Early education of children to check vision, be alert to amblyopia “visit” Amblyopia is visual development due to monocular strabismus, uncorrected refractive error and high refractive error and form deprivation caused by monocular or binocular best corrected visual acuity is lower than the corresponding age visual acuity, or binocular visual acuity difference of two lines or more. It is worth noting that the lower limits for different age reference values are: 3-5 years old: 0.5; ≥6 years old: 0.7 to 1.0. Parents should actively participate in routine eye examinations 42 days and 1 week after birth and before the child enters school. Children with low or abnormal vision should go to an ophthalmologist for a detailed examination as soon as possible, usually starting with a dilated eye exam in the ophthalmology department. Optometry for children, especially for the first time, is best done with dilated pupils. The purpose of dilating the pupil is to relax the ciliary muscle inside the eye, remove the eye’s own regulation, and make the eye completely relaxed. This allows the true refractive power of the child’s eyes to be determined. After the pupil returns to its normal size, the test is repeated once, and the refractive state of the child’s eyes is accurately known based on the number of degrees twice. The prime time to treat amblyopia is before the age of four. The younger the child, the better the treatment effect, not only the shorter the course of treatment, but also the higher the cure rate. The older the child is, the worse the treatment effect will be. 12 years old and above, the developmental period of the visual system has passed, and most patients cannot obtain satisfactory treatment results. After adulthood, there is little hope of curing amblyopia. Early detection and treatment of amblyopia is important. Parents should teach their children to check their vision early to find out if they have poor vision or even amblyopia, so that they do not miss out on treatment and cause their children lifelong regrets. The most effective way to treat amblyopia is masking therapy —— to cover the eye with good vision and force the child to use the eye with poor vision. Many children are often uncooperative when it comes to treatment because the affected eye cannot see well, so the child will secretly remove the cover and use the good eye, or refuse to cover the good eye for fear of being ridiculed as a “one-eyed dragon”. Parents must clarify the necessity of amblyopia treatment, communicate with their children in a timely manner, and obtain their children’s cooperation through encouragement and rewards so that they can complete amblyopia treatment with quality and quantity. It is vital that the child has balanced vision in both eyes. If only one leg can walk and the other leg is lame, even if the lame leg is positioned correctly, the child cannot walk in a coordinated manner. Especially if a strabismic child has amblyopia, the amblyopia must be treated first. This is because strabismus surgery can bring the eyes into proper position, but the post-operative results depend largely on whether the vision is normal in both eyes. Follow-up visits should be reinforced during the masking period to prevent the occurrence of masked amblyopia. Especially when parents change the eye mask and open both eyes, if they find that the original strabismus eye can maintain the gaze, it means that the vision of the strabismus eye is close to that of the main eye, so they should follow up as soon as possible. Strabismus coarse screening: alternate masking method combined with observation of head position Some children may have “oblique eyes” because of nasal bridge dysplasia, or they may not actually have strabismus but look like they have strabismus. Parents should not judge a child’s strabismus only by the appearance of the eyes. Parents can use the following methods to see if their child has strabismus. Face to face with the child and hold a flashlight horizontally in the left hand at the bridge of the child’s nose in the center of both eyes. Ask the child to look at the light naturally in front of him/her, and the parent to quickly cover the child’s single eye with the right hand alternately to ensure that only one eye of the child can see the light each time it is covered. During this process, the parent should carefully observe whether the reflective spot in the pupil area of both eyes is moving. If you notice a large movement of the reflective dots, it is best to bring your child to the ophthalmologist in time for investigation. In addition, if the child often squints in bright outdoor light, or often adopts a special head position such as tilted head, side face, or raised chin to see things, parents should take pictures of these scenes with a camera to collect good information and bring the child to the ophthalmology department in time. Parents should supervise their children with glasses if they have strabismus Some parents think that their children have strabismus and should have surgery to correct the eye position as soon as possible. This idea is sometimes incorrect. Because there are many factors that cause strabismus, not all children with strabismus need surgery. In some cases, the strabismus is mainly caused by refractive error and can be reduced or even corrected by wearing glasses, so surgery may not be necessary. Some children have strabismus due to monocular amblyopia, and the strabismus will improve with glasses or masking to improve the vision of the affected eye. In addition, the child’s farsightedness will decrease with age, so the child will need to be re-opened and wear appropriate glasses. For children with strabismic amblyopia, cover-ups or glasses are used to equalize the vision in both eyes. In children with internal strabismus, surgery should be considered only if the residual internal strabismus is greater than 15 trigeminal degrees after wearing corrective hyperopia glasses, while those with residual internal strabismus less than 15 trigeminal degrees do not hinder the development of fused image and binocular monovision. Parents should also observe whether the vertical centers of the two lenses are at the same level. If they are not at the same level, the effect of the vertical prism can be caused and the child can easily develop visual fatigue. The risk factors include advanced maternal age (>34 years), maternal smoking during pregnancy, premature birth, cesarean section, and low birth weight. Some types of internal strabismus have a better prognosis when operated early, around the age of 2. The older the age, the more difficult it is to restore visual function in both eyes. If the eye position is not corrected before the age of five when the visual development of both eyes is not complete, it is almost impossible to restore binocular vision. Intermittent exotropia is the most common type of exotropia in children, and children with the disease usually have good vision in one eye and no subjective symptoms, so the key to early diagnosis of intermittent exotropia often lies with the parents. In the early stage, the degree of strabismus in intermittent exotropia is unstable, and the eye position varies between orthotropia and exotropia depending on the distance of gaze, the intensity of attention or the patient’s mental state. The eye position may remain normal when the child is looking at the near or when he/she is concentrating, but may show exotropia when looking at the far, when he/she is tired or when he/she is distracted. Children often squint in bright outdoor light to avoid double vision or confusion. Some children have diplopia in some directions of vision due to extraocular muscle paralysis. To overcome double vision, children often adopt special head positions such as tilted head, sideways face, and elevated chin to compensate. Parents should start observing from the above aspects and take pictures of the child’s eye position when it is skewed with a camera to try to detect the abnormal eye position early. Most intermittent exotropia eventually develops into permanent exotropia, in which the child sees with only one eye and the other eye remains in the exotropia position. Parents should carefully observe the frequency and duration of dominant exotropia. If you find that your child’s exotropia is increasing and lasts longer than half the time of day, you should visit the hospital and consider surgery. In the month after strabismus surgery, the muscles are still in the proliferation period, so the child should not take large supplements, and should eat less fish and meat, and just eat a light diet. Parents and children should have a correct understanding of strabismus surgery, that is, surgery can only correct the eye position, but not cure the cause of the disease. The root cause of the disease is an abnormality in the center of the child’s brain that controls the collection and dispersal of the eye, not in the eye itself. Therefore, we should understand the possible overcorrection, undercorrection, recurrence and non-improvement of head position of strabismus in children after surgery, and should not blindly have too high expectations of the results of strabismus surgery.