Paediatric Ophthalmology

2024/05/16

What is Paediatric Ophthalmology

Overview

The Division of Paediatric Ophthalmology and Strabismus comprises a team of paediatric eye specialists (paediatric ophthalmologists), orthoptists and allied health staff. We are committed to delivering comprehensive and accurate diagnosis and management for all paediatric conditions, and strabismus in both children and adults.

Our services welcome referrals from polyclinics, general practitioners (GPs) and other medical professionals. Private patients can be seen as self-referrals or through the International Patient Liaison Service (IPLC).

Our Clinical Services

Our team serves children with a variety of conditions, including:

Refractive errors including myopia
Amblyopia or lazy eyes
Strabismus
Retinopathy of prematurity
Retinoblastoma and orbital tumours
Paediatric cataracts
Paediatric lids/orbits, glaucoma, retina, neuro-ophthalmology and cornea problems
Paediatric ocular trauma
Paediatric ocular inflammatory conditions (uveitis, orbital inflammatory syndrome, scleritis, episcleritis and neuritis)
Eye screening for systemic disease/congenital ocular anomaly
Paediatric eye emergencies
General eye problems such as sore eyes, allergic conjunctivitis and eyelid lump

We have a comprehensive strabismus service that manages both adults as well as children for squint, double vision and other disorders of eye alignment and movement.

Congenital esotropia
Intermittent exotropia
Accomodative esotropia
Cranial nerve palsies
Orbital fractures
Thyroid eye disease

Since the beginning of 2018, we have introduced a new POISe clinic, which runs on the first Monday of odd months. This effort is a collaboration between Paediatric Ophthalmology and Paediatric Rheumatology. It caters to children with ocular inflammation that would require paediatric rheumatology input.

Amblyopia (Lazy Eye)

What Is Amblyopia?
Amblyopia, commonly known as “lazy eye”, is a condition characterised by reduced vision in an eye that has not received adequate use during early childhood. It is not an eye disease and cannot be directly corrected by glasses or contact lenses. Due to the way the brain is developed, it does not fully acknowledge the images received by the amblyopic eye. While this condition typically affects one eye, it can also impact both eyes. It is estimated that three per cent of children under six years of age experience some form of amblyopia. If not detected and treated early enough, amblyopia can lead to permanent vision loss.

What Causes Amblyopia?
Both eyes must receive clear images during the critical period in childhood. Any disruption to clear vision in either eye during the critical period from birth to six years of age can result in amblyopia. The primary causes are often strabismus (crossed eyes) or a difference in image quality between the eyes, with one eye focusing better than the other. If one eye sees clearly while the other experiences a blur, the brain may suppress the blurry eye, potentially resulting in permanent vision reduction.

What Are The Symptoms To Look Out For In My Child?
The only way to detect a lazy eye early is to have sight tests regularly throughout childhood. Scheduled check-ups should occur at birth, six months, and annually until the child is seven or eight years old. If there are concerns about poor vision or crossed eyes, it is advisable to consult with an optician, general practitioner (GP) or eye surgeon at an earlier stage.

What Are The Treatment Options?
With early diagnosis and treatment, the sight in the "lazy eye" can be restored. The earlier the treatment, the better the opportunity to reverse the vision loss. Amblyopia can usually be successfully treated up to the age of seven, but treatment for older children may sometimes be successful in improving vision and can be attempted.

Before treating amblyopia, it is necessary to first treat the underlying cause.

Glasses are commonly prescribed to improve focusing or misalignment of the eyes.
Surgery may be performed on the eye muscles to straighten the eyes. This works by allowing the eyes to work together better.

The correction may be followed by:

Patching or covering one eye. The better-seeing eye is patched, forcing the "lazy" one to work, thereby strengthening its vision.
Medication, in the form of eye drops or ointment, to blur the vision of the good eye force the weaker one to work.

Brochure
Amblyopia (Lazy Eye) <insert>

Myopia Management For Children

Myopia, or short-sightedness, is the most common eye condition affecting children in Singapore. Notably, over half of children develop myopia by the age of 12, with an increasing number experiencing myopia at even younger age.

What Is Myopia?

Myopia is a refractive error where distant objects appear blurry, while near objects can be seen clearly. It arises from the excessive growth of the eyeball, causing light distant objects to fall out of focus within the eye. While spectacles, contact lenses and refractive surgery (LASIK) can provide good vision, they do not address the underlying issue of increased eyeball length.

Why Is Myopia a Concern?

The onset of myopia at an early age increases the risk of progression to severe levels in adulthood. Refractive errors in young children can lead to amblyopia ("lazy eye"), resulting in permanent visual loss called if not corrected early. High myopia is also a risk factor for various eye complications, including:

Cataract
Glaucoma
Retinal detachment
Macular degeneration

How Is Vision Testing Done?

Vision testing involves reading a series of letters or numbers of diminishing size on a chart placed 3 or 6 metres away. If the vision score is found to be reduced, refraction (spectacle power check) is performed to identify any refractive errors. Cycloplegic eye drops are often used in children to obtain accurate refraction. These eye drops reduce eye muscle spasms, a natural occurrence in children, allowing for an accurate examination. The eye drops also temporarily dilate the pupils to allow a full eye examination. It is important to note that the child's vision may be blurred for up to a day after dilatation.

What Are the Prevention and Treatment Options for Myopia in Children?

Myopia cannot be cured; however, there are options to control and slow down its progression.

Encouraged good eye care habits, including:

Reducing the time spent on near work (e.g., using computers and mobile devices, reading or writing) and taking frequent eye breaks every 20 to 30 minutes.
Sitting upright while reading and holding the reading material 30 cm away from the eyes.
Sitting at least 50 cm away from computer screens and adjusting the light for minimal glare.
Spending more time on outdoor activities (e.g., playing sports and enjoying the playground)

Atropine Eye Drops
- This form of treatment, available at NUH, has been proven effective in preventing myopia progression with minimal side effects, as shown in multiple randomised controlled clinical trials in Singapore.
- Administered every night over a period of two years or more, atropine eye drops can slow myopia progression by 50% to 60%.
- The pros and cons of this treatment will be discussed with you after your child's eyes have been examined.

For more information on Atropine Eye Drops for myopia, view the brochure here.

Paediatric Cataract

What Is Paediatric Cataract?

Normal Eye Vs Cataract

A cataract is the clouding of the lens in the eye. When a child has a cataract, the lens cannot focus the rays of light onto the retina normally. Instead, the lens produces blurry images, which reduce the child's vision. If the cataract is more serious, the child will need surgery to remove it.

What Are The Symptoms Of Cataract In Children?

It may be difficult to spot signs of cataract among very young children. Therefore, routine eye examinations are important. Consult your eye care specialist or ophthalmologist if you have any concerns about your child’s eyesight.

Signs and symptoms to look out for include:

Poor vision: The child may fail to recognise and follow objects or people with his or her eyes
Increased sensitivity in bright lights
Eyes with white reflex (white pupils) in photos
Eyes appear misaligned (squints)

What Are The Treatment Options?

As cataracts cannot be removed with medication or lasers, surgery may be necessary to allow the child's vision to develop as normally as possible.

Post-Surgery Care

After surgery, the child will need a corrective device such as a contact lens, intra-ocular lens or spectacles. The child may also need to wear a patch to help both eyes develop equally strong vision.

POISe (Paediatric Ocular Inflammation Service)

What Is POISe (Paediatric Ocular Inflammation Service)?

POISe is a new programme offered by the Department of Ophthalmology and Paediatric Rheumatology, designed to provide a one-stop, integrated service for children with paediatric ocular inflammatory conditions. Using a multidisciplinary approach to medical care, the goal is to enhance our young patients' journey through their diagnosis and treatment process.

The POISe clinic operates every first Monday of odd months.

What Are Paediatric Ocular Inflammatory Conditions?

Uveitis, Orbital Inflammatory Syndrome, Scleritis, Episcleritis, and Neuritis.

How Will Children Benefit from POISe?

In general, children diagnosed with ocular inflammatory conditions can expect to receive the following benefits:

Reduced waiting time between evaluation and treatment of conditions.
Fewer clinic visits thanks to a more seamless and coordinated treatment plan.
Access to paediatric-specific services in the Ophthalmology clinic.
A higher quality of medical care.

With POISe, the child is attended to by both Ophthalmology and Paediatrics specialists in a single clinic visit. This reduces the frequency of clinic visits, eliminating the need for travel between specialists. The collaboration between both specialists is enhanced, enabling more effective monitoring of the patient's progress. Procedures such as assessing the child's response to therapies, discussing test results and medication, as well as counselling, are streamlined and conducted in the same session.

POISe also provides easy access to a variety of child-friendly support services (e.g., sedation for scans) not commonly found in other Ophthalmology clinics. The child receives a higher quality of care, positively influencing the success rate of their therapy.

Squints (Strabismus)

Overview

Squints

Strabismus, commonly known as squint, is a prevalent condition among young children that may affect their sight, appearance and confidence if not detected and treated early. Every young child should have his eyes checked regularly. The treatment of squint is safe and effective, but its success requires the full cooperation of parents.

What is a Strabismus/Squint?

Strabismus is a condition that causes an individual’s eyes to point in different directions. In normal vision, both eyes are pointed straight at that object. If one eye points straight while the other eye turns away, it indicates strabismus.

How Does a Squint Affect My Child?

A squint can impact a child's vision, potentially leading to a condition known as a 'lazy eye', where the affected eye may not see clearly. Early detection and treatment are crucial for the effective cure of a 'lazy eye'. The timeliness of intervention significantly influences the outcome.

Individuals with a squint can only use one eye at a time, affecting their ability to judge distances and depth accurately. This, in turn, can affect the child's career and sports preferences in the future. Additionally, a squint can have implications for a child's appearance and self-confidence. Hence, there may be a preference for early surgical intervention to address the squint.

Finally, it is important to note that an eye with a squint may be associated with other underlying conditions that require appropriate treatment. Early assessment and intervention can play a pivotal role in addressing these associated conditions.

What Causes a Squint?

There are many causes. It may be due to a disorder of a part of the brain controlling eye movements or it may be caused by weak eye muscles, heredity, cataract, and nerve conditions. Also, any eye with poor sight tends to squint.

What Are the Treatment Options?

A child with a squint needs a full eye examination. This process may take time, especially as young children can be uncooperative and may require sedation..

Treatment strategies may include a combination of patching, spectacles, eye drops, eye exercises and in certain cases, surgery. The effectiveness of spectacles in correcting refractive errors depends on consistent wear, which can be a challenge with children. Parents play a crucial role in ensuring that their child wears spectacles regularly.

The treatment of a 'lazy eye' often involves patching the good eye to encourage the use of the 'lazy eye', enhancing the overall results of surgery. If patching or eyeglasses prove ineffective, surgery is recommended to straighten the eyes, improving both appearance and the ability to use both eyes together.

How Is Squint Surgery Performed?

Squint surgery is an operation on the muscles that move the eye. Strabismus surgery involves tightening the weak muscles and/or loosening the stronger ones so that the eyes are positioned better. Special absorbable stitches will hold the eye muscles in their new position. The surgeon will not cut the skin around the eye, take the eye out of its socket, or use any lasers during the operation.

Sometimes both eyes need to be operated upon but this provides hardly any risk to the eye.

What Are the Risks of Surgery?

It is considered a minor operation, with life-threatening or blinding complications being very rare. Children will receive general anaesthesia and be asleep throughout the surgery, which is very safe for healthy children. While double vision may occur after the operation, it usually resolves without treatment after a few months.

How Long Will My Child Take to Get Well?

Squint surgery is usually performed as a day surgery, with the child admitted in the morning and allowed to return home on the same day. Follow-up appointments are scheduled for the next day and within one week. There will be little or no pain after the operation and the eye is not patched, allowing the child to resume normal study and play after a few days. Swimming should be avoided for a month.

Does It Run in the Family?

Although most individuals with squints do not have affected relatives and exhibit normal intelligence, there is a sporadic familial occurrence. Therefore, it is advisable to monitor other children in the family if a relative has a squint.

Retinoblastoma

Retinoblastoma is the most common eye cancer in children globally. Affecting 1 in every 12,000 to 15,000 children, it typically manifests around 2 years of age. However, instances have been noted as early. Left untreated, the disease often progresses beyond the eye, infiltrating the eye socket, the brain, and eventually other parts of the body, leading to fatalities. Thus, it is not only sight-threatening but also life-threatening.

Management of Retinoblastoma at NUH

At NUH, Retinoblastoma is primarily managed by a team of experienced specialists including paediatric ophthalmologists, retinal specialists, and eye plastic surgeons. This collaborative effort forms the core of our ocular oncology team. The multidisciplinary approach extends to include geneticists, ocularists (specialists in artificial eyes), interventional radiologists, radiation oncologists, and pathologists.

With over two decades of experience, we annually manage 8-10 new Retinoblastoma cases, providing extensive, long-term follow-up care for both seeing and surviving children. The disease is thoroughly staged through appropriate investigations, and individualised treatment plans are crafted. Long-term monitoring involves the joint efforts of ophthalmologists and oncologists, with additional genetic counselling provided by Geneticists.

For more information on Retinoblastoma and the management of Retinoblastoma at NUH, please see Retinoblastoma. (Link to Retinoblastoma accordion at Oculoplastics page)

Retinopathy of Prematurity (ROP)

What is Retinopathy of Prematurity (ROP)?

Retinopathy of prematurity (ROP) is a vision-threatening eye disease that affects premature babies. This condition arises when abnormal blood vessels form in the eye(s) of the premature baby, potentially leading to bleeding and scarring. In severe cases, these vessels may lead to retinal detachment, causing the retina to shift from its normal position in the eye.

Infants born before 31 weeks of gestation and weighing less than 1,500g are at the highest risk of developing ROP

Retinopathy of Prematurity

Monitoring and Follow-Up of Patients

The baby's eyes will be frequently monitored for any changes. It is important to adhere to scheduled eye appointments, as abnormal vessel formation occurs rapidly.

What Are the Treatment Options?

Treatment strategies are determined based on the child's condition and may involve laser, injections in the eye or surgery to repair the retinal detachment.

What To Expect On Your First Appointment

A comprehensive consultation may take up to 2.5 hours, and duration of your visit may be longer if specialised testing is needed or complex eye problems are identified.

First, we will gather a detailed history about your child and what you as a parent have noticed. We may request you to share pictures of what you have noticed.
We will use various techniques to assess your child's vision, suitable for all age ranges, including infants, preverbal children, and those capable of reading an eye chart.
We also evaluate the muscle function of each eye and the ability of the child to use both eyes together. We will check for any signs of strabismus.
The health of the front portion of the eyes and the pupillary response to light will also be examined.
In most cases, new examinations will involve dilated eye examination using eye drops. The dilation process takes approximately 30 to 45 minutes. This critical aspect of the examination allows the doctor to inspect the inside and back of the eyes, assessing the health of your child's lens, retina and optic nerve. Dilation aids in measuring the focusing system of the eye to ensure proper visual focus.
After the examination, the pupils will remain dilated for several hours. This may result in some mild blurring of near vision and increased sensitivity to sunlight.
After the examination, the paediatric ophthalmology team will discuss the results with you, addressing any questions or concerns you may have.

Doctors