Text author: Dr sc. Bojan Kozomara, dr med.
Pediatric ophthalmology represents a distinct, and arguably the most demanding part of modern ophthalmology. Childhood eye diseases in our population still often go unnoticed or are detected late, leading to a significant number of visually impaired individuals in adulthood. At birth, a child’s eye is still underdeveloped, like many other organs and organ systems. Therefore, it is very important to conduct regular vision checks in children, regardless of whether symptoms of poor vision are noticed or not.
During our lifetime, the eye grows only 1.84 times compared to its size at birth, making it one of the smallest organs in our body.
Intense visual development in children lasts until the age of four, and vision is fully developed by the age of eight. As long as vision is in the developmental stage, there are therapeutic options to preserve it and improve insufficiently developed vision. Unfortunately, if visual disturbances or reduced visual acuity are not detected in time, the results of treatment in later stages are significantly poorer, and the child remains partially or completely visually impaired for life.
A pediatric ophthalmological examination is one of the most important examinations to be done by the age of 4. As already emphasized, intense visual development lasts until the end of the eighth year of life, so it is important to know that a child is never too young for an eye examination, even when they still do not know letters and numbers. The child should be prepared for the examination so that they perceive it as a game rather than a visit to the doctor.
Special cards with patterns are used for babies to determine which pattern size captures the baby’s attention, and the result is compared with tables prescribed for that age group. For preschool-age children, pictures (Lea symbols) made to the same standards and sizes as adult letters are used. For a better understanding of visual acuity, it is necessary to examine how well the child recognizes the symbols at both near and far distances.
The most common reason children come for an eye examination is refractive errors. Typically, parents notice that their child has difficulty seeing because they bring books and toys closer, watch television at a short distance, or squint and blink frequently when trying to focus on distant objects.
In older children, vision problems are often detected when they can’t see the board at school. Children with refractive errors also frequently complain of headaches after prolonged reading or playing video games.
Among the most common eye conditions that need to be treated in childhood are strabismus, amblyopia (lazy eye), congenital cataract, as well as nystagmus (eye twitching).
Amblyopia, or lazy eye, actually represents insufficient development of the optic nerve, optical pathway, or the visual center in the brain, meaning the inability to achieve maximum visual acuity in one or both eyes, even with full correction of refractive anomalies. The problem of amblyopia is particularly pronounced if it is present in only one eye. In such cases, the vision problem in the weaker eye is “masked” by the vision of the better eye, and the child does not complain or show any symptoms, often leaving the problem unnoticed.
The visual center in the cerebral cortex only processes the image from the better, healthier eye, while the weaker eye is “suppressed” by the better eye, leading to strabismus. Although an inherited component has never been officially proven, amblyopia is more common in children whose parents also have amblyopia.
Strabismus is a disorder of the position or movement of the eyeballs. In healthy eyes, both eyes are aligned properly, meaning they are positioned straight ahead of the object being viewed, and their movements are coordinated. Each eye is controlled by 6 muscles, with impulses for movement originating from the brain. Coordinated eye movements achieve perfect cooperation between both eyes, allowing the development of binocular vision, where both eyes work together to create a single three-dimensional image in the brain (stereovision). If both eyes are not properly aligned or if their movement is restricted in one direction, the brain will suppress the eye that is not aligned correctly or not following the direction of the other eye, leading to the development of amblyopia mentioned earlier, and the inability to develop binocularity and stereovision.
In some cases, when visual development is already completed and binocular vision cannot be restored, strabismus surgery may be performed for cosmetic reasons to reduce the deviation and bring the eye into proper alignment. This would improve the patient’s aesthetic appearance, while visual function would remain the same as before.
After injuries to the face and head, paralysis of some of the muscles that control the eye can often occur. Besides the altered appearance, a patient who previously had all visual mechanisms functioning well may develop double vision. In such cases, although the function of the muscle or nerve that controls it cannot be restored, surgery can bring the eye into a position that is closer to normal natural vision, thus facilitating daily functioning.
Strabismus surgery is performed when the angle at which one or both eyes “deviate” to the side cannot be corrected with prescription glasses or when improvement in aesthetic appearance is desired. The surgery involves changing the position of individual eye muscles or shortening some of them to bring the eye into the desired position.
Extremely rarely, a child may be born with a cataract in one or both eyes. Such congenital cataracts usually occur due to developmental disorders or maternal infectious diseases during conception.
Since the cloudy lens prevents light from entering the eye, even if the rest of the eye is completely healthy, the child’s vision will not develop, and it will remain highly visually impaired even after a successful later surgery.
Therefore, congenital cataracts that hinder visual development need to be operated on as early as possible, even in babies. During the surgery, similar to adult patients with cataracts, the cloudy lens is removed, and an artificial lens is implanted in its place, enabling the eye to develop visual function.
