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What Should Parents Know About Eye Exams, Bilateral Vision and the Proverbial 'Lazy Eye'?

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Pediatric ophthalmologists have to be specialists in the art of the nonverbal eye exam. Their patients may be just a couple of days old, and even the older ones sometimes cannot identify the letters on a wall chart. What's more, children may be intimidated by bulky eye exam equipment or fearful of someone putting drops in their eyes.

Dr. Sujata Singh is one of two pediatric ophthalmologists in Vermont and an assistant professor at the University of Vermont's Larner College of Medicine. Some vision problems are caught by pediatricians or teachers, she says. Usually, though, parents are the first to notice abnormalities in their kids' eyes or vision. When they do, she has the answers. Dr. Singh answers our questions about children's eye health.

Dr. Sujata Singh
  • Dr. Sujata Singh

KIDS VT: What are the most common issues you treat in children?

SUJATA SINGH: The main focus of pediatric ophthalmology is trying to reduce or prevent amblyopia, which is poor vision resulting from poor vision development. You can have bilateral amblyopia, which is poor vision in both eyes, or unilateral amblyopia, which is poor vision in just one eye. Kids can have amblyopia because their vision is still developing until they're 8 to 10 years old. When they're young, their brains are plastic enough so that we may be able to improve their vision. After age 10, it's much more difficult to rehabilitate it.

KVT: What causes amblyopia?

SS: A person can have poor vision due to an eye injury, glaucoma, retinal detachment or because they didn't develop good vision in childhood. But much of it is genetic. In order to develop good vision, you must have two clear, equal images going through your eyes to your brain. The brain puts those two images together to create depth perception and good equal vision, so you're not relying on one eye over the other. Do you remember the viral internet question that asked whether you see the dress as black and blue or white and gold? That tells us that your brain creates vision, not your eyes.

KVT: What is a "lazy eye"?

SS: Actually, "lazy eye" is not a clinical term, and it can mean a lot of different things. Some people take it to mean poor vision in one eye. Other people take it to mean a wandering eye, a crossing eye or a drooping lid. For me, as a pediatric ophthalmologist, it just means two eyes that aren't working well together.

KVT: How do you treat it?

SS: The first thing we try is patching, which kids usually hate. The idea is that you give the brain only one option — the bad eye. But kids know they have a good eye so they'll often take off the patch. Patching can be traumatic for parents to live through, let alone for the kids who want the patch off. But this low-tech approach can improve vision and give a child lifelong depth perception.

KVT: How long do kids typically need to wear the patch?

SS: It varies. Early on in pediatric ophthalmology, they would patch the good eye all day. We don't do that anymore, because you can make the good eye the bad eye if you do it for too long. If the crossing is very minor, we might only do it 30 minutes a day. Generally we don't patch for more than four to six hours per day. Studies have shown that you don't get much improvement for patching longer than that. Some kids only need to patch for weeks or months; some kids need to patch for years. We can start patching at any age.

KVT: Are there other treatment options?

SS: If a child doesn't tolerate patching, we can make the vision in the good eye fuzzy with an eye drop that impairs the ability to focus. That way, the child can only pay attention to the bad eye. The eye drop also causes dilation. The dilation lasts a long time, but the fuzziness wears off much sooner, so parents have to administer the drop more than once a week. Sometimes parents think that the drop is still working because the pupil is still dilated, and they start skipping doses, which results in suboptimal amblyopia therapy. The other options are glasses or, in more involved cases, surgery.

KVT: Are there downsides to doing dilation in children?

SS: I've found that some parents are nervous about dilation because their kids will really kick and scream. They don't like getting drops in their eyes. But once I give them a toy or bubbles afterwards, they're completely fine. Their reaction is all about the anxiety of getting the drops. It's not painful. The vast majority of the time, dilation has no negative effects on children, and it's a great diagnostic tool.

KVT: Do you see more eye problems now that kids spend more time on screens than they did years ago?

SS: In general, it's good for kids to be outdoors playing in natural light and to limit their screen time. But we don't have evidence currently that screen time is harming kids' vision.

KVT: Do you advise kids not to rub their eyes?

SS: When kids rub their eyes, usually something is going on; they have allergies, viral conjunctivitis or something else irritating their eyes. Adults often rub their eyes when they get dry. You can damage your eyes from rubbing and pressing them too aggressively, but it's usually not something to worry about.

KVT: Anything else?

SS: The vast majority of children don't need a routine eye exam unless we catch something in a vision screening, if they're complaining about their eyes or if their parents notice something unusual. If parents are at all worried about their kids' eyes or vision, they should talk to their pediatrician early on. He or she can do an evaluation and, if necessary, refer the child to us. Most parents have pretty good clinical intuition about their kids' vision. Sometimes parents will assume a child's eyes are crossed, but it's really just an optical illusion. There's a skin fold that can cover the whites of their eyes. They may look crossed, but they're not. But I'm always happy to check it out and make sure.

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