The eyes have it

Special treatment for eye diseases in children – even newborns – is not very well known among the public or even some physicians. There are 36 pediatric ophthalmologists in Israel.

By JUDY SIEGEL-ITZKOVICH
Doctor [Illustrative] (photo credit: INGIMAGE)
Doctor [Illustrative]
(photo credit: INGIMAGE)
Children are not just small people; when they suffer from eye disorders, they should be taken to a pediatric ophthalmologist. But there are only three dozen Israeli physicians who are currently working in this sub-specialty. The pediatric ophthalmologist has additional training, experience and expertise in examining children and has the greatest knowledge of possible conditions that affect children and their eyes.
“I was always interested in eye conditions,” said Dr. Ronen Rabinovich, one of the 36 specialists in the field, who studied medicine at Tel Aviv University’s Sackler Medical Faculty as part of the Israel Defense Forces’ academic program. “It combines physics, mathematics, medicine and surgery,” he explained in an interview with The Jerusalem Post, “and that is very interesting.”
Then he learned ophthalmology at Beersheba’s Soroka University Medical Center and did a fellowship in pediatric ophthalmology at the University of California at Los Angeles. He is married and has seven children aged four to 20.
After seven years of work at Sheba Medical Center, 18 months ago he came to work at Jerusalem’s Shaare Zedek Medical Center, where he works full-time, alongside a halftime pediatric ophthalmologist, examining and treating children as well as adults. On an average day, there are large numbers of parents bringing their children to the outpatient clinic to see him, besides the inpatients who need surgery and other treatments.
He also serves at a Modi’in Illit clinic where he treats large numbers of ultra-Orthodox (haredi) children for a public health fund.
“Haredi children and adults often have a lot of eye problems, and most of them wear glasses, partly because of boys’ and men’s constant need to refocus their eyes as they sway their bodies back and forth while they pray and study,” Rabinovich notes.
He advises that all children who “overuse” their eyes should rest 15 minutes out of every hour, as this can really affect their eyes.
“They have to rest them from TV, smartphones, tablets and computers,” he said.
It is good advice for their elders as well. But while sitting too close to the TV – less than three meters or so – is bad for eyesight, reading with too little light is not, although it should not be encouraged, he said.
“I think there is still less awareness of the field of pediatric ophthalmology among the public and even general practitioners and other doctors, that there are problems that can be treated or prevented. The 36 of us – all of whom I have listed on my smartphone – have an association.
But general ophthalmologists are generally leery of treating children, because surgery requires general, rather than local, anesthesia because they move. One can’t do the surgery alone.”
All children should go to a pediatric ophthalmologist before the age of eight, but ideally, they should also be examined by one before the age of three and before they go into first grade, he advises, “especially if they have a family history of eye conditions.” Typically, the pupils are dilated to relax the focusing muscles so the doctor can take an accurate measurement. By using a special instrument called a retinoscope, the doctor can reach an accurate diagnosis or prescription.
AMONG THE eye problems Rabinovich deals with are chronic “pink eye” infections (conjunctivitis); retinopathy of prematurity (ROP or Terry syndrome); crosseye or squints (strabismus); “lazy eye” (amblyopia); double vision (diplopia); cataracts; corneal abrasion and erosion; and myopia. Some are common among adults, while others are much more frequent in children. The pediatric clinic continues to treat young adults who have been cared for by the clinic as children.
“We don’t send them elsewhere just because they have grown up,” the ophthalmologist said. He spends about 80 percent of his time treating children, he said.
Our interview was delayed by half an hour because Rabinovich had to rush to the premature baby unit to inject the eyes of some ROP newborns with the drug bevacizumab (Avastin).
ROP is an eye disease affecting children born prematurely, most of them having undergone intensive neonatal care, including oxygen therapy given to treat the premature development of their lungs. It is thought to be caused by disorganized growth of retinal blood vessels that can cause scarring and detachment of the retina.
In some newborns, ROP can be mild and reverse itself. But decades ago, some premies who received too much oxygen went permanently blind. Today, blindness in preterm babies – especially those at very low birth weight – can be prevented with Avastin. Ironically, elderly people with “wet-type” age-related macular degeneration (AMD) also undergo injections with Avastin to slow their vision loss due to the proliferation of tiny blood vessels under the retina.
“We can identify ROP between six and 10 weeks after delivery and treat them before blindness sets in,” he explained.
As for “lazy eye,” the condition involves one being stronger than the other. The treatment, said Rabinovich, requires covering the stronger one so the weaker one is forced to work and become stronger.
If patients refuse this treatment, a less-optimal one is using a verylow concentration of atropine, an anticholinergic agent that functions by blocking the chemical acetylcholine, which relaxes the ciliary muscle of the eye and causes the pupil to dilate.
Diplopia can affect both children and adults, and it can be caused by dozens of factors including sinus and other infections, an irregularly shaped cornea, stroke or trauma to the eye. Double vision is the perception of two images of a single object seen adjacent to each other (horizontally, vertically, or obliquely) or overlapping.
Because some of the causes of double vision can be life threatening, it is vital for the doctor to extensively review the patient’s history and examine him carefully. When one experiences headache and double vision simultaneously, the patient should be taken immediately to the emergency room. Diplopia can be one of the first signs of a systemic disease, especially a muscular or neurological problem, and it may disrupt a person’s movement, balance or reading abilities. It is most important to determine whether the diplopia is in one eye or two.
In monocular diplopia, the double vision is caused by a problem in one or both eyes that does not resolve itself when one eye is covered. In binocular diplopia, the eyes are misaligned.
Each eye sees a single image when working alone, as when one eye is covered, but when both eyes are open the brain perceives two adjacent images.
“Sometimes we put prisms in eyeglasses, but if it doesn’t help, we have to operate. In adults, but not in children, we at Shaare Zedek use adjustable and absorbable sutures that are not completely closed. If the double vision returns or persists, we pull the sutures like shoelaces and then set the ends in place,” said Rabinovich.
Crosseye may be of genetic origin, said the ophthalmologist, and when it is, the children of Arabs who marry their first cousins (“consanguinity”) are often the victim.
The condition means your eyes are pointing at different angles, causing them not to look in the same direction because some of the muscles controlling the eyes are weak or paralyzed, too strong or prevented from moving due to some restriction.
Squints are especially common in young children, said Rabinovich, and when a childhood squint recurs, it can lead to double vision in adults.
There are also cases of congenital glaucoma (damage caused by high inter-ocular pressure) resulting from consanguinity.
Although most cataracts affect older people, pediatric cataracts may occur because of abnormal lens development during pregnancy.
Cataracts may appear spontaneously or result from genetic problems or infections. Lens malformations that occur in conjunction with medical problems are often the result of a genetic or a metabolic problem.
These cataracts may be present at birth or may develop during childhood. A tiny incision is made into the eye to create an opening in the front of the lens capsule. The milky and very soft inner part of the child’s cataract is suctioned out of the capsule, and an intra-ocular lens is then sometimes placed with dissolvable stitches within the empty capsule. Not all cataracts have to be removed surgically, said Rabinovich, who performs surgery himself. Some are small or off-center in the lens, so they can remain in place if the child’s vision develops normally.
CANCER OF the eye in children is very rare, so treating it is a specialty of a specialty, said Rabinovich. All cases are sent to Prof. Jacob Pe’er, head of ophthalmology at Hadassah University Medical Center, who is a leading expert in it. One new thing in eye cancer, Rabinovich continued, is giving chemotherapy directly to the eye instead of systemically to the whole body, which could kill healthy tissue and cause many problems, including subsequent malignant tumors.
But Rabinovich’s unit does treat capillary hemangioma, which is one of the most common benign orbital tumors in children. It appears as a red, raised lesion on the surface or as dark blue subcutaneous lesions that may extend into the orbit. They are usually on the upper eyelid and can trigger amblyopia.
“We usually treat them with beta blockers,” he explained.
Shaare Zedek has a service of optometrists, supervised by eye doctors, to fit children with contact lenses for myopia (shortsightedness) or other eye problems. They should not be used under the age of two years, even though there are younger children who need eyeglasses.
“Young children can’t insert lenses properly. They have to be very clean so as not to cause infections,” said Rabinovich, “so waiting until age 13 or 14 is recommended. It’s best to change disposable lenses daily.”
It isn’t so easy getting younger children to cooperate during vision tests. Instead of letters or numbers that they can’t read, there are objects facing different directions that young children can identify. But if they can’t help the ophthalmologist at all, Rabinovich uses little toys to catch their attention, and other methods can detect vision problems even in newborn babies. Systemic diseases such as kidney problems can be picked up from looking at a child’s eyes.
Just as all newborns’ hearing is screened before leaving the hospitals, eyes are checked by pediatricians, and if any problem is suspected, a pediatric ophthalmologist will examine them. Sometimes, a young child may even be sent for a magnetic resonance instrument (MRI) scan.
Nurses at well-baby (tipat halav) clinics do vision checks, but these are not the same as those performed by eye specialists, Rabinovich said.
“Some children with vision problems are thought to suffer from dyslexia – reading disorder – which has very different causes and treatments than eye diseases, so going to a pediatric ophthalmologist is very important to catch conditions early and diagnose them properly, he concluded.