Nystagmus In Children

8/7/14

Nystagmus is a condition of uncontrolled eye movements. Patients with nystagmus are unable to maintain their eyes in a fixed position of focus. The movements can be pendular, swaying evenly side to side, or, jerk into one direction and drift toward the opposite direction. It can be present early in life or acquired as an adult. It can occur in eyes with poor vision from other anomalous development, or eyes that appear perfectly normal. In almost all patients the vision is compromised to some degree. In some patients, the eye movement is less, and the vision better, in an eccentric position that causes the patient to adopt a face turn, tilt or head posture so they can use this quieter position (“null point”) to navigate during their daily activities. To date there have been no consistently effective treatments for this condition.

Lingua and Grace - nystagmus
Dr. Lingua and Grace Nassar

Treatment efforts have been either medical (drugs to reduce the amplitude of the nytagmus movement) or surgical (to move the “null point” into straight ahead gaze to eliminate a head turn, or, directed at reducing the effective contracture of all the eye muscles to reduce the amount of movement). In general, surgical treatment of nystagmus has been disappointing.

In 2002, Dr. Robert Sinskey, noted cataract surgeon and phacoemulsification pioneer, proposed a revolutionary concept, that nystagmus could only be truly effectively controlled by removing the forward portion of the eye muscle and detach it completely from the eye. Since the twitching eye muscles were controlled by nerves sending that pulsatile information, any operation that allowed the muscles to remain attached to the eye would never quiet the movement. He performed this novel surgery in 2000 and published the results in 2002. It did not receive attention in the nystagmus surgery community, as most experts worried that the surgery would limit normal eye movements excessively. The operation does remove the forward portion of the eye muscle but, surprisingly, the eyes are still able to move to allow reading, computing, and driving.. In 2012, I had the opportunity to view a patient he operated 10 years prior and was impressed with how successful the results were even after 10 years. Coincidentaly, I was caring for a 17 year-old patient with nystagmus who had already undergone the 2 currently accepted eye muscle procedures for nystagmus without success. His movements remained uncontrolled, he could not maintain eye contact with anyone, and is his vision was less than that needed for a drivers license. In 2013, I offered him the Sinskey procedure and the results were remarkable. His nystagmus was quieted, his vision improved (20/25) enough to qualify for a drivers license and to return to school.

Since 2012, we have adapted, augmented and perfected the procedure and performed the surgery on over 12 patients with similar remarkable results. All patients experience a marked reduction in the amplitude of the nystagmus (60-100%), and all patients demonstrate improved vision (1-8 lines of the acuity chart), especially at the reading position.

Visit the YouTube posting “Meet Grace” for an example of how this surgery can impact a child’s life and the hopes of their parents. Visit www.eye.uci.edu for further information, contact information and scientific data on the procedure.

Robert Lingua, MDRobert W. Lingua, MD
Director, Pediatric Ophthalmology and Strabismus
Gavin Herbert Eye Institute, UC Irvine

Learning-Related Vision Problems

7/29/14

Next month is Children’s Eye Health Month, and to kick it off a little early we are taking a look at learning-related vision problems. Next month children start heading back to school, so now is the perfect time to make sure you child has had a recent comprehensive eye exam.
child eye exam - Learning-related vision problems
Vision and learning are closely related. About 80% of what a child learns in school is presented visually, and 25% of school-aged children already have vision problems (5-10%of preschoolers do). By scheduling a comprehensive eye exam for your child before school starts, you will help your child be more successful and happier in school.

When children have difficulty in school, from being able to see what is written on the whiteboard to learning to read, it not only makes the learning difficult, but it also makes the child frustrated and can affect their love of learning as well. While most schools perform a quick eye check at some point during the school year to determine simple refractive errors such as nearsightedness, farsightedness and astigmatism, there are other visual disorders that can make learning difficult.

Vision is a complex process that involves the eyes working well with the brain. Specific learning-related vision problems can be classified as one of three types. The first two types primarily affect visual input. The third primarily affects visual processing and integration.

  1. Refractive vision problems. Your child holds a book close to their face when reading or they have difficulty seeing things that are far away. These are generally refractive issues and include nearsightedness, farsightedness and astigmatism, but could also include more subtle optical errors called higher-order aberrations.
  2. Functional vision problems. This type of problem refers to a variety of specific functions of the eye and the brain’s control of these functions, such as eye teaming (using the eyes together), fine eye movements, and focusing skills, peripheral awareness and eye-hand coordination. These issues can cause blurred or double vision, eye strain and headaches.
  3. Perceptual vision problems. Visual perception includes understanding what you see, identifying it, judging its importance and relating it to previously stored information in the brain. Examples would include recognizing words that you have seen before and being able to form a mental picture of the words you see.

Because most routine school and pediatrician eye exams evaluate only the refractive vision problems, it is wise to see optometrist who specializes in children’s vision problems to evaluate functional vision problems and perceptual vision problems that may affect learning.

Color blindness is not considered a learning-related vision problem, but it can cause problems for very young children if color-matching or identifying specific colors are part of the classroom activities. For this reason, make sure your child’s eye exam includes a color blind test prior to starting school.

Symptoms of Learning-Related Vision Problems:

  • Headaches, eye strain, excessive blinking or rubbing the eyes
  • Blurred vision or double vision
  • Crossed eyes or if the eyes move independently of each other
  • Holding a book very close to their face for reading
  • Bending way over a table to get closer to what they are drawing or writing
  • Using only one eye by tilting the head or covering the other eye
  • Losing their place while reading, or needing to use a finger to stay on line
  • Slow reading speed or poor reading comprehension
  • Omitting or repeating words, or confusing similar words
  • Persistent reversal of words or letters (after second grade)
  • Difficulty remembering, identifying or reproducing shapes
  • Poor eye-hand coordination
  • Distracted in class

If your child shows one or more of these symptoms, they could indicate a learning-related vision problem. To find out see an eye doctor who specializes in children’s vision for a comprehensive evaluation. If no vision problem is detected, your child’s problems could be caused by a non-visual issues, such as dyslexia or a learning disability, in which case you would need to contact an educational specialist for an evaluation.

Treatment of Learning-Related Vision Problems

If your child is diagnosed with a learning-related vision problem, treatment generally consists of an individualized and doctor-supervised program of vision therapy. Special eyeglasses also may be prescribed for either full-time wear or for specific tasks such as reading.

Remember that when children have a difficult time learning, especially while other classroom friends have no visual issues to impair learning, they may experience emotional problems as well, such as anxiety, depression and low self-esteem.

Reassure your child that learning-related vision problems do not relate to how smart they are and with the proper treatment and/or eyeglasses, things will become easier.

Susan DeRemerSusan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Children Can Wear Contact Lenses Too

7/24/14

Several studies have shown that children as young as eight years are able to wear gas permeable,[1-3] corneal reshaping,[4-8] and soft contact lenses.[9-12] Gas permeable (hard) contact lenses were originally thought to slow the progression of nearsightedness, but two randomized clinical trials have shown that they do not slow the growth of the eye,[1, 3] so they are primarily fit on children who have difficulty handling soft contact lenses or who have highly irregular corneas (the clear window on the front of the eye) possibly from trauma or eye problems such as keratoconus. children - contact lens for childrenCorneal reshaping contact lenses are worn during sleep only. They temporarily flatten the cornea so that a nearsighted child can see clearly throughout the day with glasses or contact lenses. These contact lenses have been shown to slow eye growth in children.[4-7] Typical soft contact lenses have no effect on the progression of nearsightedness,[13] but soft bifocal contact lenses (typically worn by adults over the age of 40 who otherwise have difficulty seeing clearly at near) have been shown to slow the growth of the eye.[14-17]

Children also benefit from contact lens wear other than slowing the progression of nearsightedness. Children feel better about their athletic abilities, their appearance, and their peer interactions when they wear contact lenses than when they wear spectacles.[11] They even feel smarter if they wear contact lenses than if they wear spectacles, but only if they originally didn’t like to wear spectacles. Children also report that they prefer to participate in activities while wearing contact lenses more than while wearing spectacles, and the most-preferred vision correction is contact lens wear.

It has even been shown that most children (8-12 years of age) require only about five extra minutes to learn how to insert, remove, and care for their contact lenses when compared to teenagers (13-17 years of age). They also show similar benefits as the older group. In fact, children between the ages of 8 and 18 years of age are less likely to require discontinuation of contact lens wear due to problems encountered and also less likely due to experience irritation of the eye due to contact lens wear than college students between the ages of 19 and 25 years.[18, 19] After wearing soft contact lenses for 10 years, those fit as children (7 to 12 years of age) reported similar rates of painful red eyes that required visits to the eye doctor than those fit as teenagers (13 to 17 years of age), and those fit as children as exhibited similar eye health as those fit as teenagers.[20]

Personal experience, backed up by scientific evidence, shows that children as young as eight years can routinely wear contact lenses. When considering contact lens wear for your child, determine the primary reason you would like your child to wear contact lenses. If it is to slow the progression of nearsightedness, then corneal reshaping and soft bifocal contact lenses are the most effective methods. Unfortunately, neither of these contact lenses comes in a daily disposable modality. If your child doesn’t like to wear glasses or finds it difficult to participate in recreational activities with glasses, then daily disposable contact lenses may be best for your child. Contact lenses that are thrown away daily eliminate the need to clean and care for the lenses, reducing care of the lenses to insertion in the morning and removal at bedtime.

Some doctors believe that children should not be fit with contact lenses until they are teenagers. However, there is considerable evidence that indicates children are very capable of contact lens wear, and they experience significant benefits, visually and socially. Talk to your eye doctor about contact lens wear for your child, and if your doctor says that children should not be fit with contact lenses, consider a second opinion.

References
[1] Katz J, Schein OD, Levy B, et al. A randomized trial of rigid gas permeable contact lenses to reduce progression of children’s myopia. Am J Ophthalmol 2003;136:82-90. (Go Back)
[2] Khoo CY, Chong J, Rajan U. A 3-year study on the effect of RGP contact lenses on myopic children. Singapore Med J 1999;40:230-7. (Go Back)
[3] Walline JJ, Jones LA, Mutti DO, et al. A randomized trial of the effects of rigid contact lenses on myopia progression. Arch Ophthalmol 2004;122:1760-6. (Go Back)
[4] Cho P, Cheung SW. Retardation of Myopia in Orthokeratology (ROMIO) Study: A 2-Year Randomized Clinical Trial. Invest Ophthalmol Vis Sci 2012;53:7077-85. (Go Back)
[5] Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res 2005;30:71-80. (Go Back)
[6] Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, et al. Myopia Control with Orthokeratology Contact Lenses in Spain (MCOS): Refractive and Biometric Changes. Invest Ophthalmol Vis Sci 2012. (Go Back)
[7] Walline JJ, Jones LA, Sinnott LT. Corneal reshaping and myopia progression. Br J Ophthalmol 2009;93:1181-5. (Go Back)
[8] Walline JJ, Rah MJ, Jones LA. The Children’s Overnight Orthokeratology Investigation (COOKI) pilot study. Optom Vis Sci 2004;81:407-13. (Go Back)
[9] Rah MJ, Walline JJ, Jones-Jordan LA, et al. Vision specific quality of life of pediatric contact lens wearers. Optom Vis Sci 2010;87:560-6. (Go Back)
[10] Walline JJ, Gaume A, Jones LA, et al. Benefits of Contact Lens Wear for Children and Teens. Eye Contact Lens 2007;33:317-21. (Go Back)
[11] Walline JJ, Jones LA, Sinnott L, et al. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci 2009;86:222-32. (Go Back)
[12] Walline JJ, Long S, Zadnik K. Daily disposable contact lens wear in myopic children. Optom Vis Sci 2004;81:255-9. (Go Back)
[13] Walline JJ, Jones LA, Sinnott L, et al. A randomized trial of the effect of soft contact lenses on myopia progression in children. Invest Ophthalmol Vis Sci 2008;49:4702-6. (Go Back)
[14] Anstice NS, Phillips JR. Effect of dual-focus soft contact lens wear on axial myopia progression in children. Ophthalmology 2011;118:1152-61. (Go Back)
[15] Lam CS, Tang WC, Tse DY, et al. Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial. Br J Ophthalmol 2014;98:40-5. (Go Back)
[16] Sankaridurg P, Holden B, Smith E, 3rd, et al. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest Ophthalmol Vis Sci 2011;52:9362-7. (Go Back)
[17] Walline JJ, Greiner KL, McVey ME, et al. Multifocal contact lens myopia control. Optom Vis Sci 2013;90:1207-14. (Go Back)
[18] Wagner H, Chalmers RL, Mitchell GL, et al. Risk Factors for Interruption to Soft Contact Lens Wear in Children and Young Adults. Optom Vis Sci 2011;88:973-80. (Go Back)
[19] Wagner H, Richdale K, Mitchell GL, et al. Age, behavior, environment, and health factors in the soft contact lens risk survey. Optom Vis Sci 2014;91:252-61. (Go Back)
[20] Walline JJ, Lorenz KO, Nichols JJ. Long-term contact lens wear of children and teens. Eye Contact Lens 2013;39:283-9. (Go Back)

Jeffrey Walline - contact lenses childernJeffrey J. Walline, OD, PhD
Associate Professor
Chair, Research and Graduate Studies
The Ohio State University College of Optometry

Caitlin Hernandez – Blind Actress and Playwright

7/8/14

Being a blind actress is many things: challenging and rewarding, cathartic and uplifting, fun and freeing. What most people don’t realize is that blindness, in and of itself, requires us to be actors every day. Of course, this is true of anyone and everyone, blind or not. We all wear masks, conceal truths, profess to feel things we don’t. But with a trait like blindness– something obvious and visible, which douses us daily in an eternal, inextinguishable spotlight — the play-acting invariably becomes more complex. Striving, constantly, to put others at ease, regardless of our own state-of-being, is an exhausting side-effect of blindness which few people recognize. In some ways, blind people are more accustomed to the pressures of acting than many sighted person will ever be.
Caitlin - blind actress
If I could grant anyone with special needs one wish, it would be the chance to be part of a company like CRE Outreach. For me, CRE’s magic comes in two forms. First, there’s the singular sensitivity of the sighted members of CRE: the directors, the assistants, the sighted actors who join us on certain projects, the audience members who have attended so many of our shows that they’ve learned about blindness by osmosis. Back home, as I catch my breath between answering the public’s questions and negotiating the logistics of graduate school as the only totally blind student in my program, I replay each little L.A. moment. The guiding hands and detailed explanations, so much more beneficial than the ever-present, ineffectual pointing, gesturing, and “over theres” which the rest of the world uses in abundance. The implementation of sound cues–taps on chairs, doorways, and obstacles in our paths–which become second-nature to those who know us best. The easy way we walk together. The empathy that only develops when a sighted person makes the choice to truly live blindness alongside us, even when it’s hard. And, always, always, the way they’re able to open their eyes wide enough to let us see, too.
Caitlin at piano - blind actress
Alongside our sighted compatriots, our “honorary blind people,” as we affectionately call those of the CRE contingent who can see, we’re a team of blind actors. The blind cast members are different ages and backgrounds; we have different levels of vision, different pasts, different families, different lives, different dreams. But being visually impaired binds us inextricably, regardless of our stories. We’ve all lived through those ups and downs of blindness that can sometimes feel so overwhelmingly difficult to share or explain.

CRE casts never leave shows and move on. Contact remains constant, through phone calls and texts and e-mails, voice-chatting and video-chatting and Braille letters, playing and replaying treasured recordings of the laughs, the triumphs, the moments of growth and change. It’s about so much more than putting on a show. When the curtains part on opening night, our plays almost feel like bonuses: beautiful things we were able to produce as a team, chiefly because we’re so deeply invested in this family we’ve created along the way.

Caitlin Headshot copy revCaitlin Hernandez
CRE Outreach
Actress and Playwright

Theater Company Gives Blind Actors Confidence

7/3/14

In this two-part blog post, you will learn more about an amazing program at CRE Outreach, which uses theater to engage and improve confidence among the blind participants, which is how the program started, later helping at-risk youth and military veterans. In the second post on Tuesday, one of the blind actors, Caitlin, will share her experiences as a member of the CRE Outreach troop and what it has meant to her.
theater - blind actors
When twelve visually impaired kids, ranging in age from eight to thirteen, are busy creating characters for their original play, silence is a rarity. Here, in the safe space of an acting class where everyone is visually impaired. I glance around the circle to see whose turn it is to suggest a character … and then I understand the silence. Eric is ten years old, totally blind, and autistic. He’s almost completely nonverbal. If he has ideas, which I often sense that he does, we never hear them.

It’s highly unlikely that Eric’s going to speak, or share, or rise from his hunched, self-protective crouch among the other students. I prompt him anyway. “Eric, it’s your turn. Do you have an idea for a character?”

Without warning, he lights up. A burst of energy seems to lift him right out of his hunched position, and with more clarity and volume than I’ve ever heard from him before, he declares, “I want to be a human telephone!”

Eric went on to be the lead in our show and now interacts socially with other kids. Acting has helped him build up his confidence and find his voice. And he isn’t alone.

CRE Outreach aims to transform lives one show at a time. From inception to performance, these actors play a major role in all aspects of the production. Inclusivity is the cornerstone of CRE Outreach. Our productions are based on authentic stories and rarely-heard messages, conveyed by the very people who should be sharing them.

CRE Outreach works with three different populations–at-risk youth, military veterans, and the visually impaired–using theater as an empowerment tool. For all participants, stepping into another character allows them to forget about themselves for a while. They feel new emotions, take on new experiences, and live a life which they don’t have the opportunity to live every day.

For blind actors, visual impairment is their common thread, but it’s their will to define their disability which truly binds them. To cement that bond, we introduce each new blind actor to our theater group with an exercise called “The Run.” One by one, each visually impaired actor races from one side of the stage to the other: an experience that they have never had before. Learning to use sound cues, along with textured mats on the floor, the actors break through their fears of movement and learn to navigate the stage independently. They learn to trust themselves and each other. As they run, they realize that the unknown isn’t half as scary as you’d think, when you have a family all around you.

Greg Shane - blind actorsGreg Shane
CRE Outreach
Co-Founder

6 Summertime Tips for Children’s Vision

5/20/14

Summer vacation is around the corner and for children this means more time spent outside playing, swimming, or going to the beach. All of this outside activity increases their exposure to ultraviolet rays which is of particular concern because the lens of a child allows 70% more UV rays to reach the retina than in an adult. This may put them at increased risk of developing debilitating eye diseases such as cataracts or macular degeneration as adults.
Children with sunglasses
If you are wearing sunglasses to combat the bright sunlight, then your child should be wearing them, from babies on up. Wrap-around sunglasses provide more sun and eye protection. Wearing protective goggles during sports activities is also important as the National Eye Institute reports there are more than 100,000 sports-related eye injuries every year with 42,000 requiring emergency care.

While it may be hard to get them to leave them on, or if they keep falling off, invest in a strap that can range from $4.50-$10.00. They can be made of neoprene with fun designs like Croakies or they can use an adjustable cord like Chums. In any case it also helps cut down on lost sunglasses.

Pediatricians offer the following five suggestions for children to enjoy a fun and safe summer:

1. Wear sunglasses – especially younger children

During our lives, almost half of the time we spend outdoors is before the age of 12. Sunglasses for children don’t have to be expensive, but make sure they are rated to block both UVA and UVB radiation. Glasses should also have a polycarbonate lens to withstand shattering.

2. Wear protective eye gear for ball or shooting sports

Every year there are 18,000 sports-related eye injuries in US hospital emergency rooms. The American Academy of Ophthalmology recommends that children wear polycarbonate goggles for baseball, basketball and racket sports, including tennis. It becomes even more important with shooting games like air-soft where the projectiles are so small, but can do major damage to the eye. Regular glasses are not recommended if they cannot be secured to the head or are not made from polycarbonate. Also make sure the goggles have proper sun protection for outside sports.

3. Don’t rub if sand gets in the eyes

If a child gets sand into his eyes, take the child immediately to a sink with running water. Do not allow them to rub their eyes as this can scratch the outer layer of the eye known as the cornea. Use a clean cup to pour water over the eyes to remove sand. Encourage blinking and do not discourage crying, because tears remove eye irritants. If flushing and blinking does not work, seek immediate medical attention.

4. Use a non-irritating sunscreen

While you can use adult sunscreens for children, make sure it is PABA free, since that chemical can cause irritation in some people. If your child gets a rash from his sunscreen, review the ingredient’s list and choose a different one. UVA protection from titanium dioxide or zinc oxide tends to be less irritating than avobenzone, another common ingredient.

5. Wear a wide-brimmed hat

Don’t just rely on sunscreen.  Have your child wear a hat with a wide brim.  It not only provides additional protection against sunburn on susceptible areas like the nose, neck and ears, but it also helps to protect their eyes from harmful UV rays.  Not all sunlight enters the eye direct from the front.  Wrap-arounds may help protect light from coming in the sides, but they do not stop sunlight from coming in the top or reflective glare from coming up from the bottom.

6. Check chlorine levels in your pool

Too little chlorine in a swimming pool can allow algae and other bacteria to grow, which can lead to eye infections. On the other end of the spectrum, be sure to check the levels of chloramines and the pH of the pool to avoid stinging and redness. Swim goggles are helpful to keep pool water from entering the eye. If redness and irritation persist after swimming, it could be a sign of a more serious infection and medical attention is needed.

Susan DeRemerSusan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation