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Susan Culican, MD, PhD (Guest): Hi. I'm Dr. Susan Culican. A Washington University pediatric ophthalmologist and mom doc at St. Louis Children’s Hospital.

Melanie Cole, MS (Host): Hello. This is MomDocs, a podcast from St. Louis Children’s Hospital. I’m Melanie Cole and today we’re talking about eye health and your child. So Dr. Culican, I'm so glad to have you with us today. I just want to start. For all of the parents out there, what is a pediatric ophthalmologist?

Dr. Culican: A pediatric ophthalmologist is someone who is trained in ophthalmology but has done an additional fellowship learning the specific problems that children have related to their eyes and eye care. So in addition to the general eye care that all people need, they have extra training for pediatric issues specifically.

Host: That’s cool. What a cool profession you're in. So let’s talk about our kids. When does a child get their first eye exam? Dr. Culican, how can you give an effective exam like if we have a stubborn two year old or a three year old that just won’t sit still? Tell us about that first exam.

Dr. Culican: Interestingly, the first eye exam that a child gets is not going to be by a pediatric ophthalmologist. It’s going to be by their pediatrician in the nursery at the time they’re born. So we actually partner with pediatricians all of the time to make sure that kids are getting appropriate screening. So the first thing that they're going to check is for what we call a red reflex after the baby is born to make sure that there’s a clear axis inside the eye and there’s no indication that there’s a problem or concern that needs to be preferred to pediatric ophthalmology. Of course if there is a concern then your pediatrician will send you onto us and we will do the exam, which does involve a little bit of wrangling as you suggest. So what we do is we turn the eye exam into a game.

So if you ever observe one of us doing an eye exam in a young child, you'll see that we use a lot of stickers on our noses, on the child’s nose. We use flashy spinny lights to try to get their attention to get them to follow the motion tracking so that we can measure eye muscle balance. We try to sing songs and engage the kids so that they think this is just a game and they don’t get intimated by having to have their eyes examined.

Host: So there’s a difference, right, between what you're doing, the eye exam, and that vision screening that they get at school or even just the general one standing down the long hallway in the pediatrician’s office. These are two different things, right?

Dr. Culican: Exactly. So the vision screening is what we refer to as a screening exam. What we do in our office is referred to as a diagnostic exam. The entire point of a screening program is to catch things early so that we can intervene and make sure that they don’t cause problems later on. The issue with screening is that we want to make sure we don’t miss any serious problems so they're a little over sensitive. So that screening exam you get in school or the screening exam in the pediatrician’s office is very likely to catch normal kids even though they fail the vision screening, and we’re okay with that. We’d rather see a couple of normal kids in our office for a diagnostic exam and confirm that they're actually okay than to miss the kids with problems.

As an example, my own daughter failed her vision screening three times at school. The first two times when I brought her into our office to be examined, she was completely normal, and she left with a paper that she was good to go. The third year, however, she had some significant refractive error and needed a pair of glasses. So it’s always important to follow up on those failed vision screenings to make sure that your kid’s okay, but you may find out when you get to the office that they actually don’t have any significant vision problems.

Host: I had a similar situation happen with my daughter as well. We had to go to two pediatric ophthalmologists to get tested because they got different results. For her driver’s exam, it was another one. So, yeah. I can see how it can kind of be a little confusing. How often do children need to have their eyes tested by an ophthalmologist as they grow up?

Dr. Culican: That’s a very good question because it’s a controversial topic. So the legislature in some states has mandated that children get comprehensive eye exams, either as they enter kindergarten or at some other point during their school age. We actually do not recommend this. The American Association of Pediatric Ophthalmology and Strabismus, the American Academy of Ophthalmology, and the American Academy of Pediatrics prefer that screening be the primary mechanism by which we catch vision problems in kids. The reason for this is there’s good data now that if you have mandatory eye exams for all kids, kids who don’t need glasses will be prescribed glasses. There's a financial motivation on the part of some providers to do this. What we don’t want to do is unnecessarily escalate costs and time away from work and time away from school for kids who don’t need it. For this reason, we emphasize very highly the vision screening test that you get in school and you get in your pediatrician’s office. Then if you fail one of those vision screenings, it’s very important to follow up with an eyecare provider.

Host: Well, that’s’ great information. Thank you for clarifying that for us today, Dr. Culican. So what are some symptoms or early indicators that a child isn’t seeing well? We used to hear oh if they were doing poorly in school, maybe they couldn’t see the board or headaches or any of these things. But would a child complain? Would they notice these things? Is that still what we’re looking for is school performance and headaches and all those other kinds of things?

Dr. Culican: Yes and no. So the number one way that we catch vision problems in school age kids and in preschool kids in the screenings. So that’s why those things are so important to make sure you follow through on. Most things are asymptomatic. They don’t notice any problems because this is the way their world is, and they just assume this is normal. They don’t understand that with glasses, for example, they could actually see better than they do. So we want to make sure that any kid that fails a vision screening gets in to be examined.

On the other hand, if you do have a child who’s complaining of difficulty with their vision or of headaches, it’s probably worthwhile to bring that to your pediatrician and let them determine if they need to have an eye exam. As I said previously, most kids are asymptomatic, and they don’t even realize that they have a problem.

Host: That’s so interesting isn’t it? Our eyes are so precious and important. Now, if a child does need glasses, doctor, then what can they expect during that appointment? What is it like to have their eyes dilated for a child? Is it different than when we adults do it?

Dr. Culican: Nobody likes dilation. Adults don’t like dilation. Kids don’t like dilation. But dilations a very important thing to bring up because one of the things that’s different between adults and children is the fact that kids have this amazing ability to accommodate. So I'm at an age where I can't read the newspaper anymore without putting my reading glasses on, and that’s because with time I've lost my ability to accommodate. It’s almost a linear progression over age. So little kids, little babies, have this amazing capacity for accommodation. They can actually focus through their prescription if they need glasses. To get around that, to make sure that we’re actually measuring their prescription accurately, we dilate the eyes and relax their accommodation.

One of the problems we run into in the community with the overprescribing of glasses or spectacles is that adult providers don’t recognize that there is a difference between adults and children, and they don’t perform what we call a cycloplegic refraction, the dilated refraction. So they get a prescription that’s actually inaccurate because the child is accommodating during the exam. So all the kids that come through our office get a dilated eye exam because we need to check their prescription with their accommodation paralyzed.

Host: Then what’s it like for them if you do determine that they need glasses? Is there like a depth perception issue at the beginning? Is it hard to adjust to them?

Dr. Culican: It depends a little on what the prescription is. So we’ve all heard of nearsighted and farsighted. Adults are more likely to be nearsighted. Children are more likely to be farsighted. Nearsighted children don’t have any trouble adapting to their glasses. Their accommodation is relaxed at baseline. So they just slide into their glasses and they can see more clearly, and they love them right away. The farsighted child is a little more complex. This is because of the accommodation that I discussed earlier. As they are trying to see clearly, they are focusing really, really hard. So when you put those glasses on, they don’t have to focus as hard anymore. It takes practice for them to learn to relax that accommodation because they’ve been doing it their whole life up until this point, and they don’t really recognize immediately that this is how they're going to get used to their glasses. So we emphasize to parents of kids that are farsighted it will take a few weeks for them to get used to the glasses.

We do have another little trick we can do that no kid likes, but it works really well. If a child needs farsighted prescription and they're not wearing their glasses, they're not compliant, we can actually use the dilating drops that we use in the office at home. That, again, paralyzes the accommodation so that now the only way they can see clearly is to put the glasses on. When they put the glasses on, they see more clearly. As that dilating drop wears off, then they're able to see much better with the glasses on than with the glasses off.

Host: Wow. I'm sure both parents and children love that home dilation. Wow. But if it works then I imagine that it’s just yet another tool that you can use. What about contacts? Because some teenagers want contacts because they don’t want to wear glasses. But for littler kids, contacts can be quite complicated. They can feel uncomfortable, be difficult to put in. When do we know if a child is ready for contacts?

Dr. Culican: That’s a great question and I actually have a spiel for that. So I always tell parents that you're going to know that your child is ready for contact lenses before I know it. The reason is is that contact lenses are great for fixing your vision, but they also come with a little bit of a risk. People who wear contact lenses are at a higher risk of getting a corneal ulcer, and corneal ulcers can be visually devastating. So hygiene is the most important factor when considering contact lens wear. So I tell parents when your child is washing his hands before dinner without being asked, brushes his teeth before bed without being asked, showers on a regular basis without being prompted, that’s when that child is potentially ready for contact lenses. Because the lenses needs to be cleaned and they need to be sterilized and they have to have clean hands when they're putting them in and out of their eye. So hygiene is the most important issue.

The other issue with contact lenses is related to over wear. My preference for children wearing contact lenses is that they buy daily disposable lenses so they have a fresh new lens every single time they put that in their eye and that minimizes the risk of infection. They can throw it out at the end of the day, put a new one in tomorrow. The rule is never ever sleep in your contact lenses because it causes decreased oxygenation to the cornea and that can cause visual problems in the future.

There’s another thing that has nothing to do with vision but is extremely important for young people. There’s some data in the literature that says that children are less likely to do drugs if their doctor tells them not to do drugs. So when I give my contact lens talk, I have my always and nevers. Always wash your hands before putting in your contact lenses, never sleep in your contact lenses, and never do drugs. That’s how I can, the pediatric ophthalmologist, can fit my drug talk into my practice.

Host: I love that spiel because it kind of encompasses so many of the things we want our children to learn as they're growing. What a great way to identify whether your child is ready by their hygiene ‘cause that’s so important. It is something that we parents really notice. Wow, look. They washed their hands when they got home from school. That was awesome. I didn’t even have to yell at them about that. So what a great way--

Dr. Culican: Exactly.

Host: That’s great. So as we wrap up--

Dr. Culican: I also have the conversation in front of the child. So it motivates them to try to move along that developmental trajectory as well if they're very motivated to wear contact lenses.

Host: I'm sure parents appreciate that to help with that trajectory, I'm sure. So now, what kinds of eye injuries do you see and conditions most often as a mom doc and a pediatric ophthalmologist? Give us your best eye care advice for your children.

Dr. Culican: Okay. So they fall into two categories. They fall into the ‘there’s really nothing we could have done to anticipate this. It’s just an accident and it turned out badly.’ For example, I had a child who was sitting on the front porch and a sister was throwing a ball at her. It accidently hit the light bulb on the porch light above her head and she had an eye injury with a piece of glass that fell from that lightbulb. There’s really not much you can do to anticipate or predict that.

However, there’s a large group of kids that come in with BB gun injuries to the eye, paintball injuries to the eye, any of these kinds of projectile injuries. We stress over and over again for kids who do paintball, for kids who do use guns for sport—whether that’s a BB gun or a pellet gun—that they have to wear eye protection when they're doing these activities. These are preventable injuries that if you just had on eye protection, they wouldn’t have resulted in a potentially vision threatening condition. Particularly the paintball injuries are very visually devastating, and children have been known to lose their eye over those kinds of injuries. So we do emphasize eye protection.

The other time we bring this up is around the 4^th of July. We see a lot of firework injuries. Even though burns can happen with fireworks and there can be injuries related to the chemicals in the fireworks, the most common thing we see is the blunt trauma injury of just the impact of the firework hitting the eye at a high rate of speed. Again, that can be prevented by just wearing eye protection. So that’s my best advice to parents. Eye protection, eye protection, eye protection.

Host: And it is great advice. Thank you so much Dr. Culican for joining us today. If you found this podcast enlightening, please share on your social media and be sure to check out all the other helpful podcasts in our library. Head on over to our website at stlouischildrens.org to get connected with one of your providers. I'm Melanie Cole. Thanks for tuning in.