Paediatric Ophthalmology

Paediatric ophthalmology

Paediatric ophthalmology deals with eye care in children. Often children may not  communicate that they can’t see well out of one or both eyes. The only clue may be  viewing the black board at too close a distance or not doing well at school. Hence  they need regular eye check ups through their growing years.

The visual system is in a developing phase in children, and it’s important that any eye  disorder in children be identified and rectified, as early as possible. Our child eye  specialists treat eye defects in children through medication, therapies, and eye  surgeries.


Common eye diseases/ disorders in children

  1. Strabismus or squint eye
  2. Pediatric cataract
  3. Conjunctivitis
  4. Blocked tear ducts
  5. Ptosis( Drooping of eyelids )
  6. Abnormal vision development
  7. Retinopathy of prematurity
  8. Amblyopia (lazy eye)
  9. Convergence insufficiency
  10. Congenital malformations
  11. Refractive errors such as myopia, hyperopia, astigmatism, etc

Squint or Strabismus

  • Strabismus is the condition in which the eyes are not aligned in the same direction.
  • It usually develops before the age of 5, but may appear later .
  • Children may or may not manifest this disorder.
  • Due to a residual childhood squint, adults may develop this later in life.
  • You should consult a child eye specialist for treatment if you notice that one eye of your child is turning in a different direction, up, down, inwards or outwards, whereas the other one is focussed on one spot.
  • Left untreated, a squint may lead to further severe problems like blurred or double vision and lazy eye (amblyopia), which happens in early childhood where the eyesight doesn’t develop properly in one eye.


The two most common types of squint are esotropia – where an eye turns in  and exotropia – where an eye turns out.

Congenital or infantile estropia, wherein infants develop estropia within the first six  months of life usually have a large noticeable inward turn. The chances of developing

normal binocular vision and depth perception are not good, and the child may not  develop full vision in the weaker eye. However, the best chance is with early surgery,  before 18 months of age. Multiple procedures may be required to obtain perfect  alignment.

Accomodative estropia occurs in children usually after age two and is treated with  glasses. These children are farsighted and have the ability to focus their eyes  enough to adjust for the farsightedness, which allows them to see well, both near and  far. Some children excessively strain their eyes when they focus, which causes one  eye to turn in. Wearing glasses to correct their farsightedness reduces the need to  focus and straightens their eyes. Sometimes bifocals need to be added to further  reduce the need to focus when looking at closeby objects.

Pediatric Cataract

  • Pediatric cataracts can develop in one eye or both eyes.
  • They can occur at birth or later.
  • They can be complete or partial, and partial cataracts can later progress to become a bigger problem.
  • Cataracts are specially a challenge in children as early visual rehabilitation is critical in preventing lazy eye, which is irreversible.
  • The earlier the onset of cataract, and the longer the duration, the worse is the prognosis.
  • Children born with cataracts are also at risk for developing glaucoma, strabismus, nystagmus, and poor stereopsis, further complicating successful outcomes.
  • One eye or unilateral infantile cataracts are rarely caused by a disease, except in some cases of intrauterine infections such as rubella.
  • Two eye or bilateral cataracts are often inherited.
  • Monocular congenital cataracts mostly have a good prognosis if surgery and vision correction is done by two months of age. Beyond this age, there is a possibility of having dense amblyopia in the operated eye.


The treatment plan for pediatric cataracts is worked out after a careful eye  examination and special tests. Dense bilateral congenital cataracts require urgent  surgery and visual rehabilitation. In general, bilateral cataracts operated prior to two  months of age have a good visual prognosis with approximately 80% achieving  vision of 20/50 or better.

  • Surgical: Cataract surgery in children is done under general anesthesia. It involves removal of the cataractous (opaque) crystalline lens. This is often accompanied by surgical  measures to ensure the clarity of the central visual axis in the postoperative period,  which can otherwise get obstructed by the ‘after cataract’ (collection of inflammatory  cells and fibrous tissue) formation.
  • Lenses: The use of aphakic glasses or contact lenses is the treatment for congenital cataracts in neonates, while an IOL (Intraocular Lens) implant is preferred for  children over one year of age. The child will still require glasses after the IOL  implantation after the operation. The child may require occlusion therapy for  management of amblyopia.


  • Amblyopia or ‘Lazy Eyes’ is simply defined as a decrease in uniocular or binocular vision, even after spectacle correction, for which there is no apparent organic cause.
  • It is commonly caused from conditions that produce a blurred image on the retina (e.g. congenital cataract which obstruct the light from entering the eye; high refractive errors) or abnormal binocular coordination of the two eyes (deviation of eyes) or combination of both (unequal refractive errors between  the two eyes, astigmatic refractive errors).
  • Amblyopia occurs between the ages 0-8 years, which is the critical period of development of the visual system. A patient has to undergo a complete eye examination to rule out any organic cause of loss of vision before a diagnosis of lazy eyes.


Amblyopia is treatable in certain cases and early treatment is critical for best results.

  • The first step is to clear the retinal image by giving appropriate glasses or by removal of media opacities like cataract or corneal opacities.
  • The second step is to correct ocular d ominance, if present, by stimulating the weaker eye by forcing fixation to it.
  • This is done by covering (patching) the good eye or by blurring the image in the good eye (by some drugs or by altering the spectacle number). Once Amblyopia is diagnosed, it has to be managed by strict vigilance and therapy.

Watery eyes

  • Infants who have a nasolacrimal duct obstruction have watery eyes, an increased tear lake, mucus in the nasal corner of the eyelids and matted eyelashes.
  • This is due to improper canalization of the nasolacrimal duct pathway, which drains tears from the eyes to the nose.
  • Congenital nasolacrimal duct obstruction is common and occurs in 1 to 5% of the population, with approximately 1/3 occurring in both eyes.


For the first six months of age, watery eyes are managed by a combination of  nasolacrimal sac massage and periodic topical antibiotics.

In case the lacrimal massage fails to open the obstruction, syringing and probing is  done. The child is given general anesthesia and a small steel wire is passed through  the punctum into the nasolacrimal system, and down out into the nasal cavity. This  does not hurt, nor does it create any problem in the nose. The success rate for a  single nasolacrimal duct probing is approximately 90%. It might need to be repeated  a few times to relieve the obstruction. If nasolacrimal duct probing fails, intubation  with silicone tubes is done. If none of the above procedures provide relief, the child  may require a dacryocystorhinostomy (DCR) procedure at around 3.5 to 4 years of  age. This involves making an alternate bypass between the tear drainage system  and the nasal cavity.

Red eye/Pink Eye

  • “Red Eye,” or conjunctivitis simply indicates conjunctival inflammation. • Most children who have red eyes will have simple conjunctivitis. • Other causes of a “red, teary eye” in a newborn include congenital glaucoma and nasolacrimal duct obstruction.
  • The most common causes for the pediatric pink eye are allergic conjunctivitis, bacterial conjunctivitis, viral conjunctivitis, and blepharitis (inflammation of lid margins).


  1. Crossed eyes.
  2. Keeps the object close to his eyes.
  3. Not being able to see the blackboard at school.
  4. Things looking blurry or funny.
  5. Feeling an itching, burning or scratchy sensation in the eyes.
  6. Injury to the eye.
  7. One or both the parents wear glasses.
  8. Frequent headaches along with watery or red eyes, recurring inflammation or irritation in the eyes
  9. Easy susceptibility to different types of eye infections


  • Typically the child eye specialist will do a refraction test with dilated pupils to examine the eyes to see if the child would require any prescription glasses
  • Eye conditions are treated with a mix of corrective eyeglasses and visual  aids, medical therapy and surgery if required.


Children by 2.5-3 years of age should have a basic eye examination, irrespective of  symptoms. There should be annual routine eye checkups post that. If the child  complains of eye-ache, difficulty in reading or soreness or irritation in eyes one,  should consult a child eye specialist.

The child eye specialist will start by doing a basic examination of the eye. If required,  a dilated evaluation will be done. Dilation can be done either in the same visit (takes  around 1.5-2 hours), or a home dilation may be recommended.

Squints in infants and young children sometimes improve with age. But always  consult a paediatric ophthalmologist if you notice squint in your child.

Practising eye exercises, as recommended by the child eye specialist, may help in  aligning eyes in some cases. Squint eye exercises in a vision treatment plan,  customised for the child, are advised only after a thorough eye examination.

Squint eye exercises aim to improve the coordination of the eyes and to delay the  need for surgery. They can be done at home or as suggested by the expert. Some of  the widely known squint eye exercises are:

  • Pencil exercise
  • Brock string exercise
  • Pencil pushups
  • Machine-based exercises

The duration depends upon the number of muscles to be operated, the procedure  planned and the type of anaesthesia to be used. On an average, it takes 1 hour or  so.

Squint surgery is performed under local or general anaesthesia. It depends upon the  age of the patient and complexity of squint. Squint surgery for children requires a lot  of precision and care. Squint surgery involves either weakening the muscle by a  procedure called recession (where it is inserted at a point behind the original  insertion) or strengthening it by resection (shortening the muscle-tendon length) so  that it becomes taut.

Though complications are rare, squint correction surgery might include infection of  the eyeball and retinal detachment.

Pseudo-strabismus is a common condition that needs to be distinguished from  deviation of eyes (true strabismus). With pseudo-esotropia, the infant usually has a  wide nasal bridge and wide, prominent lid folds, which makes it look like the eyes are  crossing. But, in fact, the eyes are straight. When the child looks to either side, the  eye hides behind the eyelid folds or wide bridge and looks like they are crossing. It is  important to document proper eye alignment in these cases by an orthoptic  examination. Comprehensive eye examination and follow-ups are important for

patients diagnosed with pseudo-strabismus, as a small percentage of these patients  will develop true esotropia.

Advances in IOL technology have made various state-of-the-art IOLs available. The  new lens designs include 1) Blue-light blocking IOLs that filter out harmful ultraviolet  radiation as well as blue light, 2) Aberration-free IOLs which greatly improve image  quality by enhancing contrast, eliminating glare and halos, and improving night  vision, and 3) the newer Multifocal IOLs which provide good unaided distance and  near vision with less dependence on glasses. 4) Toric IOLs are also available for the  correction of high cylindrical spectacle numbers. Depending on the patients’ visual  needs, the surgeon decides the most appropriate lens to implant in the eye.