Why do my child’s glasses keep getting stronger? This is one of the most common questions I encounter in my practice.  I see a patient after they have failed their vision screening exam at their pediatrician’s office and diagnose them with nearsightedness.  The following year, their myopia is worse and the glasses prescription has to be increased.  The year after, same thing happens.  I always reassure parents,”‘This is normal.  Expect the prescription to increase every year until they hit college age”.  But, of course, as a parent, it’s worrisome.   Parents always ask me about TV/video games/foods they can eat, anything that could help “strengthen” their children’s eyes.  Before, I would have to tell them that nothing could be done, it was just genetics.  But, not so anymore!

But, first, let’s just review what is myopia?  Myopia is what most people often call nearsightedness  – you can see up close, but not far away.

 

Myopia is the most common refractive error in kids, and it’s on the rise. My son is obsessed with asking if my husband is nearsighted or farsighted after we read this page in the Cat in the Hat book at bedtime.

 

For myopes, the light rays from the outside world are focused just in front of the retina.  It can be because the eye is a little longer than usual (axial myopia), sometimes for adults, it’s because there is a cataract refracting the light differently.  But, let’s stick to the kids for this discussion.

Myopic eye diagram

So, it makes sense if one parent is myopic, then the child has a good chance of becoming myopic as well.  Eye size is inherited just as hair color, height, etc.  My boys don’t wear glasses for real (though they are modeling them in the picture above), but I should qualify this as a YET.  I am not nearsighted, nor is anyone in my immediate family, however, my husband’s side is a different story.  So, there certainly is a good chance that they may require glasses in the future.

Now, here’s a little throwback to high school physics.  For nearsighted individuals, the lens shape (concave) helps to focus the light on to the retina.

Screen Shot 2015-03-17 at 12.56.21 PM

Now, to the good stuff?  What can be done?  Two new studies have come out which have had some very promising results in terms of decreasing the progression of nearsightedness in kids.

1.  Increase Time Outdoors

One study examined 2000 children in Australia and specifically looked at the type of activities children were doing.  They then followed-up the kids 5- 6 years later to figure out which activities seemed to make a child more nearsighted.

  • Time spent indoors
  • Time spent doing near work (reading, homework, iphone, etc).
  • Family history of nearsightedness

So, what does this mean.  Being outdoors in the sunlight, is protective.  Kids who spent 1-2 hours/day outdoors, were on average a whole diopter less nearsighted than their peers who did not.  That would mean -3.00 prescription instead of a -4.00 prescription. And, the more time kids spent indoors on devices made their myopia worse.

But time spent doing near work, in and of itself, did not cause nearsightedness.  So, the belief that too much time spent on the iPad/iphone will cause a child to need glasses is incorrect.  I am asked this leading question at least daily by parents “Using the iPhone or playing video games is bad for the eyes, right?”  .  They look at me hopefully, expecting me to dispense a lecture to the kids of the dangers of said devices.  But, unfortunately, it’s just not true.  Now, what I do tell them, is that first and foremost, too much time spent on these devices is not great for their brain.  A policy statement issued  by the American Academy of Pediatrics warned about the dangers of attention problems, sleep difficulties and obesity from too much time spent on media devices.  However, there have been no conclusive studies which link media devices with eye or vision problems.  BUT, when kids are playing on these devices, it does make it more difficult to get them outdoors, in the protective UV light and that can make them more nearsighted. So, is it the bright light or the UV light that’s protective?  Well, studies in animals seem to indicate that it might just be bright light which is helpful, though it’s still too early to draw conclusions.  However, I still recommend that kids should always wear protective hats, sunglasses and clothing when outdoors, especially here in Hawaii.

Being myopic is not just a pain for children to wear glasses, it can also have serious consequences in terms of the health of a child’s eye.  People who are myopic have longer eyes than individuals who are not.  That predisposes them to having retinal tears and detachments if their prescription is higher than -6.00 D.   It’s basically because the same amount of retina is being stretched more in a myopic eye than in a normal eye.  This can leads to areas of thinning or tears which can cause retinal detachments.

 

2.  Atropine 0.01%

Another important study assessed the effectiveness of a dilute version of a dilating drop – atropine – in delaying the progression of nearsightedness.  Studies have been done with different strengths of this drop in the past, but as you may know from going to the ophthalmologist, even when dilute, dilating drops can cause side effects, like blurry vision and sensitivity to sunlight.  But, this study looked atropine 0.01%, which is 1/100th the strength we use in the clinic.  When administered daily to kids, it slowed their nearsightedness and also decreased the elongation of their eyeball.  Therefore, they were less at risk for those dangerous retinal tears or detachments.  I now offer these drops to a high select group of patients who have nearsightedness which is worsening quickly.

Schools in China are already applying the outdoor time in an effort to decrease their incidence of nearsightedness.  And, for those kids for whom this preventative treatment is not enough, then there is hope with the atropine drop.  As more studies come out, the research will be even better in helping us slow nearsightedness in our kids.

 

Jan 2018 Update:

I have now been prescribing low dose atropine for the past 3 years.  I have about 10 patients who have completed treatment and another 40 or so who are currently undergoing treatment.  I have been impressed with its limited side effects and the its efficacy.  However, it’s a difficult treatment – simply because it requires putting an eye drop in a kid’s eye ever single day.  If you have kids, then you know, that can be quite a challenge.  It’s just adding one more thing to the list of things that needs to be done.  But, I do think it’s worth it, so talk to your pediatric ophthalmologist about it and see if your child is a good candidate.

 

I just did a recent article for Midweek about pink eye.  Feel free to check it out – I just talk about prevention and treatment of conjunctivitis.  But, that’s not the topic of this post.  The Midweek writer’s first question to me was “What got you interested in pediatric ophthalmology?”.   I’m lucky enough that this question is such a non-brainer.  Is there anything better than restoring sight to a child? Complex surgery or a simple pair of glasses – both are so important in the developing vision of children.  That question made me think about one of our my first patients here in Hawaii.  I worked for a year after my fellowship as an attending at Boston Children’s Hospital. but there I was surrounded by senior physicians.  If I needed help on a case, or advice, they were there to assist.  When I moved out here with my husband 6 years ago, it was, honestly a bit terrifying.  I had lost my safety net and I had to build a practice from the ground up, somehow convincing parents that despite looking young and inexperienced, that I actually was a capable surgeon.

Niko was just a 6 year old boy when he came into see me my first month practicing at Honolulu Eye Clinic.

He had previously been living in California and had recently moved to Hawaii.  His mom had noted that he squinted a lot.   Niko was a smart little boy, but he had real trouble with the eye chart.  When I dilated his eyes, I discovered cataractsin both eyes.  A lot of people are often surprised that children and even babies can get cataracts.  It’s obviously much more rare than in adults, but it does occur.   I met with Niko and his sweet mom, Louise and told them that we should schedule surgery for Niko.

Marking Niko's eye for surgery in the pre-op area

This is what Niko’s mom wrote about her experience:

We first found out about a vision problem when Nikolas and I were reunited in Hawaii after a year of separation due to an illness of mine. He spent kindergarten year in San Jose California with my parents and siblings while I received treatment.While in San Jose he complained about not being able to see the board at school towards the end of the school year. When I picked him up and brought him back to Hawaii I decided to take him for a complete physical and suggested to the clinic physician for an eye exam as well.  They tested his eyes and we discovered that he couldn’t read most of the letters. The optometrist doing the exam referred us to Dr. Wong. He said that Niko may have cataracts. I was shocked and worried because he had just turned 6 yrs old.
 
Dr. Wong and her staff were so warm and welcoming. Even before we stepped into the clinic, I had already spoken to her on the phone several times. She told me about herself and her experience that gave me such relief to have found someone that can help my sons condition.  She performed surgery first on the right eye about 4 wks later and the left eye another 4 wks after that. The surgeries went well and Niko mentioned that everything so much brighter than before on the way to school a few days after. I was moved to tears of joy.
He now wears bifocal glasses that he loves and thrives in school. He is always excited to see Dr. Wong and her loving staff for regular check ups. He even mentioned to me several times that when he grows up he wants to become an eye doctor just like Dr. Wong so he can also help others see better.
 

Niko gave me this card.  Six years later, I still keep this card at my house.

After surgery, Niko’s first words to me were “I  can finally see the clock in school!”  His vision improved to 20/20 in each eye.

Each time he came for his post-operative visit, Niko would show off his latest dance moves for my staff.  I mean, seriously, is there anything better than getting that letter from a Mom or this card from a six year old?  He got cute bifocal glasses which he proudly wore all the time.

And, now 6 years later, Niko is an aspiring actor and model!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I know pediatric ophthalmology is not one of the “sexy” subspecialties of ophthalmology.  Everyone wants to do Cornea or Cataract with all the fun laser cataract machines or Retina with the cool new macular degeneration drugs that are coming out.  But, peds/strabismus has its HUGE rewards and I for one, cannot think of anything else I’d rather do.

 

 

 

Children and infants may not be as interested in the fashion statement of sunglasses.  But, babies and kids spend as much as time outdoors in direct sunlight as adults, especially here in Hawaii.. In addition, the crystalline lens inside the eye of people younger than 30 years old is more susceptible to damage from UVB light than that in older adults.  Not only does this susceptibility potentially cause earlier cataracts, but because their lens lets in more damaging UVB light, the retinas of children are more prone to UV toxicity.

So, UV protection for their eyes is even more important for them than for adults.  In the same way that you cover your children in sunscreen and protective hats and clothing when they go outside, so too should their eyes be protected.  Ultraviolet radiation is a great concern in sunny places like Hawaii.  UV light is a part of the light spectrum from the sun to the earth.  Remember this picture from high school?

uv light jpg
In fact, most experts believe that children get 80% of their lifetime UV exposure by the time they are 18 years old!  UV exposure has been linked to the development of cataracts, macular degeneration and other ocular diseases. The risk of retinal damage from sunlight is greatest in children less than 10 years old, although the eye diseases do not develop until adulthood.  UV exposure is the greatest when children are out between the hours of 10 am and 2 pm and if they’re near large sandy beaches and reflective bodies of water.

All sunglasses are not the same.  Effective sunglasses should protect against UVA and UVB light. What’s the difference, you may ask?  Experts used to think that only UVB was harmful, but now additional research has confirmed that UVA light also penetrates the atmosphere causing skin cancer, premature aging and eye damage.  In fact, UVA penetrates the skin and eyes more deeply than UVB light.

However, many expensive sunglasses do not filter out UVA light.  So, it is extremely important to double check that the sunglasses your purchase protect against both UVA and UVB light.

LENSES:

Look for a label or a sticker that says one or more of the following:

  • Lenses block 99% or 100% of UVB and UVA rays
  • Lenses meet ANSI Z80.3 blocking requirements. (This refers to standards set by the American National Standards Institute.)
  • UV 400 protection. (These block light rays with wavelengths up to 400 nanometers, which means that your eyes are shielded from even the tiniest UV rays.)

It should either be marked on the sunglasses or the optician will be able to inform you.

FIT:

Sunglasses should properly fit your child’s face.  If the glasses are too big around the temples or don’t fit their nose bridge well, then they will be continuously falling down.  For infants, I really like the Julbo line.  They are soft and flexible, so they fit babies’ flat noses well, without indenting their nose.   Also, wrap around styles provide the best coverage and protection.  Here’s my son in his Julbo sunglasses when he was around 7-8 months old.

 

Once we started taking him to the beach with us, I put him in sunglasses.   It’s never too early to start having your child wear sunglasses.  Also, of course, he is wearing a large hat, full length UV rash guard and sunscreen.  I always joke with my dermatologist friend that you can spot the doctors’ kids at the beach a mile away.  They’re always totally covered up, whereas other kids are just wearing diapers or little bikinis.

 

POLARIZATION?  WHAT IS THE DEAL?

Another question I get a lot is about polarized sunglasses.  Polarization reduces glare, by filtering out sunlight that bounces on reflective surfaces so it is helpful for people who spend a great deal of time on the water.  However, it is important to note that polarization has nothing to do with UVA/UVB protection.  Just because a pair of lenses in sunglasses is polarized does not mean that it also has UV protection.

 

Above, my younger son is wearing Babiators sunglasses which we have available in our Optical Shop with polarization.  Department stores like Nordstrom also carry them, but without polarization. My older son is wearing no-name sunglasses that I picked up at the store (but they do have UVA/UVB protection) and I’m wearing the new summer Ray-Ban Erika sunglasses, which we also have in our Optical shop.   I love these, they are so light and I feel like they look like candy.  My husband says I have sunglasses addiction, and I might have a collection to rival Brad Pitt’s.  But, hey, we live in Hawaii and I just reviewed all the reasons why sunglasses are medically necessary, so it’s shopping for a MEDICAL reason (that’s my justification for my 8 pairs!)

But, getting back to the kids.  Kids really only care that the glasses are comfortable, otherwise it’s near impossible to get them to keep them on their face. At Honolulu Eye Clinic, our opticians are skilled at knowing the type and fit of glasses best suited to protect your child’s eyes from harmful sunlight.  Our optical shop carries sunglasses for infants to adults, all of which block UVA and UVB light.  I would avoid buying sunglasses for kids online unless you can try them on your children first to insure a proper fit and that your child will tolerate wearing the sunglasses.

 

 

With the holiday season fast approaching (I know, how did it become December already??), you might have started doing some early toy shopping for the little ones in your life.  Given the season, it’s no surprise that December is Young Children’s Safe Toys & Gifts Awareness Month.  Prevent Blindness America declared the day and urges parents and consumers to be conscientious when purchasing gifts for young children.  A few tips when choosing toys:

 

 

  • Choose age appropriate toys with care.  Make sure gifts are suited to the developmental and skill level of the child. And, when buying for kids that aren’t your own, keep in mind the other siblings in the house.  Now that I have 2 boys – a responsible 3 year old a rascaly 1 year old, I often find that the baby wants to play with his older brother’s toys.  You may intend a toy for an older sibling, but be mindful that it may end up in the hands of a younger sibling.
  • Discard all plastic wrapping, twist ties, etc immediately.  I never used to understand this photo below before I had children.

 

 

 

 

 

“Of course a bag is not a toy,” I used to think. And then I had my first son, and I quickly discovered how much little children love plastic bags – it’s crazy.

  • Buy quality toys with sturdy construction that don’t easily fall apart.  When my eldest son was just born, I hate to admit that I was one of those snobs that only wanted beautiful wooden toys for my children.  No plastic toys for my kids.  Now, I’m a little less strict and though I still appreciate the beauty of a hand-made toy, sometimes my son just wants a Captain America figurine.  But, you should still check to make sure that the toy has passed safety standards.  There should be a sticker: labeled, American Society for Testing and Materials standards.
  • Read the labels.  I’m not usually a direction reader, but I do read the labels and adhere to the recommendations for the age of the child who should be playing with the toy.
  • Avoid toys with cords and strings for young infants since they pose a strangulation hazard.
  • Avoid projectile toys.  I’m always reminded of the scene from “A Christmas Story” –“You’ll shoot your eye out kid.” As a pediatric ophthalmologist, this one is near and dear to my heart.

 

 

 

 

 

 

 

 

Obviously, the last place you want to be on Christmas morning is in the Emergency room for an eye injury.  There are many types of projectile toys and most of them are fun.  If you are purchasing one, you want to make sure that the child is old enough to responsibly play with the toy and that adult supervision is present.

  • Avoid the following:
    • Toys with small parts and sharp edges and points.
    • Crayons and markers that are not labeled nontoxic.
    • Toys that could shatter into fragments if broken.
    • Electric toys with heating elements.
The U.S. Consumer Product Safety Commission has some great consumer guides available on their website detailing the types of toys appropriate for each age level,toy hazards and latest recommendations.
Here is an example of a perfectly safe toy that was given to us for my son’s birthday last month.  I’m not sure if this qualifies under the “Loud Noises” category above, I think my husband believes it does!
 

I was listening to the radio the other day about the new concussion policy rules that a lot of youth football leagues now have in place.  It started me thinking about the many eye injuries I see as a consequence of sports and trying to increase awareness about these potentially devastating, completely preventable injuries.  I’m a little late – September was Sports Eye Injury Prevention Awareness Month (that doesn’t exactly roll off the tongue, does it?)  But the message is important, even if the name of the month is a bit long.

Below is one of my favorite patients and what happened to him should serve as a cautionary tale for all parents whose children are involved in sports.  This kid was 10 years old, playing baseball and accidentally walked behind the batter.  He was struck in the face with the bat (accidentally) and suffered from numerous fractures of his face, the bones around his eyes and lost vision in the right eye from the trauma.

Dr. Timothy McDevitt was able to repair the fractures in Kaliu’s face and I performed surgery to straighten his eyes.  Here he is post-op.  Click here for his mother’s testimonial about her son’s surgical experience at Honolulu Eye Clinic.


He looks great post-operatively and we were able to make the eye look much more normal. Unfortunately, there was no way to restore his vision in the right eye.  As a mother of 2 young boys, this kind of preventable injury hits close to home.  I always think that an injury like this could have been prevented if all of the children on the baseball field had been required to wear sports goggles (also called recreational spectacles).

One problem I’ve noticed is that often kids (and even their parents) will wear their regular glasses when playing sports.  But, you shouldn’t!   More than 40,000 sports-related eye injuries occur every year.  Blunt trauma, such as a ball hitting the eye cause the majority of these injuries.  Some parents also mistakenly think that the helmets with face shields are enough to project the eyes (like football helmets).  But, this is not true.  Your child’s eyes are still exposed to penetrating sports equipment or fingers! Kids and teens have high rates of sports-related eye injuries because of their wide involvement in athletics in school and their tendency to play aggressively. The types of eye injuries can vary including:

1. Corneal abrasions

2. Bleeding in the eye (hyphema)

3. Fracture of the bones surrounding the eye (orbital fracture)

4.  Retinal detachment, or even rupture of the eye.

 

Depending upon which part of the eye is damaged, permanent vision loss can result and surgery may be required to repair the eye. Wearing eye protection significantly reduces the risk of these injuries by ninety percent!

Recommended Protective Eyewear
Many people mistakenly believe that regular glasses or contacts can protect their eyes. Yet, glasses can break upon impact causing a penetrating injury to the eye and contacts do not protect the eye at all.
The American Society for Testing and Materials (ASTM) has standards for the types of sports goggles to be worn in various sports. All sports goggles should be made from polycarbonate.   Polycarbonate is a high-impact resistant plastic that offers UV protection and can be made in prescription or non-prescription lenses. Regular eyeglasses only have 5 percent of the impact resistance of polycarbonate lenses.  Even though all children’s eye glasses are made from polycarbonate, the frames can still bend and break in the eye, making them unsuitable to wear during sports.

At HEC, we carry Liberty Sport goggles, so I’m most familiar with them, pictured below.

They are a type of protective goggles especially designed to be worn during sports. Fitting most prescriptions, Liberty Sport brand goggles are tested and approved to withstand high impacts. They have very soft padding on the bridge and sides of the frame aimed to protect the bridge of the nose as well as the temples. Their wrap design helps prevent dirt, dust, and even UV rays from damaging the eyeball and the delicate areas surrounding the eye.  Liberty Sport goggles automatically come in the polycarbonate lens material mentioned above and can be ordered clear, or with polarized sunglass lenses, or also with Transitions Lenses (also known as photochromic lenses)–which turn from clear indoors to dark, sunglass-type lens when exposed to UV light outdoors.  They are also designed to fit under sports helmets (baseball, football, etc). And the best part, as mentioned above, is that we can customized them with yours or your child’s glasses prescription in them.  I have some patients that like to wear these as their regular glasses! Of course, they also come in a wide variety of colors and styles.

Whichever type of sports goggles you choose, just make sure that it has polycarbonate lenses and is certified by American Society for Testing and Materials as safety goggles.

 

 

 

 

We live in Hawaii and allergies are a huge problem here compared to the mainland.  For 8 years, I lived smack in the middle of Manhattan and the pollution and dirt never caused a problem.  But, my first month of living here, the flora and VOG of Hawaii put my allergies on overdrive!  And along with allergies and the symptoms you think of  runny nose, sneezing, coughing, comes ocular allergies.

In children, allergic conjunctivitis can present like this:

The video cannot be shown at the moment. Please try again later.

 

His eyes are only slightly red, but he has a little cough (which isn’t associated with a cold) and a little sneezing and there’s that non-stop blinking.

First, I should back up – what is the conunctiva?  It’s the mucous membrane of your eye – the white part and the pink part on the inside of your eyelid.

 

6 Signs of Allergic Conjunctivitis:

1.  Itching

2.  Tearing

3.  Redness

4.  Mucous discharge from the eyes

5.  Allergic shiners (look like black eyes underneath the eyes)

Allergic shiners (under the eyes)

6.  Blinking

 

There are many different kinds of allergic conjunctivitis that your eye doctor can diagnose.  This is not the same as “pink eye”.  There is no infection and it’s not contagious.

Types of allergic conjunctivitis:

– Seasonal or year round (perennial) allergic conjunctivitis – some people are specifically allergic to mangoes or only to VOG

– Vernal conjunctivitis – I see this a lot.  Tends to happen in young boys and needs aggressive treatment.  These boys will have really red eyes, light sensitivity and are at risk for losing vision in advance stages of the disease.

– Giant papillary conjunctivitis – that’s for all you contact lens wearers out there.  If you overwear your contacts, you can develop a reaction to the material, making your eyes red and intolerant to wearing contact lenses.

 

I am mainly going to discuss seasonal/perennial allergic conjunctivitis in this post.

So, what causes allergies?  Allergies are mediated by a type of white blood cell, called a mast cell.  It has a special form in the conjunctiva.  And, when it gets activated by the thing you’re allergic to (also called the allergen), it releases chemicals.  These chemicals, such as histamine and prostaglandins, are what cause symptoms of allergies.  They cause blood vessels to become large and leaky, causing redness, swelling and itching.

Here’s the kind of chart that other opthalmologists like to show each other when explaining allergy.  I swiped it from my husband’s presentation he had given on allergy.

 

 

Allergic response

 

So, how do we treat allergic conjunctivitis?

  • Allergen avoidance – this is ideal, but it can be hard in Hawaii.  Can’t exactly avoid VOG, and did you know cockroaches are really allergenic?  Hard to find a place here without cockroaches.  However, I always tell patients to try avoiding touching and rubbing their eyes, which is how a lot of allergens get in the eyes in the first place.
  • Cold compresses (not warm!) – I know patients sometimes get confused, we tell them warm compresses for this, cold for that.  But for allergies, we want cold compresses to make the blood vessels smaller and leak less.
  • Systemic medications – Benadryl, Claritin (anti-histamine), Zyrtec.  These medications are taken orally, and may not be helpful for the eyes at all.  In fact, they can often cause dry eye, making the symptoms of allergic conjunctivitis even worse!
  • Eye drops

 

Let’s talk about eye drops for allergic conjunctivitis.  Many patients will self-treat with over-the-counter drops such as Visine, which constricts the blood vessels and takes away the redness, but does nothing to treat the allergic reaction.  Then there are over-the-counter drops such as Visine-A, Naphcon-A, and Opcon-A which have a weak antihistamine.  They are safe and effective for short term use, but the preservatives in these drops can be harsh and irritating to the eyes.  Also, the effect from these drops lasts only about 2 hours, so patients must overdose themselves in order to get all-day relief.

When I tell patients that they shouldn’t use Visine, they’re always quite surprised.  But, it really isn’t the best drop you can use.

There are also some people who use Similasan Eye Allergy homeopathic drops, however there is no scientific evidence that these drops work.  In general, most eye doctors discourage the use of these over-the-counter eye drops.

Fortunately, we have some much better prescription drops for allergic conjunctivitis.  Pataday, Lastacaft, Bepreve, and Elestat are some of the best drops for allergic conjunctivitis.  They not only block histamine’s nasty effects, but also prevent histamine from being released.  Pataday and Lastacaft only need to be given once a day.  All of these drops are very safe, and can be used long term.

If you have a red eye, you should see your eye doctor – don’t diagnose it yourself.  There are many different causes of red eyes which can be dangerous or vision threatening (like uveitis, corneal ulcers, trauma, angle closure glaucoma, corneal abrasions or foreign bodies).  There are also many different causes of blinking in children (tic, dry eyes, Tourette syndrome, irritation from eyelashes etc). Get it checked out first!
 

Latisse Update

So, after much deliberation, I have decided not to do the Latisse challenge.  The reason is because I’m still nursing and Latisse is not FDA approved to be used in pregnant or nursing mothers.  I knew that beforehand and I’ve never prescribed it to a patient who is pregnant or nursing, but my overzealousness to have nice lashes almost got the better of me.  I figured that the amount of Latisse that is systemically absorbed is quite small.  But, when I sat down and really considered it, I realized it just wasn’t worth the risk.  Though I’m not a patient person, I would rather wait 6 months and know for sure that I am not harming my baby.  The only time I used it was when I posted the video.  So, instead I’ve put one of my staff on Latisse and I’ll be posting pics of her every 2 weeksThis is obviously not a picture of my employee’s lashes, but my son, Nikhil has the best lashes, so I just decided to post a pic of him until I get the staff pics uploaded.

 

Tear Duct Update

On a happy note, Taj’s nasolacrimal duct obstruction has completely resolved.  It’s interesting, it appeared to be worsening one day and then all of a sudden there was no discharge, no tearing.  So, parents out there – continue the massage, it really does work.  I did the Crigler massage much more consistently than the antibiotic ointment or warm compresses.

No more tearing or discharge!

 

 

This is probably one of the most common questions I get asked by parents.

How do I know if my child has poor vision?

Usually this question is asked when the children are pre-verbal or if they can’t quite yet read the eye chart. A lot of parents mistakenly think that there is no way to figure out if the infant or toddler needs glasses and that just isn’t true.  As parents, there are a couple signs and symptoms you can look out for which may indicate that your child is having difficulty seeing. These might not always mean that your child needs glasses.   Sometimes, certain things can be habit (squinting or tilting the head) or sometimes they can mean your child needs glasses or has a more serious eye problem.

– Squinting or tilting the head or face

-Headaches

– Eye crossing or drifting out (strabismus)

-Closes one eye when reading

-Difficulty walking or meeting developmental tasks – I had one little 9 month old girl as a patient, her parents noticed that she wasn’t able to pick up her Cheerios as well as the other babies her age.  They brought her in to see me and it turned out that she had strabismus (misalignment of the eyes).  I operated on it and within a few weeks, she had taken her first steps.  Click here to read the full story of this patient.

-Trouble in school.  – Your child’s teacher may comment that your child is inattentive or has trouble with certain tasks.

When should my child’s eyes be examined (or vision tested?)

The American Academy of Pediatrics and American Academy of Ophthalmology recommends that all children have their vision checked at the 4 year old visit at the pediatrician’s office.  If your child is premature, has other medical problems, or you have noticed abnormalities, the child can be checked earlier.

A lot of times, parents second guess themselves.  You know your child.  Please do not listen to anyone (doctor or otherwise) who tells you that your child is too young to have their eyes are examined.  This is simply not true.  I have caught many problems when examining young babies, because their parents (and their pediatricians) were astute enough to know that something was not right with their kid’s vision.  Listen to your instincts – they are often right.

So, on to the second part of the question.  You think there might be something wrong with your child’s vision.  But, you child is only 1 or 2 years old -surely an exam can’t be done, you wonder?  Wrong!  I can do a full and complete eye exam on almost any child and examine infants routinely.  The nice part of being a pediatric ophthalmologist is that I actually don’t need the patient to really tell me too much of anything.  I can take measurements and deduce exactly what needs to be done.  So, to the second question:

 How does the eye doctor know if my child needs glasses?

Examining a child is different than examining an adult.  Obviously, I can’t ask your kid “which is clearer, one or two?” and have them help me decide what glasses to prescribe.  But, there are lots of other techniques that a pediatric ophthalmologist uses to figure out what your child is seeing and how well.  The most important things I have are toys and a separate waiting room for kids with lots of things to occupy them.

In the exam room, I have movies for kids to watch and lots of patience…and I’m quick.  It takes a certain personality to examine kids and those are the people who are typically pediatric ophthalmologists.

 

 

 

For kids, I always perform a comprehensive eye exam.  I check vision whenever possible.  If the child does not know his letters, then I use a substitute, such as some of the charts below.

If they’re too young to know their shapes, then I will use a toy and cover one eye at a time, testing to see if they follow the toy around.  I then check to make sure the eyes are straight by checking the corneal light reflex and cover/uncover test.  If the child is old enough, I will use the slit lamp to examine the anterior structures of their eye, but if they are too young, then I will use a strong light and a magnifying glass.

But, how does the doctor check what glasses prescription they need?

I dilate the pupils to relax the focusing muscles of the eye to obtain accurate measurements of refraction.  I use a special instrument, called a retinoscope and lenses of different powers, to arrive at the correct prescription.

 The nice thing is that I don’t need your child to tell me if his/her vision is blurry, or if they see better with a certain lens.  This is the way I can figure out the correct glasses prescription that an infant requires. (I have given glasses to a child as young as 9 months old!).  And it also means I can tell when a child just says their vision is blurry to get glasses, but they don’t really need them.  By placing the different lenses in front of the child’s eye and using the retinoscope, I look for a certain reflex of light back through the pupil.  When the correct lens is in place, the reflex becomes very bright and fills the lens.

And, you might ask –

Why are kids’ eyes dilated?

Children have a large accommodative amplitudes (measurement of the eye’s ability to focus on near objects) and that can change the measurement of the prescription.  If a child is not dilated, then a prescription that is more myopic (minus) than necessary may mistakenly be given.  That is why it is important that the ophthalmologist or optometrist you take your chid to, should always dilate his/her eyes before determining the glasses prescription.  Click here for the handout I give all my patients regarding dilating drops in children.Dilating Drops handout

X games glasses (boys)

Coach glasses (popular with tweens!)

Our Juicy Couture glasses - moms and tweens love them!

And, if your child needs glasses – don’t despair.  Often, I have found that parents are more upset about the prospect of the child wearing glasses than the child is themselves.  I tell the parents to let the child choose the frames, so that they are happy with the glasses.  We have so many new great pediatric frames in our Optical Shop, that 99% of the time the child is able to find something they really like.  Almost all of the designer frames in our shop have a 2 year warranty, which is also really important with kids.

 

 

 

 

My patient below actually chose these super cute frames himself (he’s 3 years old and he knew exactly what he wanted!).

Bottom line, if you, your pediatrician, or your child’s teacher are concerned about your child’s vision, please take your child to see a pediatric ophthalmologist. There is no age too young for an examination.

 

Gunk…not exactly a medical term, but a descriptive one nonetheless. Any parents out there reading this are probably familiar with the following scenario.  After the trauma of childbirth (for mom, that is), you feel so blessed to hold your child close and the first thing you do is make sure everything on him/her is perfect.  Then, a day or two later, you may notice that there’s a lot of mucus in your infant’s eye, maybe even so much to cause it to stick shut.   The eye is constantly wet with tears.  Is it an infection?  Do you need antibiotics?

What I described is a blocked tear duct, or ophthalmologists refer to it as a neonatal lacrimal duct obstruction (NLDO).   Both of my sons suffer from this condition (UPDATE: Even my little baby girl had NLDO, so all 3 of my kids had this).  Nikhil is now 2.5 years old and his is much better, but Taj’s is actually pretty bad.  The good news is that it isn’t an infection and it isn’t contagious.  There are some things that parents can do to help improve matters and lessen the tearing.  I wanted to post on this topic since Taj currently has this and I have been treating him at home.  Just yesterday, my husband, Dr. Jeff Wong, turned to me and asked “How do you do the massage thing again?”  And I thought, if he (a well trained ophthalmologist) can’t remember how to do the massage, then, for sure my patients’ parents may be forgetting as well.

First, what is a blocked tear duct?

The tears are constantly manufactured by glands within the eyelids. After lubricating the eye, the tears normally drain into two small holes (“puncta”) located on the inner corner of the upper and lower eyelids. Look in the mirror and you can find these puncta on your own eyelids.  From there, the tears drain into the back of the nose via the tear duct (a.k.a. nasolacrimal duct). This is why we tend to have a runny nose when we cry! Infants with a nasolacrimal duct obstruction typically have a blockage at the most distant end of the duct immediately before it empties into the nose

Blockage at the end of lacrimal duct

Clinical Review Fortnightly review: Managing congenital lacrimal obstruction in general practice BMJ 1997;315:293

 

Approximately six percent of all infants are born with a nasolacrimal duct obstruction (tear duct blockage) affecting one or both eyes. Fortunately, the good news is that at least 90% of these obstructions will clear without treatment within the first year of life.

What are the signs of a blocked tear duct?

As the tears have nowhere to drain, they will well up on the surface of the eye and often overflow onto the eyelashes, lids and cheek. Normally there are bacteria in the tears and now these have nowhere to drain when a blockage is present. These bacteria tend to grow within the tear duct and cause a pus-like discharge from the inner corner of the eye and on the lashes — frequently observed when the child awakens.

It is important that see your pediatrician or pediatric ophthalmologist for a correct diagnosis.  There are other serious and vision threatening conditions which can cause tearing in a newborn and those need to be ruled out.

Here’s picture of Taj.  See the yellow crusting mucous in the corner of his left eye and on his eyelashes causing them to stick together?  Even though it looks troubling, it doesn’t bother him one bit, which is very normal.

So, what can be done?

Since these obstructions resolve by the time the baby is 12 months old, I manage the condition very conservatively.  I typically recommend the following:

  • Crigler massage (see video down below).  This is basically massage of the tear duct to get it to open up and create a patent system for the tears to flow.  To perform the massage, use your index finger in the corner of the eye, right below the eye and roll the finger downwards over the bony ridge towards the nose.  This has been proven to work.  Success rates in published studies range anywhere from 30-90%.  Do this three times a day.  It’s easy, free and doesn’t harm the baby, isn’t that the best treatment?  You can see in the video, sometimes it’s tricky performing the massage in an infant (in my case, Taj always seems to think my finger is more food for him).  Usually I will use my other hand to stabilize his face, but for the video, it was getting in the way of the shot of Taj’s face, so that’s why he’s moving around so much.
  • Warm compresses
  • Antibiotic drops – these will need to be administered by your pediatric ophthalmologist if there is a lot of green-pus discharge.  I typically recommend erythromycin ointment  and it’s what I’ve been using intermittently on Taj
  • Breastmilk – This is not a medical recommendation, and I’m going to preface this. A lot of old folklore, Ayurvedic medicine and maybe even your Hawaiian auntie down the street has recommended breastmilk for everything.  Breastmilk has a lot of wonderful properties, one of which is that it contains IgA, a type of antibody.  The theory is that squirted into the eye, the breastmilk prevents the adhesion of bacteria to the eye and decreases the discharge.  I only found one published study as to the effectiveness of breastmilk and because the journal was a bit obscure (Journal of Pediatric Tropical Medicine), I wasn’t able to read the full article to evaluate it.  However, I will say that one of the pediatricians who routinely refers to me was always recommending this to her patients and I thought this weird.  Yes, I know my background is Indian and I should be down with the Indian home remedies, but I usually require hard published data before I change my practice style.  But, Taj’s eye was pretty bad.  The antibiotic ointment wasn’t doing too much, so I figured, why not give the breastmilk a try.  And, I have to admit, it really improved things for Taj.  The swelling and amount of discharge lessened considerably.
  • Probing and irrigation.  This is surgery.  I pass tiny smooth wire probes through the tear duct and into the nose, in order to open up the passageway.  For adults, we can do this procedure in the office, but obviously a baby is not going to stay still for you to insert long thin metal probes in the eyelids, so this must be done in the operating room under general anesthesia.  It only takes about 5 minutes and usually cures the condition.  I only do this surgery if the baby is older than 12 months because as I mentioned earlier, 90% of the time, the blockage will clear itself so why put your child through the risk of general anesthesia if not necessary?  That being said, this is probably one of the most common procedures that pediatric ophthalmologists perform.  It’s very safe and effective. There are no incisions or scarring from this operation and there is no significant post-operative discomfort.  Just see here for a post by a patient’s mother about the procedure.IMG_1939

Here is what the probes look like.  I start out using the tiniest diameter probe (on the left hand side) and then increase the size, confirming that I’ve opened up the passageway.  Sometimes, if the child is older (older than age 2), then I may also insert a silicone tube to keep the duct open.  I remove this 3-6 months later.  The tube is extremely small and pliable and children do not feel it at all.

So, if your child is like mine – a newborn diagnosed with a lacrimal duct obstruction, don’t worry, 9 times out of 10, this will get better all on its own.  It resolved with Nikhil,  but, if it doesn’t, the surgery is minimally invasive and painless and that’s a reason to jump with joy.

 

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