A Fascinating LOOK at Preemies and Vision Issues

You know those super-adorable toddlers you see wearing super-cute glasses, their sweet little round faces smiling behind pint-sized spectacles? Did you know that many - if not most - of those cutie-pies were preemies? I didn't. Maybe the potential for vision problems was one of the hundred things that the head NICU nurse told me about in the hours before my girls were born at 34 weeks, but somehow or another, brand-new information is a bit difficult to digest when you're in labor and on all kinds of drugs to try to keep those babies inside you. Or maybe the medical staff was so focused on the important task of ensuring our babies' survival that long-term vision issues were not part of the conversation. After all was said and done, we were just thankful that our four-and-a-half-pound girls were healthy, and that our main concern was getting them to learn to eat so they could put on some weight and go home.

Fast forward four years.... When we went to our girls' four-year-old pediatric check-up, Caroline did not do well on the vision screening. I thought, "It's been a long appointment, it's late in the day, she's tired, there's no possible way she's really not seeing these things." The pediatrician asked if we'd noticed her having any trouble at home or at preschool, and because everything seemed fine, we went on our way. I was shocked when the same thing happened a year later at their five-year-old check-up. When we followed-up with a more thorough optometry exam, I felt pretty low at the revelation that my FIVE-YEAR-OLD only had 20/60 vision in her right eye and was barely able to see with her left eye at 20/200. How had we missed this? For FIVE YEARS?

That was went we met the fabulous Dr. Suzy Lake. She holds a Doctorate of Optometry and is Board Certified in Vision Development and Vision Therapy, and she speaks frequently to parents and professional groups, sharing with them the important of early recognition of vision problems. (You can see more of her bio at http://eyecarespecialties.biz/meet-the-optometrist.html) In addition to her professional prowess, Dr. Suzy is an outstanding and entertaining writer - reading her blog makes you feel as though you've just been cracking up about real life motherhood and marriage with one of your best friends over a cup of coffee or a glass of wine. Check it out at https://babyfocals.com

I asked Dr. Suzy to share some of her eye expertise here—a must-read for parents of preemies, and a fascinating read for everyone else...

First of all, what causes a higher incidence of vision problems in preemies than in full-term babies?

Let’s start with Retinopathy of Prematurity (ROP). The retina of the eye is responsible for not only receiving all of the visual input that we see, it also streamlines that information to our brains. The retina begins developing at 16 weeks gestation and doesn’t finish until approximately 2 months after full term birth. I’m always amazed at that fact. We get in the habit of thinking that our babies are fully “cooked” at 40 weeks gestation but actually there is still development happening inside the eyes for another 8 weeks! So, if these babes decide to make an early debut, they have missed out on a significant amount of retinal formation. The part of the retina that usually suffers the most is the tissue in the farthest periphery. Since it never gets a chance to form the correct blood vessels, the underdeveloped tissue starts to send messages to the formed areas that it needs blood. The body responds by making new blood vessels to try to help out. Unfortunately, these blood vessels are weak and are very prone to bleeding. This bleeding can cause scarring and those scars can put enough pressure to cause a retinal detachment. Because this is painless, and the child isn’t old enough to report vision changes, the detachment can go undetected for quite some time, causing irreparable damage. This is why early and frequent monitoring of preemies eye health is essential. There are 5 stages of ROP. The first 3 stages usually cause little to no long term damage but stages 4 and 5, which are more common the earlier the preemie, can have more devastating results long term.

The incidence of having a strabismus (eye turn) and Amblyopia (reduced vision in one or both eyes) also increases significantly in these babies. Caroline suffered from Amblyopia but not Strabismus. Although having fewer diagnosis is technically better, occasionally having the strabismus gives the parents a “heads-up” that something is wrong with their child’s visual system. If the eye is turned in or out, the parent is alerted to the problem and more likely to have them examined. Amblyopia can hide, undetected, for much longer as the child has no idea that their vision is poor. They assume that is how everyone sees so they don’t report a problem to their parents.

Interestingly enough, the higher incidence of glasses for premature infants usually falls on the near-sighted spectrum. Caroline was far-sighted and I will attest that many of the premature kids that I see are also far-sighted. The clinical thinking behind this is that the far-sightedness is possibly a side-note to the pre-maturity BUT because preemies tend to have more frequent medical checkups, they are caught sooner than other full term babies would be.

What are some of the warning signs that parents might see, and at what age should parents expect to notice that their child needs a professional vision screening?

Most parents think they would see their child squinting or struggling to point out airplanes in the sky, or not recognize faces if their vision was poor enough to warrant glasses. This can happen but more often than not, it doesn’t. Myopia (near-sightedness) is much more blatant in it’s presentation. It does tend to cause squinting and a decrease in obvious vision. Hyperopia (far-sightedness) is much sneakier. The strain in far-sightedness is focused at the near point. This leads to airplanes being seen, faces recognized and little warning signals for parents to quickly associate with vision changes.

What they may see is a delay in early learning. Identification of letters, numbers and even colors may occur. They may rub their eyes more or even cover one when looking at books so that the blurry eye isn’t able to interfere with the viewing. Our brains are brilliant and they don’t like to be confused with blur so they will alter our behavior to aid them. These kiddos may be the ones that refuse to sit still for book/reading time but love to climb and run and be outdoors. Vision guides the body’s movement so looking at the whole child tells you a tremendous amount about the visual system as a whole.

What about the Carolines of the world, who don’t demonstrate any symptoms of vision problems? Should we assume that preemies need early vision screening, just in case?

YES! A thousand times YES! This should be a collaborative effort with a Pediatric Optometrist (look for someone with Board Certification at COVD.org) as well as a Board Certified Pediatric Ophthalmologist. The Ophthalmologist will be taking round 1 shortly after birth. His/her job will be to evaluate the retina for any signs of ROP and then perform any surgeries necessary to stop the damage. By 6 months of age, a Pediatric Optometrist can be added to your team to evaluate and treat any vision disorders. My rule of thumb for parents is this: If your child needs a surgery, use a Pediatric Ophthalmologist. That’s what their training specializes. When you need an evaluation of the child’s visual system and/or glasses, Amblyopia treatment which usually includes some patching to ensure optimal vision, see a Pediatric Optometrist. That’s what their training specializes.

What can happen if a child’s vision problems go undetected and untreated?

In both cases of ROP and Amblyopia/Strabismus, long-term vision loss, even blindness can occur. The younger we find the problems and treat the problems, the better the outcome.

Now for the good news—what can be done to treat and even correct these issues?

So many things! Surgery, which is usually laser surgery called cryotherapy, is used to stop the deterioration of that underdeveloped retinal tissue which then greatly decreases any risk of retinal detachment. For Amblyopia/Strabismus/hyperopia/myopia we use a combination of glasses, patching and vision therapy to increase vision to normal or near normal levels. Each child is different as is their potential for best visual acuity but the earlier detection and diagnosing leads to the best outcomes.

(When patching was prescribed for Caroline, we were so relieved to find out that patching can usually be done much more subtly these days than when we were kids. In her case, a static-cling, nearly clear piece of vinyl was used to cover the right lens of her glasses for a few hours a day, so that it made her vision fuzzy in her right eye and forced her left eye to work harder and grow stronger. If other kids looked carefully, they could tell that she had something on her glasses, but it was not obvious to the casual observer.

Vision therapy can take on many forms and often does involve in-office therapy, but for Caroline, we were able to do a computer-based program a few times a week at home.)

When should a parent seek an optometrist versus an ophthalmologist, and what qualifications should we be looking for in selecting a doctor to care for our children’s eyes?

Great question. In addition to what I said above I’d stress that it’s such a collaborative effort and both are used for such different problems. Make sure you find a pair comfortable working together to ensure the best outcomes for you child. The “turf war” that can go on between these two professions is neither your problem nor your burden and shouldn’t be tolerated when dealing with the vision care of your child. Both sides should approach the child as a team to ensure best outcome.

As a general rule, the Pediatric Ophthalmologist will be involved directly after birth and will be phased out as the risk of retinal detachment or damage has been ruled out or managed. The life long vision care for your child, which should occur annually, will be taken over by the Pediatric Optometrist who will cycle you back to the Ophthalmologist for any future surgical care.

Limited funds? Check out http://www.infantsee.org/

Many thanks to Dr. Suzy Lake - both for her collaboration here, and for her wonderful treatment for our Caroline! We appreciate you!