Eye diseases in children

One third of ophthalmological patients in the West are children, and there are about 1.5 million children with severe visual impairment and completely blind people worldwide, many of whom suffer from genetically determined diseases. Naturally, the study of the structural features of the visual organ in children and the treatment of eye diseases and the visual system in childhood is rightfully becoming an independent specialty. In many countries, there is an artificial division between pediatric ophthalmology and its section devoted to the study of strabismus. This is a historically established, but absolutely unfounded division. Although the desire of some doctors to show interest in certain aspects of ophthalmology is inevitable, strabismus, being the most common eye disease for childhood and observed in many children with both visual organ pathology and systemic diseases, will lose relevance without delving into this problem by pediatric ophthalmologists. Likewise, it is pointless to assume that any ophthalmologist would be interested in pediatric ophthalmology while ignoring the problem of strabismus, or would be interested in strabismus while ignoring the extraocular manifestations of this disease.

Children have their whole lives ahead of them, and vision loss has a devastating effect on them, affecting every aspect of a child’s development. That’s why the fact that there are 1.5 million blind children in the world is much more important than it might seem at first glance.

A pediatric ophthalmologist should not only understand visual organ diseases in children, but also be able to find an approach to the child to conduct a clinical examination, collect anamnesis and provide assistance. A formal approach usually does not bring success. A doctor who has dedicated himself to working with children should be able to help the child feel "at home" even after such an unpleasant procedure as instillation of drops. It is necessary to feel special compassion for children, be able to delve into the problems of their family and understand the issues that complicate the life of the child, his parents and his entire family.

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Epidemiology of eye diseases in children

In 1992, there were 1.5 million children in the world who were severely visually impaired and completely blind. These children are blind all their lives, and all those years they have lived in this condition are a huge price for the imperfections of modern ophthalmology. 5% of blind children die in childhood. In Canada, the incidence of congenital blindness is 3% of all newborns.

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Causes of eye diseases in children

Developed countries.

1. Genetically determined diseases:
   • retinal diseases;
   • cataract;
   • glaucoma.
2. Intrauterine infections.
3. Acquired diseases:
   • retinopathy of prematurity;
   • central visual impairment;
   • injury;
   • infections (rare);
   • cataract.

Developing countries.

1. Nutritional disorder - vitamin A deficiency.
2. Genetically determined diseases:
   • retina;
   • lens;
   • measles infection;
   • traditional drug treatment.

Other countries.

The incidence of retinopathy of prematurity is increasing.

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Screening

Screening can be defined as a thorough detection of subclinical signs of a disease. It is important to remember that screening is not 100% effective. Misdiagnoses are inevitable, both in the direction of overdiagnosis and underdiagnosis. When conducting screening, the following rules must be followed.

1. The disease being screened for must represent an important health problem for both the individual and society as a whole.
2. The clinical features of the disease must be known.
3. There must be a latent or subclinical period.
4. There must be an effective method of treating this pathology.
5. Tests used in screening must be technically simple, accessible for mass use, non-invasive, and not require expensive equipment.
6. Screening uses effective tests with an appropriate level of specificity and sensitivity.
7. The disease for which screening is being performed must have a complete diagnostic service and adequate therapeutic treatment.
8. Early intervention during the course of the disease should have a beneficial effect on the possible outcome of the pathological process.
9. Screening programs do not have to be expensive.
10. Screening programs should be ongoing.

Screening for amblyopia and strabismus

The question of the need for screening to detect this pathology is still debatable due to the following theses:

1. being a one-sided condition, this pathology does not have a significant negative impact on the child’s life and his overall health;
2. treatment does not always give the expected result (low treatment effectiveness is mainly due to the difficulty of ensuring complete occlusion);
3. Screening for these diseases is an expensive procedure.

Screening methods

1. Screening at birth is effective only for detecting gross extraocular pathology. Ophthalmoscopy helps to detect opacities in the optical media of the anterior segment of the eye. Since this type of screening is performed by specialists other than ophthalmologists, refractive errors and pathology in the fundus are usually rarely detected.
2. Vision examination at the age of 3.5 years. Despite the expediency of this examination, it allows to detect only relatively treatment-resistant visual impairments. It is difficult to perform occlusions at this age due to the child's intransigence. With good training of personnel, it is possible to conduct the examination by mid-level medical personnel.
3. Screening for amblyogenic factors. Refractive disorders and strabismus can be detected by mid-level medical personnel using a photorefractometer and simple research methods.
4. School screening. In developed countries, vision screening is carried out in many schools. The examination is usually carried out by a school nurse or teacher, and if the child's visual acuity is below 6/9 (0.6), the examination is repeated, and if the visual acuity is 6/12 (0.5) or lower, the child is referred to an ophthalmologist. It is advisable to conduct a visual acuity test for both near and far vision. Treatment of amblyopia detected at this age is usually ineffective.
5. Screening in groups of children with a high risk of developing the disease, for example, among children with a hereditary predisposition to cataracts, aniridia, retinoblastoma, etc.
6. Screening for retinopathy of prematurity. Once it was established that the progression of retinopathy of prematurity can be stopped by cryotherapy or laser therapy, screening for this pathology became mandatory in many countries.
7. Screening for infectious diseases. The need for screening for this purpose remains controversial. For example, many countries have abandoned mass screening for toxoplasmosis due to the difficulty of implementing all the necessary screening criteria - treatment of toxoplasmosis does not guarantee 100% safety. The clinical course of the disease has not been fully studied and the probability of fetal damage from toxoplasmosis in the mother is unpredictable. Therefore, early intervention in the course of the disease is not effective enough. Screening for toxoplasmosis is more appropriate in countries where its prevalence is high.

The meaning of visual disturbances

Visual disorders that occur in childhood, in addition to their isolated impact on the visual system, have a special impact on the entire development of the child.

1. They can be combined with general diseases.
2. Contribute to developmental delays in other areas, such as:
   • speech delay;
   • difficulties in relationships with parents, other family members and peers;
   • autism;
   • behavioral stereotypes - repetitive aimless movements, jerky and oscillatory eye movements, etc.;
   • decreased intellectual capacity;
   • learning difficulties;
   • delayed motor development, hypotonia and weakness;
   • obesity.

Mental retardation is common in blind children and, in addition, there is a high correlation of combined visual impairment in children with mental disorders.

Treatment at early stages of the disease

The beneficial effect of early assistance to a blind child and his family has been established, including instruction to parents on the timely initiation of stimulating activities, the acquisition of appropriate toys, furniture (for example, a chair on which the child can sit and see objects around him using his residual vision). It is necessary to explain to parents in detail the peculiarities of raising a sick child.

First diagnosis of visual impairment in a newborn

1. The following help to establish a correct diagnosis:
   • detection of genetic defects;
   • clinical experience of the physician.
2. Postpone all discussions of the situation until the diagnosis is finally confirmed.
3. Share information obtained during the examination with parents.
4. Regular meetings and discussions with parents are essential. Remember that most people are only able to absorb a certain amount of new information at a time.
5. Try to convey information to parents in the most accessible form possible, using diagrams and pictures. It is important to honestly describe to parents the level of your own competence in this matter.
6. If treatment is not appropriate, explain to the parents why.
7. Explain the prognosis of the disease to your parents in accessible terms.
   • Are there any possible difficulties with the child's mobility in the future?
   • Is it possible to get a regular education?
   • Will the child be able to drive a car?
8. If necessary, seek the opinion of another specialist.
9. Explain to parents the difference between total vision loss and the vision disorder that their child has been diagnosed with.
10. Provide stimulation measures if any residual vision is present; organize the earliest possible assistance for the child.
11. Avoid a pessimistic outlook.
12. Consider what additional factors could complicate a child’s life:
    • mental retardation;
    • hearing loss;
    • other.
13. Involve parents in active participation in the conversation.

Family of a child with visual impairments

1. Parents:
   • have difficulty comprehending the gravity of the situation;
   • from the moment of diagnosis, qualified medical care is required;
   • regular psychological support has a beneficial effect;
   • bringing together parents with similar problems into groups;
   • formation of groups according to the nosology of the disease - neurofibromatosis, tuberous sclerosis, etc.;
   • organizing a nanny service to help parents care for sick children;
   • home assistance;
   • assistance through home appliances that make it easier to organize the daily life of a blind child.
2. Brothers and sisters:
   • do not allow jealousy to arise due to the increased attention of the whole family to a visually impaired child;
   • Parents should remember that healthy children are no less important to them than a sick child;
   • Family income should be distributed fairly.
3. Grandparents:
   • are often concerned about the poor eyesight of their grandchildren; psychological help for them can be provided by participating in family life;
   • can be of great benefit by caring for the child and providing moral support to the parents.