A Child's Eye Exam

Why Worry About A Child's Eyes?

We now know that children are able to see as soon as they are born. We also know that for the visual system to develop properly, children need input from both eyes. If there is some problem which interferes with vision, the connections from the eye to the brain can become weak.

The eyes also should be used together for normal vision. Eyes turning or crossing can interfere with this normal functioning of the visual system. Because of our understanding of the importance of normal vision in infants, and because of our abilities to earlier recognize and treat problems, we are now interested in examining younger children if the parents or your pediatrician feels that there maybe some problem.

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What Questions are asked?

A child's eye examination begins by discussing with the parents the problems as they recognize them. It is especially important to find out if there were problems with the pregnancy or with the child's birth. It is also extremely important to have an understanding of whether the child's growth and development are felt to be proceeding normally. It is often quite useful to know if there is a tendency for eye problems to run in the child's family. We need to know about the child's health in general. Are there other medical problems which are being looked after? Has the child had any treatment with medications or prior surgeries or procedures? Does your child have any allergies? If your child has been treated with medications, glasses or contact lenses, they should be brought to the examination as well. We also like to have the names and addresses of other physicians who may be treating your child so that we may inform them of our findings.

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How Can You Really Examine A Baby's Eyes?

Many parents are quite surprised to find that we are able to perform eye exams on children, especially young children who may not know their alphabet or even babies who cannot speak. We can assess your child's vision by watching your child follow lights or toys. A skilled ophthalmologist can get a good idea how well your child can see based on the way your child uses their eyes.

In some special situations, measurements can be made of your child's vision based on brainwave measurements while your child watches striped patterns or by observing the way your child looks at black and white stripes on flashcards.

No matter how the vision is tested, It is important to check each eye separately because it is not uncommon for a child to have an eye which does not see as well as the other eye, a condition called amblyopia or "lazy eye."

For older children who can talk but who do not yet know their numbers or the alphabet, we have pictures of common items that they can identify. Some charts use pictures of items such as birthday cakes and telephones, and others require the child to point to a letter which matches the letter on the chart. What all of these tests have in common is that they are able to show your child smaller and smaller items until we get an idea of your child's visual acuity.

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Lights, Lights and More Lights

The colored part of your eye is the iris. The black hole in the center of your iris is the pupil and this usually enlarges in darkness and gets smaller in bright light. Your child's ophthalmologist can use this pupil reflex to see if the eyes are working properly. During this portion of the examination, the ophthalmologist will be looking closely at the other areas around the eyes such as the eyelids and the tear canals that drain tears into the nose.

The tiny flashlight can also be used to see if your child's eyes are straight or turned. If your child is looking straight at the flashlight, it will reflect off the front of your child's eyes in a way that allows us to tell whether the eyes are turned or straight. This is often quite confusing in young infants because wide noses may make straight eyes look crossed. In older children, we can cover one eye and then the other and, if the eyes are truly crossed, they will jump back and forth to stay in focus on the light or the toy. There are wedge shaped pieces of clear plastic called prisms which can be used to measure how much turning in or out of the eyes there is, if it is present.

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Eyedrops! Why Me?

One of the least enjoyable but most essential portions of the eye exam is the dilation of the pupil. This not only allows the ophthalmologist to view the inside of the eye, but the dilating drops temporarily prevent the child from focusing the lens of the eye. As we age, the ability to change focus is gradually lost. Adults begrudgingly accept this fact and need to use bifocal lenses to allow them to see things clearly up close. Children have enormous range of focusing and parents are often needlessly worried when they see a child holding objects up close.

The dilating drops allow us to temporarily prevent the child from using this incredible focusing power so that we can accurately measure the child's eyes for nearsightedness, farsightedness or astigmatism. Most doctors have preferences for the dilating drops which work best for them. Some drops are given once, some are given more than once, and all take about 30 minutes to an hour to be fully effective. It may be necessary to have special drops put in at home and to return for a dilated exam.

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More Lights and Lenses

Even though your child may not wish to talk at this point or may even be asleep during the exam, the ophthalmologist with his small lenses and funny-looking long flashlight (called the retinoscope) can determine if your child's eyes are out-of-focus. By shining a dim light into the eye, we can see the eye's reflection and by holding lenses up to this reflection, see whether the child is nearsighted, farsighted or has astigmatism. It's a different technique than ophthalmologists use to fit glasses for older folks but it is nonetheless very accurate.

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More Lights Still

Now that your child's pupils are dilated, your ophthalmologist can get a very good look at the inner eye structures. The inside of the eye holds the retina which functions much as film does in a camera, processing the visual information into signals which are sent down the optic nerve to the brain. The optic nerve itself can be seen in the back of the eye as well as the blood vessels which supply the retina. Special instruments allow us to see the inside the eye in great detail. One type of light fits on the ophthalmologist's head and looks like the headlight a miner might wear underground. Another instrument is held between your child's eye and the ophthalmologist's eye.

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Other Tests

There are lots of other tests which can be used in special situations if they are required. There are tests employing X-rays or ultrasound. There are tests which can measure the electrical activity of the eye much as the EKG measures the electrical activity of the heart. All these tests can be useful in specific situations.

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After the Exam. Now What?

The eye drops which were put in your child's eyes will wear off naturally. Although some eye doctors in the past used special drops to "reverse the dilating drops," we now feel that this is usually not a good idea. Your child's pupils will stay dilated for about one day (in the case of the office administered drops) or perhaps a week or two in the case of the atropine drops which you may have been instructed to put in at home.

There is no reason to restrict your child's activities in any way while their pupils are dilated. Adults are sometimes given dark glasses to wear home after their eyes have been dilated but these are not usually necessary in children. An older child will notice that his or her vision is blurry for about 12 hours after the office drops. It is not a good idea to expect an older child to do homework or reading within 12 hours of having office dilating drops.

Your ophthalmologist will give you instructions about treatment with glasses or patches or follow-up visits. If you have any questions about all of this, please ask us. For the questions that invariably arise after the examination, they can be either saved for the next visit or you can call us, especially if there is any confusion over the treatment plan.

We hope that by explaining this process to you that you have a better understanding and a better appreciation of your child's eye exam.

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Copyright © H.J. Wisnicki, MD