Children’s eyes require special attention. The quality of a child’s vision affects various aspects of their development from academic performance to social interactions, and even self-esteem.
As the weeks inch closer to students’ return back to school, it is critical to prioritize vision care to prepare for a healthy and productive year in and out of the classroom.
Dr. Janine Smith-Marshall, director of Pediatric Ophthalmology and Strabismus Pediatric Ophthalmology at Howard University, spoke with The Washington Informer to discuss visual health challenges in children across the District, and how best to address these issues.
What are some of the most concerning visual health issues that you see in children across the District?
JSM: In general, the most common visual disability across the board for children and adults, is uncorrected refractive error. Refractive error is the inability to focus the eyes– so the need for glasses— that can cause visual disability. But certainly, most of the time, refractive error develops in childhood… For kids, uncorrected refractive error can certainly cause issues with schooling and learning, which can ultimately lead to problems down the line.
Are there signs that parents could look for with children that might suggest that they have issues with their vision?
JSM: Yes, whenever there’s any kind of developmental delay, whether that be fine motor or gross motor— so [if] kids are delayed with walking or crawling, [or] they’re not able to write properly or grasp things properly— it’s important to ensure that their vision is checked, to ensure that the visual acuity is not causing that or contributing to that.
Also, you can certainly have situations where kids are getting close to screens when they’re trying to focus, tilting or turning of their head, closing one eye. And then, the most obvious things, if there’s any misalignment of the eyes, crossing or drifting of their eyes, droopy eyelids, covering one eye, complaints of redness, irritation or extreme light sensitivity. All of those things should be checked out if they are occurring on a regular basis, understood.
How challenging is it with a child to give a correct eye exam?
JSM: It can be difficult, it’s a skill, just like anything else, which is why we do have the specialty of pediatric ophthalmology. Unlike adults, [where] you can just ask them to read a chart, or you can do tests with very little difficulty, with kids, sometimes those things can be challenging, and so we have special tests, and we are extremely good at the basics to be able to detect issues with kids.
You really have to hone in. You can’t do it as quickly, but with the right skill set it is not that much more challenging than adults.
Are teachers a valuable asset in identifying vision issues in children?
JSM: Absolutely. I mean, honestly, sometimes teachers are spending more time with kids than their parents and they are having them do visual tasks as they are assigning schoolwork, so teachers are always a valuable asset in being able to figure out if a kid is having difficulty.
Oftentimes, if a kid fails a vision screening, I’ll ask not only what the parents are noticing at home, but if the teacher has noticed any issues during school to evaluate what impact the decreased vision is having on the kid.
For younger kids, you may not see it in the classroom, because most of the things that they’re doing is table work… But usually starting around third to fourth grade is when the shift occurs, where the teacher is at the front of the classroom and the kids are copying on the board, and that’s when a lot of times, uncorrected refractive errors manifest and become symptomatic in the school.
If there is any indication that your child has a lazy eye, is that something you should be concerned about, and how is that generally corrected?
JSM: Absolutely. So, the medical term for lazy eye is amblyopia, and amblyopia is actually the inability of the brain to use the eye. So it’s called a lazy eye because the brain has essentially turned the eye off. The brain doesn’t want to use it because it has to work harder to use that eye…
Although babies are born with their eyes open, our eyes continue to develop until about 7 or 8 years of age. So anything that comes in the way of normal visual development within that seven- year time period can ultimately affect how our eyes are working. And so if we have, like, one eye that’s not focusing as well, and the brain turns it off, if that’s not caught until, say, the child is 10 years old, then oftentimes there’s not much that can be done to improve vision. That’s why it’s really important to do vision screening early and often in the medical home.
We recommend that all pediatricians and family practitioners do yearly vision screening starting at the age of three.
What is a wandering eye?
JSM: If you have crossing or drifting of the eyes, then, of course, the brain has to pick which eye to use. And so if the brain is consistently using one eye, then the vision in the eye that’s crossing in will decrease.
You can have a situation where you have a misalignment of the eyes, where one of the eyes is crossing or drifting out towards the ear, and the vision is good in both eyes. Oftentimes, if that’s the case, then 50% of the time the right eye will cross, 50% of the time the left eye will cross. So, the angle between the two eyes is abnormal, but the vision is equal between the two eyes, so that child has a misalignment of the eyes or strabismus, but does not have a lazy eye.
Misalignment of the eyes is a big risk factor for developing lazy eye, because oftentimes, before being forced to pick one eye to use, the vision in one eye will go down.
As it’s a rare condition, how does glaucoma develop in children?
JSM: Glaucoma in kids and glaucoma in adults are two different things, right? Glaucoma in adults has to do with blood flow to the nerve- so how healthy is the nerve in the back of the eye? That can be influenced by vascular issues like high blood pressure, diabetes, and can be made worse if that blood flow is not treated effectively.
However, glaucoma in children is kind of a different beast. It usually will appear very early on to in the first few years of their life, and is usually a result of some structural abnormality in the eyeball itself.
We don’t have blood vessels in the eye so that we can see clearly, but we do have a liquid called the aqueous humor, which is what carries oxygen and nutrients to the structures in the eye. So, the aqueous humor is made behind the colored part of the eye and then comes through the pupil, and then drains in what we call the angle right now. What happens is, for whatever reason, the angle, which is the area between the cornea and the colored part of the eye, usually, is not formed properly. And so there it’s like a slow drain.
So, if you have a slow drain in your sink, then even if the water is going at a slow rate, you’re going to back up, back up, back up, until that sink overflows. That’s what happens in an eye with pediatric glaucoma, there is nowhere for that fluid to drain, or the drainage of the fluids doesn’t match the production.
Instead of the drain overflowing, what happens is it causes the eye to increase pressure like a balloon that’s being blown up, and then that increased pressure can affect the structures inside of the eye, most notably the nerve in the back of the eye, which can cause glaucoma.
It really is a different situation for adults who have glaucoma, although it can be a devastating disease, the vision loss is very slow and can be amenable to laser and medical treatment. For kids who have glaucoma often, they don’t respond very well to anything other than surgery.
Also, vision loss due to glaucoma in kids is very quick and very devastating. So, the majority of kids, more than 70% of kids who have congenital glaucoma, will lose vision, as opposed to two adults, where you have a much better success rate and treating it especially if it’s caught early.
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