Paediatric ophthalmology: Things that do not require referral

There is a dearth of surgical subspecialists in Canada, and primary care paediatricians experience significant frustration in their attempts to arrange consultation for their patients with subspecialists. Even if appointments can be arranged, waiting lists are often intolerable. For example, there are only 38 paediatric ophthalmologists in all of Canada and all are concentrated in larger centres (1). The following are some conditions that only rarely require referral, and the parents can often be reassured as to the benign nature of these conditions. Bifrontal and bitemporal headaches are particularly common in preadolescent girls; they may appear to be quite severe (inducing crying or requiring a dark room and/or ice pack) and are most commonly misdiagnosed as migraine. In the absence of other localizing neurological signs or symptoms (eg, diplopia or papilledema), parents can be reassured. The yield for ophthalmological problems, such as a need for glasses, is virtually zero in this group (personal experience). By nature, children like to be close to the TV and, in the absence of ophthalmological signs (eg, squinting their eyes), parents can be reassured. It is amazing how many parents spend an inordinate amount of time dragging their children back from the TV set, yet are thrilled when their child spends time on a computer staring at screen after screen of tiny print. There is no convincing evidence that reading under conditions of reduced illumination can damage the eyes. It is a fact that children who read intensely have a much higher incidence of myopia (notably in children of Asian descent [2]), particularly if one or both parents are short-sighted; however, in spite of what Abraham Lincoln's mother told him, reading under dim conditions is no more damaging than reading with full light. Excessive blinking is very common in children younger than six years of age and is equally common among boys and girls (3). The condition starts suddenly with a high-frequency blink (which I assume the child thinks is cute). It lasts about six months and vanishes as quickly as it arrived. Blinking is not to be confused with squinting (ie, scrunching up the eyes), which is usually associated with an acquired refractive error. Blinking should also not be confused with closing one eye in bright sunlight, which is virtually pathognomic of intermittent exotropia and does require referral (although not urgently). Children with intermittent exotropia will always close the same eye when in bright sunlight. For no particular reason, children younger than six years of age may suddenly develop a rather alarming face turn or tilt of the head to one side or the other. This lasts about six months and then vanishes. Children who do this for an optical reason have an extraocular muscle weakness or overaction and, if old enough, may complain of double vision, particularly when the eyes are directed in the opposite direction from the face turn. They may also close or cover one eye to relieve themselves of the double vision. If either of these two associated features are present, or if the face turns or head tilts are persistent, referral is warranted. Pathological conditions causing photophobia are usually associated with a red, watery or painful eye. Some children, notably between the ages of three and nine years, will suddenly complain of light sensitivity – most commonly when the lights are first turned on in their bedroom in the morning. In the absence of associated signs or symptoms, the parents can simply be reassured. Some children, most often younger than six years of age, complain that their eyes feel dry and that the eyelid is actually stuck to the globe (4). Their response is to repetitively pull down the lower lid to relieve the perceived attachments. In extreme cases (eg, mucus fishing syndrome) (5), children will introduce their finger between the eyelid and the globe to remove the glue. This sets up a vicious circle of irritation and recurrent conjunctivitis. Anything inside the eye that casts a shadow on the retina would create a black spot as sometimes occurs in severe uveitis. However, children often complain of coloured spots and coloured lines (notably red) in their field of vision. Questioning as to whether these spots are always round or sometimes square or if the lines only appear on the blackboard at school confirms your diagnosis and the parents can be reassured. Adult-type vitreous floaters are rarely seen in children. Diplopia can be quite alarming to parents but is most often the result of the child discovering physiological diplopia from crossing his or her eyes voluntarily. Children with an underlying pathology will have their double vision all the time and will classically adopt a head tilt or a face turn or cover one eye with their hand. Intermittent diplopia in an otherwise neurologically normal child usually does not need to be referred unless parental anxiety is extreme. A preliminary examination to ensure that no ocular motility dysfunction is present is justified. If the examiner can satisfy himself or herself that the child is describing physiological diplopia, referral can be avoided. Before three months of age, a child's eyes might be anywhere, but the alignment should be corrected by three months of age (6). A cover test can be performed in children over the age of three months to rule out pseudostrabismus related to epicanthal folds. Children younger than one year of age who develop esotropia (inturning) have a very large amount of turn and they are obviously strabismic. Intermittent exotropia (out-turning) begins at one year of age and is usually only present when the child fixates on something in the distance. Constant nonalternating exotropia of one eye only is an ophthalmic emergency because the vast majority of these children harbour some intraocular catastrophe (eg, cataract, retinoblastoma or optic nerve hypoplasia) (7). Many children excessively rub their eyes normally, particularly when they are tired. In the absence of redness, light sensitivity or tearing, this is usually not a source of concern. A sudden symmetrical reduction in visual acuity is very common among nine-year-old girls (8) who will read the eye chart and stop in the identical spot with both eyes (often on the 20/60 line). They can often see one-half of the line of print but not the other half on the same line. In the absence of squinting of their eyes, this is most often functional and does not require emergency referral. Children will sometimes lose vision completely in one eye after experiencing trivial head trauma. The loss of vision is always on the same side as the minor blow, which is usually centred on the temporal side of the head and not the face itself or the occiput. The loss of vision generally comes on approximately 4 h after the incident and is equally common among boys and girls. Parental anxiety in this situation is usually high and referral is appropriate for that reason alone. In general, even severe blows to the side of the head do not result in decreased visual acuity. In summary, most significant paediatric eye pathology is associated with obvious signs and symptoms, in the absence of which parents can simply be reassured. Absent or asymmetrical red reflex Leucocoria (white, gray or yellow pupil) Unequal visual acuity in a child younger than seven years of age Persistent red eye Manifest strabismus Constant nonalternating exotropia Pupil irregularity after blunt trauma Eyelid hemangiomas Severe ptosis Persistent tearing and discharge in an infant Nystagmus Proptosis Tearing with photophobia Different-sized eyes Colobomas Headache with vomiting

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