The Eyes Have It

Rosie Hoban talks to an ophthalmologist and a behavioural optometrist about common eyesight problems in young children.

Dr James Elder’s career as an ophthalmologist (medical eye specialist) at Melbourne’s Royal Children’s Hospital is dedicated to preventing and rectifying eye problems in children.

Dr Elder says early detection is vital if any eye problem or refractive error is to be corrected. Fortunately, most states have screening programs operating before the child starts school. Children in pre-schools also have sight assessments.

‘Many of the more common eye problems are picked up and the child is referred to an optometrist or general practitioner, but a turned eye can often be difficult to detect unless it is ‘striking’,’ Dr Elder says, ‘the child, if detected with an eye problem that needs further treatment, may then be referred to an ophthalmologist.’

Almost all babies are born long-sighted and in most this is not a problem as it lessens with age. In a small number of children the long sightedness is excessive and results in a need to over focus which can cause one eye to turn in.

A turned eye will not impact on a child’s capacity to read, but can cause a loss of depth perception and loss of a small amount of side vision. Many children with a turned or crossed eye (strabismus) are treated with glasses and/or surgery if necessary. Long-sightedness can also lead to other eye problems such as a lazy eye.

When people speak of a ‘lazy eye’ they sometimes mean a turned eye, but more often mean that one eye does not see as clearly as the other. The medical name for a lazy eye that is not seeing clearly is amblyopia. In a pre-schooler, an eye that always turns may become amblyopic. Another common cause of amblyopia is unequal long sightedness. 

Parents may not realise their child has an amblyopic eye, as the normal eye will allow the child to function without major difficulty. Amblyopia is untreatable after age seven years and thus early detection is vital. The only reliable way of detecting amblyopia is a test of vision, hence the importance of vision screening tests.

Short sightedness is uncommon in pre-schoolers and slight short-sightedness does not require glasses. However 15 to 20% of Australians are short-sighted enough to require glasses or contact lenses by the time they are 20 years of age.

Dr Elder says many children with eye conditions suffer unnecessarily because of a lack of understanding in the community.

‘Unfortunately for children in our society who have a turned eye, the common interpretation is that they are a bit dull. If the eye turns out, they are often considered a bit devious because they cannot make eye contact. This can be unfair for children with this condition, as is the myth that children with a turned eye cannot read properly.’

‘A healthy self-esteem is very important for children in those early years and having to wear glasses or an eye patch can have a big impact on a child’s confidence. As a society we need to be more accepting of children with eye problems,’ he says. 'The majority of turned eyes can be improved to the point that most people cannot detect them, but full restoration is rarely possible because the brain will not allow the eye to ‘lock into place completely’.

More than 90% of children Dr Elder examines with a suspected turned eye, do not in fact have a turned eye. However, he agrees it is important to seek professional advice if parents are concerned, in case their child fits into the 10% category. What many parents think is a turned eye is in fact a pseudo-strabismus and is due to a broad bridge of the nose.

Another concern for parents is the affect of the sun’s UV rays. According to Dr Elder, damage to the eyes from the sun usually only occurs after many years of sun exposure, which is usually associated with a lifestyle such as farming.

Sunglasses in children are not necessary for eye protection, but are worth promoting as part of an overall sun protection ‘package’ that includes sunscreen, a hat, shade and long-sleeved shirt.

To help in the early detection of eye problems, Dr Elder recommends the following:

• Make sure your child does not miss the screening program offered at your Maternal and Child Health Centre.
• If there is a strong family history of eye problems, your child should be checked by an optometrist or ophthalmologist.
• If you think your child has a turned eye, take them to an optometrist or ophthalmologist.
• Ask yourself if your child sees the things you expect them to be able to see. For example, standing close to the television in itself means nothing, but if they also hold everything close then there may be a vision problem.

Some Children Slip Through the Gaps

Behavioural Optometrist, Anne Pezzimenti, says moderate long-sightedness in children is often difficult to detect in screening programs. It’s this group of children she considers at risk of learning problems.

Ms Pezzimenti, who also has a Masters Degree in Special Education, says ‘Moderate long-sightedness is often not picked up during screening, because it is not severe enough to make the eye turn, but it is enough to create poor images. These children are often referred to a behavioural optometrist because their schoolteacher may suspect that their behavioural problems could be linked to their vision.’

Untreated moderate long-sightedness may impact on a child’s ability to do many activities and certain sports, because the child has never learned spatial awareness. As a toddler, reaching for things on the floor develops our sense of space and this cannot be learned properly if a child is long-sighted.

‘By the time a child, who is moderately long-sighted is seven and at school, they have learned to avoid what they cannot do well. Often they have been disruptive in kindergarten and avoided activities that develop their fine motor skills such as drawing and threading, ‘ Ms Pezzimenti says.

‘The longer the problem goes on the more difficult it is to correct because the child’s visual memory skills are poor.’

Ms Pezzimenti says the following may indicate visual problems in children aged three to five. The child:

• Sits and enjoys stories, but avoids activities such as threading and jigsaws.
• Has problems sitting down in a group and seems to sit on top of another child.
• Is clumsy compared to peers and/or has poorer ball skills than peers.
• Demonstrates consistently close and/or tilted posture whilst drawing.
• Shows delay gaining fine motor skills.
• Has a family history of vision problems.
• Squints or blinks excessively.
• Complains of using his eyes for close up tasks such as colouring and drawing.
• Is still extremely tactile and still cannot lead the hands with the eyes.
• Towards the end of the pre-school year, uses either hand to paint and paints on the left side of the paper with the left hand and right side with the right hand.

Parents Applaud Screening Program

Joe Burns was four and a half when his kindergarten teacher noticed one eye was slightly turned. His parents, Jenny and Jim, had been worried about the eye, but decided to wait and see if it corrected itself. Once alerted, Joe was referred to an ophthalmologist.

Joe was diagnosed as longsighted with a slight turn in his left eye. The long-sightedness was treated with glasses and his eye turn was monitored for 18 months and found to be deteriorating. Joe had surgery to correct his eye turn a few weeks before starting school. The surgery to correct his eye involved a squint muscle transplant and he experienced little pain in the following days.

Less than two years after Joe’s surgery, his younger brother Patrick, was found to be long-sighted. The screening program offered at his kindergarten also detected that Patrick had a lazy eye. He was given glasses and a patch was placed over his ‘good’ eye to force the lazy eye to work more effectively.

For several months Patrick’s eye, then his glasses, were covered, and slowly the ‘good’ was reintroduced back into full use. At the end of the patching his lazy eye condition had been corrected. Both boys continue to wear their glasses, enjoy their sports and are thriving at school.

by Rosie Hoban

For further information about eye health go to:

The Royal Australian & New Zealand College of Ophthalmologists

The Victorian Government Better Health Channel
 

The information provided in this article is intended as a guide only. Always consult your doctor if you or your child is suffering any medical complaint. Any websites referred to by Australian Family contain information moderated by government and medical institutions or organisations.

This article was first published in Australian Family Magazine, September 2001. Updated July 2009.