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Children are brought to us with a range of conditions, usually when their parents or carers notice something is wrong. This article focuses on the more challenging complaints in babies and young children, who are the most difficult to assess. This is not an exhaustive list of presenting complaints or examination techniques, but it will give a starting point.
When your patient is a young child:
Good communication with parents is essential:
When you refer a child, it is very useful to write a referral letter. Give the letter to the parents to take with them and keep a copy for your records. In the letter, state:
It is important to encourage parents to take up a referral.
Always refer children with the following eye problems urgently:
Don't be anxious about examining a baby. If the baby is awake and attentive, there is a lot you can find out by asking the parents and simply observing the baby's reactions.
You should have realistic expectations about what a baby should be able to do by a certain age. Table Table11 shows when a baby is too young to show a visual response, when the response is likely to develop, and at what age you should be worried if a baby does NOT show the expected response. You can ask the mother or check the baby's responses yourself.
For example, if a baby of about three weeks old does not turn to a diffuse light, such as light coming from a window, you would not necessarily be worried - although you would still believe the parents if they are concerned. On the other hand, if a baby is eight weeks old and does not eventually turn to a diffuse light, then there may be a problem and you should investigate further.
Bear in mind that there can be a lot of variation in babies’ development; however, this table should be a helpful guide.
Children in this age group should have steady eyes, no squint, no history of sight difficulties and, if in a good mood, show interest in colourful or interesting objects in the room. They should respond to silent smiles, eyebrow raising, and winking.
Children in this age group should also be able to see objects presented in their peripheral visual field by a colleague while you draw their attention to your face, perhaps by making a funny noise. Cover one eye at a time if the child will allow it and ask them to identify different sized objects or, with older children, letters - make it a game.
Many children can accurately name colours by the age of three years but many cannot until they are older; it is reassuring if they can.
After the age of three, most children can participate in accurate visual acuity, visual field, and colour vision testing by someone trained and with age-appropriate equipment.
If you do not have that equipment or have not been trained to use it, you can still test a child's functional vision using everyday objects as described above.
The tips for examining a baby (above) apply equally well to young children. In addition:
The rest of this article is divided into four sections, each of which is based on what the mother or parents will say when they bring their child to see you:
For each problem, the article describes the likely causes, what you should ask the parents, what you should look for, what action you should take, and how you can talk to the parents. Where appropriate, these are described separately for babies and young children. We hope you find this useful!
Remember: Cataracts in children are not the same as cataracts in adults. Children with visual loss from cataracts need urgent surgical treatment to prevent them from developing amblyopia (lazy eyes) which may not be reversible if surgery is delayed. They should not be told to “wait for the cataract to mature”; nor to “come back when your child is older”. These messages can cause delays in treatment which can have a lasting impact on the child.
Hint: Babies and young children can be difficult to examine and you may not be able to see a white reflex, particularly if the reflex is coming from the back of the eye. Parents often see the white reflex more easily than you do because they are with the child more and they are likely to see the eyes in different lighting conditions - such as when they are looking at the child with the light coming over their shoulder. That is just one reason why it is important to always believe the parents!
There are two main causes of wobbly eyes (nystagmus) and squint (where the eyes are misaligned):
For more information on squint, see article on page 12.
If a child presents with trachoma, it is almost certain that other children and adults living in the same village or community will also have trachoma. Unless the whole community is treated, the child will be re-infected. Record the community the child is from and alert the people responsible for trachoma control in your district.
The red reflex test can reveal problems in the cornea, lens, and sometimes the vitreous. It can alert you to large lesions in the retina but it cannot be used to identify causes of poor vision related to retinal or optic nerve damage, such as retinal dystrophy or optic nerve hypoplasia.
You can have a significant impact on reducing visual loss and blindness in children by examining and referring them. Remember, one of your most powerful tools is your good communication with the parents. By helping parents to understand the importance of a referral and supporting them to take up that referral quickly, you can improve the chances of a good visual outcome for their child.
Even if you suspect that there's nothing that can be done to help the eye or vision, there is still a lot you can do to help the child and parents. In addition to referring the child to an ophthalmologist, make sure the family receives all the other services it may need, including support for the parents and low vision care, rehabilitation, and visual stimulation for the child.
Aderonke Baiyeroju, Professor of Ophthalmology, College of Medicine, University of Ibadan, Nigeria.
Richard Bowman, Ophthalmologist and Director of Training, CCBRT Hospital, Dares Salaam, Tanzania; Honorary Senior Lecturer, London School of Hygiene and Tropical Medicine.
Clare Gilbert, Co-director, International Centre for Eye Health, London School of Hygiene and Tropical Medicine; Clinical Advisor, Sightsavers, UK.
David Taylor, Chairman, International Council of Ophthalmology Examinations, International Council of Ophthalmology, 11–43 Bath Street, London EC1V 9EL. Email: email@example.com.