4. Children outgrow crossed eyes. "I don’t care how cute your kids are, they should have straight eyes," she said. Refer any patients with constant strabismus before 12 weeks of age or any strabismus at older ages.
An eye cover test is easy to do to diagnose strabismus. With the patient looking straight ahead, cover one eye, peek behind the cover, and you’ll see the eye turn in or drift outward.
Children with a wide nasal bridge, prominent epicanthal folds, or an abnormally small interpupillary distance may seem to have a crossed eye, but really don’t. Dr. Alcorn usually reevaluates children with pseudostrabismus in 6 months "to be sure we didn’t miss something," she said.
Glasses can fix accommodative esotropia (one eye moving toward the other), but must be worn all the time, except when bathing, swimming, or sleeping. Surgery is not indicated.
If the child is unable to abduct the eye (look outward from the nose), there may be an intracranial process or infection. The eye that can’t turn out will always be turned in if there’s a sixth nerve palsy. In contrast, Duane’s syndrome, a congenital miswiring that prevents an eye from looking outward, allows both eyes to look straight ahead.
The cover test also is very valuable in diagnosing exotropia (outward deviation of an eye), which is much less common than esotropia. These patients may need glasses or another intervention, and should be evaluated.
5. A bump on an eye will go away. Sties often go away with treatment, but chalazia (chronic sties) may need surgical removal. Treat both with warm compresses, topical antibiotic ointment, light massage, and daily oral flaxseed oil (generally 1 tablespoon per 100 pounds of body weight). Eventually, if needed, consider incision and curettage or possibly a steroid injection, she said.
Not all lumps and bumps are sties. Capillary hemangiomas occur in 1%-2% of newborns, usually appear by 6 months of age, and involute spontaneously. Congenital hemangiomas can be treated with topical timolol or oral propranolol, and should be monitored regularly; 50% will resolve by 5 years of age and 70% by 7 years. Orbital dermoids will not go away on their own and usually require surgical excision at age 4 or 5 years. Lymphangiomas typically present in the first decade of life and will grow. Rhabdomyosarcomas deserve emergency care – they can double in size in a day.
6. One eye is bigger, but it’s a family trait. A child with one eye bigger than the other deserves evaluation to determine if this is truly globe asymmetry or if there’s another diagnosis, such as microphthalmia, ptosis, congenital glaucoma, or proptosis from a mass pushing the eye out.
7. Glasses worsen a child’s prescription. No one is too young to wear glasses, which will not worsen vision over time, Dr. Alcorn said. Myopia is becoming a worldwide epidemic, especially in Asian populations, according to a recent report (Lancet 2012;379:1739-48).
Other data suggest that myopia is starting at earlier ages and occurring more frequently, she said. There is some literature to support letting children play outside more often to prevent myopia, so they won’t always be looking at things up close. Laser treatment is not approved in the United States for people younger than 21 years because the eyes are still growing.
Myopia is a "major global health concern" because it increases the risk for blindness, glaucoma, retinal detachment, and other problems. "We’re hoping for a cure," she said.
8. Abnormal light reflexes are just a bad picture. When a child has refractive asymmetry on a vision-screening photograph, be concerned. The child may simply need glasses, or could have leukokoria, a cataract, retinoblastoma, or another problem.
9. Different-colored eyes are cute. Maybe they are, but you wouldn’t want to miss an infection or Horner syndrome, which can affect eye color, Dr. Alcorn said.
10. Parents don’t know best. "Listen to parents," she said. "They know their children!"
Dr. Alcorn reported having no relevant financial disclosures.