Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

If we carefully read through the two issues of Pediatric Annals devoted to the subject of ophthalmology, we cannot help but be impressed once again that early diagnosis of an abnormality and direction of care by the pediatrician may prevent irreversible damage.

We must always bear in mind that constant suppression or disuse of a macula will cause atrophy of the nerve. This makes it imperative that infants and children with cataracts and those with strabismus receive the earliest treatment possible.

As Dr. David R. Stager emphasizes in his discussion of amblyopia in this issue, deprivation amblyopia due to cataracts may be treated successfully at a few months of age but is quite resistant to treatment after a year or two.

When is the optimium time for removal of cataracts? All of us, I am sure, are keenly aware of the emotional loss to an infant who is deprived of early visual experience of the relationship to parents, family, and environment.

The safest and most effective time for surgery for congenital cataracts was under discussion for many years. There were ophthalmologists who preferred to wait until a child was between two and five years of age, on the theory that the eye would not develop its full size if the lens was removed too early.

Within the past 10 or 15 years, however, early surgery, even by six months of age, has been generally advised if the infant is healthy.

In this regard, it is of interest to note that the late Dr. Frederick Cordes recorded that Dr. G. J. Guthrie, writing in 1823, stated:

If the child be healthy at three, four and certainly six months, the operation ought to be performed with every hope of success. If operation is delayed until the end of the third year the child acquires ... an irregular rolling motion of the eye, which it does not readily lose.

My own experience is limited to one infant with bilateral postrubella cataracts. The cloudy lenses were removed when the baby was six months of age, and contact lenses were applied three weeks later. The mother had no difficulty applying the lenses, and the infant readily accepted them.

Fortunately, both cataracts and retrolental fibroplasia are extremely rare at the present time. Strabismus, with its danger of amblyopia in the unused eye, still remains the most common ophthalmologic problem of the practicing pediatrician.

The first two articles in this issue of PEDIATRIC ANNALS deal fully with the problems and treatment of both strabismus and amblyopia.

The article on strabismus is contributed by Dr. John F. O'Neill, of the George Washington University Medical Center. The author emphasizes the importance of diagnosing as early as possible the cause of the deviation so that treatment may be started at once and the optimum results obtained. The various methods of treatment are all reviewed. Dr. O'Neill stresses the difference in importance, nature of diagnosis, and treatment of eyes that are strabismic at birth in comparison with those that gradually develop strabismus and those in which strabismus is of sudden occurrence.

The second contribution, by Dr. David R. Stager, director of the Ophthalmology Service at the Children's Medical Center of Dallas, covers clearly and fully the important problem of amblyopia. I cannot help but feel that a great many pediatricians overlook the early development of this disabling condition. This life sentence of partial blindness can often be prevented - and the responsibility for this prevention lies largely in the hands of the pediatrician. Dr. Stager differentiates between amblyopia due to disuse, as so often follows strabismus, and amblyopia due to suppression,…

If we carefully read through the two issues of Pediatric Annals devoted to the subject of ophthalmology, we cannot help but be impressed once again that early diagnosis of an abnormality and direction of care by the pediatrician may prevent irreversible damage.

We must always bear in mind that constant suppression or disuse of a macula will cause atrophy of the nerve. This makes it imperative that infants and children with cataracts and those with strabismus receive the earliest treatment possible.

As Dr. David R. Stager emphasizes in his discussion of amblyopia in this issue, deprivation amblyopia due to cataracts may be treated successfully at a few months of age but is quite resistant to treatment after a year or two.

When is the optimium time for removal of cataracts? All of us, I am sure, are keenly aware of the emotional loss to an infant who is deprived of early visual experience of the relationship to parents, family, and environment.

The safest and most effective time for surgery for congenital cataracts was under discussion for many years. There were ophthalmologists who preferred to wait until a child was between two and five years of age, on the theory that the eye would not develop its full size if the lens was removed too early.

Within the past 10 or 15 years, however, early surgery, even by six months of age, has been generally advised if the infant is healthy.

In this regard, it is of interest to note that the late Dr. Frederick Cordes recorded that Dr. G. J. Guthrie, writing in 1823, stated:

If the child be healthy at three, four and certainly six months, the operation ought to be performed with every hope of success. If operation is delayed until the end of the third year the child acquires ... an irregular rolling motion of the eye, which it does not readily lose.

My own experience is limited to one infant with bilateral postrubella cataracts. The cloudy lenses were removed when the baby was six months of age, and contact lenses were applied three weeks later. The mother had no difficulty applying the lenses, and the infant readily accepted them.

Fortunately, both cataracts and retrolental fibroplasia are extremely rare at the present time. Strabismus, with its danger of amblyopia in the unused eye, still remains the most common ophthalmologic problem of the practicing pediatrician.

The first two articles in this issue of PEDIATRIC ANNALS deal fully with the problems and treatment of both strabismus and amblyopia.

The article on strabismus is contributed by Dr. John F. O'Neill, of the George Washington University Medical Center. The author emphasizes the importance of diagnosing as early as possible the cause of the deviation so that treatment may be started at once and the optimum results obtained. The various methods of treatment are all reviewed. Dr. O'Neill stresses the difference in importance, nature of diagnosis, and treatment of eyes that are strabismic at birth in comparison with those that gradually develop strabismus and those in which strabismus is of sudden occurrence.

The second contribution, by Dr. David R. Stager, director of the Ophthalmology Service at the Children's Medical Center of Dallas, covers clearly and fully the important problem of amblyopia. I cannot help but feel that a great many pediatricians overlook the early development of this disabling condition. This life sentence of partial blindness can often be prevented - and the responsibility for this prevention lies largely in the hands of the pediatrician. Dr. Stager differentiates between amblyopia due to disuse, as so often follows strabismus, and amblyopia due to suppression, as when an eye has a cataract. This important article should be read by all pediatricians.

The third article is a comprehensive review of the neurologic conditions affecting the eye. It is contributed by Dr. John L. Keltner, of the University of California-Davis School of Medicine. One of the important features of this article is the detailed, step-by-step directions for examining a child with visual difficulties. Newer and simplified methods are described for measuring the visual acuity, visual fields, the pupils, the fundus, and the ocular motor function. There is an excellent discussion of the various types and causes of nystagmus. Among other subjects discussed are cranial nerve palsies, papilledema, papillitis, and drusen.

The final article, by Harriet Bruere, director of the Child Resource Center near St. Louis, deals with dyslexia. This subject, while not an ophthalmologic entity, is included because it is so often spoken of as "perceptual difficulty." Ms. Bruere clarifies the present concepts concerning learning difficulties and demonstrates the stages in the diagnosis of this condition.

Her article is introduced by Dr. J. Denis Catalano, who gives reasons for discussing this subject in a review of ophthalmology and warns against the ineffectiveness of certain "treatment" methods advised by certain optometrists.

10.3928/0090-4481-19770201-03

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