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May 21, 2019
May
21
2019

Child-Watery Eyes & Refractive Errors

Watery Eyes in Infants and Children

Watery eyes in a newborn can be due to neonatal conjunctivitis, nasolacrimal duct obstruction (NLDO) or congenital glaucoma. Sometimes watery eyes in a young child can be caused by seasonal allergies.

Tears flow out from the eye through the nose via a tear duct called the nasolacrimal duct which opens into the inferior meatus of the nasal cavity. The opening is partially covered by a mucosal fold called valve of Hasner which usually disappears several weeks after birth.

NLD obstruction is quite common, about 1 in every 20 babies born is present with this condition.

What are the symptoms of a blocked NLD?
  • Waterlogged eyes
  • Mucoid discharge
  • Matting of lashes
  • Sometimes eczema of the skin over the lids due to constant dripping of tears
  • Pressure over the lacrimal sac often produces retrograde reflux of mucopurulent material through the lacrimal puncta

The infection results from stagnation of bacteria in the warm, moist environment of the lacrimal sac. Enlargement and abscess formation may occur in the lacrimal sac in infants with dacryocystoceles.

TREATMENT

The majority of infants with NLDO spontaneously improve during the first several months of life.

Digital massage of the lacrimal sac (Crigler’s massage) is commonly recommended. The goal of the massage is to force fluid through the distal NLD and cause the obstruction to open. If massage is used, it is important to use proper technique, which requires direct digital pressure over the lacrimal sac. The presence of mucopurulent reflux through the puncta indicates that pressure is being applied appropriately. It is not necessary to stroke the finger in a downward motion over the lacrimal sac as commonly taught; compression of the lacrimal sac is the only requirement to proper massage. Many a time parents don’t perform the massage correctly and often get frustrated with its efficacy. A topical antibiotic is recommended if there is significant discharge.

If children do not improve with time and conservative measures fail, surgical treatment is indicated. NLD probing has a fairly high success rate if done within 9 months of birth. In an older child probing is always attempted, if unsuccessful a dacryocystorhinostomy (DCR surgery) should be performed.

General Guidelines for Children with Refractive Errors
  • Play in the garden or an open ground
  • Let sunlight brighten your houses as it protects from myopia; artificial lights have no impact
  • Avoid rubbing as it is associated with increase in astigmatism
  • Wear spectacles all the time
  • Ideal age to use contact lenses for children is > 14 years
  • Ideal age to surgically correct the error is > 18 years
  • Eye exercises, yoga, homeopathy, acupuncture and contact lenses (ortho-k) do not have any effect on myopia progression
  • Get your child an eye check-up by 1 year of age if a sibling or parents use spectacles
While watching monitors
  • Upper limit for the duration of TV watching per day is < 1 hour/day
  • Take a break for 5 minutes after 20 minutes of TV
  • Minimum distance from the TV should be 6 feet and from laptop should be 1 feet
How to choose the RIGHT spectacles for children?

Spectacle Frames:

  • Half rimless or total rimless frames are best avoided in children as the lens falling off or chipping is common
  • Plastic frames are better than metal frames in terms of retaining a good fit for longer
  • Silicon nose rests/pads are useful to reduce pressure imprints on the nose
  • Round or oval eye wire is better than the rectangular ones as it covers the eye
  • Middle level bridge provide better coverage while looking up as well as down than a high or top level bridge
  • A temple with a side-spring is useful as it provides excellent fit for very long

Spectacle Lenses:

  • Avoid glass material as they have low safety profile
  • CR39 plastic is cheaper compared to polycarbonate material. However, polycarbonate is tougher
  • Anti-scratch coating is highly recommended for all plastic lenses
  • Anti-reflective coating and/or high index lenses are necessary for > 4 diopter lenses only
Tackling Refractive Errors in Children

Refractive errors are one of the most important causes of visual impairment in children.

Uncorrected refractive errors can lead to poor vision, quality of life, and scholastic achievement in academics and extracurriculars. It could also lead to inattentiveness and problems like amblyopia or lazy eye and strabismus or crossed eye. A successful correction of a refractive error ensures normal development of binocularity and stereopsis.

One of the most common treatment modalities in children involves the use of spectacles. However, spectacle correction though simple is not straightforward. To achieve a satisfactory correction one should consider an individualised approach.

Important factors that need to be considered while prescribing glasses are the child’s age, type and magnitude of refractive error, amount of anisometropia, and presence of amblyopia or strabismus.

An infant’s world is confined to nearby objects, as a result uncorrected hyperopia is more detrimental than myopia in infants. Very high myopia or can be associated with amblyopia. Kids often get used to these types of vision problem, and might not mention it to their parents. As a result, their amblyopia might not be diagnosed for months or even years, while parents chalk up poor grades or clumsiness to a child not being academically or athletically gifted.

What is Amblyopia?

Commonly known as lazy eye, it is a condition where due to many reasons the eye does not acknowledge the images seen.

What causes Amblyopia?

During the critical period of growth (birth to 6 years old), both eyes must receive clear vision. Anything that interferes with clear vision, like an uncorrected refractive error, will result in amblyopia or anisometropic amblyopia. This is a neurologically active process and results in suppression of the image with a permanent decrease in vision that later cannot be corrected by glasses or any form of treatment.

Early detection and treatment by using glasses, drops and patching offers some of the best outcomes.

If the amblyopia is because of a squint, muscle surgery to improve the alignment of the eyes may be an option.

Patching: eye patches are not just for pirates
  • A child needs to wear an eye patch which is a broad band aid taped on the stronger or good eye for a period of 2 to 3 hours while awake for several months to years depending on the condition. Though it is a challenge, children usually adapt well, and the patch simply becomes part of their day.
  • Beyond 8 years, when kids reach visual maturity it becomes rather hard to treat this condition.
  • When correcting farsightedness in children who are less that 6 years, it is advised to under correct the refractive error, the residual refractive error being just above the mean for that age group. This will act as a stimulus for emmetropia except in conditions like amblyopia and esotropia (convergent squint) where it is imperative to give full cycloplegic correction. In school-going children myopia should be fully corrected.
  • Compliance to the proper spectacle use is as important as a good prescription. This can be improved by the use of frames that fit properly and use of restraints such as a head band in younger children. The spectacle should cover the eyes completely to avoid peeking over the glass.
Did you know?
  • All infants are hyperopic, i.e. have farsightedness, average cycloplegic refractive error being +2.0 D. As they grow a process of emmetropization or becoming normal occurs between 12 months to 6 years
  • It is estimated that 3% of children under 6 have lazy eye
  • An eye patch blocks vision in the child’s good eye forcing the brain to recognise the images seen by the weaker eye

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