Children’s eyes are different from adults’ eyes – an obvious statement but one that must be taken into consideration when seeing children of all ages. Paediatric eye care will be a bimonthly series of articles looking at some of these differences.
The National Service Framework (NSF) for children 2004 set the guidelines for specialist children’s clinics in the NHS in the England (similar legislation was enacted in the rest of the UK).1 Before that, children could be seen in the same clinics as adults and specialist paediatric care was not always available.
Specialist paediatric ophthalmology led to better investigation into the causes of congenital conditions with earlier diagnosis which could potentially result in better outcomes. The genetics of eye disease is now much more routinely investigated and can provide information to parents about the risk of having further children with a similar condition or of the child or other members of the family having an affected child in the future.
Dispensing
The first article deals with spectacle dispensing and has been written by Jessica Gowing, senior dispensing optician at Great Ormond Street Hospital for Children in London. She has a wealth of knowledge of fitting spectacles for children of all ages and with many different conditions.
Successful treatment of eye disease and accurate refractions are of little use if the child spends most of the time looking over the top of their glasses, a common problem if frames do not fit well and slip down the nose. Worse still are the spectacles that are not worn because they are uncomfortable or the child hates how they look, so it is important to ensure the frame fits well and also looks good. Children’s glasses are frequently broken, so having a spare pair is helpful. However, having two pairs of poorly fitting glasses is not of much benefit to the child.
Uveitis
Uveitis usually causes ocular pain, photophobia and reduced vision in an adult but in a child, the inflammation can be marked but produce minimal symptoms. The disease may have existed for some time and caused a lot of damage before it is diagnosed and treatment started.
Uveitis is unrelenting and although modern treatments are more likely to arrest the disease, the strong drugs themselves can result in unpleasant side effects. Uveitis is also associated with other systemic problems, the most common of which is juvenile idiopathic arthritis (JIA); both conditions are prone to ongoing flare ups which are difficult for a child to live with.
Amblyopia
While any ocular disease must be treated, the visual development in the young also has to be monitored as amblyopia can occur as a sequela to the primary condition. During the critical age for visual development, dense amblyopia can develop over a very short period.
Regular refraction and orthoptic monitoring are necessary during this period and where one eye is stronger than the other, patching should be initiated. Once the child is past the amblyogenic period (approximately seven and nine years of age), long-standing amblyopia is unlikely to improve, even if the eye condition is successfully treated.
Glaucoma
Eyes in young children are more ‘elastic’ than adults’ and the eyes enlarge rapidly if the intraocular pressure is raised so paediatric glaucoma leads to enlargement of the globe with increased axial length and resultant myopia. The stretching can also cause splits in the posterior limiting lamina (Descemet’s membrane) resulting in corneal clouding which then affects vision.
Management includes drops and surgery together with regular refraction. The prescription can be made up as spectacles but, especially in unilateral cases, once the intraocular pressure is under control, contact lenses may be a preferable option. The inherent difficulties of fitting contact lenses include large flat corneas, possible scarring from the previous breaks in Descemet’s, proptosis, ongoing medical treatment and drainage tubes.
Aphakic glaucoma is not uncommon after cataract surgery in infants so the aphakic prescription must be managed as well. In these children, contact lens fitting is an option both for visual (in unilateral aphakes) and cosmetic (thick spectacle lenses) reasons and once IOP is controlled, whether to fit lenses or not should be decided on a case by case basis.
Dry Eye and blepharitis
A common condition in all age groups is blepharitis. Organisms, present in most people’s eyes, may be harmless but in susceptible individuals, can cause keratitis. Staphylococcus aureus is one such organism. In conjunction with medication, treatment for blepharitis includes lid hygiene, ie heat, and meibomian gland expression.
This procedure is not easy on a squirming young child, so often it is not carried out effectively. The eyes are painful and photophobic and once the active infection is controlled, the cornea is likely to be scarred so amblyopia and photophobia result.
Dry eye and blepharitis can be closely associated or each can occur in isolation. As with adults, ocular lubricants are the mainstay of treatment for children. However, compliance is not always straightforward.
Parents may be excellent but school staff are not necessarily prepared to instil the drops during the school day. For children who require frequent drops, the treatment given is insufficient and so the condition is not adequately treated or managed.
Cataract
Congenital cataract causes a major impact on visual development. Rahi and Dezateaux found the incidence at five years to be 3.18 per 10,000 live births.2 The timing of the surgery is critical to achieve the best acuity while, at the same time, allowing the eyes to develop sufficiently before surgery is carried out.
Vishwanath et al found the risk of aphakic glaucoma is reduced if surgery is postponed to six weeks of age but, particularly in unilateral cataract, the visual acuity has the best chance of developing well if surgery is carried out very early.3 It is therefore important to plan the optimum date for surgery to take both these issues into account.
Cataract frequently occurs in association with syndromes such as Down’s syndrome or Lowe’s syndrome and investigations need to be carried out both to exclude problems in the individual and to consider risks of cataracts in future siblings or offspring.
Examination
And what about other issues affecting the child with an eye abnormality, and how should you go about actually examining them? Having an eye problem in childhood is likely to affect the general development and should not be considered alone as the eye problems will impact on their life both at home and at school and can also affect other family members in different ways.
This needs to be considered whenever a young patient is reviewed. Examinations need to be adapted both in frequency and in technique. We can use hand-held instruments which allow the child to sit comfortably on a parent’s lap while being examined but it still may not be possible to examine them adequately, in which case the correct treatment will not be initiated and the condition can worsen.
Infants and young children can be very compliant by falling asleep and then sleeping soundly enough to allow a thorough examination to be carried out but otherwise it may be necessary to carry out an examination under anaesthetic (EUA).
Parents or carers are the lynchpin of successful treatment whether it is patching the child’s better eye to reduce amblyopia, instilling eye drops or reporting adverse signs as soon as they occur. When prescribing for a child, we rely on the parents or carers to carry out the instructions they are given, and in order to do this, they need adequate instruction from the clinician.
It sounds easy to tell a parent to instil eye drops twice a day but it is not always obvious how to use a dropper bottle or unit dose vial and it helps to demonstrate to them how to go about it. Carers may be concerned that one drop is not enough or assume that they should use the whole of the vial or instil several drops ‘just to be sure’.
If a child has sufficient understanding of their condition or treatment (Gillick competence4), discuss with both parent and child what the treatment is and why it is important to carry out the instructions they have been given. For example, when fitting young people with contact lenses, those who understand the risks of poor hygiene and are shown how to carry out the relevant cleaning techniques can be better than their parents at following the rules for adequate lens care.
As with all patients, good record keeping is necessary for both patient and practitioner because, unfortunately, in modern practice, litigation is always a possibility even though it may not be justified. Records may need to be referred to at a later date, either for clinical reasons or, in the case of a complaint being made.
In the UK, records for adults have to be kept for six years after the patient episode; children’s records need to be kept until the patient is 25 years old or eight years after their death as the young person or their family can take legal action until then (BMA ethics5). Practitioners should bear this in mind and maintain their professional insurance for several years after they retire.
Paediatric eyecare
- Spectacle dispensing - Jessica Gowing
- Uveitis - Reshma Pattani
- Amblyopia - Bronwen Walters
- Glaucoma - Stephanie Figg
- Dry eye and blepharitis - Yetunde Obadeyi
- Cataract - Chris Lloyd
- Children in an eye clinic ¬ Lynne Speedwell
Lynne Speedwell is head of optometry at Great Ormond Street Hospital.
References
1 https://www.gov.uk/government/uploads/system/uploa... _National_Service_Framework_for_Children_Standard_for_Hospital_Services.pdf
2 Rahi JS, Dezateaux C. (2001) Measuring and Interpreting the Incidence of Congenital Ocular Anomalies: Lessons from a National Study of Congenital Cataract in the UK Clinical and Epidemiologic Research
3 Vishwanath M, Cheong-Leen R, Taylor D, Russell-Eggitt I, Rahi J. Is early surgery for congenital cataract a risk factor for glaucoma? Br J Ophthalmol. 2004;88(7):905–910
4 Gillick v West Norfolk and Wisbech AHA (1985) British and Irish Legal Information Institute.