Your Child’s Eyes – PediaCast 470
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- The Pediatrics in Plain Language Panel returns to the studio as we consider your child’s eyes. We explore vision screening, blocked tear ducts, lazy eye, pink eye, styes, splashes, scratches and objects that get stuck in the eye. We hope you can join us!
- Eye Care
- Vision Screening
- Blocked Tear Duct
- Lazy Eye
- Pink Eye
- Objects in the Eye
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.
It's Episode 470 for August 27th, 2020. We're calling this one "Your Child's Eyes". I want to welcome all of you to the program.
Our Pediatrics in Plain Language panel joins us again this week. You will recall that when Dr. Mary Ann Abrams and Dr. Alex Rakowsky joined me in the studio, well, not in the studio, but we're doing it remotely because there is this little thing called the COVID-19 pandemic.
So, if you're like two years out listening back to an old episode, all of our interviews are remote right now as we practice social distancing during this unprecedented, at least in modern times, pandemic.
But anyway, when Dr. Abrams and Dr. Rakowsky joined me, we try really hard to cut out the medical jargon and used plain language in the podcast. That's why we call it our Pediatrics in Plain Language panel. Now, that does not mean that we oversimplify things because we want you to understand what's going on with your child, at least to the point that you're comfortable in your understanding and in making medical decisions and taking an active role in your child's care.
So, oversimplification is one ditch on the side of the road. The ditch on the other side of the road is too much information. And by that, I mean the teeny tiny nitty-gritty details that most parents do not need or want unless, of course, that is what you want. In which case, as pediatricians, we do want to support you in discovering that level of detail for your child.
But most parents are happy with the basics, a little beyond so that there is understanding to make medical decisions, understand treatment and watch for worsening symptoms or complications. Because if you know what to expect and why to expect it and when to expect it, you're going to be in a better position to know when to be concerned and when to call your child's doctor.
And if you do that earlier rather than later in a disease process, it's more likely your child will get the help they need when he or she needs it which will improve their health and wellness and, ultimately, the quality of his or her life which are all very important things.
We also know when parents understand the reasoning behind treatment recommendations. So, when parents understand what works and why it works, there is sort of an "Aha!" moment. And after that, you're more likely to want to be involved with decision-making and following treatment plans because you understand what's going on and the importance of specific recommendations.
All of these is tied to a concept we call health literacy, which is important for parents and our young patients. However, I do think health literacy is sort of a medical jargon term in and of itself because what do we mean by health literacy?
Well, I look at it this way. Reading literacy is recognizing and understanding the meaning of words, so being able to read. Health literacy is recognizing and understanding the meaning of health and wellness concepts.
Now, not to the degree of attending medical school but enough to feel comfortable taking a part in healthcare decisions and wellness decisions in a way that's beneficial.
All of this to say, the goal here is not simplification but rather understanding and that takes using language that people who are not doctors can understand. Now, sometimes, we have to use medical jargon because there's not a plain language word available. In that case, we use the big words but then we do our best to explain what those words mean.
Sometimes we use the big words intentionally followed by an explanation, so when you hear the jargon again, and maybe a few more times after that, along with the explanation, learning occurs. Which is particularly important when the big words relate to a condition that impacts your family and will continue impacting your family for some time to come.
I have one more point to make in all of these and I've saved the most important point as my final point in this a little bit long-winded introduction, and that is this. If your child's pediatrician, or pediatric provider whoever that is, is explaining something to you and you're like, "Whoa, whoa, wait. Hold on. I'm confused. I don't understand what you're talking about."
If that happens, it is absolutely okay to interrupt the conversation and say, "Whoa, whoa, whoa, wait a minute. Can we go back? I really want to understand this." So, don't be afraid of it.
Interrupting is perfectly fine. It means you are advocating for your child's health because at the end of the day, you're the one carrying for your child at home following the treatment instructions, watching for difficulties or complications. And you really do need to know what is going on. And interrupting that conversation with your pediatrician to get clarification right then and there when you need it to help you understand, that is very important.
It not only helps you, the parent, understand but it also helps your child's doctor because there's so many things that are second nature to us in medicine that we often just assume that parents understand.
And when a parent interrupts and asks us to explain something in more detail, we make a mental note of that. It's like, "Oh. Hey, wait. This person isn't understanding." And that can then lead to us doing a better job for future patients like, "Okay, this is a stumbling point for a lot of parents. I need to explain this better."
So, we're all in this together, like they sing in the High School Musical. I'm not going to sing it. But we are all in this together, as parents and pediatricians and every other pediatric healthcare provider out there, as we care for kids and strive to improve health and wellness for every child, for every reason everywhere.
So, plain language health literacy, really important things, which is why we dedicate several episodes each year to this important idea.
Today, we're going to take a look at your child's eyes through a plain language lens, as we explore some eye and vision topics. Things like blocked tear ducts in babies, lazy eye in toddlers, pink eye and its many forms.
What to do if a liquid or chemical splashes into your child's eye or an object, like a piece of dirt or a small insect that either drops or flies in and clings to the surface of the eye, what if that object or a finger or a toy scratches the surface of the eye? Which is actually a fairly common occurrence. What symptoms suggest that that may have happened and when do you seek help?
Then we'll wrap up by considering sties, which are those little bumps on the eyelid that can create mostly little problems, but sometimes big problems.
So, lots coming your way as our Pediatrics in Plain Language panel assembles to talk about your child's eyes and vision.
Before we get to Alex and Mary Ann, I do want to remind you, you can find us wherever you get your podcasts, so Apple Podcast, Google Podcast, iHeart Radio, Spotify, SoundCloud, and most mobile podcast apps for iOS and Android.
Of course, reviews are helpful wherever you listen to PediaCast. We always appreciate when you take a moment to share your thoughts about the program.
And we love connecting with you on social media. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.
We also have a Contact link over at the website, pediacast.org, if you would like to ask a question or suggest a topic for a future program. Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call or contact your doctor.
So, let's take a quick break. We'll get Dr. Mary Ann Abrams and Dr. Alex Rakowsky settled in to the studio, at least connected to the studio as the case may be and then we will be back to talk about eyes and vision. It's coming up right after this.
Dr. Mike Patrick: Our Pediatrics in Plain Language panel is in the house once again. You will recall that Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio State University College of Medicine and a pediatrician with Primary Care Pediatrics at Nationwide Children's Hospital. Dr. Alex Rakowsky, also an assistant professor of Pediatrics at Ohio State and a pediatrician with Olentangy Primary Care at Nationwide Children's.
I think I speak for most of the audience when I say we love when the two of you stop by for a visit. So, thanks again for being here today.
Dr. Alex Rakowsky: Thanks, Mike. Always.
Dr. Mary Ann Abrams: Thanks. We love stopping by.
Dr. Mike Patrick: Yeah. Let's talk plain language. Mary Ann, explain to us once again what is plain language and why is it important?
Dr. Mary Ann Abrams: Well, as we talked about before, plain language is using living room language, words that your family members would understand, if you're sitting around talking about it over the dinner table or somebody stops you in the neighborhood or whatever. It's language that conveys the meaning clearly without a lot of other words that aren't needed to get the meaning across, not a lot of fancy or technical words.
And it's important when we really need to get the message across. It doesn't mean that beautiful writing and complex writing and grammar aren't important or necessary or desirable, but plain language is the tool that we use to really convey a message clearly.
And I just have a couple thoughts I might add today to the discussion. One, a study just came out looking at the publicly available information about the COVID-19 pandemic and, unfortunately, found that reading level for most of that material is in the high school range. And we know that the average adult in the United States reads around eighth grade level. And then, there are these all kinds of other issues that talk about practical information in a rapid changing environment.
So, it's important, especially in times like this that information be as clear as possible so people understand and know what they need to do. And it behoove all of us, it reminds us constantly that we really do need speak and write as clearly as possible.
The other interesting thing I just came across is a really interesting description when we talk about plain language and in the health world, it's often complicated by too much information but also by technical terms and we often talk about jargon.
And this was a description of different kinds of jargon that I thought I'd just share few ideas, where I that I might add a few more next time we talk. Clearly, we could call technical terms a form of jargon, but they also identify the couple other ideas.
One, what we call alphabet speak. So, we end up using a lot of abbreviations in healthcare and some of those we know are very technical and it doesn't matter that much. But there are some that we take for granted. And we don't do that on purpose, but we say things like CBC or NPO and even EKG. And we sort of think everybody knows that an EKG means an electrocardiogram or a test that see how your heart is beating. So, this alphabet speak is something that fits in that word of jargon.
Another word kind of that's jargon are words that are familiar to people. Maybe they heard them in high school biology class or they hear them on TV. They watch medical shows. And so people hearing them and they used a lot but they don't really know what they mean.
And those are words like ulcer, cultures, sepsis, febrile. So, you hear those and you kind have a gut feeling of what they mean, but when a doctor or nurse goes like to about your child, it's like, "What really is going on here?"
So, I think we're going to stop there. There's a few more categories. And just to keep people hanging on the edge of their seats, I'll talk a couple of those next time we're together.
Dr. Mike Patrick: Yeah, that sounds great. I will remind folks that up until the COVID-19 pandemic hit, which I think those are two terms now that a year ago people would have been like, "What? What are you talking about?" But now it's a little more clear.
Before it hit, we were cruising along, sort of following loosely the contents that's available in a book called What To Do When Your Child Get Sick, which is available from the Institute For Healthcare Advancement. Which is a non-profit organization that takes plain language pretty seriously and they just want folks to be able to understand their child's health in very clear language.
And they have this book, is only 12.95 and we actually have discount code for folks that you can use. It's POD 719, P-O-D 719 and that gives you a 40% discount. So the book ends up being $7.77. And I'll put a link to that book in the show notes.
And I want to point out that we don't get any financial kickback on this book or this organization. We're not financially connected with them at all. Just as resource, everything could be very helpful, and we can offer that price for folks.
And then, we do have lots of other episodes in the past that we've done with our Plain Language panel. And in SoundCloud, we have a playlist of all of our past episodes on Pediatrics in Plain Language where we've covered things like fever and illness, newborn baby care, keeping kids safe, reading and family literacy, fitness fact.
So, just a lot of these plain language episodes and there's a playlist of them if you'd like to see all of them in one place over at SoundCloud. And I'll put a link to that playlist in the show notes for this episode over at pediacast.org.
And then, finally, we have a Pediatrics in Plain Language survey because we'd love to hear your feedback on these episodes that we present. And if you have any suggestions for future topics, we'd love to hear from you there. And I'll put a link to that survey again in the show notes.
Now, as we get started here in considering your child's eyes, I would like to say we are not eye specialists. We are general pediatricians, but we see lots and lots and lots of little eyes in the exam room. And we also know someone who is a pediatric ophthalmologist and I did a show with her, Dr. Julie Lange. That is going to end up being PediaCast CME Episode 49.
I know we have a lot of pediatric providers in the audience, so if you're a pediatrician, family practice, doctors, nurse practitioners, physician assistant, you take of kids, I encourage you to check out PediaCast CME Episode 49, where we do talk about a lot of the things we're going to talk about today but in much more detail. And so, I'll put a link to that in the show notes as well.
So, Mary Ann, how do you go about screening baby eyes and vision? What's your approach as you think about eyes and babies?
Dr. Mary Ann Abrams: Well, it's very interesting. Clearly, a little baby can't cooperate with what we think of as the usual eye exam, where you look at the chart and say letters or the shapes. But we do screen and check baby's vision because it's very important.
There are several things that can be present, even when a baby is born, that if they're not caught, they can lead to serious eye problems. And we could catch some of those things in those first months and couple years of life.
So what we generally do, we've kind of take two approaches. We ask the parents questions to get their sense of how the baby is doing and developing their eyesight in particular here. And there are some things that we can do on our exam.
So, we ask parents things like, does your baby seems to look at you? Did they seem to respond if you accidentally shine a bright light in them or turn the light on? Do the eyes look the same, whether it's the outside of the eye or when their eyes are open and they're alert? Do they seem to be aligned or to be straight, be going in the same direction at the same time?
And we ask parents if there's family history of people who had serious eye problems as babies or children or even as adults. And if there's a history of people needing glasses or having other illnesses that run in the family that can be associated with eye problems.
And then, we take a look at the baby's eyes themselves. Mainly what we're looking for in first months and a couple years is to get a good look in the eye itself with the ophthalmoscope which is that tool that we held in our hand. And we're basically looking at the front of the eye to make sure there's nothing blocking the view.
So if there's something that looks like it's a dark spot while we're looking through the lens of the eye, the pupil of the eye, the opening of the eye that gets in the way of looking through, that would be a concern. We're always looking to make sure that we can see through that pupil that opening of the eye to the back of the eye.
And that color, usually it show at the start about reddish orange and we want that to be visible without anything blocking it and we want it to be the same in both eyes.
So, that's something that we always take a look at and it helps a whole lot if the baby is wide awake and happy and kind of looking around. It can be harder when they're little fussy and insistent on crying or keeping their eyes squished shut tight.
We've working kind of backward. We look at the outside of the eye to see if there's any swelling or redness or drainage or anything that looks uneven on one side or the other. And later, as the baby is more alert, more older and able to look around more and look at things farther away, we'll look at the alignment of the eyes and make sure they're straight and that those pupils react to light equally in both eyes, say, if we shine a light in their eyes.
Dr. Mike Patrick: Yeah, and one thing that I think is important when we think about plain language is even the terms of the eye specialist that we use. So, as you're doing this exam on a baby and you find an abnormality, you're worried that they're not tracking correctly.
We're worried that maybe they're not able to see or you're looking for that red reflexes as you're looking with that light. And so you see something that's a different color than red or if there are black spots or something. So you know there could be something in the eye that's concerning. That's something that we're going to then refer to an ophthalmologist right away.
But you also hear of optometrists and opticians and that could sometimes get a little confusing for parents. An ophthalmologist is a medical doctor who has then specialized training in the eye and really looking at diseases and treating disease of the eye. Whereas an optometrist is someone who goes, so you don't go to medical school, you go to a different school to become an optometrist.
And then, there are some diseases of the eye that you may take care of like dry eye, for instance, but then if there's a more significant that would require surgical intervention, then you would send them to the medical doctor, the ophthalmologist.
And then optometrist also help us figure out what our glass prescription is. And then the optician is the specialist in making those glasses.
This get a little bit confusing all these different terms but it is the ophthalmologist is the medical doctor that we generally send you to if we find an abnormality.
Yeah, Mary Ann?
Dr. Mary Ann Abrams: Really good point because if we see any of those kinds of things for these young babies, we are concerned about something seriously wrong and we want them to get to an ophthalmologist which is the doctor who is specialized in treating eye disease. Some can even do operations and surgery on the eye. And ideally, a pediatric ophthalmologist, just because some of these things can be very rare, is someone who's got the most skill in seeing a lot of young children and treating this.
That being said, seeing an ophthalmologist, even if they're not a pediatric ophthalmologist if that's the best available because of where you live, that's a point, too. But don't confuse it with someone whose specialty if not that kind of pediatric or child diseases.
Dr. Mike Patrick: What about blocked tear ducts? So, this is something that we see a lot in infants. What is a blocked tear duct?
Dr. Mary Ann Abrams: Blocked tear duct are pretty common. And what they basically reflect is that when your eyes constantly are making tears to help them protect the surface of the eye, to wash out dust or things that get in the eye, to protect the eye, but they have to go somewhere. And the way our bodies are built, we have tear ducts which come from the eye and kind of run down to the back of the nose and drain that way.
So, for some reason, it's not uncommon for babies to have that little tear duct be kind of blocked whether it's clogged up or it's really narrow when they're born. It can vary especially if it's a premature baby or whatever, but we'll often see that. Sometimes we'll see like a reddish bump or just a little bump toward the area, the eye closest for the nose. And it usually isn't painful unless it kind of gets a little bit of inflammation or some soreness because some bacteria build up, because those tears end up pulling in that area. They can't go down and drain away as easily.
So, it's kind of a nice diagnosis because it's pretty usually obvious what it is. And the good news is most of the time, it goes away on its own by about six months of age. And there's a few things parents can do to help that along.
But if it doesn't go away by six or seven months, we usually do like to have them see an ophthalmologist because they want to make sure that might not be something really rare. And they can sometimes do a little probe to open that up and help those tears drain perfectly, normally.
So, what we ask parents to do, they can use like a little compress, a little damp washcloth on that area two or three times a day. And then do what we call a little massage, which is pretty firm with their fingertip in that area trying to kind of push that gently but firmly. Push that area a little bit to try to push through and open up that tear ducts.
Dr. Alex Rakowsky: Yeah, if I could just add to the massage part, it is kind of freaky to tell a parent to stick your finger in your child's eye. Usually, I have the parents actually try it on themselves to find what we call a puncta, that little sort of drain. Just try it on themselves just to kind of get a feel for where it is. And then do it when the baby's sleeping because it's so much easier instead of having them moving baby's head to try to get your fingertips because that can cause harm.
So a lot of parents are really afraid of it but if you can demonstrate in the office a few times, they'll get a lot more comfortable with it.
Dr. Mike Patrick: Yeah, and then let them practice in the office while you're watching and see if they're getting the right technique.
Dr. Mary Ann Abrams: I usually show them kind of how firmly, not too firm, but not too lightly to push so that they feel a little bit comfortable putting that right amount of pressure on it, too.
Dr. Mike Patrick: So in the case of blocked tear duct, the duct is not what's making the tears, it's what's draining the tears. And so, if that gets blocked, you get that excess of tears.
But if your child has like yellow or greenish discharge that just keeps coming back or there's any redness around the eye, this is something that you'd want to have your doctor take a look at right away. Until you have that diagnosis and you're kind of used to what this looks like, when it comes and goes, you don't want to make this diagnosis at home on your own but have someone definitely take a look.
As we move on from infants to toddlers, Alex, how do you screen eyes and vision in toddlers? What's your general approach there?
Dr. Alex Rakowsky: As always, parental concerns. It's always start off if the parents have any concerns that the child's having what we call lazy eye, where the eyes don't seem to be lined up properly. They seem to be squinting to see close or far. They see redness out of the eye.
If they see on a picture, I actually had this happen, been at this for around 27 years, three times a parent come in and say, "In the picture, I noticed that there's a red dot and on one eye and nothing else on the other."
But if there's a parental concern, I always start of for that, just an open-ended question, any concerns about your child's eyes. Then, it really boils down to kids at this age should be able to focus pretty well. It's hard to kind of get a test done in the old fashion way where we have the sort of vision test which they called Snellen test, where they sit 20 feet away, and then tell you what letters they see. It's hard to convince a toddler to do that.
But you can still do some fun things. You can have like pictures or blocks or colors. You can kind of range on to kind see what they see, tumbling pictures or little objects that they can point to. A lot of hospital systems are using automated test where, essentially, they look into a camera and they're asked to find the bird in the camera.
And then, that automated tells you if there's a lazy eye, eye movement to the side, if there's a roundish issue called the stigmatism, if there's one eye that seems to have the light bounce back a little bit different. Can they be nearsighted or farsighted?
So, that's become the norm for a lot of the larger system. It's an expensive tool to have, so a lot of pediatricians don't have it and rely on the chart. So, it really boils down to what your pediatrician does but it really starts off with parental concern.
Dr. Mike Patrick: Yeah, absolutely. And I think that's important as parents observe their kids when they're playing, when they're reading, when you're watching television, if you're noticing concerning patterns to bring that up with your child's doctor.
You mentioned lazy eye. What exactly is a lazy eye?
Dr. Alex Rakowsky: I love this topic because having a large family, I have a few children when they're on three or four months just look at their hands and they twist their hand around because you learn to look at things three dimensionally.
So, when babies are born, we think that they only see things two dimensionally. And as they get around three or four months, they now use their eyes to focus in and see depth in what they're seeing. And to see depth, you need to have two functioning eyes that are lined up.
So, a lazy eye is, after that time period where you're lining up those eyes to see well, those eyes are now lining up properly. And then it could be either the lining up all the time, which will be called a tropia or if it's just a temporary, where they're tired and looking at TV for a long time, reading for a long time. But one of the eye gets tired and then moves to the side.
Totally like the name lazy eye because it's not really a lazy eye. It's really where there's either muscle problem or an eye-brain connection problem. Or that eye is not being told to focus in or cannot focus in. So, there really is a medical issue with trying to line up those eyes perfectly to see through dimensionally.
Dr. Mike Patrick: So, one issue I think is sometimes comes up is if you just look at the kid's eyes, sometimes the way that your face is made, it can look like one eye is going in or one guy is going out but it's not necessarily happening. It's really more of an illusion based on like the eyelid folds and if there's a little more skin on one side than the other.
Because I don't know if you ever gone to a science museum and you look at something that makes your face look exactly the same on both sides with the mirror, that you never look quite right? So we are a little asymmetric, we were not exactly mirror images of our left and right sides of our face.
And so, sometimes you can get this illusion. And then, in other times, it really is a problem. And the best person to figure out which of those things is going on really is your child's doctor. And if we think that there really is an issue with one eye going in or going out, then that's another reason that we would send you off to see an ophthalmologist because there are some things that they can do to fix that.
Dr. Alex Rakowsky: Yeah, it really boils down again to parental concern. Do you send that one eye kind of drifting one way or the other, or they're not lined up correctly? Again, if you have an automated test, that can really kind of pick up for a major one, cause you're going to miss like an eye that gets tired and then they start to drift when they get tired.
What we do is just shine a pen light or shine a light in a darkened room just to see if the light bounce off from the same part of the pupil or the dark part of the eye. And then, if you're worried about quote and quote, lazy eye, use something called a cover test, where you essentially cover the eyes repeatedly just to tire him out to see if one eye starts to get a wiggle to it. And then you worry about that eye kind of losing functionality or losing the way it's being worked. Then you have to worry about, I don't like the term lazy eye, but a lazy eye.
Dr. Mary Ann Abrams: And I would just add, as both of you have said, that whether we call it lazy eye or anything else, that if you're concerned as a parent and what we pick up on when we see your child and want you to get it checked out, it's urgent, not whenever you get around to it. They may not be an emergency but do make that appointment, keep that appointment, go to that appointment.
Because one of the most important things for helping children's eyes maturing, develop vision, is to keep stimulating or giving the back of the eye, where all the nerves are, continuous input. And what can happen is if one eye is out all the time looking the other way, the other eye is going to get all the input and that one is going to basically not get any input and that's probably why it's called lazy. It's going to be a lazy and not getting any of the work.
But the bad part of that is over time, it can permanently cause the vision to fail, to not develop, and then there's nothing to do about that. If a child gets to a school age, five, six, seven years, and that have gone undetected and not treated, but it's easily treated depending on what the cause is, that can have very, very serious consequences. It has kind of a soft sounding name but it's an important issue.
Dr. Mike Patrick: Absolutely and I think this is really important for parents. And it's kind of an amazing thing too when you think about it because the brain wants to see a clear picture. And if your two eyes are not focused at the same point, you're going to have double vision or blurry vision. And so in order to get that clear picture, your brain will just start ignoring one of the eyes.
And then once it starts to do that, the pathway, the nerve pathway that takes visual signals into the brain can become compromised. And then you can permanently lose vision in that eye and that's a condition that we call amblyopia. So big term, but it just means that you've lost vision in an eye because of the lazy eye that was not taken care of.
There are other causes of amblyopia as well. And it turns out that about 3% of the population is affected with the amblyopia. That's about 10 million people in the United States. So, this is definitely a significant issue. And if you do can have a concern about your child's eye going in or out, make sure that you do let your doctors know.
Dr. Alex Rakowsky: And very preventable. So, for majority of cases, it's very preventable if we catch and work on it on time.
Dr. Mary Ann Abrams: And it's important too because even if you do grow up and have perfect vision in the one good eye, you need two eyes to see, as Alex said earlier, three dimensions. So, it can affect certain jobs you want to do. It can affect your driving. It can affect all kinds of things when you can only see in two dimensions.
And if you don't appreciate what that actually means, try looking at the mirror and doing something with only one eye. And suddenly, you realize you're missing a lot of perspective or part of what you really need to do to brush your teeth or do put on makeup, or shave, or whatever. It's really good to have two eyes. We call that binocular vision, meaning bi meaning two, two eyes.
Dr. Mike Patrick: Yeah, absolutely. Let's move on to school-aged kids and teenagers. So, Mary Ann, what's your approach there in terms of a well checkups, the eye screening that you do for these older kids?
Dr. Mary Ann Abrams: Well, as Alex said, as the older the children become, the better able they are to fully participate in some of the regular vision screening tools that people are most familiar with, the Snellen chart, which is the letters. Sometimes people keep using the automatic but, hopefully, by the time they're school-aged, they know their letters. And if not, you can still use eye charts with different shapes or designs on them. And you want them to be able to have good vision by testing each eye individually, as well as both eyes.
And we try to check vision every year up until at least maybe 12 years old. And then ideally just keep screening every time I see kids through their teen years, but at least every couple of years to make sure nothing has changed.
The other thing is to be asking parents and then the kids, as they get older, if they have any eye concerns. Especially when they get to school, they may have trouble seeing in the classroom. If they're playing a sport, they may have some issues.
And it can be surprising. Sometimes, it can kind of sneak up on kids or maybe just sort of gradually gotten worse, or, "It's only if I go to a movie," or something like that. But asking them and listening, if they said they do, like, "Gosh, I have a little trouble seeing at school." Just looking at their school performance and how they engage in the classroom, which is also important.
And then, again, we'd like to keep checking in on those all the way through young adulthood.
Dr. Mike Patrick: Yeah, absolutely.
Dr. Alex Rakowsky: If I can just add, so majority of kids pre-computers would have something called near, they'd be nearsighted. Other words, they would see well close by, but then they would have problems seeing far.
So, majority of children who had glasses and were growing up back when the dinosaurs roamed the world. But we wore glasses because we couldn't see far. And the Snellen chart is really designed to look for nearsightedness. In other words, can you see far, so I'm not missing that?
But now with computers, a lot of kids were getting like old men eyes where they have problem seeing near. So, they actually may do relatively well on the Snellen or they may fail the long distance one but they have problem seeing up close.
So, just because your child can see 20/20, which means they can see the border 20 feet which what you should be seeing at 20 feet, doesn't mean that they may not have a problem seeing close by. And we're seeing more and more that in clinic because of so much computer, laptops, especially cellphone use. So, that's something to remember if your parents say, "There's a problem." If you do a test it's 20/20, haven't really ruled out that there may be a true issue.
Dr. Mike Patrick: And really, I think you make a good case too for kids seeing at least an optometrist here and there and having a more formal exam and making sure that their vision is okay even if you think everything is all right.
Let's move on and talk about some problems in eyes. One thing folks hear a lot about is pink eye. What is pinkeye, Alex?
Dr. Alex Rakowsky: Pinkeye is a description. So, it's essentially saying, "I have a bad diagnosis of fever." So, it's essentially you have pinkness in your eyes. The pinkness can be caused by many different things.
The three big categories are going to be allergies. So it sounds more scraggly than usual because allergies in Ohio seem to have peaked a little bit more recently.
So we have like the pinkish eyes and the runny nose and sort of tickly throat because you have irritation of the eyes. And depending on the time of the year, that actually may be the most common reason for pink eyes. Nothing else going on except for allergy symptoms.
The second major category is something called the viral cause or viral, and the fancy term for a pink eye is called conjunctivitis, or conjunctiva is the white of the eye. And now, we have irritation or pinkness of the conjunctiva, so it's viral conjunctivitis. And in those situations, you have a classic head cold. You see this more in the fall, winter, or early spring. The kid's sneezing, may have a low-grade fever, may have some coughing and the eyes are pink.
And then a third major category but the least common of the big three is a bacterial conjunctivitis where either have allergies or virus, and you scratch your eye from digging at them and a bacteria set up shop or you're rubbing them in. Or you get a bacterial infection from let's say an ear and an eye at the same time.
You now have a more painful eye. It tends to be a little more beefy red, may have puss, may have more of sort of fluid or discharge coming out that eye. Again, this time a year, probably allergy, number one, two, three, virus four or five, six and then bacterial. In the winter, virus kind of takes over but you always have to worry about the bacterial ones.
Dr. Mike Patrick: And this is again in a situation where you're really best seeing your child's doctor because it can be sort of nuance. I mean, that's a big term. Maybe I shouldn't use nuance. But there are subtle small differences between a viral conjunctivitis, which is classically what we call pink eye when it gets like a really bad pink.
Oftentimes that's a virus that's doing that or a bacterial conjunctivitis or the allergic one. And we're treating this all differently, but they can present with somewhat similar symptoms. There are subtle differences but good idea to see your child's doctor when you're not quite sure.
In terms of the allergies, so allergic conjunctivitis, Mary Ann, how do you go about treating that when you see patients with allergy, itchy, watery red eyes from allergies?
Dr. Mary Ann Abrams: Yeah, I think it you kind of hit on, we've touched on how you differentiate, how you tell the difference between these other causes with infections and what makes probably an allergic eye conjunctivitis. If you said itching, it kind of swollen pop the redness, both eyes, not just one eye. Our clues, if you got a strong history in the person of allergies or family history of allergy, those can kind of also clue you in.
So, then we get down to what to do about it. Because people can be pretty miserable and we often talk about the initial things to do to make them just more comfortable. If it's mild, you can just use some cool compresses to just reduce that irritation.
Sometimes, just extra lubrications, some artificial tears if they're older. And trying to avoid if you know it's due to allergy to a cat or a dog or an animal versus if it's going outside for a whole season or year round, sometimes those avoidance things just aren't going to work.
So, then we try, if we need to go further, we try to use medicine, eye drop medicines that really address the allergic part of the eye. So, these are eye drops you can use usually a couple times a day and they help cut down on the body's reaction to the things that are making the allergy symptoms occur. And most of those are prescription, they're safe.
There's a variety of ones that are a little bit more, maybe a little, you want to pay a little bit more attention in terms of how often they're used or whether use them at all. Or they may be used for kids or adults that have much worse than them. Some work better than others.
And then, the other question is do you want to take like allergy medication by mouth. Usually, just if you only have the eye symptoms, it's nice to be able to work with eye drops. If you got the nose symptoms, allergic rhinitis, rhino meaning nose, then you might benefit from another medication.
Dr. Alex Rakowsky: Yeah, if I can just add. Our goal as pediatricians is to have you child have as normal life as possible and enjoy most everything that every other child can do. So, if you're in the know that your child, every time you go hiking, for example, go to the park is going to get miserable because he'll get pink eyes and also film in their eyes from allergies, it's okay to do two things.
Either give the allergy eye drops before you go, or when you get home, actually wash it out just really with saline drops, almost like contact lens's drops just to kind of, not for the contact lens but for the drops that you can use in your eyes, so like dry eyes, just to clean some of that pollen out of the eyes.
So, these are controllable things. Speaking with somebody who gets allergic conjunctivitis or pinkeye a lot, they can be miserable. You're driving and all of a sudden, there's like a film in front of your eyes. You're at to the point where it's really hard to go outside some parts of the year around here. But as long as you're really active about trying to prevent things, most kids can do fine with this and even old guys like me.
Dr. Mike Patrick: And then you mentioned, you made a point of differentiating viral conjunctivitis from bacterial conjunctivitis. Why is it important to differentiate between those two things, Alex?
Dr. Alex Rakowsky: Yeah, for viruses, you don't really have to treat it. In other words just part of the viral illness. There are a lot of school systems and daycare that will ask you to put eye drops in there, like antibiotic eye drops in there, just because. And it's really not worth the fight most times.
Also, for little kids that tend to sort of lick their hands, don't wash their hands, et cetera, and they're going to go sticking their fingers in the eyes, I'll give them antibiotic eye drops just to kind of keep that eye clean. But for most viral conjunctivitis, those are viral pink eye, you really don't need to do anything besides taking care of the symptoms. You can just use regular saline eye drops for that just to kind of keep the eye clean.
For bacterial infection, you really do need to treat with an antibiotic. And then for a virus, if you're going to do like an eye drop just to soothe the eyes, you do it once or twice a day, compared to bacterial where you're going to be given eye drops four, five, six times a day depending on how bad the infection is and depending on the antibiotics drop.
Dr. Mary Ann Abrams: The other thing is everything else is fine, they don't have anything else going on in the eyes, there's no pain or light doesn't hurt their eyes, and you're not compelled by a school or daycare requirement that they can't come back without the eye drops, it's okay to watch a couple of days and use some compresses to try to get rid some of that matting.
Because all that crust builds up and, invariably, it looks a lot worse than it might really be just because it's still crusted. Sometimes, it looks a lot worse in the morning because they've been sleeping all night and it builds up. Give it a couple of days with those warm washcloth and gently clean it up. Sometimes it will go away on its own and then you've saved the trip.
But as Alex said, a lot of times it's tough because these things are contagious and when there are kids in the group, and kids touch each other, hopefully not now, but they don't want to spread within the whole room or the center might have to close down for a while. But if your child is at home and doing fine, you might give it a day or two.
Dr. Mike Patrick: And I think it's important for parents to understand the difference because if you do get prescribed an antibiotic eye drop for a viral conjunctivitis or pink eye because you're again trying to prevent a bacterial one on top of the virus, because your child have their fingers in their mouth and rubbing their eyes, because you got this itchy watery eye from the viral infection.
It's important to understand that even though you're using an antibiotic, that if it's a viral conjunctivitis, that is still going to be contagious, even though you're using the antibiotic, pretty much until the eye symptoms are gone. And so frequent hand washing and trying to encourage your kids not to touch their eyes or their face is going to be really critical in terms of preventing the spread of this.
Dr. Mary Ann Abrams: And trying to separate towel from washcloths at home for taking care of your youngsters' face.
Dr. Mike Patrick: Yeah, absolutely.
Dr. Mary Ann Abrams: And use another for next person in line.
Dr. Mike Patrick: As we think about kids rubbing their eyes, the next topic is really getting things in the eye including fingers and dirt and other foreign bodies. What's your approach, Alex, when a kid has a foreign body in the eye? Or an eyelash, and eyelashes are really complicated.
Dr. Alex Rakowsky: So, even before we get into like medical equipment...
Dr. Mary Ann Abrams: Foreign body, foreign body.
Dr. Mike Patrick: Oh, foreign body, yes. So, foreign meaning...
Dr. Alex Rakowsky: Doesn't belong there in the eye.
Dr. Mike Patrick: Doesn't belong, yeah, and body is a thing. So, foreign body, something in the eye that's not supposed to be there.
Dr. Alex Rakowsky: Even before we get into the medical stuff, two things just to kind of quickly think about. One, calm the child down, because having something in your eye will freak almost anybody, let alone a small child. So, just calm them down because the more they have anxiety about it, they'd go digging in the eye. They can make it worse. So, that's key number one.
My key number two, get a good history. I mean, what happened? Were you playing outside and got some dirt in there? Do you have an eyelash in there? But then you can figure out exactly what you're worried about.
Once you know what happened, then the key is to figure out, okay, is it because I got something in there? Or is it because I scratched the eye? So, there actually is something in there. If it's like an eyelash, then you can use saline drops and just gently try to get it out with a finger or a Q-tip. I like to take the cotton, just make a little one dot of it and try to get it out.
If it's something where you're outside, you got potentially dirt in there or sand in there. Or just some time, we usually have a dry period here in Ohio. When baseball season starts and kids line in to second base, kick up a sandstorm, and then second base, they get something in their eye. You have to wash it out before he starts to scratch the eye.
So, again, saline and try to open the eye most as best as you can and getting the stuff out of there. But if it's something more serious like potential glass, fiber glass, piece of metal, piece of wood, you really should get seen by emergency room, preferably urgent care, to help clear that stuff out of there.
Dr. Mary Ann Abrams: And that's why it's so important, Alex said, you want to know what the history is. So we throw that word around a lot. And a lot of people think, "History, well, that's what happened in 1776."
But history means the story of what happened. And some of the things like what we're talking about now, knowing exactly what was happening right before this pain, because usually, suddenly, they're like, "Ah!" Knowing exactly what was happening before that will clue us in or clue you in on to how serious this could be.
Don't just say, "He was playing in the field and got something in his eye." You want to know what kind of a field? Was it an area with a bunch of junkie stuff like old rusty stuff sitting around? Because that would make more glass, broken glass, or pebbles or whatever.
All those things are clues, just whether maybe a bug has fallen in the eye or a little bit of dust or could be a little sharp piece of glass or metal had gotten in their eye, and that has horrible consequences if it's not treated shortly and appropriately.
Dr. Mike Patrick: Fortunately, the eye is very sensitive and so any persistent pain or your child is squinting, the light seems to bother them, any of those things are going on and persist, they keep going on and you think, "Oh, this should had gone away by now, it's been a few minutes," just get help. Have someone, a medical professional at the urgent care or an emergency department or your child's doctor to look in the eye and see exactly what's going on. It's going to be very important.
But a lot of the little foreign bodies here that you blink a few times, your tears, your body will secrete more tears under the eye and as the tears wash across the eye just help to wash it out naturally, if it's something really small. But if it's something that's larger that you can actually see, blinking over and over again might actually scratch the eye. So, if it's something that's not resolving quickly, make sure that you see someone about that.
What about chemicals, like a chemical splash, Alex? When do we worry about those?
Dr. Alex Rakowsky: That's again step one, step two, get a good history or get a good story of what happened. Try to calm the child down as best as you can, so they don't go digging at it. And that's where you call your Poison Control Center because you do treat different chemicals in different ways.
So, saline is probably going to work for the majority of these things but there may be one or two where like, "You got to go to ER now." But I will call the Poison Control Center first and get recommendations from them just to kind of move forward, because that can be devastating.
Dr. Mike Patrick: Absolutely. Yeah, very very important and especially household cleaners. And again, persistent pain and discomfort after something's gotten in the eye is a telltale sign that you need to get this taken care of.
Dr. Alex Rakowsky: And there are some that you don't want to dilute in the eye. So, there may be something there like do not put saline in there. But again, you have to figure out what got in the eye because otherwise, you're really shooting in the dark.
Dr. Mike Patrick: Yes, absolutely.
Dr. Mary Ann Abrams: And act very quickly. That's not something you want to wait too long for. If there's any question that could have been something more than they got shampoo in their eye or something like that, call that Poison Control Center ASAP. They're really responsive but if you're not sure, you want to get that taken care of as fast as you can.
Dr. Mike Patrick: 1-800-222-1222. There's a little jingle that goes along with that whenever I think of the Poison Control number, that jingles goes in my mind, 1-800-222-1222. So, just remember that, that will get you your local Poison Control Center no matter where you live in the United States. You call 1-800-222-1222 and then it will get you your local poison center.
Dr. Mary Ann Abrams: Sing it...
Dr. Mike Patrick: What's that?
Dr. Mary Ann Abrams: Sing it one more time, Mike.
Dr. Alex Rakowsky: No, maybe not.
Dr. Mike Patrick: 1-800-222-1222.
Dr. Mary Ann Abrams: Some people I know, I've not heard of it.
Dr. Mike Patrick: You're not going to be able to get that out of your head the rest of the day.
Dr. Alex Rakowsky: And speaking of that, parents, it is good to have that number on your speed dial or at least a favorite in your cellphone. In fact, a lot of sort of cities now do have it as a favorite. As you have your contact list, and you have your grandma, grandpa or whatever, then also have Poison Control. And wherever it is where they come from, it's just an automatic, so.
Dr. Mike Patrick: So, what about scratches in the eyes. This can happen if there is something in the eye that gets in there and you're blinking, it can scratch the surface of the eye. Or just from rubbing the eye, you can also have kids who have pink eye or conjunctivitis and they rub so vigorously or a fingernail gets in there that they actually scratch the surface of the eye. How do we diagnose that and treat it, Mary Ann?
Dr. Mary Ann Abrams: As Alex said, figure out what happened and see if you can figure out where that scratch came from. But even if you've gotten something out of the eye, if that's still painful after an hour or so, I think it should be looked at by a healthcare provider that can actually look at the surface of the eye. Because as you said, Mike, the eye is very sensitive and the cornea which is the clear part, you actually can't really see over at the front of the eye has so many sensitive nerve fibers. If they are still hurting, that's a sign that there's been damage there.
So that can be checked. Most pediatricians and medicine doctors have what you need which is from basic equipment to take a look in the eye with a little bit of a dye and special light and to see if there is a sign of a scratch.
So, the good news is as long as you know that this was not some kind of an injury where something could be embedded in the eye, that most of these especially the smaller ones clear up very quickly on their own. They can heal overnight or within a day or two but they hurt a lot.
We used to do morphine medicine drops and patch the eye. We're not really sure that does anything except annoy a young child and cause people to rub their eye more. So, we try to pair it with good use of over-the-counter pain medicine and maybe put a little lubricating drop in there just to help it soothe.
If it's a young child, maybe even a little bit of antibiotic ointment to kind of smooth that area over and try not to have anything that would take the mother or father or more while it's healing. And then, if it's not better or almost a 100% better by the next day or 24 hours later, probably want to check that again because persistent pain in the eye is a bad thing, but it's a good sign that something could be more serious.
Dr. Mike Patrick: Yeah, absolutely. So, this is one of those things until it gets better, your child is probably going to be checked every day to make sure that this is going away. Most of them are going to go away in a day or two. And if it's the last thing longer than that, then that's going to be another reason to send your child to our friendly pediatric ophthalmologist, the eye specialist, to make sure it's not turning to something deeper and ulcer that there's not an infection or more internal eye damage that's associated with this injury.
Speaking of, yeah, yeah?
Dr. Mary Ann Abrams: It actually make it worse. So, this is a great situation where if someone in the house has leftover prescription eye drops, do not use them for something like this because it can really aggravate, make it a lot worse instead of a lot better.
Dr. Mike Patrick: That's a really good point. And you may have a grandparent who had cataract surgery and they have a steroid eye drop. You do not want to put that in the eye without ophthalmologist telling you that that's what you need to do for a particular reason. Very important.
Speaking of significant really bad eye injuries like a puncture in the eye or something in the eye, Alex, that's something that you want to go in to an emergency room for right away, right? So, they can get you connected with the ophthalmologist.
Dr. Alex Rakowsky: Yes. And we both do urgent care and that's something we would just send automatically instead of ER. So, most ERs have either an eye doc close by or somebody on call. And if you live in an area that's more rural, you can call 911, not to actually take the child to the emergency room but to see which one may actually may have an eye doctor available the quickest. Because that really is something where the ophthalmologist needs to kind of do surgery or do some kind of patching very quickly. Yeah, that's not an urgent care, that's an ER.
Dr. Mike Patrick: Yeah, to the emergency room, absolutely. Because they're going to be able to get the ophthalmologist in there as quickly as possible.
So, our final topic, Mary Ann, sties. These are pretty common in kids. What is a sty? There's some bigger words that we can use in association with that, chalazion, hordeolum, but what's a sties? The quick and easy term.
Dr. Mary Ann Abrams: So that's a great plain language, not plain language question, but there's two things that can cause this sore areas or bumps around the eye. And a stye is also technically called a hordeolum.
And it's usually more of a relatively sudden onset but not like that, but maybe over a day or two and it represents an infection. And we have little glands along the eyelashes on the top and the bottom of the eye to help keep the eye moist and to keep that area clean and to keep bacteria from just starting to grow there. But if may be one of those little glands gets blocked or something kind of gets in there, it can cause a little bit of an infection to start growing, some bacteria to grow or infection in that little gland.
And it gets red. It swells a little bit and it's a little tender. So, you'll see a little red and tender bump along the eyelid itself. Sometimes, it will cause some tearing and inflammation on the rest of the lining of the eye there as well.
Again, the good news is it usually goes away on its own. Sometimes, you can get a secondary infection that's really bad. But most of the time, a warm compress several times a day for several days, three to seven days and that will go away. It doesn't need medication, prescription antibiotics or whatever. Sometimes, if they keep coming back, and maybe get an ophthalmologist take a look at it.
If you see a little firm bump that isn't tender, sometimes you can have like a recurring blockage there, a little sterile inflammation and that's another fancy name called the chalazion. And that's more of the body just reacting to the normal fluid that might be building up in there but not infected.
And that too you can use warm compresses several times a day and sometimes those come back or don't go away and then again, we would have you see an eye doctor, an ophthalmologist.
Dr. Mike Patrick: Terrific. And so any bumps around the eye or the eyelids and you have a concern about them, just have your child's doctor take a look and then they can ask you more questions and figure out what you need to do with that. But those are pretty common.
Dr. Alex Rakowsky: Even take a picture and then send to us. So, now then, since we're all in our favorite pandemic time, so maybe one of those where you just take picture, send it by MyChart to see if it's what Mary Ann called a chalazion, which is like more of eyelid zit. We don't want to rush you in just to get seen for something that you can put warm compresses on. So, you can always start with that.
Dr. Mary Ann Abrams: Or maybe a telehealth visit too, where we could ask questions.
Dr. Mike Patrick: Yeah, that's right. That's a good point.
Dr. Mary Ann Abrams: So, that's some of the nice thing about it, being able to do some of these visits over the phone. It saves people time but they could still have their kiddos seen.
Dr. Mike Patrick: Yeah, absolutely. Speaking of that, Alex, tell us a little more about the Primary Care Pediatrics network at Nationwide Children's. And how is telehealth visits going, are you seeing folks in person now?
Dr. Alex Rakowsky: So, we're a large system. We have 13 physical clinics. We have a series of school-based clinics and a few mobile clinics. So, we see upwards of 250,000 patient visits a year, and so it's a really large system.
We're probably 80% in-person, 20% telehealth and I may have the numbers a little off but we are basically open at least for the majority of kids to kind of get seen in person regardless of age.
And we are fortunate that the COVID rates in Franklyn County Central Ohio had been fairly low over the last week or so. So, it's kind of getting us more encouragement to get kids in person.
So, using telehealth, like Mary Ann mentioned, especially for things that you can do over the phone more by some kind of meeting, by Zoom or something like that. But we're almost back, the big thing is going to be school clinics because we do have like a lot of large children's hospitals, big presence in school, and not only for pediatrics but also for behavioral health. And it's going to be hard to kind of get that rolling.
Dr. Mike Patrick: Yeah, absolutely. And asthma clinics that we have in the schools as well, and lots and lots of that.
Dr. Alex Rakowsky: Yeah. We've been doing a lot of those by phone.
Dr. Mike Patrick: I will put...
Dr. Mary Ann Abrams: The flu shot session will be coming up very soon.
Dr. Mike Patrick: Yes, and it's going to be important for kids to get their flu shots this year, really, very important. It's important every year but I think with COVID, you don't want flu going around your house while we're all worrying about COVID. That's for sure.
And I will put a link to Primary Care Pediatrics at Nationwide Children's Hospital in the show notes for this episode over at pediacast.org. And again, I'll also put a link to the book What To Do When Your Child Get Sick, our Pediatrics in Plain Language Survey, and the Pediatrics in Plain Language playlist over at SoundCloud. I'll put a link to all those things in the show notes.
And then, if you're really interested, especially if you're a pediatric provider and lots more detailed information on eye issues and injuries, PediaCast CME Episode 49. I'll put a link to that episode in the show notes as well.
So, once again, Dr. Mary Ann Abrams, and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital. Thanks so much for stopping by today.
Dr. Alex Rakowsky: Thank you.
Dr. Mary Ann Abrams: Great to see you. Thank you, Mike.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that.
Also thanks to our guest this week. Our Pediatrics in Plain Language panel, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's.
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