Copyright ©1998 -2001 by Larry Bickford. All Rights Reserved.

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The EyeCare Reports
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PLEASE READ THIS: The information contained herein is not intended as a substitute for medical advice and care from qualified, licensed health care providers. The reader should regularly consult a physician in matters relating to his or her health and particularly with respect to any symptoms that may require diagnosis or medical attention. The information is presented here to educate and inform and to guide you to an understanding of cause, prevention as well as treatment.


Children's Vision Development,

Eye Health & Vision and First Aid

by Dr. Larry Bickford, O.D.

The child's vision system is dynamic, constantly changing and adapting to both the body's growth and development cycle as well as the visual world outside.

This article discusses the development of the vision system, recommendations for early detection and prevention and guidelines for pediatric vision care. There's also a section on "first aid and emergencies" and discussion about some common childhood eye problems.

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Children's Vision Development

The human vision system at birth is poorly developed, but rapidly becomes the remarkable combination of nerve tissue, muscles and optical lenses that provide us with the sense of vision. The information processed by the eyes is sent directly to the brain and is interpreted as vision. That information is also used to provide us with the awareness of space and location. The eyes learn to move and scan across the visual world, sensing time and space. Colors and shapes become valuable clues to help us understand our environment.

By six months of age, most of these systems are fully or nearly fully developed. But there's a lot of fine tuning and structural changes going on which need to be monitored as the child grows into adolescence and adulthood.

It was previously thought that infants didn't see all that well, not reaching the 20/20 standard until later childhood. In the last few years, our knowledge of the infant's and toddler's visual world has expanded. We now know that even at 1 month, the infant sees quite clearly----at least to about 20 inches (50 cm). They just don't need or care to process information from further away than their mother's and father's faces, or mother's breasts. Pretty soon thereafter, probably by 3 months, the infant's vision system is developed to the point of providing pretty good quality vision, specially tuned for her/his needs!



Checking Children's Eyes

What the doctor looks for:

The primary care physician should be observing the eyes for anatomical, functional and perceptual development. The eye structures are examined. The eyelids are checked to be sure they are opening and closing properly, the ocular surface is checked to see if there is adequate tear fluid production, the pupil/iris observed for normal formation and reaction. The eye muscles are checked for coordination and alignment. We also look to see if the child fixates on, (pays attention to) objects in the his/her visual space, and to what degree he/she recognizes and understands what is being seen.

The parents should also be the examiners of their children. Report any unusual findings to your primary care provider or eye doctor.

What the parents should look for:

With very young infants, it is normal to notice one eyelid not working in coordination with the other, or observe the eyes misaligned at times. By three months, the eyes should look straight and appear attending to the task of seeing. By six months, the system works pretty well. Parents should report any obvious problems, such as: one eye more often than not "stuck" in one position or apparently operating independently of the other; an eyelid not blinking; cloudiness of the eyes; dark brown areas on the otherwise light-colored iris; one eye "bulging out" or more prominent than the other; obviously unequally sized pupils; or the infant rubbing his/her eyes.



Early Detection and Prevention

Early detection of an eye problem can often facilitate the treatment of the condition, thereby helping the vision system to develop more normally. Sometimes intervention can prevent a problem from having a more significant impact later on in the child's development. Errors in the development of the human vision system and other eye health problems include:

Vision: You observe that your child can't see well. She/he stumbles beyond "normal" clumsiness or doesn't recognize people or things at certain distances.
Farsighted optics (hyperopia) sometimes cause the eyes to turn in, causing esotropia, a form of strabismus. High degrees of hyperopia can also cause eye fatigue and blurred near vision. Nearsighted optics (myopia) cause distance vision to be blurred. A significant difference between the two eyes (anisometropia) can result in a condition which causes amblyopia (poor best possible vision) and mis-coordination.

Squinting: 1. In normal lighting: Often is an attempt to see more clearly, or a neurological problem with eye lid muscle control. 2. A greater than expected reaction to light: This can be a sign of an injury to the exposed parts of the eye or internal infection.

Eye Turning: 1. Turned-in (crossed) or turned-out (wall) eyes. Improper position or incorrect muscle length can result in one or both eyes being misaligned or unable to track. This is called strabismus. This type of problem can cause poor spatial perception, clumsiness, and reading disabilities. 2. Eyes that roam in rhythmic, sometimes rapid movements is a condition called nystagmus. This can be a sign of neurological disorders of the eye or brain.

Excessive or Insufficient Blinking: Eyelid blink reflex problems can result in or be caused by dry eyes, irritation, infection or neurological dysfunction.

Neurological Developmental Problems: Symptoms are often similar to the problems outlined above. Lack of development of good visual acuity from misalignment or from a neurological anomaly, is called amblyopia. Also, there may be fixation problems, attention deficits, and binocular vision (3-D, stereopsis) defects.

Pupil Abnormalities. 1. Reflexes. The black-appearing pupils should be of equal size at any light level, clearly smaller when a penlight is shined onto the eye and larger when it is removed. 2. A white or cloudy looking pupil is a sign of potentially serious illness.

Swelling and redness of the eyelids. Many things can cause this, including insect bites, allergies and minor infections. May resolve without treatment. If the swelling is painful and warm to the touch, rapidly worsens and/or is accompanied by fever, seek immediate medical attention. Call 911. This could be a rare, but serious, potentially life-threatening condition in children.

Redness of the "white of the eye"(sclera) and inside of lids. "Pink Eye" Conjunctivitis (inflammation of the thin, normally transparent membrane which lines the outside of the eye and inside of the eyelids) can be caused by chemical or particle irritation, bacteria, virus or allergies.

Bacteria-caused infections often have mucous discharge which is yellowish, sometimes tinged with green. The discharge often dries on the lashes, forming crusting and "glued shut" eyes upon awakening. The child is clearly uncomfortable. Sometimes, the condition will resolve on its own but often antibiotic drops or ointments are used to quickly kill the bacteria and help the tissues heal. If signs and symptoms last more than three days, appear to be worsening, is accompanied by fever or other illness (e.g.: sinus, ear infection), seek medical attention.

Virus-caused infection may cause the eye to appear very red, often with tearing but little or no pain. The eye often looks much worse than it feels. Sometimes the child is hardly aware of the problem, but is spreading the infection, eye to hand to someone else's hand and then to his/her eye. The infection goes away on its own. Hygiene (keeping hands away from eyes, hand washing, no shared towels) helps with the prevention of the spread of the virus is the goal here. There is no effective drug treatment for virus infections, except for herpes virus, which is often quite painful before treatment.
Some doctors prescribe antibiotics, which have no effect except perhaps preventing secondary bacterial infection, a valuable treatment for ill children, but otherwise a questionable practice.


Allergy-caused conjunctivitis: The eyes are red , often tearing and always itching, often intensely. Washing out the irritant and lubricating, non-medicated eye drops are used to limit the reaction and help with the symptoms. Sometimes oral antihistamine medication is recommended. Medicated eye drops are now available for adults, perhaps soon to be approved for children.

Excessive tearing, in the absence of obvious infection: Some children are born with narrow or closed puncta (the small opennings in the eyelids through which tears drain into a ductwork called nasal-lacrimal system. Others develope the condition as the result of infection or injury. Treatments include: warm compresses and massage of the lid, mechanical dilation of the openning, antibiotics (for infection-caused condition). Sometimes the situation resolves by itself.
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Below are the guidelines based upon recommendations from the American Optometric Association and commonly practiced by most eye doctors:

Age Birth to 2 years: By six months of age, by a capable pediatrician or by an eye doctor if there are risk factors or observed problems.

2-5 years: At age 3 or as recommended if there are risk factors.

6-18 years: Before entering the first grade and every two years thereafter. Annually or as recommended if there are risk factors.


Factors placing an infant or toddler at risk include:

*Premature delivery, low birth weight, oxygen given at birth, grade III or higher intraventricular hemorrhage

*Family history of retinoblastoma, congenital cataracts, or metabolic or genetic diseases, including hyperthyroid, diabetes and heart disease

*Infection during pregnancy, especially rubella, toxoplasmosis, syphillis, gonorrhea, herpes, cytomegalovirus, HIV

*Difficult or assisted labor, low Apgar scores

*Known or suspected central nervous system dysfunction, e.g.: developmental delays, cerebral palsy, seizure disorder, hydrocephalus

*High refractive errors, anisometropia (large difference between eyes)

*Strabismus (crossed, uncrossed eye position)

The eyes are a normally hardy organ system. First aid is rarely necessary, but being prepared and knowing how to act may save your child's vision, or at least prevent a minor problem from becoming something serious.

You should have a "first aid kit", one that you take with you and one for the house. The items underlined are listed later with "where to buy" information.

1. Foreign object (e.g.: sand, a piece of leaf, a bug, etc.) gets in eye, floating in the tears or stuck under the eyelid. Often, normal extra tearing will wash it out. If not, simply try to flush it out, preferably with saline solution. In an emergency, use drinking water. You may have to hold the child's eyelids open or perhaps pull it, gently, a bit away from the eyeball. Don't worry if your intervention makes him/her cry even more--- all the better to produce more tears! It is common for the eye to keep hurting for a few minutes after flushing it out. But if pain persists, or you can see something still there, seek medical attention. Do not try to remove an embedded object yourself. You can apply an emergency patch to keep the eyelids closed, which may keep the child more comfortable while in transit to the doctor's. Cover the eye with, preferably, sterile gauze pads or clean tissues and hold it there, applying gentle pressure to hold the lids still. DO NOT press on the eye. You can also use surgical tape to secure the patch: start tape at the forehead, over the gauze and to the cheek.

2. Liquid product in eye: For most "safe" things (milk, juice, hand soap or shampoo), flush it out as above, irrigating for one or two minutes. For a chemical that you know is not alkaline (like lye), flush for 5-10 minutes. It you don't know what it is, or if it IS alkaline (most household products will so indicate if it is), flush for at least 20 minutes and have someone call for medical help or the local Poison Control Center. Do not stop irrigating until medical help arrives unless instructed otherwise. Make sure the flushed-out chemical doesn't run into the other eye or into the nose or mouth.

3. Trauma: A blunt object hits the eye. First, be certain, if you can, that something actually hit the eye, and not just the bones around it. Objects larger than the space between the eyebrow and cheek rarely contact the eyeball, depending upon the child's anatomical bone structure. Examine the eye closely. If you can't open the eyelids, observe the pupils of unequal size (shine a penlight and observe the pupils) , or see bleeding, seek immediate medical attention. If the child appears to be in continued pain and is constantly rubbing the eyes, complains of blurred or doubled vision, or was hit by a high-speed object, consult with your doctor. Meanwhile, you can cover the injured area with a cold pack for 15 minutes every hour or so. Wrap the ice pack in a moistened cloth so that you don't cause damage from freezing.

4. Injury caused by sharp object: Patch as above and seek medical attention. If an object remains in the eye, DO NOT remove it! Cover the eye and call 9-1-1.

It is always best to call your optometrist or ophthalmologist in an emergency. Ask your pediatrician if he/she feels comfortable handling eye emergencies. Many are not equipped with the instrumentation or medications to properly manage eye problems. The same applies to the Emergency Room staff. If you do not have a relationship with an eye doctor, make certain your pediatrician or family doctor does, so that your child can be quickly referred to the appropriate practitioner when necessary.

When it comes to the pharmaceutical treatment of common eye infections, there is really only one medication used for young children: the broad-spectrum antibiotic brand named Polytrim. Occasionally, for more serious infections tobramycin (Tobrex) is used. Sodium sulfacetamide (Sulamid, Blef) is rarely used today, and is appropriate solely as a prophylactic (preventative) antibiotic, if at all.

There is currently NO drug treatment for common viral eye infections (except for herpes-family virus), and no "approved" medications for children with allergic eye problems, although in the last year two products have become available and may soon be used. Bland, basic tear replacement drops sometimes provide symptomatic relief.

Never use "get the red out" drops for infants or children without the clear recommendation of your doctor. They contain a drug which may act as a stimulant, and sometimes as a depressant with systemic (whole body) effects in kids.

Saline: A salt water solution. Available as "irrigating solution" and products for rinsing soft contact lenses. Non-preserved, single use containers best, peroxide-preserved also excellent, other "sensitive eyes" products also OK. Avoid products (including nose sprays/drops) containing the mercury-based preservative Thimerosol ! (Drug stores.)

Gauze: 1 1/2" or 2" pads best, roll OK. Sterile best. But even a clean handkerchief or wad of tissues will work. (Drug stores.)

Surgical tape: Any tape that sticks well to skin. (Drug stores)

Penlight or flashlight: Drug, hardware, electronics stores.

Cold Packs: Drug and sporting good stores.

Hand wipes: To clean your hands before treating the child. Supermarkets, drug stores.