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Assessing infant vision
Vision problems in newborns are relatively rare. Unless there is some reason to suspect eye problems (like family history, prematurity, or exposure to certain diseases), infants are not typically seen by ophthalmologists (medical doctors who specialize in eyes). The newborn eye problems that are usually detected are structural abnormalities which can be observed by others, rather than problems with the function of the eye. Just as parents are usually the first to notice that their baby can focus and watch objects move, they are often the first to suspect a vision difficulty.
Cataracts
Of all the rare newborn eye problems, one of the more common is clouding in the lens of the eye, called a cataract. Cataracts may be small, allowing an image to clearly reach the back lining (retina) of the eye, but more usually the clouding involves enough of the lens that the baby cannot hope to see clearly with that eye. A baby may have a cataract in one or both eyes. When a cataract is present from birth, it is called a congenital cataract.
Causes
There may be a tendency for congenital cataracts to run in families. Some cataracts occur as part of syndromes that also affect other parts of the body, so your ophthalmologist (who is a medical doctor) may ask questions about your child's general health. While bilateral cataracts may be traced to a woman's prenatal exposure to disease or environmental contaminants, it is even more difficult to determine the cause of unilateral cataracts. Cataracts may also develop later in childhood as a result of an eye injury or disease. Most of the time, it is not possible to determine what caused the cataract.
Treatment
If a baby has a cataract, his brain will not be able to practice seeing clearly out of that eye. Because early brain development is so important in the development of vision, if this stage is missed, the child's vision in that eye will be permanently impaired if the situation is not corrected. Also, cataracts can grow over time if not removed. This means a baby with a cataract must be seen immediately by an ophthalmologist, preferably by a pediatric ophthalmologist, who specializes in babies and children. Pediatric ophthalmologists are particularly good at assessing the vision of young patients who are unable to tell us what they can see. In the case of a baby with a cataract, the pediatric ophthalmologist will also be looking for possibly related eye conditions, like a smaller eyeball (microphthalmia), glaucoma, or malformations elsewhere in the eye.
At some point, a cataract that obscures a baby's vision will need to be removed. This has to be done surgically, removing the lens of the baby's eye (a lensectomy). The sooner this is done, the better the chance the baby has to develop vision in that eye. The surgery can be done when the baby is just a few days or weeks old if her general health is good..
Hearing that a baby has a major vision problem is not pleasant, and facing immediate surgery can seem overwhelming. If there is a question about how much the cataract impacts your baby's sight, by all means try to get a second opinion, but do it quickly. An ophthalmologist who is urging immediate surgery does so to preserve your child's vision.
Although any surgery on a baby seems major to a parent, this is a fairly common procedure and takes only a few hours total. In most cases, the lensectomy is an outpatient procedure. After the surgery, the baby is said to be APHAKIC (ay-FAKE-ik), which means without a biological lens in that eye. If an implant was inserted in place of the natural lens, the baby is said to be PSEUDOPHAKIC (soo-doe-FAKE-ik).
Although this is the usual plan of treatment for a serious cataract, a cataract which does not completely obscure vision may or may not require surgery, and so deciding what to do and when to do it is more complicated. Preserving the best possible vision in the eye is the first priority. With a less-than-complete cataract, the child may be able to develop some vision "around" the cataract. In addition, such a child might also develop fusion, coordinating the images from both eyes into a three-dimensional image (which is a significant achievement, and harder once the lens has been removed). Whether there is more to be gained by keeping a semi-obscured but focusing lens, or by removing the lens to gain clear vision but losing the ability to accommodate near-to-far, is a decision to be made carefully.
Even though cataract removal is the most common reason for aphakia, there are other abnormalities which may also require removal of the lens.
Once the cataract is removed, images can clearly reach the retina. Unfortunately, the only way to remove the cataract is to remove the lens, which focused images on the retina. This means that an aphakic baby or child will need an artificial corrective lens in order to be able to see clearly in that eye. The new lens will be a contact lens, eyeglasses, a lens implant, or some combination of those.
Long term effects
Vision expectations - The more closely you keep to your ophthalmologist's recommendations about lenses and patching, the better your baby's vision is likely to be. However, even under the best of circumstances, aphakic children will not develop perfect vision in the affected eye(s). With corrective lenses, aphakic children can expect to have vision that is fine for most occupations and for driving a car.
Appearance of the eye - Your child may have some lingering cosmetic effects of cataract eye surgery. The iris (colored ring) may be bruised during surgery, and will take several months to recover as much as it ever will. Your child's pupil (dark center) may be left with a teardrop shape, which will gradually get rounder, and may eventually round up completely. The iris may not dilate or contract quite as well as an unoperated eye, so the size of the pupils may not match in all lighting conditions.
Astigmatism - The cutting and restitching of eye surgery may lead to an uneven eye curvature, so your ophthalmologist will be checking regularly for astigmatism. Astigmatism is usually corrected by using rigid contact lenses. In some cases, further surgery to correct the astigmatism may be necessary.
Amblyopia and Strabismus - A major concern for aphakic children is keeping a balance in visual development between the two eyes. An imbalance is called amblyopia. In the case of unilateral aphakia, when one eye focuses normally and the other doesn't, it is nearly impossible for the brain to rely equally on the two eyes, so amblyopia almost certainly results. Children with amblyopia are at high risk to develop misaligned eyes (strabismus) because of the tendency to use the eyes one at a time rather than together. Untreated amblyopia can lead to blindness in the weaker eye, so it is very important to watch for this, and to return to the ophthalmologist frequently for evaluation. Treatment for amblyopia and strabismus will include patching and/or surgery.
Glaucoma - Children who are aphakic because of congenital or developmental cataracts are much more at risk for a buildup of pressure inside the eye, which can lead to very serious damage to the optic nerve. Your ophthalmologist will need to check the pressure routinely. Since the child must be very still to measure the pressure, it may be necessary to conduct this exam under anesthesia.
Physical development - You may wonder about your child's physical development with somewhat impaired vision. Parents of other aphakic children will tell you that (barring other physical difficulties) their children reached, crawled, walked, and read at about the same times as other children. These little folks find other ways to make up for any loss of focusing or depth perception. If your aphakic child finds it frustrating to play games that require quick changes in depth perception (e.g. ping pong), try games that are played in two dimensions (e.g. pinball) or have larger, slower balls (e.g. soccer).
Psychological effects - The more normal you expect your child to be, and the more matter-of-factly you treat him, the more comfortable your child will be with his vision situation, and with himself as a person.
CORRECTIVE EYEWEAR
Contact lenses
When a baby has a cataract in only one eye ("unilateral" or one-sided cataract), a contact lens is the usual choice for a new corrective lens. This will keep the size of the corrected image that reaches the brain about the same size as the image that comes from the normal eye, making it easier for the brain to reconcile the two images into one. Of course, contacts may also be worn if the child is aphakic in both eyes. Although taking care of contact lenses takes some doing, and there is a possibility of eye irritation or infection, they do give a natural appearance, and most children can tolerate them.
Eyeglasses
Eyeglasses change the size of the focused image that reaches the eye. This is not a problem for children who have bilateral aphakia ("two-sided" lens removal -- cataracts in both eyes), and this method is often used for such children. On the other hand, a child with a cataract in only one eye will not be able to satisfactorially blend the normal-sized image from the healthy eye with the corrected image size through an eyeglass lens, so eyeglasses are not used as the main correction for unilateral cataracts.
Since aphakic eyes, by definition, do not have an adjustable biological lens, they cannot accommodate (adjust or focus near-to-far) on their own. A corrective lens will only give clear vision at a certain distance (depending on the prescription). To help your child see clearly at several different depths (focal lengths), your doctor may prescribe eyeglasses with bifocal lenses.
For many children with unilateral congenital cataracts, the affected eye is somewhat smaller than normal (microphthalmia). This condition is masked somewhat by wearing eyeglasses, whether or not they have a corrective lens.
Lens implants
In adult patients, lens removal for cataracts is usually followed by implanting an artificial lens inside the eye in the place of the biological lens. The use of these implants, called intraocular lenses (IOLs), is becoming more common for pediatric patients. This sounds like good news -- no contacts or glasses to keep up with! However, for geriatric patients, the size and abilities of eyes are pretty stable, while eye size and vision in babies and young children are changing constantly. This means a young patient with an IOL will still need to wear a contact or eyeglasses as he/she grows to "fine tune" the correction of the implant.
PROTECTING APHAKIC EYES
Ultraviolet protection
In addition to focusing the image that comes into the baby's eye, his biological lens serves to protect the inside and back of his eye (retina) from ultraviolet radiation. In fact, the lens can develop cataracts as a result of unprotected exposure to the sun. An aphakic child is missing that protective function of the lens, and so his retina is more vulnerable to sunlight damage. As a result, it is important for aphakic babies and children to wear sunglasses or a brimmed hat when outdoors. Wrap-around sunglass styles are more protective. Select lenses that block 99% or 100% of all UV light. (Some labels say "UV absorption up to 400nm", which means the same thing.) Baby-appropriate sunglasses may be bought through your optician, at specialty sunglass stores (like the chains often found in malls), at baby supply stores, or from discount or department stores. Make sure you are buying real sunglasses and not just toys.
Wearing sunglasses can help your baby in another important way. By getting regular early practice wearing glasses before your baby has to wear corrective eyeglasses, he will already be used to having them on his face.
Here are some ideas to encourage your child to wear sunglasses:
- Everyone in the family owns sunglasses, and is careful
to always wear them.
- We have many pair of inexpensive sunglasses, so there's always a pair
within reach.
- Jason gets to help pick them out at the store, and we emphasize how great
they look.
- I try to remember that even if he only has them on half the time, that
cuts his risk of damage by about 50%, which is significant.
- We use bribes! "Everyone who leaves their sunglasses on gets to watch
a movie when we get home."
- Now that he's old enough to understand, we just tell him that he needs the
sunglasses to protect his eyes, and to keep them healthy.
- Stay calm.
- When he was younger, we would try to keep his hands busy with toys or
food.
- Keep the glasses clean. We wash them many times a day.
- Give an ending point, so it doesn't seem like forever. "You may take
your sunglasses off when we get in the car."
There is a common idea that babies and young children will not tolerate wearing glasses, but the little sunglasses now are so cute that your baby will get lots of positive reinforcement and soon enjoy putting them on himself.
Check with your ophthalmologist or optician to see if your child's contact lenses are available with a UV coating. Even so, sunglasses will still be appropriate.
Protective eyegear
Particularly as your child is old enough to participate in sports or other visually risky activities, it is a good idea to protect the remaining vision by having your child wear safety glasses, available in a variety of styles. Check with your doctor to see if protective eyegear is appropriate for your child.
HELPING YOUR OPHTHALMOLOGIST TO HELP YOUR CHILD
There are several things you can do as a parent to maximize your child's opportunity to develop good vision. The most important is to follow your child's patching schedule. In addition, here are some ways to help make visits to the ophthalmologist more productive:
- Take note of your child's behavior. When does he seem to favor one eye or the other? When do his eyes seem straight or misaligned? Be prepared to give a detailed report.
- Notice your child's posture, particularly the head, at different times. Does your child lean her head over toward her shoulder, or does she turn her head to look at you with one eye? Particularly in young children, these behaviors seem adorable and sweet, but they may indicate your child is preferring one eye or the other, and should be mentioned to your ophthalmologist.
- As you take pictures of your child, make sure to keep some face shots for your ophthalmologist to look at. This will help chronicle what is happening between office visits and at different times of the day.
- Play peek-a-boo games at home by covering one of your child's eyes, then the other, or by peeking around a corner with just one eye. This will help your child feel more comfortable with having the doctor cover his eyes alternately.
- When you return to the ophthalmologist's office, you'll be asked how your child is doing with patching. If for some reason you have not patched according to the doctor's recommendations, it is tempting to avoid mentioning this. However, please do tell the whole truth. The doctor will only be able to accurately assess your child's progress if you are completely honest about what has been happening.
- In the ophthalmologist's office, your very young baby or child may feel more secure if you hold him peeking over your shoulder and turn your back to the doctor for the exam.
- Our son loves his ophthalmologist, and we want to keep that affection going! When our son is having a difficult time with contacts or patches, we've been tempted to play on his attachment to the doctor by saying, "Remember, Dr. Friend wants you to do this!" So far, though, we have avoided saying anything that, thinking it might backfire and make our son dislike the doctor. Instead, we just give the real reason for needing to do whatever it is. (For instance, we say, "This contact lens will help you see better" and "Wearing the patch will help your eye learn to see".)
- Keep your appointments with the ophthalmologist if at all possible. Since young children's vision can change rapidly, it's important to monitor it closely. At first, your child will have visits every few weeks. After a couple of years, you'll probably be going to the doctor every three months or so. After school age, your doctor will probably seeing you for maintenance visits a couple of times a year.
WEARING CONTACT LENSES
Finding an optician
Your baby's ophthalmologist will probably have a recommendation for which optician to use for ordering and fitting the contacts. It is common for opticians and ophthalmologists to work in partnership, since they are likely to have questions for each other, share medical records about the baby, etc. This may seem like a "sweetheart deal" for their businesses, but is really to your advantage in the long run. The neighborhood one-hour type optical places will not be able to provide the same level of service. In major metropolitan areas, it will be easier to find opticians who specialize in putting contacts in babies' eyes. In smaller cities, you may have to take what you can get.
Establish a relationship with a particular optician, not just a store. You'll need to call often about fitting, caring for, and replacing lenses, and it will help if you know each others' names and faces.
Inserting and removing contact lenses
The following instructions may seem daunting and complicated, but they will help you feel more confident as you get started. Just like anything else, caring for contacts for a baby requires a learning period during which you'll feel clumsy, but soon you will develop your own routine that seems like second nature.
Inserting contacts
Before attempting to put in your child's lens, make sure you have enough time. When you're first getting started, leave yourself ten or fifteen minutes so you won't be rushed. If your baby is very young, you might try when your baby is deeply asleep.
Choose carefully your place to put in the lens. Avoid locations where there are lots of people or other distractions. Select a location where you could more easily find the contact if (when!) you drop it. Solid-colored bedspreads and carpets are good choices. Make sure your hands are clean. (Your optician may sell special handsoap that is fragrance-free and less irritating to sensitive eyes.) Keep your fingernails short and smooth to lessen the likelihood of scratching your baby's face.
Get everything ready before you start the process:
- contact lens(es) clean and inspected for damage
- tissues to wipe tears (baby's and yours!)
- open contact container
- moistening solution for contact if it dries out (soft lenses)
- bottle, or be ready to breastfeed baby
- flashlight to look for lens in eye or if it is dropped
- someone for moral support or to help hold baby
Restrain your baby. There are several ways to do this. You'll probably want the baby crossways in front of you, lying on his or her back. Up until Jason was about four months old, we could put his lenses in when he was asleep. After that, we would invariably wake him up! So eventually you have to figure out how to do this when the baby is awake. You can use an infant seat or a car seat to hold the baby's body, but will need some help to hold his arms still. Another way to restrain the baby (which seems barbaric, but most people end up using) is to "sit on" your baby. Here's how this works for us: I am right-handed, so I sit on the floor or bed crosslegged with Jason sitting in my lap facing right. I then put my right leg over his arms and legs and cross my legs again. I lean his head back across my left leg, which gives me a great angle to put the lens in. This method has several advantages: it doesn't require any other equipment or people, and the baby's head is naturally tilted back for more comfortable insertion. No baby likes to be held still, especially as he gets older, but figuring out how to do this firmly and efficiently is actually kinder than repeatedly chasing and tackling your baby. Next, get the contact out of its case. It will be drippy from the storage solution. For easier handling, it needs to be moist enough not to stick to your fingers, but not so wet that it slides off your finger. You'll develop a knack for this.
There are two basic kinds of aphakic lenses for babies: silicon soft lenses and rigid gas permeable lenses. They are cared for differently, and you put them in differently. First, a method for inserting silicon soft lenses: Since I am right-handed, I hold the contact in my right hand with my thumb and index finger slightly pinching it at the 4 and 8 o'clock positions, so the lens is fan-shaped. The curved fan edge will go in the baby's eye first. (If you hold the contact with your fingers directly across from each other, say at 3 and 9 o'clock, the lens is likely to fold in half when you insert it.)
I use my left wrist to hold Jason's forehead back across my left leg, and use my left thumb and forefinger to pluck up the top lid of his eye. Next I slide the contact (still between my right thumb and middle finger) up in under that top lid. There's lots of room under the lid. I used to worry that I might put in the lens too far up, and that it would disappear up over his eyeball! But don't worry -- the muscles are attached all around the eyeball so that the lens cannot get "lost" -- you'll always be able to see at least some of it. At this point, it is more important to get the lens in the eye somewhere than to worry about exact placement -- the lens and the eyeball are shaped so they will "find" the correct placement in a few seconds. Your baby will be crying. You may be, too, but it is almost over!
While Jason is still restrained, I pluck up his lower lid slightly with my right hand to make sure the lower edge of the contact isn't still hanging out of his eye. Next I watch for a few seconds to see if the contact pops out. If all seems well, keep the baby in your arms a while and give him a treat (nursing, bottle, juice cup) which will help calm the baby, while leaving him/her in a still, cradled position so you can get a closer look at the contact in place (we hope!).
Rigid gas permeable (RGP) lenses are somewhat easier to take care of and insert. You will still need to prepare in the same way and restrain your baby, but since these lenses are smaller (about the size of the central dome of the silicon lenses), you won't have to get your baby's eyelids as far apart to insert the lens. The lens is rigid, so rather than pinching it to hold it you can balance it on the tip of your right index finger and, holding the baby as described earlier, just touch the lens to your baby's iris. Check the lens position in the baby's eye as described above.
In addition to ease of insertion, care, and removal, RGP lenses have the advantage of being less expensive. So why doesn't everyone use them? Your ophthalmologist will prescribe the kind of lens that can best fill your baby's prescription. Having your baby see well is worth whatever care you need to devote to caring for and handling the lens.
What might go wrong:
- If you drop the contact, rinse it off and start again.
- If your baby rubs his eye (he almost certainly will), be VERY vigilant for
a lens popping back out or sliding out of place.
- If your baby cries so much while you're working on him that his lids are
swollen and slippery with tears, take a deep breath, remind yourself you're
being helpful in the long run, wipe everyone's tears, and try again.
- If both you and baby are just too stressed, it's okay to wait a few
minutes and try again. You will eventually get the contact in!
Removing contacts
It may sound obvious, but before removing your baby's contact lens, make sure the contact is actually in his eye! Babies lose contacts so often. A couple of times I worked quite a while on our son's eye before it occurred to me that there was nothing to remove.
Although in Jason's early months we were able to put his silicon soft lens in while he was sleeping, we never figured out how to take it out while he slept. Now that he has a RGP lens, it is easy to take it out while he's asleep, and that seems less traumatic for everyone.
Getting ready to take contacts out is much like getting ready to put them in. You'll need:
- an open contact container with storage solution in it
- tissues to wipe baby's tears
- flashlight to look for lens in eye or if it is dropped
- someone for moral support or to help hold baby
Restrain your baby as you would to insert the lens. Choose a moment when the baby is looking toward you, and you can see most of the contact. For a silicon soft lens, use your two index fingers, one on each lid of the eye, and gently press the fingers down then toward each other. The lens will flex and pop out. You'll develop a "touch" for how gentle / firm to be. To remove a RGP lens, hold the eyelids apart, and gently touch the cup of the little suction tool (provided by your optician) to the center of the lens and it will lift right out.
When you get comfortable handling the contact (believe it or not, that time will come!), teach someone else how to do it. If your baby is regularly away from you (for instance, in daycare), teach someone else whom you trust and who will see your baby often. Make sure you have a backup so if you are sick or away from your child his care will not be interrupted. This person needs to know all you do to insert, remove, and care for the contact, including your baby's schedule for wearing the lens.
Checking on and realigning contact lenses
Since your baby can't talk, it is up to the people around him to check his contact frequently. If the baby is routinely with other people, it is important for each caregiver to know how to check his eyes.
Very quickly you will get used to the "look" of your baby with contacts in. At first, we would take a peek while Jason was asleep -- we could get a good long look at the contact, his surgical line, the shape of his pupil, etc. without disturbing him.
Learn where the edge of the contact lens is compared to the edge of the iris (colored part). Sometimes a surgical line (like a dent in the surface of the eye) is visible, and might be confused with the edge of a contact.
When a lens is centered, you will see an extra "dome" over the pupil where the middle of the contact is. Use a flashlight to try to see two light reflections in the same eye, one coming from the middle of the lens and one more off to the side. Behind the "dome", the color of the iris may look lighter or darker.
It can be hard to see a contact when you are very close to the baby, as when you are holding him. You could let someone else hold him and so he's facing you, or both you and baby could face a mirror and you'd look at his reflection.
Your baby's lens can't slide so far off center as to get completely lost in the back of his eyeball, but it can drift out of place, particularly when he has been rubbing his eye, so check for this occasionally. If your baby's lens is tinted, it is easier to see whether it is in or out of place. If your baby's suddenly begins to wander, that could also indicate his corrective lens has slipped out of place.
To reposition the lens, try one of the following techniques:
- through the baby's closed eyelid, gently stroke the
contact back toward the pupil a few times
- with the baby's eye open, locate the lens, and move it back into place
with your fingertip
- for older children, hold the lens stationary with your finger and ask the
child to look at the lens (which moves the eye into place under the lens rather
than moving the lens into place)
- remove and reinsert the lens
Babies may feel irritation in one eye, but rub the other eye or rub both eyes. So if you notice the baby rubbing, suspect a problem in either eye.
Lots of things can make a baby's eye red. It is common for the "white" of the eye to be a little pink for a few minutes after putting the lens in or taking it out, but watch this VERY carefully. If at any time the eye stays red for more than a few minutes, or if the baby is "clawing" at his eye, or if his cries are unconsolable screams, call your baby's eye doctor and ask for advice. You will probably be advised to remove the contact and bring the baby in for a look.
It is a good idea to periodically have your optician check your baby's lens. An optician can tell if the contact is getting clean enough, and can help you look for imperfections in the contact. This service might be free, or might be included in the cost of a contact lens insurance plan.
Insurance and paying for contacts
Aphakic contact lenses can be expensive ($60 to $140 each, depending on type), and you will lose lots of them -- everyone does! So figuring out how to pay for them is an important consideration. Talk with your optician about contact lens insurance, which is a one-time or annual fee you pay that allows replacement of lenses at a reduced cost. This usually pays for itself after you lose one or two lenses, which won't take long. Such a policy may also cover regular lens "checkups" where the optician inspects and cleans the lens.
If you have medical insurance, it may not immediately automatically pay for your baby's aphakic lens. (Most policies won't pay for any lenses they consider cosmetic.) Have your pediatric ophthalmologist write a letter to the insurance company reminding them that these lenses are not cosmetic, but are required for vision. Under these circumstances, most lens replacement costs are reimbursed.
Some credit card companies have loss protection programs. See if your credit card company will replace lenses which are purchased on that card and then lost.
Talk to your ophthalmologist and optician about whether your type of lens is available in tinted colors. Having a tint makes your life better for several reasons. If the lens is dropped, the tint makes it much easier to find. If it slides out of place in your baby's eye, it is easier to locate and replace. Even when it is in place, the lens is easier to see if it is colored. (Jason currently has a lens which makes his green eye look blue. Rather than being annoying, this is really helpful, since I can check on his eye from across the room!) Because a colored lens is less likely to need to be replaced, your insurance may cover the cost of the tinting (which in any case is minimal).
Contact lenses of the sizes and strengths commonly used for aphakic children are not usually stocked by opticians, so they have to be ordered individually from the manufacturer by your optician. This process can take several days, but may be sped up if you pay express mail charges. Check with your optician about ordering another lens as a backup at the same time. If you keep the backup lens unsealed in its container and then don't use it, you may be able to return it for a refund. Your optician may agree to keep the backup lens for you, in which case you probably wouldn't have to pay for it until you need it, but you also wouldn't have it accessible if you go on a trip or the office is closed for holidays. Having a backup lens is important: not only does it keep your child in uninterrupted vision, but it keeps you in the practice of putting the contacts in every day.
PATCHING
Children who wear a contact lens for aphakia will need to have one or the other of their eyes patched from time to time. Patching an eye blocks the vision in one way or another, and is often used to temporarily prevent a baby from using the stronger eye so the vision in the weaker eye will develop. It may be that the muscles of the weaker eye need more use, or that the baby's brain needs to practice using the weaker eye.
Blocking vision is also called "occluding," so you will hear patches of various types referred to as "occluders." Your baby's eye might be patched from time to time using contact lenses, an adhesive eye patch, or other patching methods (eyedrops, "pirate" patch, or covered eyeglasses). Each has advantages and disadvantages, and you may use different methods in combination, or change methods as your baby grows. Your child will need to follow a patching program until he is visually mature, usually by 9 or 10 years old, although in the later years he will only need to patch occasionally.
Regardless of the occluding method, you will work with your baby's doctor to use the schedule he or she recommends. Patching schedules will change as your baby's eyes develop and change. You might patch regularly for several hours each day, or patch for one or more days at a time. It is important not to over-patch, or vision will deteriorate in the occluded eye! So there is a balancing act necessary to keep vision developing in both eyes.
Staying motivated
Your ophthalmologist will tell you that the most important factor in the development of your child's vision is YOUR compliance with the patching program. Children do not really enjoy being patched, regardless of the methods you use, and each method involves some hassle. It is tempting to put off patching, maybe just for today... and before you know it, you are really off your routine. It will be helpful if you ask some other adults to help you stay motivated. Here are some thoughts to help you stay on track:
- Someday my child will thank me!
- My child is depending on me.
- If my child had a broken leg, we'd use a cast. My child needs the patch, so we'll do it.
- I'd better patch today, because tomorrow may be even more hectic!
- When we are in a routine, this is easier for everyone.
- Patching will not only help improve his vision, but also eventually his appearance (keeping eyes straighter), and reduce the likelihood of needing strabismus surgery.
- If I don't do this, my child may end up blind in his weaker eye!
- Everybody else has trouble staying motivated, too. I am not alone.
- What worked last week will change for this week. That's okay.
Occluding contact lenses
In order to patch with a contact lens, you can either use a darkened lens or a regular prescription lens. The dark lenses are not used very often, because it is hard to keep a consistent coating on the lens, and because the appearance of the eye with a black lens is not very natural. It is more common to patch with a regular prescription lens that is strong enough to blur the baby's vision in that eye, forcing him to use the other eye.
The main advantage of patching with a contact is a social one: during the months and years when the baby is learning to relate to the world and developing a self-concept, his appearance will be as close as possible to normal. There is less explaining to do since strangers probably won't notice anything unusual about your baby's eyes. Also, using a contact avoids the skin problems sometimes associated with regular sticky patch use. The baby can't easily take the contact out and can't look around it.
The disadvantages of using an occluding contact are that you have to take the lens in and out regularly, as well as care for it properly. You also must check the child's eye to make sure the contact is in place. This increases your work, but it may well be worth it.
Adhesive Eye Patches
When most people think of eye patches, oval adhesive eye patches come to mind. They are easy to attach and remove, and they are readily available (pharmacies and most supermarkets carry them, in addition to opticians). This is the easiest patching method to learn to use. If you need to buy them frequently, check about bulk prices for a large quantity. Especially at first, you'll need to keep patches stashed in lots of convenient locations (diaper bag, Grandma's house, car, etc.) Adhesive patches are available in a couple of brands and in sizes for infants and older children.
These patches have a few disadvantages. They can be rather expensive in the long run if you need to replace peeled-off patches several times a day. (Ask your ophthalmologist to write a prescription for these medically necessary items, and see if your insurance will reimburse you.) They are only available in light skin tones, like first-aid bandages. Wearing an adhesive patch can really be sweaty and uncomfortable. If your child will be wearing them routinely, try one on yourself several hours and you are guaranteed to be more sympathetic! Children occasionally peel off their patches and try to stash them in the closest hiding place -- their mouth! Watch for this choking hazard.
- One brand (Coverlet) comes with little
stickers to decorate the patches (and you could use any stickers you like if
this motivates your child).
- One of our children thought it was a great idea to draw an eye on the
patch! Others use a marker to draw a smiley face or "HI" on the
patch. This seems to alleviate some of the pity that strangers feel for a child
in an eyepatch.
- As your child is getting used to wearing patches, you might try applying
them before your child wakes up. You won't have to force your child to be
still, and your child may not immediately notice what has happened.
- Ask the child to close both eyes before you put the patch on.
("Pretend you're sleeping.") Her face will be more relaxed than
if she's squinting one eye, and the patch will go on more smoothly.
- Let the child try putting the patch on independently. Give some tips
("Touch only the pad", "Start at your eyebrow").
Also, let the child peel off his or her own patch when the time comes.
- Try to put it on when she will be playing with other children or otherwise
distracted.
- Be cheerful yourself.
- "Paint" the skin around the
eye with Maalox (yes, the chalky white antacid liquid) and allow it to dry
before applying the patch.
- Rotate the patch or don't attach it in exactly the same place each day.
- Occasionally use a gauze square fastened with bandage tape to avoid
irritation to the same area of the skin.
- Ask your optician or ophthalmologist about products to coat the skin
before using the patch.
- Use an adult-sized patch with the adhesive trimmed in various patterns
from day to day.
- Use a different brand patch.
- Try a large adhesive bandage designed for knees. These are less expensive
than eye patches, but may not adhere as well.
- Say, "keep your patch on"
and replace it firmly and cheerfully.
- Cut slits around the patch where it hits her nose so it fits better and so
she can't get such a good grip.
- Offer a reward if the child leaves the patch on a certain length of time.
- Patch in terms of time your child can understand. For instance, I'll say
that he may take the patch off when Daddy gets home, or when the video he's
watching is over, or after lunch. (This takes the focus off begging me.)
- Younger children can be kept in mittens so they can't use their fingers to
peel the patch.
- After attaching the patch, try wrapping and taping gauze bandage around
the child's head to make the patch less accessible.
- Use surgical or first aid tape around the edge of the patch to make a
really thin edge that's hard to peel off.
- Make or purchase splints to keep the child's elbows straight. The child
can still play, but can't reach his or her eyes.
We have found that the ability for babies and children to tolerate adhesive patches comes and goes in stages. (The period between 9 and 18 months is particularly difficult for many children.) Being consistent is the most helpful way to stay on track with your patching. It also helps to be matter-of-fact and positive about the patch, avoiding saying things to your child like "I know you hate this, but you have to wear it." At some points you may want to alternate with other patching methods.
Other patching methods
Eye Drops
Atropine eye drops are sometimes used to temporarily paralyze the focusing muscles in an eye, which "patches" that eye. Atropine is most commonly used for long-term occluding (days or weeks at a time) or for non-compliant children, but has some drawbacks. It is hard to tell just when the drops take effect and wear off, so it is not as "definite" as other patching methods.
Patches On Eyeglasses
Particularly if your child is already used to wearing eyeglasses, you may find it easiest to patch with a felt or leather-type pocket which cups around the frame of the glasses. From a social point of view, this attracts a lot of attention, and it must be worn properly so the child can't peek around the edges. On the other hand, such a patch is very easy for you to take on and off, and you can easily tell if it is in place!
There is also a patch that fastens to the inside of eyeglasses using a suction cup, which works well for a compliant child. The inside of eyeglasses can also be blurred with sticky plastic (like Contac brand paper or shelf liner). Both of these methods depend on the child's not peeking around the patched lens.
"Pirate" Patches
"Pirate" patches (on an elastic band) are not usually used for children for social reasons and because compliance is so low, but they are an option if the child is very cooperative. When our son was three years old, he thought looking like a pirate was really cool! They have the advantage of being easily put on and removed without the skin problems associated with adhesive patches.
RELATED WEBSITES
American Academy of Pediatric Ophthalmology and Strabismus- Rich site, searchable by topic, abstracts of relevant research, public forum for answers to questions
American Academy of Ophthalmology - Educational site dedicated to general ophthalmology
American Society of Cataract and Refractive Surgery- Primarily for adult cataract issues
c 1999 Nancy Penney