Pediatric Ophthalmology

Little girl laying on a dock looking at goldfish in a jar.

Blocked Tear Ducts

Approximately one-third of all newborns have excessive tearing. It occurs when a membrane (a skin like tissue) in the nose fails to open before birth, blocking part of the tear drainage system. If tears do not drain properly, they can collect inside the tear drainage system and spill over the eyelid onto the cheek. Rarely, the tear duct itself may become infected leading to a serious infection called dacryocystitis. If the skin of the inner portion of the eye becomes red and swollen and the child is having difficulty opening the eye, you should contact your ophthalmologist or primary care physician immediately as this condition requires emergent treatment with antibiotics.

Tear Duct Probing And Irrigation Videos

Tears are produced to keep your eyes moist. As new tears are produced old tears drain from the eye through two small holes called the upper and lower punctum, located at the corner of your upper and lower eyelids near the nose. The tears then move through a passage called the canaliculus and into the lacrimal sac. From the sac, the tears drop down the tear duct (called the nasolacrimal duct), which drains into the back of your nose and throat. That is why your nose runs when you cry. In infants with overflow tearing, the membrane blocking the tear duct prevents tears from draining into the back of the nose and throat.

Tearing can also be caused by wind, smoke or allergies, or other environmental irritants. A very rare condition called congenital glaucoma can also cause excessive tearing. With congenital glaucoma other signs and symptoms will accompany tearing, such as an enlarged eye, a cloudy cornea, high eye pressure, light sensitivity and eye irritation.

Treatment of Blocked Tear Ducts

Blocked tear ducts can initially be treated by applying massage over the lacrimal sac, applying antibiotic eyedrops or ointment to the eye, and cleaning the eyelids with warm water.. To massage the tear ducts, place your finger under the inner corner of the infant’s eye next to the nose, and roll your finger over the bony ridge while pressing down and in against the bony side of the nose. This movement helps squeeze tears and mucus out of the sac.

The blocked tear duct often spontaneously opens within six to twelve months after birth. If overflow tearing persists, it may be necessary for your ophthalmologist to open the obstruction surgically by passing a probe through the tear duct.

Tear Duct Surgery

Dr. Dorfman and Dr. Cardone perform tear duct surgery as an outpatient surgical procedure. Surgery is usually performed at the approximate age of 1 years old after all conservative measure such as massage and antibiotic drops fail to resolve the condition.

Under sedation, a thin, metal probe is gently inserted through the tear drainage system to open the obstruction. The drainage system is then flushed with fluid to make sure the pathway is open. The procedure is usually completed in a matter of minutes.

Your child should soon be able to resume normal activities upon discharge from the surgical center. Clear liquids in small amounts are advised for the first few hours following surgery. As soon as the effects of the anesthesia have subsided, a normal diet may be resumed. You may bathe the child and the child may resume all usual activities the day after surgery. Swimming however, should be avoided for 2 weeks.

Following the surgery, your child will be on an antibiotic drop twice daily. Parents may see some blood tinged tears, or nasal discharge. Tearing may persist for a time after the procedure due to normal post-operative swelling. All these should resolve within a short time after surgery. Your child will return to see Dr. Dorfman or Dr. Cardone 1-2 weeks following the procedure.

In a small percentage of patients the tearing may persist despite the surgery. In these cases an additional probing procedure is required, often with placement of tubes within the tear drainage system to stent the tear ducts open.

Focus Effort & Eye crossing

There are many types of eye crossing in children, however, one of the most common is related to the ability of the far-sighted children to focus at near.  Children with far-sightedness have more difficulty seeing objects up close than in the distance and thus require more effort to focus on objects at near.  The ability to focus on a near object also requires that the eyes turn inward to remain focused on the object. Since eye crossing and focus effort are linked together, children can develop crossed eyes when they are using too much effort to focus on objects of interest.

To see better and reduce the effort of focusing, children with a large amount of far-sightedness and eye crossing will require glasses. As the glasses reduce the amount of effort the child needs to focus on objects it also reduces the amount of eye crossing.  This condition is called accommodative esotropia.

Some children may have additional crossing only at near and can benefit from bifocals.  This provides extra focusing help at near.  If these measures do not work the child may require surgery to realign the eyes.

What if glasses straighten the child’s eyes?

The child whose eyes are held straight by glasses will be followed closely to assure that proper visual development is occurring.   As the child grows older it is possible to eventually wean them out of the glasses once visual development is completed.  Children whose eye alignment improves, but is not satisfactory may need surgery in addition to glasses.

Parents of children with this condition, often notice that the eyes continue to cross when the glasses are removed.  Crossing of the eyes upon removal of the glasses suggests only that the glasses are helping and emphasizes the need to keep glasses on the child at all times.  This crossing may continue until the child either outgrows the farsightedness or readjusts the relationship between focus effort and convergence. Most children whose crossed eyes are straight with glasses begin to maintain good alignment without glasses at about eight or nine years old.  The child with significant farsightedness or other significant optical problems may never be able to maintain good eye alignment without glasses or contacts.

What if glasses do not straighten the eyes?

When glasses completely realign the eyes and equal vision is achieved nothing further is required.  However, when the glasses do not completely realign a child’s eyes, surgery may be required.  Strabismus, like so many other conditions, requires an individualized treatment plan.  Treatment goals, briefly stated are to make your child see well with each eye individually, to make the eyes as straight as possible so that they can function as a pair, and to improve appearance. Dr. Dorfman and Dr. Cardone try to reach these goals by the safest, fastest, most effective means. Surgery is always held as the last resort by our physicians.

Special thanks to Pediatric Ophthalmology Consultants for providing the original Focus Effort and Its Relationship to Crossing of the Eye.

Amblyopia or Lazy Eye

Approximately 5% of all children will develop an eye condition that can result in permanent visual loss if not detected and treated early. Often, this decrease in vision can remain unnoticed by the most observant of parents because children usually will not exhibit any change in behavior. Children can play and interact without showing any clues that one eye is not seeing as well as the other.  Children sometimes do not realize that their vision is abnormal because they have not grown to know the difference.

Children are not born with completely developed vision. Nerve connections and visual processing are still incomplete until the child approaches 8 years old.  Until this age, the eyes are still learning how to see.  Normal visual development requires that both eyes of a child receive a focused image and that the eyes remain straight. Any condition that blurs a child’s vision within this period, such as a need for glasses, eye misalignment or a drooping eyelid, can interfere with the development of normal vision. Because the brain becomes confused with the vision of a blurred or crossing eye, it will ignore this eye and only use the good eye. Like a muscle that weakens with disuse, the eye that is not being used will also weaken resulting in visual loss.  Decreased vision from this disruption of visual development is called amblyopia or “lazy eye”.  The longer this goes undetected the harder it is to treat.

As a child approaches 8 years old, the learning process in the eye is complete and can not be changed. What vision a child has developed at this age whether good or bad is what he or she will have for the rest of his life.  This is why it is so important to identify these children as early as possible, ideally at 3 years old. This allows for treatment to be started early and better visual outcomes.

Treatment depends on the condition which is blurring the child’s eye or causing a misalignment, but usually involves patching therapy.  An eye patch is used to cover the normal seeing eye in order to force the weaker eye to be used.  With time, and if initiated early enough, this can strengthen the eye and improve vision.

Dr. Dorfman and Dr. Cardone have years of experience in working with children and treating pediatric eye disorders.  If you suspect that your child has a visual problem or you have a family history of childhood eye disease please contact our office or your pediatrician for an evaluation.

Patching Instructions

What Is Patching?

Patching is a technique for treating amblyopia (lazy eye). The better seeing eye is covered to encourage the development of vision in the weaker eye. Amblyopia can be caused by unequal eye glass prescriptions, crossed eyes, or other abnormalities that affect vision in young children.

How Long Will A Child Need to Wear the Patch?

This will vary with each individual child. As a general rule, the younger the age of the child and the shorter the time the eye has been affected the less time it will take for treatment. In young children vision may change rapidly. Occasionally, vision in the good eye may be decreased when the patch is removed, but will usually return to normal as soon as that eye is used again.

To ensure that a child is given the best possible chance to develop normal vision, patching may be continued for a few weeks or months after vision stabilizes. Once vision has improved in the weak eye there is a small chance that it may worsen again. Because of this, close monitoring is necessary throughout childhood.  If the vision does not improve after a reasonable period of effective patching, your ophthalmologist may recommend that this treatment be discontinued.

At first your child may not want to wear the patch. It is important to keep encouraging you child to wear the patch to improve the vision. If you are having trouble, try placing the patch on the eye before your child wakes up.  TV, video games or another favorite activity may help pass the time when wearing the patch.  It is crucial that you child wears the patch while awake as the patch will not improve vision if the child is asleep.  Avoid using the patch when your child is engaged in activities that might be dangerous such as sports, bicycle riding, etc.

What Kind of Patch Should Be Used?

The patch should be comfortable.  It should remain firmly in place and should not allow any peeking around the edges. Commercial patches come in “regular” and “junior” sizes and are available at Eye Surgery Associates and most drug stores.  Eye patches with elastic and occluders which clip onto glasses, are not recommended as they may allow peeking. The patch should be attached directly to the skin around the eye for best results.

Retinoblastoma

Retinoblastoma is the most common pediatric eye tumor that occurs inside the eye. This tumor usually develops by eighteen months of age, and over 90% of patients are diagnosed prior to the age of three. The tumor occurs at a rate of 1 in 15,000 to 1 in 30,000 live births. The gene responsible for this tumor has been identified and studied in great detail. Years ago, retinoblastoma was uniformly fatal, but now, with early intervention, we can preserve both life and vision.

The retinoblastoma tumor originates in the retina, the light sensitive area of the eye that enables us to see. The tumor will normally present as an abnormal red reflex (commonly known as a “red eye” in photographs) in which the pupil of one eye appears whiter, as seen in photo below. These abnormal red reflexes can also occur from other conditions such as strabismus (or crossed eyes), cataracts, or most commonly due to the angle at which the photo was taken. All pediatricians currently screen for retinoblastoma during your infant’s well baby visits. However, despite proper screening, the tumor can still go undetected. In 2002, during Dr. Dorfman’s presidency at the Florida Society of Ophthalmology, we began a public awareness campaign to promote early detection of this tumor. The campaign is aimed at teaching parents on how to recognize an abnormal red reflex. We want parents to recognize that both eyes should have an equal and symmetric red reflection in childhood photographs. An asymmetric reflection, especially a white reflex, can be a sign of retinoblastoma. Recognizing the abnormal appearance of a child’s red reflex in photographs obtained at home can lead to early diagnosis, and the ability to save you child’s life.

Part of our public awareness campaign, was the distribution of a poster demonstrating this intraocular tumor. Both the Florida Society of Ophthalmology and the Florida chapter of the American Academy of Pediatrics, have been able to distribute this poster on a statewide basis to pediatric offices and photo labs. We encourage you, after reading this article to educate your friends and family regarding this condition.

Fortunately, the overall survival rate is more than 95% and our goal is to continue to promote early detection of this life threatening disease. Most of the symptoms of a retinoblastoma, will first be detected by a parent. Please take the time to look at the red reflex in your child’s photograph, and if you are uncertain, please take your child to an ophthalmologist as soon as possible for a comprehensive examination. We also encourage you to emphasize the importance of this condition to your friends and family.

Early diagnosis and intervention is critical to the successful treatment of this disease.

Retinopathy of Prematurity

Many babies who are born prematurely develop an eye condition known as retinopathy of prematurity (ROP). This results from an abnormal growth of blood vessels in the retina, at the back of the eye. Most cases of ROP are mild and cause no serious problem, but sometimes more severe disease develops that must be treated (usually with a laser) to prevent blindness. Dr. Dorfman and Dr. Cardone screen and perform laser surgery on premature infants in neonatal intensive care units in both Dade and Broward County. They are one of only a few ophthalmologists in South Florida who provide this service.

ROP does not develop until a month or more after birth. For this reason, every small premature infant must have an eye examination at 6 weeks. The risk is higher and lasts longer for very small infants, very premature infants, and infants exposed to high oxygen concentrations.

When a baby is found to have ROP, examination of its eyes must be repeated every 1 to 3 weeks until it is clear whether treatment will be necessary, or the condition is getting better on its own.

Because ROP can cause blindness, and because this can usually be prevented if treatment is given at the proper time, it is extremely important for all eye examinations to be done exactly when they are supposed to be. If the baby still needs eye care following discharge from the hospital, appointments for an outpatient examination will be made. You must make sure these appointments are kept.

Examination of a premature baby’s eyes to look for ROP is done in a special way that is quite different from the way an older person’s eyes are usually examined. In most cases, it is necessary to place instruments in the eye that make it possible to see the entire retina. This upsets the baby, but it is not painful because an anesthetic drop is given before starting. Sometimes, the white part of the eye appears red following the examination.

When no ROP develops, or when mild ROP clears, the baby’s eyes usually turn out to be normal. Sometimes though, there is a need for glasses at an early age, or problems such as crossing of the eyes may be seen. For this reason, it is a good idea for any baby who was born prematurely to have its eyes examined again at the age of one, or sooner if you notice anything unusual about the way the eye looks.

When severe ROP develops, even if it is treated properly, the baby’s retinas may become scarred so that vision is reduced in a way that cannot be helped by glasses. If your baby begins to show signs of severe ROP, Dr. Dorfman or Dr. Cardone will explain to you in detail what you should expect.

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