Protecting the Gift of Sight in Kids

Deborah Kotob, ABOM

Course Objectives:

Upon completion of this program, the participant should be able to:

Understand early eye development and the risks to children's vision.
Describe the factors contributing to myopia development and methods of myopia control.
Describe the risks of sports injury to vision and the requirements for sports protective eyewear.

Faculty/Editorial Board

Deborah Kotob, ABOM, is the Director of Education and Training for Jobson Medical Information. Her experience spans more than thirty years in the optical industry. During this time, her roles included optical boutiques owner, optician, optical frame sales, and over ten years in lens manufacturing as a Lens Consultant, Trainer, and LMS content developer. She lectures, trains, conducts webinars on a variety of optical and practice development topics.

Credit Statement

This course is approved for one hour of ABO CE credit, Ophthalmic Level 2, Course # STWJHI069-2

Protecting the gift of sight in kids requires early detection of disease/disorders, visual system developmental problems as well as protection from impact injury, chemical burns and sun damage. This course covers developmental milestones for the human visual system and identifies risk factors encountered at the different stages from prenatal through school years.

Threats to sight start young whether from chemical burns when a toddler gets into cleaning products or sun damage from unprotected eyes overexposed to sunlight outdoors or from physical injury. But eye injury is not the only threat to a child's sight. Comprehensive eye exams are promoted by the medical field, the National Eye Institute and Prevent Blindness America to create awareness among parents that their child's visual system development is crucial and requires regular scheduled comprehensive eye exams to catch and treat problems early (Fig. 1). The importance of starting eye examinations early cannot be overstated because developmental issues of a child's visual system need to be caught early to prevent vision loss and in some cases, even blindness. Normal visual system development has long ranging effects on a growing child's cognitive, perceptual and social development. Raising awareness is the name of the game when it comes to normal visual system development and the prevention of eye injury to protect a child's sight!

Close to 20 percent of children under 18 have been diagnosed with an eye condition that can impact visual system development if untreated. The most common are refractive error, amblyopia, binocular vision dysfunction (BVD), convergence insufficiency, nystagmus, congenital cataracts and strabismus.

Eye development should be monitored closely by the child's pediatrician and eye doctor for early detection and treatment of problems. The risk to eye health begins in the womb. Early development of the visual system begins prenatally and so can problems. Premature birth puts the infant at high risk of permanent vision loss, even blindness. An eye health risk factor for preemie babies is bacterial meningitis, which is linked to a high risk of vision loss. Babies born to mothers who smoke during pregnancy have a fivefold risk of developing bacterial meningitis. Another eye health risk associated with premature birth is retinopathy of prematurity which has long-term consequences increasing the risk for developing retinal detachment, myopia (nearsightedness), strabismus (crossed eyes), amblyopia (lazy eye) and glaucoma in the future. Premature babies need to be monitored by the eye doctor to track if eye development is normal. Roughly 90 percent of all infants diagnosed with this eye disease will develop normal vision; without any treatment however, they will continue to be at risk of developing other eye conditions throughout their lifetime.

After the first few months, the baby's central vision is developing, and they may start to focus on objects held in front of their eyes. During this period, visual coordination progresses, allowing them to focus on and follow a moving object. At three months, their immature retina is still forming neural connection with the brain. By five months, they see in three dimensions and begin developing depth perception and recognizing objects. The visual system matures over several years but by 6 months of age, the child's vision is their preeminent sense. Normal visual system development is essential for normal social, perceptual and cognitive development. Babies and children are learning machines, and 80 percent of learning is through visual stimulus.

From birth to around 7 years of age, normal development of the visual system is threatened when conditions exist that prevent the brain from receiving in focus visual signals. According to the American Optometric Association, the following conditions cause blurred visual input or binocular vision dysfunction: amblyogenic bilateral refractive error, amblyogenic anisometropia, constant unilateral strabismus, congenital cataracts, hemangioma, corneal scarring. These conditions can lead to amblyopia, which left untreated, can lead to severe vision loss. Amblyopia, often called lazy eye, is when one eye becomes weaker in infancy or early childhood. Misalignment where one eye looks straight ahead while the other eye turns inward, outward, upward or downward is called strabismus, which must be treated early in the child's visual system development to avoid amblyopia. The ability of both eyes to focus on an object simultaneously continues to develop up to around age 7. Misalignments need to be treated during this development stage to allow the eye to develop normally. On that note, babies can be born with cataracts, a clouding or opacity of the lens of an eye, or they can develop them after birth.

Congenital cataracts happen before birth or during a baby's first year of life. The clouding can be in one or both eyes. Because the baby can't see their world clear-ly through a cataractous lens, the brain receives blurred visual input making it difficult for brain and eyes to work together so the baby's visual system can't develop normal sight and normal control of eye movements. Abnormal connections between the brain and the eye may become irreversible if not treated early. Cataracts in children are often discovered during the eye screening at birth, or at pediatric vision screenings.

An interesting sidenote: While not related to normal eye development, a baby's final eye color will develop in the first three years of life with most of the change occurring at around nine months. The final color is determined by the amount and arrangement of melanin pigment in the iris. We have all watched as those baby blue eyes become brown in their toddler years. Interesting note: Blue eyes are not actually blue. The blue iris lacks melanin, the pigment that gives brown eyes their color. Our eyes appear blue because of the white collagen fibers in the connective tissue of the non-pigmented iris scatters and reflects light. Since blue wavelengths of light are most likely to scatter, blue light is reflected, and the iris appears to be blue in the non-pigmented iris.

A toddler's vision faces threats from the measles virus (cases are beginning to reappear after this disease was thought eradicated). Measles can harm the eyes and vision but is preventable with a vaccine. Another risk to eyesight arises from chemical burns, which can cause permanent damage to both external and internal eye tissue in children.

Many children are farsighted when they begin school, but most do not require glasses as they can use accommodation to focus the light onto the retina. As they age, children's eyes grow and lengthen, and hyperopia, aka farsightedness, often improves on its own. However, in the presence of anisometropia or uncorrected strabismus, amblyopia ("lazy eye") can occur.

A growing concern and threat to vision that begins in childhood is progressive myopia that leads to high myopia (greater than -6.00D). High myopia has become a global health concern reaching epidemic proportions. It is estimated that 90 percent of myopia cases will develop in early childhood. Progressive myopia is strongly linked to genetics and environmental factors. Nothing can be done about genetics, but environmental factors are modifiable. Therefore, it is best to begin myopia management as soon as possible for optimal results. Myopia generally worsens through the teenage years and stabilizes in adulthood. Current research indicates that genetic and environmental factors contribute to the development as well as the progression of myopia in children.

Many factors contribute to myopia progression in children, and great effort has been made in the development of guidelines and management/treatment protocols. Most treatments to control myopia progression aim to slow the elongation of the eye, not just treat the refractive error. Current myopia management treatments use dual focus contact lenses, specialty eyeglasses lenses and prescription eye drops. The first FDA approved treatment for pediatric myopia progression was for the MiSight dual-focus design daily wear pediatric contact lens which creates myopic defocus to inhibit progression in juvenile onset myopia. Their three-year clinical trial showed a reduction in myopic progression of -0.73 D and axial length reduction of 0.32 mm at three years compared to the control group. The urgency behind slowing myopia progression lies in the high risk of complications and disease such as a three times higher risk of developing cataracts, a four times higher risk of glaucoma and a 10 times higher risk of retinal detachment.

An increase in active time outdoors of about two hours per day where the child is looking around and focusing at various ranges significantly reduces the risk of developing myopia. One study found that those who did not spend time outdoors were 40 percent more likely to develop myopia than those who are spending three or more hours outside in the summer and at least one hour in the winter. The study conducted in Great Britain followed 7,000 children ages 8 to 9 years old. The Sydney Myopic Study assessed 4,000 school aged children. According to professor Kathryn Rose, head of orthoptics at University of Technolog y Sydney, which led the Sydney Myopic Study, “An eye that's myopic is an eye that's growing too fast, too quickly and what we are actually thinking may be occurring is that when children spend time outdoors, they are getting enough release of retinal dopamine to actually regulate the growth of their eye.” Many studies link near work activities especially screen time as a contributing factor for both nearsightedness and digital eyestrain. Parents and kids should be made aware of the 20-20-20 rule: Every 20 minutes, focus at least 20 feet away for 20 seconds. Blue light from digital devices has not been proven to be dangerous to a child's eyes because the intensity level of emissions from screens is low. But it may contribute to digital eyestrain and discomfort when the child spends extended time in front of a screen. Another important note is that screen time should be avoided within two to three hours of bedtime to prevent sleep problems. Screens emit a substantial amount of blue light which prevents melatonin, our sleep hormone, from rising to make us sleepy and helping us sleep soundly. Sleep deprivation is linked to attention span and alertness, which has a direct impact on learning and behavior.

Eye injuries are the most common cause of blindness in children, and baseball is a leading cause of eye injuries in children ages 14 and older. Because regular eyeglasses and sunglasses can shatter on impact, they do not offer enough protection to protect the eye from sports-related injuries. In fact, they can inflict even more damage to the eyes. Eye injuries can include painful corneal abrasions, blunt trauma and penetrating injuries, inflamed iris, fracture of the eye socket, swollen or detached retinas, traumatic cataract and blood spilling into the eye's anterior chamber. All athletes who have poor vision or blindness in one eye should take particular care to protect their remaining vision.

Prevent Blindness America provides the following steps to avoid sports eye injuries:

Never wear regular eyeglasses while playing sports as they may shatter upon impact. Only wear prescription protective sport eyewear fitted by an eyecare professional.
Sports eye protectors should be padded or cushioned along the brow and bridge of the nose. Padding will prevent them from cutting the skin.
Athletes who have monocular vision, diminished vision in one eye, should always wear sports eye protectors recommended by an eye doctor.
All sports eye protection should have 100 percent ultraviolet (UV) protection.

Healthy eyesight is not to be taken for granted; early life exposure to excess sunlight impacts our eye health later in life when cumulative damage leads to cataracts and even blinding disorders such as age related macular degeneration. Acute eye conditions from the sun such as photokeratitis are a painful sunburn of the conjunctiva. For children, even their regular pair of eyewear should have lenses with 100 percent UV protection. I am a big proponent of photochromic lenses for children because they provide complete UV protection and make vision outdoors more comfortable, but they also have a high level of high energ y visible (HEV) blue light protection. When a child's defenseless eyes are exposed to sunlight, they are more vulnerable to the cumulative effects of photooxidation that damage the retina.

Keeping children's eyes safe from impact injury is imperative. More than 90 percent of children's eye injuries are preventable with protective goggles according to National Eye Institute. Children should wear eye protection made with ASTM safety rated frame materials and lenses made from polycarbonate or Trivex (Fig. 2). Sports that pose a high risk for eye injury include baseball, basketball, football, racquet sports, soccer, hockey, lacrosse, paintball and any contact sport activity where a thumb or other object could be jammed into the eye. This includes water sports like water polo, where a finger in the eye is a common occurrence. As their trusted optician, it is your responsibility to ensure that the eyewear dispensed is appropriate for the planned purpose, e.g., sports and safety.

According to the Coalition to Prevent Sports Eye Injuries, glasses, goggles, face shields and helmet attachments offer kids protection from eye injuries during school sports and physical education classes. Protective eyewear meeting ASTM guidelines when properly fit can mean the difference between safety and an eye injury. More than 40 percent of eye injuries are sport/recreational activity related. The AOA reports that among all eye injuries reported in the Eye Injury Snapshot, more than 78 percent of people were not wearing eyewear at the time of injury. And roughly 40,000 of these injuries result in legal blindness in the injured eye.

The National Eye Institute cites eye injuries as the leading cause of blindness in children in the United States, and most injuries occurring in school-aged children are sports related. And the report also states that currently, most youth sports leagues do not require the use of eye protection (nei.nih.gov/sports).

Prevent Blindness America has named September Eye Injury Awareness Month. Only eyewear marked with ASTM approval for a specific sports activity should be used in the production of sport eyewear (F803 standard for sport eyewear intended for racquetball, squash, handball, tennis, women's lacrosse and badminton, F910 for baseball and F513 for hockey).

Some ways to protect our children's eyes:

A child's eyes should be checked prior to starting any sport. They can't duck or dodge the ball if they can't see it, and good vision will improve their game.
Every sport has specific requirements for eye safety, and proper fit should be a requirement.
Buy prescription glasses made of polycarbonate or Trivex material for the highest impact rating. Polycarbonate can withstand a projectile traveling at 90 mph.
For contact sports, choose eye guards or glasses with padding at the nose and brow. It is not just the eyes at risk of impact injury, and glasses can be made safer and less likely to contribute to an injury when properly padded.
Eyewear frames for sports should be made of polycarbonate and meet ASTM standards with strong frames that secure with a strap.

Now for sport protection. The following are protection devices recommended by Prevent Blindness America for popular sports that can cause eye injuries in children:

Baseball/softball—type of eye protection: faceguard/visor (attached to the helmet). Helmet-mounted faceguards/visors are the most protective; clear faceguards/visors made of polycarbonate material. Polycarbonate is impact resistant, thinner and lighter than plastic, shatterproof and provides UV protection. Helmet mounted faceguards/visors should be National Operating Committee on Standards for Athletic Equipment (NOCSAE) approved (nocsae.org ). Sports eye guards (goggles or spectacles): Eye guards offer reduced protection compared to a helmet-mounted faceguard or visor but are better than a naked eye exposed to a ball with an impact that can result in eye/vision loss. Sports eye guards should meet ASTM F803-19 or the most current sport-specific ASTM standards.
Basketball—type of eye protection: sports eye guards (goggles or spectacles). Sports eye guards used for basketball should meet ASTM F803-19.
Soccer—type of eye protection: sports eye guards (goggles or spectacles). Sports eye guards used for soccer should meet ASTM F803-19.
Football—type of eye protection: polycarbonate visor shield attached to faceguard. These shields offer additional protection against objects having the potential to penetrate openings in the faceguard grid. They also provide the wearer UV protection.
Hockey—type of eye protection: wire or polycarbonate visor/shield (attached to the helmet). A polycarbonate mask attached to a helmet provides the most protection without cage wires blocking the visual field. (Note: Goaltenders must wear full wire cage face protectors) All hockey eye and face protectors should bear The Hockey Equipment Certification Council (HECC) approval label (www.hecc.net).
Women's lacrosse—type of eye protection: sports eye guards (goggles). Sports eye guards used for women's lacrosse should meet ASTM F3077-17 standard or the most current version of that standard. Beginning in 2020, women's lacrosse eye protectors must bear the Safety Equipment Institute (SEI) Certification Mark (www.seinet.org ).
Field hockey—type of eye protection: sports eye guards (goggles). Sports eye guards used for field hockey should meet ASTM F2713-18 standard or the most current version of that standard.
Racket Sports—type of eye protection: sports eye guards (spectacles or goggles). Sports eye guards used for racket sports (e.g., racquetball, squash) should meet ASTM F3164-19 standard or the most current version of that standard.
Water Polo—type of eye protection: swim goggles with polycarbonate lenses. American National Standards Institute (ANSI) impact resistance standards require that the lenses regardless of thickness pass impact resistance test. ANSI established the following safety eyewear standards: 1. Z-87 basic impact guidelines for safety eyewear lenses requires a 3.0mm minimum lens thickness regardless of material. Drop ball test must withstand the impact of a 1 inch steel ball drop from 50 inches. 2. Z-87+ high Impact standard for safety eyewear lenses requires minimum 2.0 mm thickness and withstand the impact of a one quarter inch ball traveling at 150 feet/second, and 3. Z-87+ high impact standard applies to all safety frames.

Another risk to eye health for children and teens comes from improper contact lens care. The threat of injury to their young eyes is due to a higher risk for serious eye infections that can cause impaired vision and in the worst case even blindness. ECPs bear responsibility for training contact lens patients on contact lens care. Emphasize the importance of proper wear, cleaning and hygiene, and ensure the child and parent understand the potential associated risk of infection with improper wear or contact lens cleaning.

The following are CDC contact lens precautions and recommendations:

Don't sleep in your contact lenses unless prescribed by your eye care provider. Sleeping while wearing contact lenses has been shown to cause up to eight times greater risk of an eye infection.
Always wash your hands with soap and water before handling your lenses.
Dry your hands well with a clean cloth before touching your contact lenses, every time.
Keep contact lenses away from all water. Water can introduce germs to the eyes through contact lenses. Remove contact lenses before swimming and avoid showering in them.
Properly clean your lenses. Rub and rinse your contact lenses with contact lens disinfecting solution—never water or saliva—to clean them each time you remove them.
Do not "top off" solution. Use only fresh contact lens disinfecting solution in your case—never mix fresh solution with old or used solution. Use only the contact lens solution recommended by your eyecare provider.
Take care of your contact lens case. Clean your contact lens case by rubbing and rinsing it with contact lens solution—never water—and then empty and dry with a clean tissue. Store upside down with the caps off after each use.
Replace your contact lens case at least once every three months.
Visit your eyecare provider yearly or as often as he or she recommends.
Remove your contact lenses immediately and call your eyecare provider if you have eye pain, discomfort, redness or blurred vision.
Carry a backup pair of glasses with a current Rx , in case you have to take out your contact lenses.

In conclusion, a child's eye health and visual system development can face many hazards along a child's journey to adulthood, making regular eye exams imperative so that conditions can be caught and treated early. Regular eye exams might be the most important action a parent can take to ensure their child's vision is developing normally. Considering that 80 percent of what a child learns is through vision, the ability to see clearly can impact performance in school both academically and at sports, and can have an impact on behavioral issues.

On a final note, when the doctor writes a separate prescription for general purpose versus sport/safety eyewear and sunwear, it imprints on the parent as very important that the child have a separate pair of eyewear for sports. Photochromic lenses are available in both polycarbonate and Trivex materials, and they provide sun protection in the clear general-purpose pair of eyewear and sports specific eyewear while blocking up to 100 percent of UV outdoors and up to 95 percent of HEV blue light outdoors. In my book, this makes them the perfect solution for children and teens whether in their general-purpose pair or their sports pair. Furthermore, high quality photochromic lenses can reduce indoor blue light from screens to make your child's screen-time more comfortable—a win-win!