CLINICAL SERVICES - PAEDIATRIC OPHTHALMOLOGY & ADULT STRABISMUS

 OUR CLINICAL SERVICES : WHAT WE DO

The Paediatric Ophthalmology and Adult Strabismus Service deals with eye-related ailments and conditions that affect children whether congenital or developmental. The service also treats adult strabismus (squints). The comprehensive range of clinical services provided by the Service cover conditions including:

1. General Paediatric Ophthalmology
2. Visual Assessment in Children
3. Refractive Errors: Short-sightedness (Myopia), Astigmatism and Long-sightedness (Hyperopia or Hypermetropia)
4. Squints (Strabismus) in Children and Adults
5. Lazy Eye (Amblyopia)
6. Eye Infections in Children
7. Paediatric Cataract
8. External Eye and Corneal Diseases in Children
9. Eye Allergies in Children
10. Glaucoma in Children
11. Droopy Eyelid, Eyelid Problems in Children
12. Orbital Disease in Children
13. Eye Injuries in Children
14. Eye Tumours in Children
15. Retinopathy of Prematurity Screening and Treatment
16. Eye Screening for Systemic Disease / Congenital Eye Disorder
17. Orthoptic Assessment
18. Electrophysiology Tests for Children

Some of the common clinical conditions handled by our Paediatric Ophthalmologists include:

Refractive Errors

Refractive errors occur when the optics of the eyeball are not perfect, causing light rays entering the eye to fall in front of or behind the retina, resulting in blurry vision. These include short-sightedness (myopia), long-sightedness (hyperopia or hypermetropia) and astigmatism.

A child wearing spectacles

Most children are hyperopic, or long-sighted when they are born. The eyeball is small and images are focused behind the retina. The child is able to bring the image forward to be focused on the retina by actively contracting the muscles of focus within the eye so as to obtain a clear image. Most hyperopic children do not need glasses, unless the power is higher than expected for age. Hyperopic power tends to decrease over time as the eyeball grows.

Myopia or short-sightedness occurs when the eyeball becomes too big or long. Distance images fall in front of the retina. Only near objects are focused on the retina. Myopia increases as the eyeball grows.

Astigmatism occurs when the shape of the cornea is not perfectly round (e.g., more like an egg than a ping-pong ball). Some parts of the image may be in focus whilst others parts are not, resulting in blurred, distorted vision. Children with astigmatism (>1.5 dioptres) often need to wear glasses.

Myopia (Short-sightedness)

The facts and myths of myopia are distinguished in the table below.

FACTS

MYTHS (Untruths)

Myopia is worsening in Singapore Currently about 10% of primary 1, 60% of primary 6, and 80% of 18 year olds are myopic. These figures continue to increase over time. Myopia is more common in those who do more near work Studies show that children who read more books per week have an increased risk of myopia. True myopia is irreversible Myopia increases as the eyeball grows. Once the eyeball has grown, it will not get smaller. Myopia increases with age Myopia often becomes evident in primary school years, and increases at about 1.00 - 1.50D till the age of 11 - 12 years, and stabilizes in the mid-teens or early 20s. Atropine eye drops decrease the rate of myopic progression Studies show that atropine is effective in controlling myopic progression. Short-term, it is quite safe. However, because long-term effects are unknown, this medication is reserved for those children whose myopia is rapidly increasing. That said, doctors at SNEC, in conjunction with Singapore Eye Research Institute (SERI), continue to work to determine if atropine (administered differently) or other modes of treatment will help provide safe and effective means of retarding myopia progression.

Myopia is reduced by avoiding the use of glasses, reducing the power of glasses, by contact lens wear, use of bifocal spectacles, intake of dietary supplements including vitamin A, through eye exercises, accupressure and vision training devices. The truth is there is no conclusive scientific evidence that these modalities are effective in preventing myopia progression. Myopic children should have laser surgery Refractive procedures such as LASIK should generally only be performed in adults after myopia has fully stabilised and are generally contraindicated in children.

Singapore has had a National Myopia Prevention Programme run by the Health Promotion Board (HPB) for several years now. Their recommendations for myopia prevention, which we support, are as follows:

When reading, place the book 30 cm away and ensure that there is sufficient lighting When watching television, sit at least 2-3 m away ensuring there is some background lighting After 30-40 minutes of close work, rest your eyes by looking at a distant object (e.g., out of the window) for 2-3 minutes Encourage daily outdoor activities Encourage your child to sleep early Maintain a healthy balanced diet

Squint (Strabismus) Surgery

A squint occurs when one eye is straight and the other eye is turned away. This condition can happen at any age. The squinting eye can turn inwards, outwards, up or down and can be constant or intermittent.

        
 Child whose left eye is turned inwards        Adult whose left eye is turned outwards

When the squint is constant, the child may develop:

1. Amblyopia or lazy eye
2. Poor binocular vision
3. An abnormal head position

Many Asian babies may appear to have an in-turning squint. This occurs when the fold of skin covering the inner part of the eye causes the eyes to appear closer together. This appearance tends to "get better" over time as the baby grows and the skin folds becomes smaller as the bridge of the nose develops. A trained doctor, or ophthalmologist, will be able to tell you if your child has a pseudo-squint.

Doctors at the Singapore National Eye Centre manage the entire spectrum of strabismus from the more common childhood to complex adult strabismus. Different strabismus have different treatments (e.g., spectacles, patching, fusion exercises) and not all require surgery.

The Service sees about 700 new strabismus cases and perform about 250 strabismus surgeries each year. Our surgical data is audited annually. The aims of surgery range from improvement of cosmesis, binocular vision and range of ocular movements to correction of double vision or abnormal head posture due to strabismus.

Childhood Cataracts

Childhood cataracts, while less common than adult cataracts, can lead to severe visual impairment if not treated early. The treatment of childhood cataract is more challenging and complex than adult cataracts. Treatment includes not just surgery but long-term follow-up for proper spectacle prescription, amblyopia (lazy eye) treatment and monitoring for conditions such as opacification of the posterior capsule, glaucoma and retinal detachment (which are known to be associated with cataract surgery in childhood).

	Child with bilateral cataracts; left eye  protected with plastic shield one day  after cataract surgery, and right eye  still with cataract in situ.

Retinopathy of Prematurity (ROP)

Retinopathy of Prematurity (ROP) occurs in premature babies as a result of abnormal development of blood vessels in the immature eye. Excessive abnormal blood vessel growth can progress to bleeding within the eye and tractional retinal detachment resulting in permanent structural damage to the delicate structures inside the eye and subsequent blindness. ROP remains a major cause of childhood blindness in both the developed and developing world. Babies with lower birth age and weight are at greatest risk and require regular screening in the early weeks of life.

Doctors from SGH / SNEC have provided screening for premature babies since the 1980s and we currently screen about 250 very premature (birth weight < 1,500g, gestational age < 32 weeks) babies in various hospitals around Singapore each year. About 30% of the premature babies born in Singapore develop ROP. Most cases regress spontaneously but 6% will require laser treatment. Close monitoring of ROP is also conducted by SNEC’s paediatric ophthalmologists as up to 18% of the cases may progress onto the more severe Stage 4 – 5 disease which requires swift and more complex treatment. Where needed, the Service’s paediatric ophthalmologists work in conjunction with retinal ophthalmologists at SNEC to provide optimal and holistic care.

Amblyopia or Lazy Eyes

Amblyopia ─ a condition where vision is one or both eyes is poorly developed ─ affects 2 to 5% of the population. Early detection and treatment is important as this condition is best treated before the age of 8 years. Treatment later in life is often unsuccessful, resulting in permanent poor vision. An eye check should be done at age 4 by the family doctor, a paediatrician, or ophthalmologist. Eye checks should be done early if a visual problem is suspected (e.g., if the child appears to have trouble seeing, or if he/she appears to have a squint, or if there is obstruction of vision by droopy eyelids, cataract, etc.)

Doctors in SNEC see about 250 new cases of amblyopia per year. The average age of these children is 5.1 years (range 3 months to 14 years). Causes include refractive errors, strabismus (squints) and sensory deprivation (e.g., blocked vision from a droopy eyelid). In Singapore / Asia, most amblyopia (90%) are refractive (i.e., caused by high spectacle error). Accurate assessment of spectacle power is therefore important. Children may be treated with glasses, patching or both. Successful treatment depends on how severe the amblyopia is, and the age of the child when treatment is begun. Amblyopia is best treated early when the part of the brain responsible for vision is still developing. Once the child reaches the age of 8 years, treatment may be ineffective.

In a recent survey, more than 90% of parents were happy with their doctor’s explanation and felt they understood the condition well. Most parents (70 – 80%) had a positive attitude and managed to comply with treatment. However, some had difficulty and required more support and encouragement. All children compliant with treatment showed improved vision within 6 months of starting treatment.

Visual Electrophysiology

The SNEC – SERI electrophysiological lab provides ERG (electroretinogram) and VEP (visual evoked potential) tests to children of all ages. This is an objective test to assess both retina and visual cortical (brain) function, and is useful when cause of poor vision is uncertain, where confirmation of a diagnosis is needed, or when visual function needs to be monitored.

Our laboratory provides paediatric electrophysiology services to children islandwide. Between 2003 – 2009, the laboratory has performed ERG / VEP tests for about 280 children aged between 4 to 8 years old. By providing a relaxed and child-friendly environment, assessment was possible in more than 90% of children. The majority of children (50%) are found to have a retina problem with a smaller percentage (15%) having an optic nerve or brain dysfunction. These tests provide useful information about the children’s visual function and helps doctors decide on appropriate management.

Please visit the following relevant links:

Paediatric Ophthalmology and Adult Strabismus Clinical staff
I Want an Eye Examination / an Appointment
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Read more on related Eye Conditions and Treatments:

Childhood Myopia
Squints (Strabismus)
Lazy Eye (Amblyopia)