Why You Should Add an Eye Exam to your Back-to-School Checklist

By Dr. Rahul Bhola, pediatric ophthalmologist at CHOC Children’s

Routine vision screening or eye examination at an early age is very important to detect risk factors, such as lazy eye, that can cause irreversible loss of vision or blindness. Fortunately, early detection and timely management of these issues can prevent permanent visual impairment.

A majority of vision impairment issues go undetected, since young children with impaired vision are often unaware of their vision issues—it is, after all, how they’ve always seen things. It is on us as parents and educators to look for signs of visual impairment.

How can you tell if a child has trouble seeing?

Preschool children will most likely not be able to communicate their issues. Early signs that your child or student may need comprehensive vision exam include:

  • An eye appears to be misaligned (crossing or drifting out)
  • Squinting, closing, covering one eye or rubbing one or both eyes
  • Complaining of headache, nausea or dizziness during visual tasks such as reading
  • Excessive clumsiness or poor depth perception
  • Tilting head to one side
  • One or both eyelids droop down
  • Family members have been diagnosed with eye problems

Without early detection and intervention, children with an untreated eye problem may suffer from serious irreversible vision loss or even blindness in some cases.

The most common cause of visual impairment in children is refractive errors. This means the shape of the eye doesn’t bend light correctly, causing a blurred image. Children with refractive error need glasses, and without correction they are at risk for a lazy eye or irreversible vision loss.

Correcting vision can improve social interaction for kids

I recently treated a five-year-old boy who was referred by his pediatrician for an eye exam. When I met this patient, he was extremely shy and socially withdrawn. During his eye exam, which only took about 20 minutes, he was diagnosed with severe farsightedness. This explained what his parents had assumed was introvert behavior; if he got too close to something, it was blurry!

His parents called my office a few days later. After wearing glasses for just a few days, their son was a totally different kid, interacting socially appropriately for the first time in his life. During his follow-up appointment, he was so excited to tell me that he had finally seen stars for the first time!

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The Effects of Too Much Screen Time on Children’s Vision

By Dr. Rahul Bhola, pediatric ophthalmologist at CHOC

Technology has become an integral part of our daily lives. As we become increasingly more reliant on and absorbed in technology, many children are exposed to smart devices at less than 5 years of age. These devices have also become an integral teaching tool in classrooms—more than half of teachers in the United States use smart devices in elementary school. According to the U.S. Department of Education, 97 percent of classrooms in the U.S. have at least one computer. School screen time coupled with at-home smart device usage can on average expose a student aged 8-18 years to media for more than ten hours a day.

As children’s exposure to screen time rises, many parents wonder how harmful excessive exposure to electronic media can be. While on one hand, an early exposure to technology might prepare children for future careers in technology-related fields, or jobs that require mastery of technology as a fundamental key to success. On the other hand, children overly immersed in this technology and not otherwise challenged can become socially stunted and ridden with health-related issues due to decreased physical activity.

Dr. Rahul Bhola
Dr. Rahul Bhola, pediatric ophthalmologist at CHOC.

One of the biggest health issues related to smart devices are vision related. A recent study by the National Eye Institute found that the frequency of myopia, also known as near-sightedness, has jumped exponentially in Americans over the last few decades. Two clear reasons for this spike in myopia are an increased amount of time spent looking at things up close and also a lack of outdoor activities. Focusing on things too close to the eyes for a prolonged period puts excessive strain on the eyes and has been found to hasten the progression of myopia. Although genetic risks of myopia cannot be modified, limiting the amount of strain on eyes by avoiding excessive time spent looking at things up close can minimize environmental risk factors. It is imperative to prevent prolonged exposure of up-close work (such as reading) in children by allowing small breaks (during prolonged reading sessions, for example).

The American Academy of Pediatrics (AAP) recently revised the recommendations for screen time in childhood.

  • 18 months and younger: no screen time is still best. The exception is live video chat with family and friends.
  • 18 months to 2 years: limit screen time and avoid solo use. Choose high-quality programming, and watch with kids to ensure understanding.
  • 2 to 5 years: limit screen time to an hour a day. Parents should watch as well to ensure understanding and application to their world.
  • 6 or older: place consistent limits on the time spent and types of media. Don’t let screen time affect sleep, exercise or other behaviors.
screen time
The American Academy of Pediatrics released new guidelines on how much screen time is appropriate for children.

A separate study recently found that excessive screen time usage in adolescents was associated with development of acute onset esotropia, or crossing of the eyes, and that limiting usage of these gadgets decreased the degree of eye crossing in these patients. A portion of the patients in this study had to undergo surgery to correct esotropia.

Excessive screen time can also lead to “Computer Vision Syndrome” which is a combination of headaches, eye strain, fatigue, blurry vision for distance, and excessive dry eyes. There’s a number of things you can do to help avoid these symptoms:

  • Check the ergonomics of the workstation. Placing the screens 20 to 28 inches away from the child’s eyes and aligning the top of the screen at eye level so that the children look down at the screen while they work.
  • Restrict entertainment-related screen time to two hours or less a day
  • Practice the 20-20-20 rule: After every 20 minutes of screen time, take a 20-second break and look 20 feet away.
  • Remind children to blink regularly to avoid excessive dry eyes.

Pink Eye: What Parents Should Know

By Dr. Sidney Weiss, pediatric ophthalmologist at CHOC

‘Pink eye’ is a common term for a viral infection of the conjunctiva of the eye- also called viral conjunctivitis. When a child gets pink eye, this means there is an inflammation of the membranes covering the inner eyelid and the whites of the eye. This can occur in one or both of the eyes. It may appear alone, or as part of a generalized upper respiratory infection involving fever, sore throat and nasal blockage.

It has also been called ‘swimming pool conjunctivitis’ because the infection is often spread in swimming pools.  Chlorine in swimming pool water does not effectively kill viruses nor does it prevent the spread of this infection.

Besides being characterized by pink or even red eyes, there is often some drainage from the eye that may include a colored discharge, or clear tears. The infection is contagious so long as the eye is red and especially so long as discharge is coming from the eye. Your child may complain of sensitivity to light, eye discomfort and blurry vision. Pink eye may be uncomfortable, but very rarely will it threaten vision. If the child’s cornea becomes affected, the vision may be affected more significantly. If you suspect this, consult your child’s pediatrician.

Viral conjunctivitis usually resolves on its own within a few days. If you do consult your pediatrician, they may recommend supportive care, such as increased hygiene, removing the discharge as it appears, and frequent hand washing. They also may prescribe a topical antibiotic for the eye in order to prevent a super-infection by bacteria.

pink eye
Dr. Sidney Weiss, pediatric ophthalmologist at CHOC

There are several other potential causes of pink or red eyes.

Bacterial infections of the eye are less common than viral infections, but the signs and symptoms are quite similar, including a red or pink coloring, sensitivity to light, and eye discomfort. The discharge associated with bacterial infections tends to be thicker and more colorful. Antibiotic drops are generally quite effective in resolving these infections.

Eyes that appear to have a pink tone do not necessarily mean that a virus is present.  Dry eyes, environmental toxins, and eyes allergic to environmental irritants may appear pink, and may even have a clear discharge.

Allergies are also a very common cause of pink or even red eyes, with itching being a common characteristic. The whites of the eye may even appear swollen, and a clear or off-white discharge is common. Topical over-the-counter antihistamines are generally effective in moderate cases, but prescription topical steroid drops may be necessary to resolve the tougher cases.

Meet Dr. Rahul Bhola

CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Rahul Bhola, an internationally recognized expert in pediatric ophthalmology.

Dr. Bhola comes from a family of physicians. His parents practiced internal medicine for more than 40 years in India, and the empathetic and holistic care they provided to their patients inspired him to pursue a career in medicine.

“Very early on in medical school, I developed a special interest in pediatrics, and the surgical finesse of ophthalmology later cemented my passion for pediatric ophthalmology. A gift of vision is the most important sense a child can have,” Dr. Bhola says. “Giving a ray of light to those who struggle with vision is very gratifying to me. Treating children is important to me because they have their entire lives ahead of them and improving their vision positively impacts their entire family.”

Dr. Bhola attended medical school and completed an internship at University College of Medical Sciences in Delhi, India. He completed two residencies in ophthalmology at Maulana Azad Medical College in New Delhi, India and the University of Louisville, Kentucky. He pursued fellowships in pediatric ophthalmology at the University of California Los Angeles and University of Iowa.

“The biggest reason I was inspired to join CHOC was the mission of the hospital. I feel that CHOC’s mission to nurture, advance and protect the health and well-being of children is in close alignment with my personal goals as a physician,” Bhola says. “I seek to nurture the healthcare of children by delivering state-of-the-art ophthalmology care to our fabulous community. CHOC has the resources, reputation and experience to provide great care.”

At CHOC, Dr. Bhola will provide comprehensive eye care, treating patients with a variety of eye disease and disorders. In addition to treating refractive errors (the need for glasses), Dr. Bhola will provide more specialized care for diseases like amblyopia (lazy eyes), pediatric and adult strabismus (crossing or drifting of eyes), blocked tear duct, diplopia (double vision), pediatric cataracts, pediatric glaucoma, tearing eyes, retinopathy of prematurity, ptosis (droopy eyelids), traumatic eye injuries and uveitis.

Dr. Rahul Bhola
Meet Dr. Rahul Bhola, pediatric ophthalmologist at CHOC Children’s.

The Need for Regular Eye Screenings

Dr. Bhola is passionate about providing education on the need for regular eye screenings. For example, kids complaining of headaches may be taken to a neurologist. However, eye problems like refractive errors (the need for glasses), convergence insufficiency and strabismus can result in headache from excessive straining of the eyes, which may affect school performance and even social withdrawal in some children. These conditions are likely to be identified at regular vision screenings.

Unique Approach To Treating Pediatric Glaucoma

Dr. Bhola is among the very few surgeons nationally skilled in treating pediatric glaucoma surgically using the illuminated microcatheter. This highly-specialized, minimally-invasive approach of canaloplasty has been used for treating pediatric glaucoma only within the last five years. The onset of juvenile glaucoma often occurs between the ages of 10 and 20. It can be secondary to genetics, or traumatic.

“Even though childhood glaucoma is an uncommon disorder, it often goes undetected and can eventually result in blindness, underscoring the importance of regular eye screenings,” says Dr. Bhola.

As a Level II pediatric trauma center, and the only one in Orange County dedicated exclusively for kids, CHOC’s trauma team treats a variety of critically injured from across the region. This includes children who have sustained sports injuries, during which damage to the structure of the eye can cause glaucoma.

Patient-Centered Care

Dr. Bhola’s philosophy of care is to treat his patients as if they were his own children.

“My main philosophy is to provide patient-centered care, delivered with compassion and excellence. I remember their life events, and celebrate their achievements with them. It’s important that a patient remembers and trusts you completely with their care. I love when my patients send me holiday cards and copies of their school photos and let me know how they are doing. They became part of my family. I always treat every patient of mine like they are my own child,” Dr. Bhola says.

He also focuses on treating the whole person rather than the disease, and involving patients in their care.

“I don’t treat the disease, I treat the individual. Healing is more than treating the disease. I want to be at their level so I always talk to them directly and not only talk to their parents. I involve their entire group during treatment,” he says.

At CHOC, Dr. Bhola is eager to provide holistic eye care for his patients.

“My practice will offer complete comprehensive vision care to all patients, which includes both medical as well as surgical care. Our patients come to us for glasses, contacts, regular vision screenings, and we also provide more specialized care like glaucoma, cataract and strabismus surgeries,” Bhola says. “Systemic disorders such as diabetes, sickle cell anemia, juvenile rheumatic disease and lupus, have coexisting eye issues that may go undetected if children aren’t seen for regular eye screenings. CHOC patients with systemic disorders such as diabetes now have better access to holistic care.”

As division chief for CHOC Children’s Specialists ophthalmology, Dr. Bhola is passionate about providing state-of-the-art care to patients and training the next generation of pediatric ophthalmologists.

“My main goal is to build a state-of-the-art ophthalmology division, not only delivering excellent patient care but also engaging in vital research and disseminating education to the next generation of ophthalmologists and referring providers,” Bhola says.

When not treating patients, Dr. Bhola enjoys cooking, practicing yoga and meditation and spending time with his wife and two daughters.

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Contact Lenses: Is Your Child Ready?

You might think your child’s glasses are adorable, but she could very well disagree. Is your child ready for contact lenses though? In honor of Children’s Eye Health and Safety Month, we chatted with Dr. Sidney Weiss, a CHOC Children’s ophthalmologist, about how parents can find out.

 With the advent of low-maintenance contact lenses that are replaced daily, children as young as 8 might be able to wear lenses, Dr. Weiss says. Children ages 12 and older are better equipped to wear and maintain contact lenses designed to last for two weeks or a month, though he still recommends one-day lenses for children this age.

contact lenses
Dr. Sidney Weiss

But age isn’t the first criteria for knowing a child is ready for contacts. Most importantly, the child needs to show enthusiasm for wearing them, Dr. Weiss says.  Along with that, children must understand that contact lenses require responsibility and rigorous hygiene.

“Children must have the cognitive ability to understand that wearing contact lenses imposes a serious responsibility to protect the health of the eye,” Dr. Weiss says.

Hygiene is Key

Parents must be able to judge a child’s ability to maintain good personal hygiene, which is key to ensuring safe contact use. Users must be vigilant about washing hands before inserting, removing or simply adjusting contact lenses.

Poor hygiene and improper lens handling pose several risks to users, Dr. Weiss says.

“Corneal infections are the prominent threat to children wearing contact lenses,” he says. “Even with proper hygiene and technique, infections can and do occur. Far less common are fungal and even more exotic sources of infections.”

A scratch on the cornea can result during insertion or removal; if a foreign object gets between the lens and the cornea; or if a child too vigorously rubs his or her eye, Dr. Weiss says.

“The most common signs of trouble are the presence of a red eye or the observation of a white spot on the affected cornea,” he says. “Symptoms of pain, light sensitivity, and decreased vision are common. These should alert the child and family to seek professional help.”

Proper Materials

In addition to frequent hand washing, contact lens wearers must use proper materials to clean and store the lenses. Never use water or saliva to clean a lens. If the child uses eye drops, only use clear drops rather than any product that appears milky. Swimming in contact lenses is discouraged, but if undertaken, lenses should be removed and thrown out afterward. Don’t share lenses with others and don’t sleep in lenses.

In addition to good hygiene, children must have basic small motor skills to wear contacts. Though Dr. Weiss says parents can assist children in inserting the lenses, the child must be able to remove them in case of an emergency.

Parents should supervise insertion and removal for at least several months after a child begins to wear contacts. Following hand washing, a basic insertion technique requires the child to look up, pull the lower eye lid down and forward, and place the lens onto the eye with the other hand. Removal also begins with hand washing, and essentially requires a pinching motion to pluck the lens from the eye.

Astigmatism’s Effect

Even with enthusiasm and good hygiene and motor skills, some children may still not be ready for contacts, especially if they have astigmatism. Astigmatism is a defect in the curve of the eye that creates a football-like shape and can be harder to fit for contacts.

“The common spherical contact lenses available do not correct astigmatism,” Dr. Weiss says. “This circumstance may lead to disappointing vision in these children as opposed to their vision when wearing glasses, and consequent failure. Astigmatism-correcting contact lenses are more expensive and hard to fit well, and are best fit on older children and adults.”

Astigmatism or not, proper fit is crucial for contacts. That’s why all appointments with ophthalmologists or optometrists must be kept and repeated on a timely basis, and children should not procure lenses from non-professionals, Dr. Weiss says.

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