Oh Say, Can Your Patients See? By Pediatric Ophthalmologist, Pamela Gallin, FACS
Vision loss is a silent disease. Often in children, the loss is asymmetrical; one eye sees a lot better than the other one. This childhood loss accounts for 2%-5% of the adult population. It is estimated that about 20% of all school-age kids have difficulty seeing.
Vision loss can be reversed until about 7-9 years of age. In 1981 David Hubel and Torsten Weisel won the Nobel Prize for their research that decoded how vision works.
In babies, vision loss is most often structural: corneal opacities, cataracts, retinoblastomas. The red reflex is not clear, and often different than the other eye.
For those older than one year it is frequently from strabismus (eyes turning in ((esotropia) or out (exotropia)). The invisible and most common issue is the visual loss, which can occur in different types of refractive (optical) basis. In these kids, the red reflex is normal, and structurally the eye is normal. However, the optics of the eye are out of bounds. This can be because the optics are not the same (one eye myopic/the other not, one eye hyperopic/the other not), or the eyes are very myopic (nearsighted) or hyperopic (farsighted). Both myopic and hyperopic kids have trouble seeing at a distance.
Because the targets young kids see are not very tiny, they seem to be functioning normally. Older school-age kids often go close to an object, and parents and the kids are unaware that they cannot see.
How can we find these kids?
The standard of care from the American Academy of Ophthalmology, the American Academy of Pediatrics, and the American Association of Pediatric Ophthalmology and Strabismus is PHOTOSCREENING. This uses a device to shine a light into the eye and decode the optics of the eye. It will tell you if it is in bounds or out of bounds, and if a detailed Ophthalmological exam is needed.
Older kids can read the Snellen Chart. The Snellen number chart has nine digits, which works well for kids who do not read the English alphabet.
When a child is diagnosed with decreased vision, it is a medical emergency to decode the time frame of care. Cataracts and tumors are treated immediately.
For the amblyopic kids, their brains are quite “moldable.” The younger they are, the much faster it goes in reversing the visual loss. As they approach seven years of age, the changes most often are slow. School-age kids have increasing visual demands. Treatment for a visually impaired child has them function with the less well seeing eye, and it is quite challenging for both the kids and parents. The earlier they begin, the faster it goes. Maintenance of the vision until nine is mandatory and a bit of a long haul.
Vision is a silent disease and has significant consequences for children on many levels. The earlier they are diagnosed, the better the outcome and the easier it is to treat them. Vision loss is a national health issue. Find the Kids, Please.
More About The Author:
Dr. Pamela Gallin is one of the highest-ranking female surgeons at New York Presbyterian-Columbia Medical Center, where she is a Clinical Professor of Ophthalmology in Pediatrics at the Morgan Stanley Children’s Hospital and The Edward S. Harkness Eye Institute of Columbia University Medical Center. She is Director Emeritus of Pediatric Ophthalmology and Adult Strabismus.
 https://www.cdc.gov/visionhealth/basics/ced/fastfacts.htm  https://eyewiki.aao.org/Photoscreening  https://pediatrics.aappublications.org/content/109/3/524  https://aapos.org/glossary/photoscreening