What is a pediatric ophthalmologist?

What does a pediatric ophthalmologist do?

A pediatric ophthalmologist is a medical doctor who specializes in children’s eye health. They treat pediatric eye conditions, manage chronic disorders, prescribe medicine and perform eye surgery for children when needed.

A pediatric ophthalmologist has more extensive training, experience and education in children’s vision conditions, working with children and examining children’s eyes than a non-specialized eye doctor. 

A child may be referred to a pediatric ophthalmologist when a pediatrician, optometrist or comprehensive ophthalmologist feels there may be an eye alignment issue or other eye problem that requires specialized medical or surgical attention.

A pediatric ophthalmologist typically offers a full range of services related to children’s eye health for babies, children, adolescents and teens. A pediatric ophthalmologist may offer:

• Comprehensive pediatric eye exams 
• Diagnosis and treatment of a variety of pediatric eye conditions
• Prescriptions for glasses or contact lenses for kids
• Eye surgery for children

Pediatric ophthalmologists may also provide ongoing monitoring and care for children who have a family history of certain eye conditions or a health condition that may make them more likely to develop an eye condition. These may include Down syndrome, juvenile diabetes, juvenile idiopathic arthritis (JIA), prematurity and neurofibromatosis.

Eye conditions treated by pediatric ophthalmologists

A pediatric ophthalmologist manages and treats a wide range of common and uncommon childhood eye conditions. These may include refractive errors, structural and alignment issues, genetic eye conditions, childhood ocular cancer, eye infections and injuries. 

Strabismus, amblyopia and more common eye disorders

Refractive errors in children

Just as with adults, refractive errors are common in children. There are different types of refractive errors caused by the shape of the eye, cornea or the lens. If your child has a refractive error, the light that enters the eye doesn’t focus on the retina properly. This may cause blurry or distorted vision.

These refractive errors may be seen in kids:

• Nearsightedness (myopia) – Caused by the eye being too long, myopia typically makes far-away objects look blurry.
• Farsightedness (hyperopia) – Caused by the eye being too short, hyperopia typically makes nearby objects look blurry (but can also affect far vision). 
• Astigmatism – Caused by an irregularity in the shape of the cornea or lens, astigmatism can cause trouble seeing clearly at all distances.

Treatment options for refractive errors in children typically include prescription glasses or contact lenses. If your child has progressive myopia, their pediatric ophthalmologist may discuss strategies to slow its progression. Depending on the child, these may include specially designed myopia-control eyeglasses or contact lenses, low-dose atropine eye drops*, and lifestyle measures such as spending more time outdoors.

*Note: While many studies have looked at and eye doctors have used atropine eye drops over the years, the U.S. Food & Drug Administration (FDA) has not approved it for the indication of myopia control. It is considered off-label use.

Structural and eye alignment issues in children

Eye conditions involving the structure and alignment of the eyes are also common in children. These may cause trouble with focusing or block a child’s vision.

Amblyopia, commonly known as lazy eye, affects how the brain and the eyes work together. A child with lazy eye typically has one “stronger eye” that the brain depends on, so vision in the weaker eye does not develop normally. Common causes include eye misalignment (strabismus), a large difference in prescription between each eye (anisometropia), or something blocking vision such as a cataract or drooping eyelid (ptosis). 

Treatment for amblyopia may involve treating any underlying refractive error. An eye patch or low-dose atropine eye drops may be used to temporarily block (or blur) vision in the stronger eye, which may improve vision in the weaker eye. Early treatment of amblyopia can be important to a child’s visual development.

Strabismus is a common childhood eye condition, also known as crossed eyes, wandering eyes or eye misalignment, in which the eyes face in different directions. In children with strabismus, there may be an issue with how the eye muscles and the brain work together, or with one or more of the muscles that keep the eyes aligned. 

A child with strabismus may need treatment for any other underlying eye conditions, such as refractive error or amblyopia. Treatment for strabismus may include special lenses (such as prism lenses), eye exercises for certain eye-teaming problems, medication (eye drops, ointments, injections) or strabismus surgery. 

Ptosis occurs when one or both of the upper eyelids droop down due to muscle weakness. Ptosis may be present at birth (congenital ptosis) or develop during childhood (acquired ptosis). This condition can cause other eye issues, including astigmatism or amblyopia. In severe cases of ptosis, the drooping eyelid can block part of a child’s vision. If treatment for ptosis is needed, eyelid surgery may be recommended.

Eye infections and injuries in children

Eye infections are common in kids. They can spread at day care or school and may be caused by bacteria, viruses or fungi. Infections seen frequently in children may include:

• Pink eye (conjunctivitis) – An inflammation of the conjunctiva, a membrane that covers the white part of the eye and inner eyelids. It can be caused by bacteria or viruses (or allergies, in which case it’s not an infection). Bacterial pink eye may be treated with antibiotic eye drops or eye ointment.
• Stye (hordeolum) or chalazion – Kids can also develop a stye, a pimple-like bump along the eyelid typically caused by a bacterial infection in an eyelid gland. Or, they can get a chalazion, a bump under the eyelid typically caused by a blocked meibomian gland. 

Both conditions may benefit from warm compresses at home as a first step to resolving the problem. Treatment for a stye may include drainage or medications such as antibiotic eye drops or ointment. Oral antibiotics might be prescribed if there is an infection around the eye.

In addition to eye infections, eye injuries and trauma are also a common reason for a visit to a pediatric ophthalmologist. Eye injuries in kids may include a scratched eye (corneal abrasion), a foreign object in the eye or blunt eye trauma, such as getting hit with a ball.

Some eye injuries are emergencies. If a chemical splashes into a child’s eye, it is recommended to flush the eye immediately with plenty of clean water and seek emergency care at an eye doctor’s office or urgent care facility. If the eye has been cut or punctured, don’t rinse it, press on it or remove anything stuck in it. Gently cover it with a shield, such as the bottom part of a paper cup, and go to the emergency room. After any blow to the eye, it is important to get care right away if the child reports having pain, trouble seeing or a black eye.

Congenital cataracts and other less common eye conditions

A pediatric ophthalmologist can also treat less common eye conditions. These may include the following:

Congenital, genetic or hereditary eye conditions

Some of the rare or uncommon conditions pediatric ophthalmologists treat may be present at birth, linked to genetics and/or inherited from a parent. These may include:

• Congenital cataracts – A child’s natural lens, located inside the eye and directly behind the pupil, is clouded at birth. This is a rare condition, and the cause is often unknown. However, congenital cataracts may occur along with another condition, such as Down syndrome. If needed, treatment may include cataract removal surgery and possibly a patch on one eye to prevent amblyopia. During pediatric cataract surgery, the cloudy natural lens is removed. Depending on the child’s age, eye development and individual circumstances, an artificial intraocular lens (IOL) may be implanted during the initial surgery or at a later time. Contact lenses or glasses may also be needed to provide optical correction.
  
  Children who have cataract surgery in infancy require lifelong eye pressure checks. In one landmark study, about 1 in 5 operated eyes developed glaucoma within 10 years.
  
   
• Congenital glaucoma – An abnormal buildup of fluid pressure inside the eye. Children can be born with congenital glaucoma or develop it shortly after birth. Congenital glaucoma is caused by problems during eye development that prevent fluid in the eyes from draining properly. In some cases, there may be a gene mutation that causes congenital glaucoma. Treatment for congenital glaucoma may include eye surgery to fix fluid drainage problems. Medications, such as beta blockers or diuretics, may also be prescribed. Pressure-lowering eye drops or other medications may sometimes be used temporarily or as additional treatment before or after surgery.
• Ocular albinism – A type of albinism that affects the eyes and can lead to various eye conditions. Like albinism, ocular albinism is caused by a gene mutation that may be inherited from a parent or occur on its own. Ocular albinism is linked to eye problems that may include blurry vision, involuntary eye movements (nystagmus), color blindness, light sensitivity (photophobia), low vision, refractive errors or strabismus. Treatment varies based on the condition. For example, refractive errors may be treated with prescription glasses or contact lenses.

Childhood eye cancer

Retinoblastoma is a type of eye cancer that starts in the retina, with the majority of cases in children under the age of 2. The most common early sign is a white or unusual reflection in the pupil, often first noticed in a flash photo, followed by a crossed or wandering eye. A child with either sign is recommended to be seen by an eye doctor promptly. 

Retinoblastoma is caused by gene changes that may be inherited or happen on their own. Treatment for retinoblastoma may include chemotherapy, cold therapy, laser therapy or radiation therapy. In some cases, if these treatments aren’t an option or don’t work, eye removal may be recommended.

Although rare, there are other types of eye cancer that can also affect children. These may include childhood intraocular melanoma, a type of cancer that starts in cells that make pigment in the eyes. The causes are not fully understood, but a fair complexion can increase risk. Treatment for childhood intraocular melanoma may include eye surgery or laser eye surgery, radiation therapy or targeted therapy.

Other uncommon eye conditions

Children may also need to see a pediatric ophthalmologist for other uncommon eye conditions. These may include:

• Retinopathy of prematurity (ROP) – A disease in which abnormal blood vessels grow in the retina. Retinopathy of prematurity may happen because normal blood vessel development can get disrupted in babies who are born very prematurely or weigh less than 3 pounds at birth. Treatment isn’t always necessary but may include surgery, laser treatments or eye injections that stop blood vessels from growing. One of these injected medications is FDA-approved for ROP while others are used off-label. Retinal surgery may be required for advanced ROP complicated by partial or complete retinal detachment. Procedures may include scleral buckle surgery or vitrectomy.
• Pediatric uveitis – Inflammation in the middle layer of the eye (uvea). Uveitis can be triggered by the body’s response to an infection, such as COVID-19 or toxoplasmosis. Or, it may be linked to conditions, such as systemic lupus erythematosus (SLE) or juvenile idiopathic arthritis. Cases of uveitis may become chronic. Treatment for uveitis may include steroids, other medications that calm the immune system or eye surgery. 
• Fourth nerve (superior oblique) palsy – A problem with a nerve that controls an eye muscle can cause problems moving one or both eyes, leading to double vision, strabismus or other eye problems. Fourth nerve palsy may be present from birth or caused by damage to the fourth nerve from a head injury, tumor, Lyme or other tick-borne diseases, or other condition. The condition may heal on its own. Depending on the cause and severity, management may include observation, prism glasses, temporary occlusion to relieve double vision, treatment of associated amblyopia or eye-muscle surgery.
• Retinitis pigmentosa (RP) – A rare genetic condition that causes the retina to slowly deteriorate over time. One FDA-approved gene therapy for retinitis pigmentosa is available, but only for people whose disease is caused by changes in both copies of a specific gene (RPE65), which is confirmed by genetic testing. It can improve how well people get around in dim light, but it is not a cure. Gene therapies for other forms of retinitis pigmentosa are still being studied. Pediatric ophthalmologists may treat any refractive errors or other conditions. In some cases, gene therapy may be recommended.
• Nystagmus – A condition that causes constant or erratic eye movement. Infantile nystagmus (congenital nystagmus) often becomes apparent in the first months of life and may be inherited. Acquired nystagmus may occur later in childhood (or in adulthood) and can be caused by certain medications, such as anti-seizure medicine, or health conditions, such as problems with the inner ear. There are not many treatment options for nystagmus, but surgery may be recommended. In addition to a pediatric ophthalmologist, children with nystagmus may see a low vision specialist and/or occupational therapist.

Some doctors manage conditions that others may not. Contact your pediatric ophthalmologist’s office to make sure they can treat a certain disorder.

SEE RELATED: What is a pediatric optometrist?

How pediatric ophthalmologists diagnose and treat eye problems

Pediatric ophthalmologists have an array of diagnostic tools, medical tests and ophthalmological equipment they may use to diagnose and manage the conditions listed above, in addition to others.

Diagnostic tools and eye tests

After the eye doctor gets a general idea of your child’s condition, they may do a comprehensive eye exam. This is more involved than routine childhood vision screening and may include one or more of the following tests:

Vision screening and evaluation

The eye doctor will use several tests to gauge how well your child can see. Vision screening and evaluation may involve:

• Visual acuity test – This test may check how well your child can see using a card, wall chart or a computer screen. It may involve identifying letters, numbers, shapes or symbols. The test may be adjusted to the child’s age and abilities. Your child’s eye doctor may also use stereo testing, which may involve wearing polarized glasses while looking at an image, like an animal or shape, to check depth perception.
• Instrument-based screening – Tests using instruments can help to check vision and eye structure and screen for conditions, like amblyopia. Your child’s eye doctor may use an autorefractor, which tests how the eyes focus on an object. This typically involves looking into a machine and focusing on a picture, like a hot air balloon. As part of a comprehensive eye exam, they will also use other instruments, such as a slit lamp, a microscope with a bright light that helps them look at the front of the eye, and an ophthalmoscope to see the back of the eye.

Vision screening and evaluation is a key part of a comprehensive eye exam for kids. It can help the eye doctor determine if they have a refractive error or other condition affecting their vision.

Pupil dilation

Some exams require the child’s pupils to be opened wider so the doctor can see more of the inner eye. Pupils are dilated using eye drops, which may sting mildly for a few seconds. Your child’s vision will usually be blurry for several hours afterward. Their eyes will typically be sensitive to light for a little while.

Dilating drops may also temporarily relax the eye’s focusing muscles, allowing the pediatric ophthalmologist to obtain a more accurate measurement of refractive error. This is known as cycloplegic refraction and is particularly important in children.

The eye doctor may do tests that don’t require dilation, then put the dilation drops in your child’s eyes. They will then typically have to wait for the drops to take effect. Once that happens, the eye doctor can do the tests that require dilation.

Eye alignment exams

A doctor can perform testing to diagnose and determine treatment for conditions, such as strabismus and amblyopia. There are several tests that can help your child’s eye doctor check eye alignment. These may include the cover test, in which the eye doctor covers one eye with a plastic device while watching the movement of the other eye, then switches sides. The eye doctor also may use other tests, such as a corneal reflex assessment using a pen light while your child focuses on an object.

Exams under anesthesia

Some eye tests may be difficult or impossible to perform while a child is awake and alert. When an adequate examination cannot be performed while a young child is awake, an examination under anesthesia may be recommended. Depending on the condition, the ophthalmologist may measure eye pressure, examine the cornea and anterior segment, perform a dilated retinal examination, obtain measurements or imaging, and perform other specialized testing.

Tests that may need to be done under anesthesia if they can’t be done while the child is awake may include a fundoscopic examination to look at the back of the eye, including the retina, macula and vessels.

Treatment options

Pediatric ophthalmologists may also provide any treatment needed to improve or relieve the state of your child’s eye condition. Depending on the diagnosis, surgical and nonsurgical treatment options may include:

Eyeglasses, contact lenses or eye patches

Your child’s eye doctor may prescribe eyeglasses to correct a refractive error, like nearsightedness, farsightedness or astigmatism. If the refractive error is small, your child may not need vision correction. It may take a period of adjustment for kids to get used to wearing glasses. A pediatric ophthalmologist can help by ensuring they have the correct prescription and comfortable frames that fit well. As a parent, providing positive reinforcement may also help.

Growing children typically need updated prescriptions more frequently than adults. Your child’s eye doctor will set a schedule for repeat eye exams. If their prescription changes, they may need new corrective lenses.

If your child wants to try contact lenses, it’s important to understand the risks and make sure they can handle contact lens hygiene. Consider asking the pediatric ophthalmologist about daily disposable lenses, which may reduce the risk of eye infections. There are contact lenses that may slow the progression of myopia that children may begin wearing between 8 and 12 years old.

If your child has an eye condition, like amblyopia or strabismus, the eye doctor may prescribe special glasses, such as prism lenses or an eye patch.

Lubricating or medicated eye drops or ointments

Many pediatric eye conditions may be treated with eye drops or ointments. Common eye medications for children may include:

• Antibiotic eye drops or ointments may be prescribed to treat an eye infection, such as pink eye or a stye.
• Allergy eye drops may be used to treat an eye condition, such as pink eye caused by allergies.
• Lubricating eye drops (artificial tears) may be used to help soothe the eyes in kids who have pink eye or minor eye irritation.
• Steroid eye drops may be used to treat inflammatory eye conditions, such as pediatric uveitis.
• Vision-blurring (atropine) eye drops may be used instead of a patch to treat amblyopia by putting drops in the stronger eye.

Your child’s eye doctor may prescribe these eye drops or others to help treat your child’s eye condition.

Medication injections

In some cases, injections in or around the eye may be used to treat certain pediatric eye conditions. For example, your child’s eye doctor may use steroid injections, rather than drops, to treat uveitis or a stye. An eye doctor may use injections of botulinum toxin A to treat strabismus by weakening the overactive eye muscle. And injectable medications that block blood vessel growth (anti-VEGF injections) may be prescribed for retinopathy of prematurity (ROP).

Oral medications

Medications for some eye conditions may be taken orally in some cases. For example, oral steroids may be prescribed in some cases to treat a condition, like uveitis. Oral allergy medications may be used for cases of allergic conjunctivitis. And oral medications, such as carbonic anhydrase inhibitors (CAIs), may be prescribed along with surgery for congenital glaucoma. 

Surgery

Some pediatric eye conditions may require surgery. Examples of pediatric eye surgeries may include:

• Cataract removal surgery may be required for visually significant cases of congenital cataracts. In pediatric cataract removal surgery, the cloudy lens of the eye is removed and replaced with an artificial intraocular lens (IOL) during the initial surgery or at a later time.
• Eyelid surgery may be recommended for children with severe ptosis. Types of eyelid surgery may include levator resection, which involves tightening the eyelid muscle, and a frontalis sling, which involves attaching the eyelid to the forehead muscle.
• Glaucoma surgery may be used to treat congenital glaucoma. Various types of surgery may be used to reduce the pressure in your child’s eye by allowing the fluid to drain better. In some cases, this may involve placing a shunt to help with drainage.
• Retina surgery may be used to treat retinopathy of prematurity. Surgeries may include scleral buckle surgery, in which a band is placed temporarily to support the retina, and vitrectomy, in which the vitreous humor (gel inside the eye) is removed and replaced with saline solution. 

A pediatric ophthalmologist may perform these and other surgeries to treat a pediatric eye condition. The type of surgery will depend on the condition and individual case. For children with complex eye conditions, patient care teams may work together to provide surgical and nonsurgical care. For some conditions, vision therapy for kids may be an option, but research is still being done on its effectiveness.

Low vision care

When an eye condition causes lasting vision impairment, a low vision evaluation can help. Individually fitted magnifiers and other low vision aids can help many children read and see at a distance with greater ease. Your child’s eye doctor can also provide documentation to support vision services at school.

When should you see a pediatric ophthalmologist?

It is recommended that babies and children get regular vision screenings, which can be done by a pediatrician, family doctor, a comprehensive ophthalmologist, a primary care optometrist or other healthcare provider. A comprehensive eye examination by a pediatric ophthalmologist may be recommended in some cases. This may include if a child:

• Has a vision issue
• Fails a vision screening (or can’t get screened)
• Is at risk for developing certain eye problems

For example, it’s recommended that children with a family history of eye problems, such as amblyopia, congenital cataracts, congenital glaucoma, retinoblastoma or strabismus, see a pediatric ophthalmologist. The same applies to children with medical conditions, such as Down syndrome or prematurity, that can increase the risk of eye conditions.

If your child has a vision issue, a health condition or a family history of eye conditions, talk to your child’s pediatrician or family doctor about getting them evaluated by a pediatric ophthalmologist.

Depending on your insurance, you may need a referral from an optometrist, pediatrician or family physician for your insurance provider to cover the appointment.

Preparing for your child’s eye appointment

It’s recommended to take some time to prepare for your child’s eye appointment with a pediatric ophthalmologist. You may want to gather your records, including:

• Your child’s medical history
• A list of any medications they take and doses
• Results of previous vision screenings
• Family history of eye conditions
• Information for their other medical providers

During the visit, you can expect that the eye doctor will ask you for details about your child’s medical and family history and conduct a variety of tests. 

Pediatric ophthalmologists have specialized training in working with children, so you may expect them to use toys and other techniques to get your child’s attention during the exam. They even have ways to test vision on babies, toddlers and nonverbal children. For example, they might use bright lights to check how a child responds. 

Protecting your child’s vision

A pediatric ophthalmologist can be an important partner in protecting your child’s vision. It’s recommended to stay on the schedule of visits your child’s eye doctor recommends and to prioritize your child’s eye health.

In addition to regular eye doctor visits, steps you can take to help maintain your child’s eyes healthy include:

• Serve a healthy diet rich in vision-friendly foods, such as colorful fruits and vegetables, leafy greens, fish and nuts.
• Encourage your child to spend time outdoors.
• Limit screen time and teach your child the 20-20-20 rule, which is to look up from the screen every 20 minutes at an object 20 feet away for 20 seconds.
• Prioritize the use of proper eye protection for sports and other activities to prevent eye injuries.

By taking these simple steps and working with your child’s eye doctor, you can help keep their eyes healthy for life.