every nine days, each infant underwent screening by an ophthalmologist, who assessed whether referral for treatment was warranted. Those who were referred were designated as having referral-warranted ROP (RW-ROP). Either immediately before or after the exam, a non-physician staff member in the neonatal intensive care unit (NICU) took images of the infant’s retinas and uploaded them to a secure server at the University of Oklahoma, Oklahoma City. Trained non-physician image readers at the University of Pennsylvania, Philadelphia, then downloaded the photos, independently evaluated them following a standard protocol, and reported the presence or absence of RW-ROP.

Through the telemedicine approach, non-physician image readers correctly identified 90 percent of the infants deemed to have RW-ROP based on examination by an ophthalmologist. And they were correct 87 percent of the time when presented with images from infants who lacked RW-ROP. The examining ophthalmologists documented 244 infants with RW-ROP on exam. After referral, 162 infants were treated. Of these, non-physician image readers identified RW-ROP in all but three infants (98 percent). “This is the first large clinical investigation of telemedicine to test the ability of non-physicians to recognize ROP at high risk of causing vision loss,” said Eleanor Schron, Ph.D., group leader of NEI Clinical Applications. “The results suggest that telemedicine could improve detection and treatment of ROP for millions of at-risk babies worldwide who lack immediate in-person access to an ophthalmologist,” she said.

About 450,000 (12 percent) of the 3.9 million babies born each year in the United States are premature. The number of preterm infants who survive has surged in middle income countries in Latin America, Asia, and Eastern Europe. In these parts of the world, rates of childhood blindness from ROP are estimated at 15 to 30 percent — compared to 13 percent in the United States.

One advantage of telemedicine ROP screening is that it can be done more frequently than screening by an ophthalmologist. “It’s much easier to examine the retina when not dealing with a wiggling baby,” said Dr. Quinn. “If a baby is too fussy or otherwise unavailable when the ophthalmologist visits the NICU, the exam may be delayed until the ophthalmologist returns — sometimes up to a week later.”

Weekly ROP screening — or even more frequently for high-risk babies — is a realistic goal for telemedicine and could help catch all cases needing treatment, according to the report. In the study, imaging was restricted to occasions when an ophthalmologist examined the baby. In practice, hospital staff could implement an imaging schedule based on the baby’s weight, age at birth, and other risk factors. “With telemedicine, NICU staff can take photos at the convenience of the baby,” said Dr. Quinn.

Telemedicine for evaluating ROP offers several other advantages.

Telemedicine may help detect RW-ROP earlier. In the study, about 43 percent of advanced ROP cases were identified by telemedicine before they were detected by an ophthalmologist — on average, about 15 days earlier.

Telemedicine could save babies and their families the hardship and hazards of being unnecessarily transferred to larger nurseries with greater resources and more on-site ophthalmologists. “Telemedicine potentially gives every hospital access to excellent ROP screening,” Dr. Quinn said.

Telemedicine might also bring down the costs of routine ROP screening by reducing the demands on ophthalmologists, whose time is better allocated to babies who need their attention and expertise. In a separate analysis, the study found that non-physicians and physicians had similar success in assessing photos for RW-ROP. Three physicians evaluated image sets from a random sample of 200 babies (100 with RW-ROP based on the eye exam findings; 100 without) using the standard grading protocol. On average, the physicians correctly identified about 86 percent of RW-ROP cases; the non-physicians were correct 91 percent of the time. The physicians correctly identified about 57 percent of babies without RW-ROP; non-physicians were correct 73 percent of the time.

The cost of establishing a telemedicine ROP screening program includes acquisition of a special camera for taking pictures of the retina, training of NICU personnel to take and transmit quality photos, and establishment and maintenance of an image reading center. “As we move along this road, advances in imaging and grading of images may streamline the process even more,” Dr. Quinn said.

The e-ROP Cooperative Group includes the following clinical sites and resource centers:

Children’s Hospital of Philadelphia
Johns Hopkins University, Baltimore
Boston Children’s Hospital
Nationwide Children’s Hospital and Ohio State University Hospital, Columbus
Duke University (cost-effectiveness center), Durham, North Carolina
University of Louisville, Kentucky
University of Minnesota, Minneapolis
University of Oklahoma (Inoveon ROP Data Center), Oklahoma City
University of Texas Health Science Center at San Antonio
University of Utah, Salt Lake City
Vanderbilt University, Nashville, Tennessee
Hospital of the Foothills Medical Center, Calgary, Alberta
University of Pennsylvania (data coordinating center and image reading center), Philadelphia

For more information about ROP.

Click to view a video about e-ROP.

National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892
301-496-4000,
TTY 301-402-9612

Contact Lens Fitting For Children

8/26/14

Fitting Techniques

The techniques the contact lens professional utilizes to fit an adult with a GP lens must be altered to fit an infant or small child. The ability to capture a reliable image with a topographer or accurate keratometric readings is often impossible to obtain in small children. Keratometric readings obtained at the time of surgery or an exam under anesthesia should only be considered as a starting point or a guide to the initial diagnostic lens. The application and evaluation of a diagnostic lens is the best method to obtain an appropriate fit in small children. I utilize diagnostic lenses that do not have a UV filter. I find these lenses allow me to better interpret the fluorescein pattern when using a handheld burton lamp or LED cobalt flashlight. Once the appropriate fit has been determined, the lens is remade incorporating a material that provides an ultraviolet filter. I find it easier to determine the approximate corneal shape and curvature initially with a relatively flat fitting lens on the eye. If the diagnostic lens being evaluated vaults the anterior corneal surface, the interpretation and extrapolation of corneal curvature is difficult if not impossible. As in any GP fitting, the goal is to equally distribute lens mass and provide peripheral fulcrums to maintain stability and a central position. This central position of the lens is especially important in higher powers to minimize spherical aberrations. In recent years, I have found myself fitting looser and larger GP diameters. A general rule to follow with small children and GP lenses is that a tight lens will tend to dislodge from the eye and a loose fitting lens will tend to displace off the cornea onto to bulbar conjunctiva.

As with GP fitting on small children, soft lens fitting techniques are also a bit different. In order to determine appropriate movement of a soft lens on a small child, the “spring back” test may be helpful. With the soft lens on the eye, digitally displace the lens off center. If the lens immediately “springs back” into place on the cornea, the lens may fit too tightly on the ocular surface. If the lens stays off center while manually closing the lids to mimic a blink, the lens may be fitted too loosely on the ocular surface. In addition, retinoscopy over the soft lens to determine if the reflex maintains clarity during the blink is a finding seen with a well fitting lens. If the reflex is clearer with a blink, the fit may be too steep. If the reflex is worse with a blink, the fit may be too flat. The reflex seen with a well-fitted soft lens will maintain the same clarity before, during and after a blink. The retinoscope is not only used to determine the final lens power with any type of lens but also an important instrument to guide you to the best cornea lens relationship. Pediatric fitters of contact lens should be proficient with a retinoscope.

Little Lenses for Little People?

The pediatric contact lens professional is not limited to “off the rack” products. In addition to custom GP lenses, there are many lens manufacturers of custom made soft and silicone hydrogel contact lenses that allow us the opportunity to provide any child any parameter. In addition, liberal exchange policies implemented by these manufacturers of custom products allow us to provide these products to the patients who require them in a fair and effective manner. However, the delay in time to deliver the product to a pediatric patient in an urgent situation is a potential problem. Any delay in optical correction and visual rehabilitation with a young pediatric patient may result in permanent loss in vision.

Silicone Hydrogel Custom Products

After many years of anticipation, in 2010 Contamac received FDA approval for Definitive, a latheable silicone hydrogel material. The Definitive material can be manufactured by a limited number of laboratories in the U.S. in virtually any group of parameters. This inherently wettable, high water content and low modules material has a DK of 60. While 60 DK is not as high as other “off the rack” silicone hydrogel materials, the effective DK in many of the parameters utilized in pediatric fitting is higher than the same parameters made in HEMA-GMA materials. While this material is a welcome addition to our armamentarium of contact lens options in our practice, my clinical experience specific to pediatric indications and this material has led me to two conclusions. The application of a lens to the eye of a small child manufactured in the Definitive material is more difficult than HEMA-GMA materials and the time delay of up to ten days is often too long in an urgent case common to the pediatric patient. In time, both of these concerns can be overcome with practice and improved efficiency on the part of the patient, the practitioner and the laboratory.

New News About an Old Lens

Silicone Elastomer (Silsoft) has a long and well-documented history of being the lens of choice for the majority of pediatric professionals to manage small children following cataract surgery. The truth is that there would be many “blind” children if not for this particular lens. Silsoft Super Plus contact lenses for pediatric aphakia (>20 diopters) are available with the following parameters: diameter, 11.3mm, base curves: 7.5 mm (45.00D), 7.7mm (43.75D), and 7.9mm (42.75D), optic zone of 7.0mm and powers ranging from +23.00D to +32.00D in 3D steps. The Silsoft material has an oxygen permeability (Dk) value of 340, with oxygen transmissibility (Dk/t) of 58 at 0.61mm. One of the concerns about Silsoft has been the limited availability of parameters. As a result of the tireless efforts of Joe Barr, O.D., B+L may ultimately decide to expand the parameters of their Silsoft Super Plus product. While this announcement is far from official at the time of this article, I would like to applaud Joe and encourage you to do the same. Whether you are a proponent or opponent of Silsoft, any improved technology to provide children with the opportunity to safely develop better vision is worthy of the efforts. On behalf of the industry, the children and their families, thank you Joe.

Conclusion

As contact lens professionals, we have the responsibility, opportunity and privilege to provide products and service to young patients and their families. These products and associated services are necessary to maintain and or develop possibly the most important gift one may ever possess, the gift of sight. Again I ask you, are you a “healer of children”?

Buddy Russell, FCLSA, COMT
Associate, Specialty Contact Lens Service
Emory University Eye Center

Common Pediatric Eye Diseases

8/21/14

In the third of this series, Buddy Russell, from the Emory University Eye Center, provides a great overview of common pediatric eye diseases.

Some Conditions Frequently Seen in Pediatrics

A basic understanding of some of the conditions that may be present in pediatric patients is important to not only know what they are but also understand well enough to explain to the parent or caregiver. The following is intended to be an overview of some of those conditions and not a complete explanation.

Nystagmus – Nystagmus is a vision condition in which the eyes make repetitive, uncontrolled movements, often resulting in reduced vision. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern. As a result, both eyes are unable to hold steady on objects being viewed. Unusual head positions and head nodding in an attempt to compensate for the condition may accompany nystagmus. Most individuals with nystagmus can reduce the severity of their uncontrolled eye movements and improve vision by positioning their eyes to look to one side. This is called the “null point” where the least amount of nystagmus is evident. To accomplish this they may need to adopt a specific head posture to make the best use of their vision. The direction of nystagmus is defined by the direction of its quick phase (e.g. a right-beating nystagmus is characterized by a rightward-moving quick phase, and a left-beating nystagmus by a leftward-moving quick phase). The oscillations may occur in the vertical, horizontal or torsional planes, or in any combination. The resulting nystagmus is often named as a gross description of the movement, e.g. downbeat nystagmus, upbeat nystagmus, seesaw nystagmus, periodic alternating nystagmus. Having nystagmus affects both vision and self-concept. Most people with nystagmus have some sort of vision limitations because the eyes continually sweep over what they are viewing, making it impossible to obtain a clear image. If a refractive error is found, contact lenses may be the most effective way of obtaining best-corrected vision.
Strabismus – Strabismus is any misalignment of the eyes. It is estimated that 4% of the U.S. population has strabismus. Strabismus is most commonly described by the direction of the eye misalignment. Common types of strabismus are esotropia (turn in), exotropia (turn out), hypotropia (turn down), and hypertropia (turn up). Eye misalignment can cause amblyopia in children. When the eyes are oriented in different directions, the brain receives two different visual images. The brain will ignore the image from the misaligned eye to avoid double vision, resulting in poor vision development of that eye. Also, an eye that sees poorly tends to be misaligned. The goal of strabismus treatment is to improve eye alignment, which allows for better work together (binocular vision). Treatment may involve eyeglasses, contact lenses, eye exercises, prism, and / or eye muscle surgery.
Amblyopia – Amblyopia, sometimes called a “lazy eye,” occurs when one or both eyes do not develop normal vision during early childhood. Babies are not born with 20/20 vision in each eye but must develop it between birth and 6-9 years of age by using each eye regularly with an identical focused image falling on the retina of each eye. If this does not occur in one or both eyes, vision will not develop properly. Instead, vision will be reduced and the affected eye(s) are said to be amblyopic. This common condition, affecting up to 4% of all children, should be diagnosed and treated during infancy or early childhood to obtain optimum three-dimensional vision and to prevent permanent vision loss. What causes amblyopia?
Congenital Cataract – A congenital cataract, or clouding of the crystalline lens is present in 2-3 per 10,000 live births of children. The presence of a visually significant cataract in a child is considered an urgent disorder. The resultant form deprivation of vision requires immediate surgery to remove the obstruction, prompt optical correction and amblyopia therapy in unilateral cases. Until the 1970s, it was generally believed that there was no means of restoring the vision in an eye with a unilateral congenital cataract. However, subsequent studies demonstrated that excellent visual results could be obtained with early surgical treatment coupled with optical correction with a contact lens and patching therapy of the fellow eye. However, treatment results continue to be poor in some infants with unilateral congenital cataracts due to a delay in treatment or poor compliance with contact lens wear or patching therapy of the fellow eye. The Infant Aphakia Treatment Study (IATS) was designed to compare the visual outcomes in children 1 to 6 months of age with a unilateral congenital cataract randomized to optical aphakic correction with contact lenses or an intraocular lens (IOL). Children randomized to IOL treatment had their residual refractive error corrected with spectacles. Children randomized to no IOL had their aphakia treated with a contact lens. In previous publications we have shown that the visual results are comparable for these two treatments at 1 year of age, but significantly more of the infants randomized to IOL implantation required additional intraocular surgeries.
Accommodative Esotropia – Accommodative esotropia refers to a crossing of the eyes caused by farsightedness. Accommodative esotropia is a type of strabismus. Children who are farsighted easily and automatically focus on objects at distance and near through accommodation. As a result, a child who is farsighted usually does not have blurred vision. However, in some children who are farsighted, this accommodative effort is associated with a reflex crossing of the eyes. Accommodative esotropia can begin anywhere from 4 months to 6 years of age. The usual age of onset is between 2 and 3 years of age.Full-time use of the appropriate hyperopic glasses prescription or contact lenses will often control the esotropia. When wearing the correction, the child will not need to accommodate and hence the associated eye-crossing reflex will disappear. However, after removing the prescribed correction, the crossing will reappear, perhaps even more than before the child began wearing the correction. Sometimes the correction will only cause the crossing to disappear when the child views a distant object. However, when gazing at near objects, crossing may persist despite the use of the correction. In these circumstances, a bifocal lens is often prescribed to permit the child to have straight eyes at all viewing distances. One potential advantage of contact lenses compared to spectacles when correcting hyperopic powers is the decrease in accommodative demand. The increased effort to converge the eyes with spectacles requires one to over come the resultant base out prism when viewing a near object.

Buddy Russell, FCLSA, COMT
Associate, Specialty Contact Lens Service
Emory University Eye Center

Treatment Options For Children

8/19/14

Here is part two in Buddy Russell’s series; this one focusing on contact lenses as a treatment option for children.

We Are Not Born With Good Vision

The human visual system at birth is poorly developed, but rapidly becomes the remarkable combination of nerve tissue, muscles and optics that provide us with the sense of vision. Those babies born with “perfect” eyes have only the opportunity to develop normal vision. The information processed by the eyes is sent directly to the brain and is interpreted as vision. During the first few weeks, the child sees shapes, lines and space between objects. The child’s visible world is most usable within 8-14 inches of his/her eyes. During this time, the eyes may appear to wander. After about a month or so, the normal child’s eyes will appear more coordinated and they start to show more interest in looking at objects. It is usually in the third month that a child who has normal eyes can fix and follow on a near object. The growth of the eye is a dynamic process, influenced by genetics and the environment.
Early detection of any eye problem is key to treating the disorder. The prevalence of vision problems in children is higher than you might think. For example:

1 in 10 children are at risk from undiagnosed vision problems
1 in 25 will develop strabismus
1 in 30 will be affected by amblyopia
1 in 33 will show significant refractive error
1 in 100 will exhibit evidence of eye disease
1 in 20,000 children have retinoblastoma

As a result of his granddaughter and her eye problem, former President Jimmy Carter initiated a program in 2002 called InfantSEE. This program allows children to have an eye exam at a very young age at no charge to the family. Participating eye doctors provide a more thorough exam than the busy pediatrician. As a result, there is a greater opportunity to detect and treat eye disorders that may otherwise go undetected.

“Have to” Contact Lenses

Fitting pediatric patients is not usually about routine visits and patients who want to wear contact lenses. It is about critical and often urgent situations and patients who have to wear contact lenses. The more common medical indications for contact lenses can be categorized into three groups; anisometropia, irregular corneal astigmatism and “large” refractive errors.

Anisometropia

One of the more common conditions potentially leading to a permanent loss of vision in a young patient is anisometropia. This difference in the refractive errors of the two eyes can lead to suppression of the less clear image. As a result of the non-focused eye, the brain of a young patient simply turns off the blurred eye. Early detection is key to successful treatment. Following the diagnosis of this problem being present, simply correcting the refractive error may be enough. However, it has been reported that as little as one diopter difference between the two eyes corrected with spectacles and the resultant anisokonia, can lead to foveal suppression impacting stereopsis and depth perception. The use of a contact lens or contact lenses alters the effective image size due to the vertex distance being zero compared to either the magnification or minification of the image size due to the vertex distance with spectacles. One of the most severe examples of this condition would be a child with a unilateral congenital cataract and managed with spectacles postoperatively.

Irregular Corneal Astigmatism

Whether acquired or congenital, the presence of irregular corneal astigmatism of the anterior curve of the cornea is best managed with a contact lens. This condition is to be considered urgent if the patient is of a young age. The eye may forever loose the opportunity to be corrected as the resultant amblyopia develops over a short period of time. By neutralizing the corneal irregularities with a contact lens, the eye of a young child will hopefully gain enough vision improvement to avoid the potential permanent loss.
Obviously, patching the better eye may also be necessary if the treated eye’s vision is not as correctable as the unaffected eye. The length of time the child is to be patched is to be determined by the pediatric ophthalmologist or optometrist, as this area of treatment is sometimes controversial. The factors that are considered include the level of vision obtained, age of the child and the condition of the other eye.

Large Refractive Errors

The optics of spectacle correction in high powers have inherent properties that include distortion, prismatic effect and minification / magnification. For instance, the decrease in image size when one views an object through high minus spectacles may result in less vision. This decrease in image size may impact the opportunity to fully develop normal vision in a young child. The smaller image size that is due to the vertex distance of spectacles may be better managed with a contact lens that has a vertex distance of zero thus providing a larger image. This larger image size often increases best-corrected vision.

“Fitting” the Caregiver

Arguably, the most important factor with young children having a good outcome is the parents / caregivers. The technical challenges that exist in these cases are secondary to the ability the fitter must possess to effectively explain and train the person or persons that will take care of the child outside of the office. They must be your partner in the child’s treatment. They must understand the urgency of the situation, they must understand the seriousness of the problem, they must be trained to properly apply, remove and care for the lens / lenses, they must also follow any and all instructions concerning the child. Many of these parents struggle with feelings of nervousness, guilt and sadness. My strategy is to be sensitive to their feelings but not let them feel sorry for themselves too long as the clock is ticking. I provide verbal instructions, written instructions, videos, my email address and a 24-hour phone number. I welcome the caregiver to ask any question at any time. I do my best to let them know that I do care and that I want them and their child to be successful. I am tough on them. There is no good excuse not to do as I have instructed them to do.

When the child and the parent / caregiver are convinced that I am confident in my ability and they know that I do care, the partnership develops as we walk the path together. I want the child to know that they are coming to see me. I want them to know I will reward their cooperation with all phases of the visit. This positive reinforcement may be in the form of a piece of candy, a small toy or just a sticker when the child allows me to see their eye, measure their cornea or intraocular pressure or they just tell me what they can see. Kids love to please us just like they love to please their parents. Reward them for it. Whether you consider this approach bribery or positive reinforcement, it works.

Buddy Russell, FCLSA, COMT
Associate, Specialty Contact Lens Service
Emory University Eye Center

Pediatric Contact Lenses

8/14/14

Because August is Children’s Eye Health Month we are pleased to present a four-part series on pediatric vision issues and contact lenses by Buddy Russell, FCLSA, COMT. With over thirty years experience fitting contact lenses, Buddy is currently an associate of the specialty contact lens service at Emory University Eye Center in Atlanta, Georgia. Buddy is a clinical instructor in Emory’s Ophthalmic Technology Program and teaches students and ophthalmology resident’s contact lens technology.

$Child refractive exam - pediatric contact lenses$ He is a licensed dispensing optician, a Fellow member of CLSA and has been certified by JCAHPO as a Certified Ophthalmic Medical Technologist. He lectures at national and international meetings on contact lens related topics. Buddy has written articles for a number of publications, two chapters for CLSA’s advanced training manual and is a peer reviewer for the Cornea publication. He is also a contributing editor for CLSA’s Eyewitness journal. His current areas of research include pediatric aphakia and keratoconus. He joined the faculty at TVCI in 2006.

The first article will examine that pediatric contact lenses for children go beyond vision correction, the second will explore lenses as a treatment option, the third will look at a variety pediatric eye conditions and the final post will discuss the contact lens fitting challenges you face when you work with children.

Introduction

Working with the pediatric patient and their caregivers / family can be challenging, rewarding, fun, and yet sometimes frustrating. Many of these cases often include factors that are unique to the young patient. In addition to the technical challenges of obtaining the objective data, the fear of uncertainty is often present. The uncertainty of the unknown can either paralyze you or motivate you to step up and simply do what must be done.

The Definition May Vary

The definition of pediatric contact lens fitting can be different to different people. The fitter who works with the occasional twelve-year-old neophyte wearer will define pediatric fitting different from the person that works with babies on a routine basis. Pediatrics is generally defined as a branch of medical care that deals with infants, children and adolescents. The word pediatrics is derived from two Greek words (pais = child and iatros = healer), which means healer of children. Are you a “healer of children” or do you tend to feel better about someone else assuming the challenge and responsibility? This article will discuss some of the conditions, contact lens indications, fitting techniques and challenges that are present with the young patient.

Refractive Indications

What age is “appropriate “ to fit a contact lens on a child? In the absence of a medical indication, Jeff Walline, OD and his colleagues have addressed the answer to this question in the published literature. In addition, the American Academy of Optometry published a position paper in 2004 that stated that by the age of eight, a child was able to handle contact lenses and assume some degree of responsibility. We are all aware that not all eight year olds are capable of dealing with contact lenses. For that matter, not all eighteen year olds are mature enough to assume responsibility for anything. Some of the concerns that a contact lens practitioner may have in fitting these young children include the risk of safety to the child’s health, too much chair time, physical limitations, lack of hygiene, and lack of maturity. These are all legitimate concerns when you consider the child can see well with spectacles.

What does the literature reveal concerning these questions and concerns? Are the answers there?

CLIP Study

The Contact Lens In Pediatrics study compared 169 neophyte wearers in two age groups (children age 8-12 and teens age 13-17) over a period of three months. The summary of the clinical findings in the publication is that adverse events was low and the younger children took a little longer to train application and removal of the contact lenses. The more impressive outcomes from this study was determined by a tool used more frequently in child psychology referred to as the Pediatric Refractive Error Profile (PREP) survey. The PREP survey is a clinically validated quality of life instrument to assess how a child “sees” him or herself. This 26-question survey revealed that contact lenses improved the child’s self image in regards to their appearance, increased confidence in themselves while participating in activities and overall satisfaction of their form of vision correction. These findings were consistent in both age groups. More than 80% of both age groups found contact lenses easy to clean and take care of as all participants were fitted with 2-week disposable soft lenses and used a multipurpose disinfection care system.

The ACHIEVE Study

The Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) were published in 2009. Jeff Walline, OD and his colleagues designed this study to find out the effects that glasses and contacts had on the self-perception of the child. This study examined 484 myopic children 8-11 years. The participants were randomized to spectacles (n=237) or contact lenses (n=247) and followed for three years. The children were evaluated at baseline, 1 month and every 6 months for three years by a validated psychology tool for self-perception referred to as the Self-Perception Profile for Children (SPPC). The SPPC instrument allows a 4 point self-assessment in 6 categories; scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct and global self-worth. The participants revealed the most dramatic areas of improvement with contact lenses compared to spectacles in the areas of physical appearance, athletic competence, scholastic competence and social acceptance. Similar to the low occurrence of adverse events with contact lens wear found in the CLIP study, over the three year period there were only 13 adverse events among 9 subjects. In addition, the ACHIEVE study found very similar rates of myopic progression in both groups of patients over the three year period (1.08D spectacle group and 1.27D contact lens group).
What can we conclude from these two studies?

One is that we are in a position to not only help a young person see but we are also in a position to do it safely and assist the child by instilling more confidence in themselves at a young age that may impact them as they mature into an adult who feels good about themselves. Young children are accustomed to following rules. When properly trained, these same young patients may grow into some of the most compliant patients that we have in our practice. There are some practical considerations for prescribing contact lenses to the younger patient. Mary Lou French, O.D. has stated the three M’s are important for success; Maturity (good hygiene, good communication skills, signs of responsibility), Motivation (why do they want contacts? Does the child want them or just the mom or dad? Are they active in activities where freedom from spectacles is important?), Mom (is the mom / dad / older sibling willing to help?). Don’t let age be the deciding factor. Consider your position as one that may positively impact the young patient in how they “see” and feel about themselves.

Buddy Russell, FCLSA, COMT
Associate, Specialty Contact Lens Service
Emory University Eye Center

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Conclusion

Some Conditions Frequently Seen in Pediatrics

We Are Not Born With Good Vision

“Have to” Contact Lenses

Anisometropia

Irregular Corneal Astigmatism

Large Refractive Errors

“Fitting” the Caregiver

Introduction

The Definition May Vary

Refractive Indications

CLIP Study

The ACHIEVE Study

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