Vision Problems in Babies

Babies can't see properly when they are born - this is normal. By the second week after birth, they see up to 25 centimetres away - babies whose vision is as expected tend to get fascinated with faces, bright colours and lights in the weeks that follow.

You should, however, inform your paediatrician if you notice any of the following signs while playing with your baby or generally spending time with your baby:

• Your baby is not looking at your face or not responding with a smile even at six to eight weeks of age.
• Your child is unable to make eye contact or does not follow different lights or objects, especially in the first three months.
• If you notice a misalignment of the eyes - eyes which are crossing inwards or drifting outwards - in your baby after four months of age. 
• Your baby's eyes appear too small or too large (as if the eyeballs are bulging).
• If you notice cloudy, white, whitish-grey or yellow pupils of your baby’s eye.
• The pupils of your infant’s eyes appear asymmetrical.
• One of the eyelids of the infant’s eyes is drooping (ptosis).
• Your baby's eyes are moving uncontrollably from side to side (nystagmus). 
• Your child rubs his or her eyes or blinks frequently. 
• Your baby cries a lot during the night.
• Your baby seems scared of rolling over to his or her side, and his or her movements seem restricted.

Medical professionals may see some additional symptoms of vision impairment in infants:

• At the first baby checkup, the doctor may notice a shadow in red reflex during the eye exam. Red reflex is the reddish-orange reflection of light that comes from the back of the eye (fundus) - this is observed when using an ophthalmoscope or retinoscope.
• The doctor may also find a cloudy cornea or cloudy vitreous (gel in the eye) during the first doctor’s check-up after birth.
• The child is unable to make eye contact or interact.
• The size of the eyes can be unequal, pointing to infant glaucoma.
• Drooping eyelid (ptosis).
• The doctor may be able to see the signs of strabismus as early as six months after birth. Strabismus is a condition in which the eyes are not properly aligned, and may point in different directions. The child may squint, given the effort required to focus and see something. 
• The infant recognises the family by their voice but not by their faces.

Vision loss in infants can be either prenatal (when the baby is in the mother’s womb), perinatal (from the 28th week of pregnancy till the first month after birth) or postnatal (anytime after birth).

• Prenatal causes include structural deformities in the eye (anophthalmos, microphthalmos, coloboma) and congenital cataract.
• Retinal problems, infantile glaucoma and congenital cloudy cornea can also affect the visual ability of the child.
• In the perinatal period, eye conditions like cortical impairment, ophthalmia neonatorum, and retinopathy of prematurity lead to vision loss in children.
• Postnatal conditions, though unusual, can affect also the baby’s ability to see.

If you see any signs of eye problems in your baby, alert your paediatrician. Early diagnosis, followed by medical treatments and visits to the eye specialist, can help in preventing permanent vision loss in infants. Do consult an ophthalmologist if you have a family history of eye problems.

To diagnose any visual impairment in your baby:

• Your paediatrician or ophthalmologist will examine your infant’s cornea, anterior chamber, lens, and reflex of the pupil.
• Your doctor will examine the red reflex to rule out congenital cataract, advanced ROP, and other visual deformities. 
• Your doctor may use a handheld slit lamp to examine the baby’s eye. 
• Your doctor may use atropine eye ointment to dilate (expand) the pupils for better examination. If your child is distressed or uncooperative during the visit, don't worry - the examination can be repeated after a few hours or the next day.
• To check your baby’s ability to look in the nine cardinal directions of gaze (up, down, left, right, etc.), your ophthalmologist might use Jampolsky’s dictum of “one toy-one look”.
  The doctor will use soft toys, brightly coloured objects or even mobile phones and move the objects in different directions. For this test, it is crucial that the objects should only have visual effects - they should not make any sound as the child could be attracted by auditory signals, which would defeat the purpose of the examination.
• Another test called the Worth’s ivory ball test may be used in an infant above six months of age. In this test, the doctor uses small bright-coloured sweets which are commonly used to decorate cakes and check if the child can see and pick them up.

There is a narrow window of opportunity to treat a visually impaired infant. If the treatment is not given within the first six months of life, the child starts to develop binocular vision. In binocular vision, the child suffers from strabismus, reduced vision in one eye and loss of ability to judge the depth and speed of objects. 

Also, if the child does not get early treatment, he or she may suffer from amblyopia, which is a developmental disorder where one of the eyes becomes weak as the brain can’t recognize signals from that eye. With the help of early diagnosis, treatment of some visual conditions can help prevent permanent blindness in infants.

• Currently, there is no treatment for anophthalmia (being born without one or both eyes). However, for infants with mild or moderate microphthalmia, conformers (a clear acrylic shell placed in the eyes to hold the shape of the eye socket) can help in proper growth of the socket. In severe microphthalmia (abnormally small eyes), the surgical treatment options like expandable orbital implants, orbital osteotomies, conjunctival sac and lid reconstruction, may prove beneficial.
• You cannot completely reverse coloboma (gap or hole in any part of the eye due to missing tissues), but there are some methods to improve the quality of vision. For example, the use of glasses or contact lenses to correct refractive errors, using low vision devices, and using blurring eye drops in the stronger eye to maintain symmetry with the weaker eye.
• The treatment of persistent fetal vasculature involves surgical removal of the faulty lens along with reattachment of the retina back to its place (if required). The child would require contact lenses to maintain proper eye function.
• Congenital cataracts are removed by aspirating them through a small cut followed by implantation of an intraocular lens inside the eye. After the surgery, the child may require vision-correcting eyeglasses or contact lenses.
• Infantile glaucoma can only be treated by early surgical treatments like:
  • Goniotomy: It is a surgical procedure done with the use of a lens called goniolens. In this procedure, an opening is made in the blocked trabecular meshwork (a group of tiny canals located in the drainage angle) of the eye which helps in proper drainage of fluid from the eye. 
  • Trabeculotomy: It is a surgical procedure to remove a piece of tissue from the eye's drainage angle to create an opening which allows the eye fluid to drain out of the eye. 
  • Trabeculectomy: It is a surgical procedure where a small hole is made in the sclera (eyewall) which is covered by a thin trapdoor. The extra fluid inside the eye drains through the trapdoor to a small reservoir present under the eye surface, covered by the eyelid. 
• There is currently no treatment for retinitis pigmentosa, but you can slow down the progress of the disease by avoiding direct exposure to sunlight, by taking antioxidants and by regularly visiting the eye specialist.
• The treatment of ophthalmia neonatorum (conjunctivitis in babies up to 28 days of age) involves prescribing antibiotics - azithromycin, erythromycin for the bacterial infection - along with cleaning discharge from the eye using saline.
• Laser therapy and cryotherapy can be useful while treating retinopathy of prematurity (ROP). Eye surgeries like scleral buckling and vitrectomy could be done in the case of retinal detachment.
• Early treatment of some neurological conditions can help in retaining complete vision. The parents should take their infant to a neurologist for treatment of these conditions. 
• Keratomalacia can be treated by using antibiotic drops and ointments. The child should be given diet and supplements for treating vitamin A deficiency.

First and foremost, all parents-to-be should get themselves tested for sexually transmitted infections - a simple test and treatment, if required, can prevent many complications in the future.

You should also take your baby for a basic eye examination at different stages of life, to help prevent visual impairment. These stages must include:

• At birth: The first eye examination should be done by an ophthalmologist within the first month after birth.
• At six months of age: This is the optimal time for an eye examination. All the refractive errors can be diagnosed by the sixth month because the eye movements and accommodation of the lens is fully developed by then. 
• Aged 18-24 months: At this time of life, detection of some malign tumours like retinoblastoma (cancer of the retina) becomes easier. With early detection, you can help save your child’s vision. 
• Three years of age: By this time, the ocular (eye) development is 90% complete, so a complete eye examination is beneficial.
• Before the beginning of preschool (five to six years of age): A complete eye examination is necessary before your child joins school, to make sure that there is no visual impairment that can affect the child’s reading ability. 
• Annual eye exam for schoolgoers: Children going to school should be tested annually for their eye examination.

When it comes to babies, especially their eyesight, prevention is indeed much better than cure. This begins from the time of pregnancy - so make sure you get proper check up during pregnancy and vaccinations during pregnancy. This will help to avoid future health complications for your baby. It will also alert you and your doctor to any problems that could occur in the future, so you can be adequately prepared.

Your baby's first eye check-up will happen in the hospital before you are discharged. After that, it is up to you to take your baby to a paediatrician regularly and report any worrying symptoms related to the eyes.

Early detection and treatment is the best way to deal with any eye problems your baby may face. There are medicines and surgical options available for conditions like infant cataract and infantile glaucoma. For keratomalacia, caused by vitamin A deficiency, the treatment may involve vitamin A supplementation and antibiotic eyedrops. 

For some conditions, like retinitis pigmentosa, there is no cure as of now. However, parents can delay the loss of vision by taking proper precautions. They can also help their child adapt to a life without sight through therapy and love.