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Dr. Moses Gross (photo by Mimi Choi)

At what age should parents consider taking their child to first see an optometrist?

I’ve traditionally seen kids at age 3, but they can be seen anytime depending on the eyes of the parents: if mom or dad have a "turned" eye (strabismus), their child should be seen at 6 months initially, to rule out lazy eye (amblyopia). While all optometrists are fully qualified to examine children of any age, there are clearly some who prefer to limit their practices to pediatrics. It is a good idea to ask your family optometrist ahead of time, if they feel comfortable in examining your child. If not, then could they refer you to someone who will.

What should parents look for if they suspect their child may have vision problems?

Watch for one eye turning in or out. The term "crossed-eyes" is generally a misnomer: it is a rare case when both eyes turn in simultaneously – especially when fatigued. Watch for constant rubbing of one or both of the eyes.

Look for blepharospasm, an involuntary spasm of the upper and lower eyelids. This can vary from a mild twitch to a violent spasm, resulting in a typically vigorous scrunching or squeezing together of the eyelids to create an exaggerated blink. Sometimes children will do exaggerated blinks as means to attract attention to themselves, then it becomes habitual. Sometimes the optometrist has to apply skilful psychological calesthenics to determine if the blepharospasm if real or contrived.

Watch for clumsy behaviour, such as bumping into door corners. This may indicate that the child has a peripheral vision problem. Note if he has a habit of reaching for toys and missing. It could mean that both eyes not working in sync, causing depth perception to be adversely affected. Obvious things to look for are red eye(s) with or without yellowy-greeny discharge, causing the child's eyes to be "glued shut" when they wake up in the mornings. Squinting, of course, should necessitate a definite trip to your friendly neighbourhood optometrist.

How are a child’s eyes tested before he or she is able to read?

We check visual acuities, using charts with children’s figures, tumbling Es or rotating Cs (where the letter E or C is shown in different rotations, and the child has to mimic what they see). With infants, we use kinetic drums: cylindrical drums on a rotating base, that have vertical black on white lines of varying thickness on the outside. The drum is spun, then held in front of a child so they will have no choice but to look at it. As the vertical lines start to slow down in movement, the child's eyes should go into a jerk-type nystagmus: this is where the child visually locks on a black bar, follows it horizontally across its visual field, then when the bar disappears around the corner, the eyes snap back to their original starting point and lock on another bar, thereby repeating the sequence. If the infant has good acuity, then the classic nystagmus is seen. If the child has a lazy eye, then they will not be able to accomplish the necessary pursuits and the eyes will remain stationary.

We check refractive status (i.e., nearsightedness, astigmatism etc.) with specialized instruments like autorefractors and retinoscopes. Depth perception is checked with stereographic slides that the child observes through polarized lenses to create the illusion of depth. Sometimes the parents get more of a kick out of this test than the children.

The whole idea of doing a meaningful eye examination on a child revolves around doing special objective tests, where the child just has to react, as opposed to subjective ones, where the child has to make decisions in order to give us useful information.

Are annual eye checks appropriate for young children?

I have traditionally believed in annual tests for children – they can change so quickly that it's important to be there and perform any preventative maintenance that may be necessary, like patching, eye exercises, temporary glasses, etc.

At what age are contact lenses appropriate?

The short answer is: at any age. I have fitted soft contacts as early as on an 11-month-old albino child. Because she was born without an iris (the coloured part of the eye), she was extremely light sensitive, and unable to develop visually in a normal fashion. She needed to have contacts with a special opaque tinted iris, in order to block light, the way a normal iris does. The parents were taught to insert and remove and care for the lenses, and I'm proud to say that that child went on to develop so normally that she earned an honours MBA and become a well-respected member of the Toronto Stock Exchange.

Assuming that eye health, motivation and most of all, a sense of responsibility are in evidence, I would advise full-time fitting of disposable lenses to boys usually aged 13-14, and to girls aged 11-12 (girls mature faster than boys).

For special needs, such as gymnastics and hockey, boys or girls, even at age 7 or 8, could be given daily disposable lenses on a part-time basis.

What effect, if any, have you noticed related to the Ontario government’s decision to de-list annual optometry check-ups from OHIP coverage?

OHIP has been gradually de-listing optometric services for the last 10-15 years. The most notable being contact lens assessments, which were cut about 10 years ago. Coincidentally, during that same time frame, OHIP has not given Optometry any increase in our fee schedule, until just this past month.

Government de-listing of routine, preventative, diagnostic eye exams have resulted in a slight reduction in our patient volume. Less volume of exams generally means more quality time spent one-on-one with each patient. The increase in fees allows purchase of more cutting edge technology, enabling earlier detection of potentially sight-robbing conditions.

It is inevitable that OHIP de-listing of routine, preventative, diagnostic eye exams will lead to some unfortunate people to skip their recommended periodic eye exams, ostensibly due to financial handicap. Let it be known here and now, that our Hippocratic oath stipulates that we cannot refuse treatment to anyone who cannot afford to pay for our services. People also don’t know about the special cases of eye disease which IS covered by OHIP, i.e., diabetics.

I would much rather absorb the cost of treating a needy individual to a routine eye physical, than have that person, at a later date, show up in our office with some serious condition that WOULD be covered.

Thanks, Dr. Gross!

Dr. Moses Gross has been a practising optometrist in Toronto for over 30 years.