1. Why should my child see a pediatric ophthalmologist?
The American Academy of Pediatrics states the following on its website www.healthychildren.org : “Children are not just small adults. They cannot always say what is bothering them. They cannot always answer medical questions, and are not always able to be patient and cooperative during a medical examination. Pediatric ophthalmologists know how to examine and treat children in a way that makes them relaxed and cooperative. In addition, pediatric ophthalmologists use equipment specially designed for children. Most pediatric ophthalmologists’ offices are arranged and decorated with children in mind. This includes the examination rooms and waiting rooms, which may have toys, videos, and reading materials for children. This helps created a comfortable and non-threatening environment for your child.

If your pediatrician suggests that your child have his eyes checked, a pediatric ophthalmologist has the widest range of treatment options, the most extensive and comprehensive training, and the greatest expertise in dealing with children and in treating children’s eye disorders.”

Click here for more detailed information regarding the training a pediatric ophthalmologist has, and the types of treatment pediatric ophthalmologists provide.

2. What is “lazy eye”?
Different people mean different things when they say “lazy eye”. Some mean a drooping eyelid, some mean eye misalignment, and others mean that one eye just doesn’t see as well as the other, even though they may be straight.
• A drooping eyelid is called ptosis. In a young child, a drooping eyelid may cause astigmatism, which can lead to amblyopia. A drooping eyelid may be a sign of a more serious medical condition.
• Eye misalignment is called strabismus. It needs to be evaluated and treated by an eye doctor to allow the brain to use both eyes together.
• Amblyopia means poor vision in an otherwise normal eye due to disuse by the brain: in effect, the brain "forgets" how to use the amblyopic eye. Like strabismus, amlbyopia needs evaluation and treatment by an eye doctor to restore and maintain good vision in the weak eye. Amblyopia should be detected and treated as early as possible. It gets harder and harder to treat with each passing year, and is very difficult to treat after age 9.

3. I heard there is a drop than can be used to treat amblyopia. Is that true?
Amblyopia is treated by forcing the brain to use the weak eye. This is often done with a patch over the good eye, but in certain cases can in fact be done by deliberately blurring the strong eye with a drop called atropine. Though amblyopia may not respond as fast to the drop as to a patch, the drop can be a great help, in particular with kids who will not keep a patch on. There is no drop that will help eye misalignment.

4. What is nearsightedness?
Nearsightedness simply means that is easier to see up close than far away. Usually this is because the eye is too long and brings light to focus before it reaches the retina. The eye has no mechanism for correcting that on its own, so a nearsighted person requires contact lenses or glasses to see clearly at distance. Though very young children may be nearsighted, nearsightedness more commonly shows up at age eight or nine, and tends to increase through the teens, eventually leveling off in the late teens. This increase in nearsightedness would occur whether glasses were worn or not; it is not the glasses that make the eyes get more nearsighted.

5. What is farsightedness?
First, a surprising fact: farsightedness is not the opposite of nearsightedness, and it does not mean that things are clear at distance but blurry up close.

A farsighted eye is too short, so that it would bring light to focus behind the retina. The eye has a mechanism for pulling that focal point up to the retina so that the eye can see clearly, and this mechanism is called accommodation. Accommodation is the focusing mechanism that we all use when we shift from looking at something far away to something close up. (For instance, when we turn 40 and have trouble seeing up close, we are not becoming farsighted, but are just running out of accommodation.) A farsighted person can see 20/20 both at distance and at near, without glasses, as long as he or she can accommodate enough. In fact, it is normal for children to be farsighted; most children begin life moderately farsighted and may in fact become more farsighted until about age six or seven before leveling off for a couple of years. The farsightedness then tends to decrease into the teens, so that most children end up with negligible refractive error (neither nearsighted nor farsighted) in their teens. All those years they were farsighted, but not having any problem seeing because they could accommodate enough.

So which farsighted children need glasses? First, those whose farsightedness produces crossing of the eyes (accommodative esotropia). These children need glasses, not so much to help them see, but instead mostly to keep their eyes straight. Second, some children are extremely farsighted, so much so that they are not able to accommodate enough to see clearly. These children may need glasses for their extreme farsightedness even though their eyes are straight. Finally, children who are significantly more farsighted in one eye than in the other do require glasses to keep them from getting amblyopia, or to help treat their amblyopia.

6. What is astigmatism?
Astigmatism is non-spherical curvature of the cornea. Whereas a nearsighted eye brings light to focus before it reaches the retina, and a farsighted eye brings light to focus behind the retina, an eye with astigmatism does not bring light to one focus: part of the image is focused at one place and part at another, so a person with astigmatism does not see clearly either at distance or at near. If the astigmatism is a large amount, or different in one eye than in the other, then glasses will be needed. Many people with small amounts of astigmatism see fine without glasses.

7. My child sees 20/20 and yet you say she needs glasses. Why?
If your child sees 20/20 with each eye and still needs glasses, then he or she most likely has accommodative esotropia (crossing of the eyes related to farsightedness). Children with accommodative esotropia are typically more farsighted than most, so that when they use the extra focusing power needed to see clearly despite their farsightedness, the eyes cross. Their glasses are needed to keep the eyes straight, not to let them see. If your child can see 20/20 with one eye, but not with the other, then he or she has amblyopia, and glasses are needed to compensate for the difference in the farsightedness of the two eyes---to put the eyes on a “level playing field,” so that the brain has a chance to use the more farsighted eye.

8. My child sees 20/40, yet you say she does not need glasses. Why?
Most likely this is because your child has relatively mild refractive error: either mild nearsightedness or mild to moderate astigmatism. These conditions do not harm the eye in any way, and as long as your child is able to see adequately in school, I’ll often recommend having him or her sit in the front half of the class, reserving glasses for when he can no longer see clearly or adequately in school. Note that with a given amount of refractive error, a child in kindergarten may function fine, but the child in second grade with the same amount of refractive error may have difficulty and need glasses. Thus it is not just the actual measurement that matters, but the child’s visual requirements as well. If in the office we choose to go without glasses but you subsequently find that the child is struggling without glasses, then just call the office and we can give you a glasses prescription.

9. My child is struggling with reading. Are the eyes causing this?
The eyes are almost never the cause of reading or learning problems. Because of this, eye related treatments such as reading glasses, tinted plastic sheets to lay over the page, eye exercises, or so-called “vision therapy” are almost never the correct treatment for your child’s reading or learning problem. Nevertheless, it is wise to have your child’s eyes examined by an ophthalmologist if there is a struggle with reading or learning, for two reasons: first, to make sure that he is not one of those very few kids who do have an eye problem that is contributing to the reading or learning difficulty, and second, so that you and the school will both know that you can strike eyes off the list and move on to educational evaluation and educational remediation to see what really is the cause of the reading or learning difficulty. Please see the following for more information regarding the role of the eyes in children’s learning problems. (links)

10. I’m an adult. Why should I see a pediatric ophthalmologist?
For most of your eyecare needs, you really are best served by your general ophthalmologist. However, issues of double vision and eye misalignment are ones that your general ophthalmologist does not deal with nearly as frequently as he does other problems, whereas a pediatric ophthalmologist deals with these issues all day every day. Thus a pediatric ophthalmologist is prepared to evaluate and treat your double vision or eye misalignment in a more efficient way, including an appropriate recommendation regarding whether further medical work-up or a scan of the brain may be need. A pediatric ophthalmologist is also comfortable and proficient in using non-surgical treatment such as prisms to control double vision whenever possible, instead of surgery. If surgery is necessary, the pediatric ophthalmologist is best equipped to do this, as this is what he does all the time (whereas, if you need a cataract removed your general ophthalmologist is your best choice for that).

11. I think my baby’s eyes are crossed. How can I tell?
Many newborns do in fact have transient eye misalignment, either crossing or an outward drift. This generally goes away in the first several months of life and should be gone by six months. More commonly, what appears to be crossing is in fact the illusion of crossing due to the broad nasal bridge, so that when the child looks even a little bit to one side, less white shows on the nose side of that eye, making it look crossed. One of the best ways for you to try to determine whether your child has true crossing or this “pseudoesotropia” (the illusion of crossing due to a broad nasal bridge) is to look at a flash photograph. Look carefully at where the light hits the pupil of the two eyes. If the light hits the pupil in the same place on both eyes, then the eyes are straight. If not, then there may be eye misalignment, and your child should see an eye doctor.

12. How can you tell whether my baby needs glasses when he can’t talk to you?
After the pupils are dilated, the eye doctor uses an instrument called a retinoscope, which is a special handheld light used to view the “red reflex” (the orange pupil that you may see in a flash photograph taken at night). By looking at this red reflex with the retinoscope through lenses, it is possible to measure objectively any nearsightedness, farsightedness, or astigmatism that may be present, accurately enough to prescribe glasses if needed, or to know that they are not needed. Note that if as an adult you go to the eye doctor for the first time, he or she will begin by using the retinoscope to measure your prescription in just the same way. However, because you’re able to tell him which is better, one or two, he will refine that retinoscope measurement according to your response. In a young child who is not able to respond, or who can not reliably answer which is better, the retinoscope measurement is used directly as a prescription.

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