Eye Alignment Disorders (Strabismus)

Dr. Burke is one of Cincinnati’s most trusted resources concerning Double Vision.

What is double vision?

Diplopia, the medical term for double vision, is the perception of the same image in two different visual locations. The brain attempts to deal with double vision by attempting to ignore or suppress one of these 2 different images. If this neural adjustment is unsuccessful, closing one eye or covering one side with an eye patch may be necessary.

What is visual confusion?

Visual confusion is the perception of two different images superimposed onto the same space. One of the most common examples of visual confusion that is particularly dangerous and often debilitating occurs when driving. Adults with visual confusion may describe cars going in the opposite direction crossing over the center line and coming straight at them. This visual confusion is caused by the brain shifting the image of the oncoming car and superimposing it on the road straight ahead.

What are the symptoms of strabismus in adults?

Strabismus often causes complaints in adults. They may complain of double vision (diplopia), visual confusion, loss of binocular (3-D) vision, partial loss of peripheral visual field, and awareness of or neck pain caused by a compensatory head position (head tilt or head turn). Many adults project upon themselves a decreased self-image because they are aware of the negative impact that misaligned eyes (strabismus) causes in many social and vocational settings.

For additional information click here.

Dr. Burke is one of Cincinnati’s most trusted resources concerning Esotropia.

What are the common types of esotropia?

There are four types of esotropia. The four types are infantile or congenital esotropia, accommodative esotropia, late onset non-accommodative esotropia, and a combination of accommodative and non-accommodative causes referred to as mixed mechanism esotropia.

What is infantile esotropia?

Congenital or infantile esotropia describes a constantly crossed or turned in eye in an infant less than 12 months old. This type of esotropia occurs in up to 1% of infants. In almost all cases of infantile esotropia, early surgical treatment is necessary to realign their eyes.

If you suspect your child has esotropia, what should you do?

Besides parents, a pediatrician or family doctor is often the first person to suspect strabismus. Any baby whose eyes do not appear straight by the age of 3-4 months should have a thorough pediatric ophthalmologic exam. Strabismus that is not treated early in the child’s life may cause amblyopia (poor visual development in one or both eyes). As soon as a child is suspected of having a misaligned eye (Strabismus), a complete exam with a Pediatric Ophthalmologist is necessary to determine if there is an eye problem.

If I just wait, will my child’s misaligned eyes get better by themselves?

No. Children do not outgrow strabismus. Treatment for strabismus is required. These treatments may include glasses, amblyopic therapy (patching or eye drops), and eye muscle surgery.

What is Strabismus?

Strabismus is the encyclopedic word that describes a problem in which the eyes are not properly aligned with each other. The eyes are not properly aligned and do not focus on one object together at the same time. An eye may be misaligned all of the time (constant) or only some of the time (intermittent). The common types of horizontal strabismus are esotropia and exotropia. When the eyes are vertically misaligned, this is referred to as hypertropia.

What are the risk factors for Strabismus?

One of the highest risk factors for strabismus is having a family history of strabismus. Significant prematurity, cerebral palsy and other neurological problems, and genetic disorders also increase the risk of eye misalignment.

How is strabismus diagnosed?

Pediatric ophthalmologists are experts in the examination techniques to confirm the diagnosis of strabismus. Most patients are referred to pediatric ophthalmologists by pediatricians, family doctors, and other ophthalmologists and optometrists because on their examinations an eye misalignment problem is suspected.

Who specializes in the treatment of Strabismus?

The American Association for Pediatric Ophthalmology and Strabismus is an organization of pediatric ophthalmologists dedicated to the prevention and treatment of eye problems in children and the treatment of strabismus in people of all ages.

What is pseudo-esotropia?

Pseudo-esotropia is the illusion that the eyes are crossed where indeed they are straight and properly aligned. The eyes of infant often seem to be crossed. Infants and young children often have a wide and flat nasal bridge causing the folds of skin at the inner corners of the eyelids to partially cover the inner corners of each eye giving the illusion that the eyes are crossed. This is particularly noticeable when the child is looking to either side. Photographs often catch a child in these positions causing many parents to suspect the child may have crossed eyes. This illusion of strabismus improves as the child’s face grows and, in most children, is no longer noticeable by the age of 5.

What is accommodative esotropia?

Accommodative esotropia is a common form of crossed eyes occurring in up to 2% of children and typically developing after 12 months and before 5 years old. Accommodation refers to the powerful force that allows the eye to focus. When we accommodate on a close target, this powerful focusing force also activates convergence, or the turning inward of the eyes to look at or be aligned upon nearby objects. These two activities (focusing and turning the eyes inward) are both controlled by the same nerve and happen at the same time. This whole process is called accommodative convergence. Most children with accommodative esotropia are farsighted. Farsighted children have to use their focusing mechanism inside their eyes (accommodation) more powerfully than do most children. Because the same nerve controls focusing and turning the eye inward, the farsighted child who is working very hard to focus may cross (over-converge) the eyes at the same time. This is called accommodative esotropia or may also be described as focusing-related-crossing.

How is accommodative esotropia treated?

Most children with focusing-related-crossing, or accommodative esotropia, are treated with eyeglasses. The power of the eyeglasses is determined by performing a refraction. In most cases of accommodative esotropia, the focusing muscles inside the eye must be relaxed with eyedrops (cycloplegia) to accurately measure the full amount of the child’s farsightedness (hyperopia). About 75% of children with accommodative esotropia will have straight eyes wearing eyeglasses. Glasses will only help the child if they are prescribed accurately and worn full-time. As soon as the glasses are removed, the eyes will cross again. For this reason your child must wear the glasses during all waking hours. In the remaining 25% of patients, glasses alone may not be enough to straighten your child’s eyes. This type of strabismus is referred to as mixed mechanism esotropia. In these cases, eye muscle surgery may be required in addition to glasses. Eye muscle surgery is only used to treat the crossing that is not relaxed by the glasses (the non-accommodative component). That means your child will continue to need glasses to keep their eyes straight even after surgery (for their accommodative component).

What is mixed mechanism esotropia?

When the crossed eyes (esotropia) are caused by both focusing reason (accommodative) and by a muscular reason (non-accommodative), the crossing is referred to as mixed mechanism esotropia. The accommodative component requires to use of glasses. Surgery is often necessary for the muscular imbalance (non-accommodative) part.

Why is it important to have strabismus treated?

The most important reasons to treat eye misalignment problems (strabismus) are first to straighten the eyes and second to restore binocular (3-D) vision. In children it is particularly important to treat eye misalignment problems (strabismus) to preserve normal visual development or assist in the therapy of and the stability of amblyopic therapy.

Click the following links for more information.
Infantile Esotropia
Accommodative Esotropia
Pseudo-Esotropia
Strabismus Surgery
Anesthesia

Dr. Burke is one of Cincinnati’s most trusted resources concerning strabismus treatment in children and in adults.

What is Strabismus?

Strabismus is the encyclopedic word that describes a problem in which the eyes are not properly aligned with each other. The eyes are not properly aligned and do not focus on one object together at the same time. An eye may be misaligned all of the time (constant) or only some of the time (intermittent). The common types of horizontal strabismus are esotropia and exotropia. When the eyes are vertically misaligned, this is referred to as hypertropia.

What causes Strabismus?

The eyes move faster and more precisely than any other part of our body. The eye muscles are controlled through nerves from the brain. Strabismus is caused when these neural connections that control the eye muscles are out of balance.

What are the risk factors for Strabismus?

One of the highest risk factors for strabismus is having a family history of strabismus. Significant prematurity, cerebral palsy and other neurological problems, and genetic disorders also increase the risk of eye misalignment.

If you suspect your child has Strabismus, what should you do?

Besides parents, a pediatrician or family doctor is often the first person to suspect strabismus. Any baby whose eyes do not appear straight by the age of 3-4 months should have a thorough pediatric ophthalmologic exam. Strabismus that is not treated early in the child’s life may cause amblyopia (poor visual development in one or both eyes). As soon as a child is suspected of having a misaligned eye (Strabismus), a complete exam with a Pediatric Ophthalmologist is necessary to determine if there is an eye problem.

If I just wait, will my child’s misaligned eyes get better by themselves?

No. Children do not outgrow strabismus. Treatment for strabismus is required. These treatments may include glasses, amblyopic therapy (patching or eye drops), and eye muscle surgery.

Who specializes in the treatment of Strabismus?

The American Association for Pediatric Ophthalmology and Strabismus is an organization of pediatric ophthalmologists dedicated to the prevention and treatment of eye problems in children and the treatment of strabismus in people of all ages.

What are the symptoms of strabismus in children?

For most children, there are no symptoms from strabismus. However, the most common sign of strabismus is that the eyes are not straight. Parents might also notice the child squint or close one eye in bright sunlight, close or put one hand over an eye while watching television or reading a book, or they may have an unusual head tilt or head turn while attempting to look closely at a target.

What are the symptoms of strabismus in adults?

Strabismus often causes complaints in adults. They may complain of double vision (diplopia), visual confusion, loss of binocular (3-D) vision, partial loss of peripheral visual field, and awareness of or neck pain caused by a compensatory head position (head tilt or head turn). Many adults project upon themselves a decreased self-image because they are aware of the negative impact that misaligned eyes (strabismus) causes in many social and vocational settings.

What is double vision?

Diplopia, the medical term for double vision, is the perception of the same image in two different visual locations. The brain attempts to deal with double vision by attempting to ignore or suppress one of these 2 different images. If this neural adjustment is unsuccessful, closing one eye or covering one side with an eye patch may be necessary.

What is visual confusion?

Visual confusion is the perception of two different images superimposed onto the same space. One of the most common examples of visual confusion that is particularly dangerous and often debilitating occurs when driving. Adults with visual confusion may describe cars going in the opposite direction crossing over the center line and coming straight at them. This visual confusion is caused by the brain shifting the image of the oncoming car and superimposing it on the road straight ahead.

How is strabismus diagnosed?

Pediatric ophthalmologists are experts in the examination techniques to confirm the diagnosis of strabismus. Most patients are referred to pediatric ophthalmologists by pediatricians, family doctors, and other ophthalmologists and optometrists because on their examinations an eye misalignment problem is suspected.

What is pseudo-esotropia?

Pseudo-esotropia is the illusion that the eyes are crossed where indeed they are straight and properly aligned. The eyes of infant often seem to be crossed. Infants and young children often have a wide and flat nasal bridge causing the folds of skin at the inner corners of the eyelids to partially cover the inner corners of each eye giving the illusion that the eyes are crossed. This is particularly noticeable when the child is looking to either side. Photographs often catch a child in these positions causing many parents to suspect the child may have crossed eyes. This illusion of strabismus improves as the child’s face grows and, in most children, is no longer noticeable by the age of 5.

Why is it important to have strabismus treated?

The most important reasons to treat eye misalignment problems (strabismus) are first to straighten the eyes and second to restore binocular (3-D) vision. In children it is particularly important to treat eye misalignment problems (strabismus) to preserve normal visual development or assist in the therapy of and the stability of amblyopic therapy.

What are the common types of strabismus?

Strabismus is commonly designated by the direction of the misaligned eye. The common types of strabismus are esotropia, exotropia, and hypertropia. Esotropia, often called “crossed-eyes”, is the most common type of strabismus and refers to an eye that turns inwardly. Exotropia is used to describe an eye that turns outwardly and is often called “wall-eyed”. The most uncommon eye misalignment problem is when one eye is displaced up or down and this type of vertical strabismus is called hypertropia.

What are the common types of esotropia?

There are four types of esotropia. The four types are infantile or congenital esotropia, accommodative esotropia, late onset non-accommodative esotropia, and a combination of accommodative and non-accommodative causes referred to as mixed mechanism esotropia.

What is infantile esotropia?

Congenital or infantile esotropia describes a constantly crossed or turned in eye in an infant less than 12 months old. This type of esotropia occurs in up to 1% of infants. In almost all cases of infantile esotropia, early surgical treatment is necessary to realign their eyes.

What is accommodative esotropia?

Accommodative esotropia is a common form of crossed eyes occurring in up to 2% of children and typically developing after 12 months and before 5 years old. Accommodation refers to the powerful force that allows the eye to focus. When we accommodate on a close target, this powerful focusing force also activates convergence, or the turning inward of the eyes to look at or be aligned upon nearby objects. These two activities (focusing and turning the eyes inward) are both controlled by the same nerve and happen at the same time. This whole process is called accommodative convergence. Most children with accommodative esotropia are farsighted. Farsighted children have to use their focusing mechanism inside their eyes (accommodation) more powerfully than do most children. Because the same nerve controls focusing and turning the eye inward, the farsighted child who is working very hard to focus may cross (over-converge) the eyes at the same time. This is called accommodative esotropia or may also be described as focusing-related-crossing.

How is accommodative esotropia treated?

Most children with focusing-related-crossing, or accommodative esotropia, are treated with eyeglasses. The power of the eyeglasses is determined by performing a refraction. In most cases of accommodative esotropia, the focusing muscles inside the eye must be relaxed with eyedrops (cycloplegia) to accurately measure the full amount of the child’s farsightedness (hyperopia). About 75% of children with accommodative esotropia will have straight eyes wearing eyeglasses. Glasses will only help the child if they are prescribed accurately and worn full-time. As soon as the glasses are removed, the eyes will cross again. For this reason your child must wear the glasses during all waking hours. In the remaining 25% of patients, glasses alone may not be enough to straighten your child’s eyes. This type of strabismus is referred to as mixed mechanism esotropia. In these cases, eye muscle surgery may be required in addition to glasses. Eye muscle surgery is only used to treat the crossing that is not relaxed by the glasses (the non-accommodative component). That means your child will continue to need glasses to keep their eyes straight even after surgery (for their accommodative component).

What is mixed mechanism esotropia?

When the crossed eyes (esotropia) are caused by both focusing reason (accommodative) and by a muscular reason (non-accommodative), the crossing is referred to as mixed mechanism esotropia. The accommodative component requires to use of glasses. Surgery is often necessary for the muscular imbalance (non-accommodative) part.

What is exotropia?

A child whose eye turns outwardly is said to have a wandering eye or be “wall-eyed”. Exotropia refers to an outwardly drifting eye. About one percent of children have an outwardly wandering eye. The most common presentation in a child is where the eye drifts only part of the time. This is called intermittent exotropia.

What is infantile exotropia?

Congenital or infantile exotropia describes a constantly outwardly deviated eye in an infant less than 12 months old. This type of exotropia is very uncommon. Although it may be no more worrisome than the much more common infantile esotropia (crossed eyes), many with infantile exotropia have some type of neurological insult with developmental delay.

What is intermittent exotropia?

Children with intermittent exotropia have a strong tendency to let an eye turn out, but the eye does not turn outwardly all the time. When the child does control the alignment, the eyes are straight and functional normally together. The most common age of onset is between 2 and 5 years of age. During the early stages, the child has straight eyes looking at anything closer than 3 to 4 feet. The eye will drift or wander outwardly when the child looks at things far away and is especially noticeable when the child is tired, ill, or daydreaming. Parents often notice that the child squints or tries to close one eye in bright sunlight. As time passes, control is gradually lost and the eye will begin to wander more frequently and stay in the outwardly deviated position for a longer period of time. Surgical realignment of the eye muscles will ultimately be necessary in over 90% of patients with intermittent exotropia.

Additional Information:

Strabismus in Children

Strabismus in Adults

Esotropia

Accommodative Esotropia

Exotropia

Examination Techniques for Strabismus

Strabismus Surgery

Anesthesia

Dr. Burke is one of Cincinnati’s most trusted resources concerning pseudostrabismus in infants and toddlers.

What is pseudostrabismus?

Pseudo means “not real” and strabismus refers to an eye misalignment problem. Pseudostrabismus is therefore an illusion causing the eyes to appear as if they were not properly aligned. The most common type of pseudostrabismus is pseudo-esotropia (appearing crossed-eyed).

What is pseudo-esotropia?

Pseudo-esotropia is the false impression that the eyes are crossed. This illusion of crossing is caused by the infant’s facial appearance where the folds of skin that cover the bridge of the nose (the space between the eyes) and the shape of the eyelids partially covers the inner corner of the eyes. These features cause less visible white space between the colored part of the eye (iris) and the inner corner of the eyelid. This may give the illusion that the eyes are crossed when looking straight ahead or more commonly when the eyes are turned to either side. This appearance is especially noticeable in photographs.

What should you do if you suspect crossed eyes?

It is common for parents to be concerned about their child’s visual development especially when they noticed what appears to be crossed eyes. Misaligned eyes are a true cause for concern and, whenever suspected, requires an examination by a pediatric ophthalmologist. If left untreated, true strabismus can quickly lead to poor visual development in one or both eyes. Children do not outgrow true crossing of the eyes, a type of strabismus called esotropia. Pseudo-esotropia is not true misalignment so is often referred to as being “outgrown”. This is because, in most cases, the facial growth allows the illusion of crossing to “fade away” by the age of 4 to 5 years.

For additional information click here.

Dr. Burke is one of Cincinnati’s most trusted resources concerning nystagmus in children.

Nystagmus is a rhythmic, involuntary oscillation of one or both eyes.
The “what causes” and “what can be done about” of nystagmus are constantly evolving.

Some forms of nystagmus are physiologic, whereas others are pathologic.
Distinguishing infantile or congenital forms of nystagmus (with onset in the first month of life) from an acquired type is important because underlying neurologic disease is found more often in the acquired forms of nystagmus.

If your infant or child is suspected to have or has nystagmus, a thorough evaluation by a pediatric ophthalmologist is indicated.

More Information:

https://emedicine.medscape.com/article/1199177-overview

https://www.nlm.nih.gov/medlineplus/ency/article/003037.htm

https://www.nystagmus.org/aboutn.html

https://www.aapos.org/terms/conditions/80

Dr. Burke is one of Cincinnati’s most trusted resources concerning eye muscle surgery.

What do I need to know about strabismus (eye muscle) surgery?

Eye muscle surgery is performed in an attempt to correct an abnormal eye alignment (strabismus). Even though eye muscle surgery typically requires a general anesthetic, most people are able to return home within hours after the surgery is completed. During the surgery, the eyelids are held open with a speculum and the eye is gently rotated to bring the muscles into the surgeon’s view. Incisions are made on the superficial tissues of the eye, the conjunctiva. It is through these openings that the muscles are operated. Eyes muscles are repositioned during the surgery. It may be necessary to perform surgery on one or both eyes. The eye muscles are reattached to the globe with sutures that absorb within 6-7 weeks. The conjunctiva is also sutured closed and the stitches will be absorbed within the first 2 weeks. Recovery time is rapid. People are usually able to resume most of their normal activities within a week. Strabismus surgery is usually a safe and effective treatment for eye misalignment problems.

Is the eye removed during strabismus surgery?

The eyeball is never removed from the socket during any kind of eye muscle surgery.

Are there are risks to eye muscle surgery?

The most common issues postoperatively are residual misalignment (that may or may not require additional surgery) and double vision (almost always only temporary). As with any surgery, eye muscle surgery has certain health and eye risks. These include infection, bleeding, excessive eye tissue scarring, and other extremely rare complications that could lead to the loss of vision.

How many surgeries will it take to straighten the eyes?

About 8 out of 10 patient’s achieved good eye alignment initially after surgery. Sometimes, however, the result is too little (an undercorrection) or too much (and overcorrection). If either of these were significant, this may be cause for a reoperation in a short time after the procedure. There are other times that the initial good eye alignment may begin to wander again many months or even years after the procedure. Over a lifetime, about 40% of patients require 2 or more eye muscle surgeries.

How common is eye muscle surgery?

Over 250,000 patients undergo eye muscle surgery every year in the United States. The overwhelming majority of these patients do very well.

What should I expect after eye muscle surgery?

It is normal for the white part of the eye to be red after surgery. It usually takes several weeks for the redness to disappear. Significant pain is unusual. Most pain, soreness, and foreign-body sensation improves within a few days. Postoperative eyedrops and ointment will need to be placed in the operated upon eye(s) for one week after surgery.

Are there any restrictions after surgery?

Normally there are no postoperative activity restrictions except no pool swimming, no contact lenses, and no eyelid or eyelash cosmetics for 2 weeks after surgery.

Additional Information:

https://www.aapos.org/terms/conditions/102

https://www.aapos.org/terms/conditions/25

Dr. Burke is one of Cincinnati’s most trusted resources concerning exotropia in children.

A child whose eye turns outwardly is said to have a wandering eye or “wall-eye.” If the eye is turned out all the time, it is called exotropia. Children with intermittent exotropia have a strong tendency to let the eye turn out, but it does not turn out all the time. When the child does control the eye alignment, the eyes are straight and function normally together.

Exotropia occurs in about 1 out of 100 children. The most common age of onset in children is between 2 and 5 years of age. The eye will drift or wander outwardly when the child looks at things far way, especially if the child is tired, ill, or daydreaming. Children do not do this “on purpose.” Sometimes in sunlight the child will squint or close one eye. When the eye is turning out, the brain “turns off” or suppresses the central vision causing a loss of binocular or 3-D vision.

Surgical realignment is ultimately necessary in over 90% of cases because the amount and duration of the drifting increases. When surgery is done, there is an excellent chance of the eyes will be straight and that there will be normal vision and good binocularity.

Whenever an eye misalignment is suspected, your child should have a complete evaluation by a pediatric ophthalmology specialist.

What is exotropia?

A child whose eye turns outwardly is said to have a wandering eye or be “wall-eyed”. Exotropia refers to an outwardly drifting eye. About one percent of children have an outwardly wandering eye. The most common presentation in a child is where the eye drifts only part of the time. This is called intermittent exotropia.

What is infantile exotropia?

Congenital or infantile exotropia describes a constantly outwardly deviated eye in an infant less than 12 months old. This type of exotropia is very uncommon. Although it may be no more worrisome than the much more common infantile esotropia (crossed eyes), many with infantile exotropia have some type of neurological insult with developmental delay.

What is intermittent exotropia?

Children with intermittent exotropia have a strong tendency to let an eye turn out, but the eye does not turn outwardly all the time. When the child does control the alignment, the eyes are straight and functional normally together. The most common age of onset is between 2 and 5 years of age. During the early stages, the child has straight eyes looking at anything closer than 3 to 4 feet. The eye will drift or wander outwardly when the child looks at things far away and is especially noticeable when the child is tired, ill, or daydreaming. Parents often notice that the child squints or tries to close one eye in bright sunlight. As time passes, control is gradually lost and the eye will begin to wander more frequently and stay in the outwardly deviated position for a longer period of time. Surgical realignment of the eye muscles will ultimately be necessary in over 90% of patients with intermittent exotropia.

Click the following links for additional information.

Exotropia
Strabismus Surgery
Anesthesia

Dr. Burke is one of Cincinnati’s most trusted resources concerning amblyopia in children.

What is amblyopia?

Amblyopia is poor vision in an eye that did not develop normal sight during early childhood. The term amblyopia refers to the decreased vision caused when the brain does not receive enough visual stimulation during the critical period from birth through age 8. – the time of life when the sense of sight is developing, maturing, and stabilizing. It is sometimes called “lazy eye.” The condition is common, affecting approximately 2 or 3 out of every 100 children. The prognosis is good if amblyopia is discovered and treated early.

What happens to cause amblyopia?

Amblyopia is caused by any condition that affects normal use of the eyes or from any factor that prevents a clear image from being focused inside the eye during the brain’s visual development cycle (infancy till 8 years of age).

In amblyopia, the right and left eyes send significantly different qualities of visual information to the brain. The brain learns to depend on the stronger eye for its visual information. If this situation is not corrected, the brain eventually chooses to accept the images from the stronger and ignores or suppresses the images from the weaker eye. The brain’s choice usually is made early in childhood when the brain’s visual pathways are still developing. This critical period begins at birth and the visual maturation process ends around the age of 8. If amblyopia is not diagnosed and treated within this critical period, the weak eye does not learn to see resulting in a lifelong loss of vision in that eye.

How does vision normally develop?

The brain is born with the wiring diagram for vision but the circuits must be turned on and continually used to stimulate and fully complete the brain’s development. This means newborn infants are born with a potential to see and, as they use their eyes during the first year of life, vision significantly improves. The maximum visual system potential is reached around 2 years of age but the brain’s visual development does not become fully mature and stable until around the age of 8.
Additional Information

What are the types of amblyopia?

There are four major types and causes of amblyopia: strabismic amblyopia, deprivational amblyopia, refractive amblyopia, and structural amblyopia. The end result of all forms of amblyopia is reduced vision in the affected eye(s).

What is strabismic amblyopia?

Strabismus (misaligned eyes) is the most common cause of amblyopia. Strabismic amblyopia develops when the brain “turns off” the misaligned eye causing the child to use only the straight eye.

What is deprivational amblyopia?

Deprivational amblyopia develops from any condition or problem that blocks or prevents the normal pathway of light entering the eye thus “depriving” young children’s eyes of the normal visual experience.
This type of amblyopia may be caused by ptosis, cataract, corneal scarring, and eyelid distortions like that caused by hemangioma.

What is refractive amblyopia?

Refractive amblyopia happens when there is a large or unequal amount of refractive error in a child’s eye. Unequal focusing between the eyes (refractive error) is the second most common cause of amblyopia. Typical refractive errors are eye conditions that are corrected by wearing glasses. Amblyopia occurs when one eye is out of focus compared to the other eye. The brain “turns off” the unfocused or blurry eye resulting in amblyopia. Parents and pediatricians may not think there is a problem because the child’s eyes may be straight and appear perfectly normal. Also, the “good” eye may have normal vision. For these reasons, this is the most difficult type of amblyopia to detect since it requires careful measurement of vision and may not be found until the child cooperates for a vision screening test.

What is structural amblyopia?

Internal structural abnormalities of the retina or optic nerve
may cause amblyopia. When there are congenital or developmental problems of the optic nerve or retina, less and/or blurred information is transmitted to the brain resulting in amblyopia.

Is poor vision always amblyopia?

Poor vision in one eye does not always mean the child has amblyopia. Vision can often be improved by prescribing glasses.

What happens without treatment?

Without proper treatment, the condition may produce profound loss of vision that lasts a lifetime.

When should treatment be started?

Once amblyopia is detected, it should be treated as soon as possible.
Amblyopia must be detected and treated as early as possible to maximize vision potential. The earlier in life amblyopia is detected, the easier it is to treat.

Can you treat amblyopia after age 8?

There is an age limit to which amblyopia can be successfully treated. In a previously untreated amblyopic eye, except in rare occasions vision cannot usually be significantly improved in children who were older than 8 years of age.

How is amblyopia detected?

It is not easy to recognize amblyopia. Most children are unaware of having one strong eye and one weak eye. Unless the child has a misaligned eye or some other obvious abnormality, there is often no way for parents to tell that something is wrong. Amblyopia is detected by finding a difference in vision between the two eyes. Vision screening is regularly performed by your pediatrician. Since it is important to detect amblyopia as early as possible, newly developed instruments are available to assist the pediatrician to screen for refractive errors that have a high tendency to cause amblyopia. These instruments are particularly useful in infants and preverbal children.

What determines the success of treatment?

Success in the treatment of amblyopia depends upon how severe the amblyopia was when detected and how old the child was when treatment started. If the problem is detected and treated early, vision can improve for most children. Fortunately, if the decreased vision can be found before age 8, the damage caused by amblyopia may be reversible with treatment. Amblyopia may require treatment until 8 or 9 years of age. After this time amblyopia is very unlikely to recur.

What are the goals of therapy?

In all cases, the goal of amblyopic treatment is to achieve the best possible vision in each eye. While not every child will be improved to normal, most can obtain a substantial improvement in vision.

How do you treat amblyopia?

To correct amblyopia, a child must be made to use the weak eye. Glasses may be prescribed to correct errors in focusing. If glasses alone do not improve vision, then patching or covering the stronger eye is necessary. Occasionally, amblyopia may be treated by partially blurring the vision in the good eye with an eye drop to force the child to use the amblyopic eye.

What are the two steps need to treat amblyopia?

The first step is to insure that clear images are produced in both eyes.
When necessary, one of the most important treatments of amblyopia is correcting the refractive error with the consistent use of glasses.
The second step is to strengthen the vision in the weaker eye.
The mainstay of amblyopia treatment is to force the use of the non-dominant eye by patching the better-seeing eye.

Why don’t glasses fix amblyopia?

With amblyopia, the brain is “used to” seeing a blurry image and it cannot interpret the clearly focused image that the glasses produce. With time, however, the brain may “re-learn” how to see and the vision may improve. When glasses alone do not increase the vision to normal, the better eye is patched to make the amblyopic (weak) eye stronger.

How do you make the amblyopic eye stronger?

The mainstay of treating amblyopia is patching the dominant (good) eye during waking hours. Typically, 2-6 hours per day is necessary but, in some difficult cases, even up to full-time patching may be required. Although this amount of therapeutic patching will frequently improve the vision within a few months, maximal results may take up to a year of patching. Once the vision has improved in the lazy eye there is a small chance that it can worsen again. Therefore, close monitoring will be necessary throughout childhood. On occasion, residual patching of an hour or 2 a day may be necessary until 9-10 years of age to maintain good vision and prevent recurrence of amblyopia.
Once vision has been improved, less hours of maintenance patching or less frequent use of the penalizing eye drops may be required to keep the vision from slipping or deteriorating.

What is the most common method to treat amblyopia?

The most common method to strengthen the weaker eye is to have the child wear a patch over the stronger eye for a certain number of hours every day. Your child’s progress will be monitored closely requiring frequent eye exams. Once your child’s vision has become normal or reached its maximum level of improvement, the patching will be weaned slowly to prevent recurrent visual loss. In selected cases, as an alternative to patching, eyedrops may be prescribed to blur vision temporarily in the stronger eye.

Is patching always successful in treating amblyopia?

In a few cases, treatment for amblyopia may never improve enough to be equal to the vision in the good eye or may not even succeed in substantially improving vision. Patching may be tried for several months (even if no further improvement in vision is noted) to ensure that the child has been given the best chance to develop normal vision.
It is hard to decide to stop treatment, but sometimes it is best for both the child and the family. Children who have amblyopia in one eye and good vision only in the other eye should wear safety glasses full time to protect the normal eye from injury.

Is there anything that makes the patching more therapeutic?

Although the most important part of patching is to keep the patch on for the allotted amount of time, there have been reports that the performance of detailed near activities (reading, coloring, hand-held video and computer games) may be more stimulating to the brain and produced better or more rapid recovery of vision.

Is amblyopia inherited?

In many cases, the conditions associated with amblyopia may be inherited. That means parents, siblings, or close family relations may already be known to have amblyopia. Children in a family with a history of amblyopia or strabismus should receive early and regular vision screening.

How do you get the child to patch?

Proper motivation is very important to successful patching. Be positive and encouraging. Make it seem a consistent part of your daily routine. Initially patching may take lots of urging, patience, and one on one stimulation and distraction, since your child will now be using an eye that sees poorly. Many children will resist wearing a patch. Successful patching may require persistence and plenty of encouragement from family members, neighbors, teachers, etc. Children will often throw a temper tantrum but, with parental consistency, persistence, and perseverance, they eventually learn not to remove the patch. Rewards are often useful in the younger child. On the other hand, an older child may be more cooperative or more open to bargaining if patching is performed during certain, desirable activities such as watching a preferred television program or be permitted to play video or computer games.

Do you straighten the eyes before treating amblyopia?

Amblyopic treatment is usually performed before surgery to correct misaligned eyes. Treating the cause alone cannot cure amblyopia. The weaker eye must be made stronger in order for vision to improve. Prescribing glasses or performing surgery can correct the cause of amblyopia, but your pediatric ophthalmologist must also treat the amblyopia. If amblyopia is not treated, a permanent and lifelong visual deficit will be the result.

Patching Compliance – What parents need to know?

Parents must be totally committed. You and your child must adjust to the idea and the reality of wearing an eye patch. It is crucial that you commit to the fact that your child will wear an eye patch. By the tone of your voice and your attitude, you convey to your child that there are no options and that you – the parents – will be in charge of the patch. As with many other difficult situations with children, the three most important ingredients to success are patience (to deal with your child’s behavior caused by the their the anxiety caused by patching), persistence (to accomplish the patching goals), and support (for you and your child from your spouse, other family members, and from relatives and friends).

What may you expect from amblyopia therapy?

Your efforts now are likely to result in good (if not normal) vision in the (once) weaker eye for the rest of your child’s life. Dr. Burke has been through amblyopic therapy with thousands of patients. The overwhelming number have had excellent results. But you – the parents – must be committed and have perseverance to help your child achieve the best vision result possible.

What types of patches are available?

Patches are of two types: adhesive patches applied directly to the skin and one-sided, slide-on cloth covers used with eye glasses. “Pirate” patches with elastic ties or occluders that clip on the glasses are not recommended.

What if, while wearing the patch, the child has an unusual Head position?

The cause of an unusual head position (head tilt or head turn) while patching is almost always due to peeking around the patch to use the better eye. Obviously this type of “patching” would be of no benefit to the amblyopic eye and this type of behavior must be stopped. A different or improved adhesive patch may help avoid peeking.

What if you need restraints?

If restraints are necessary, custom designed pediatric arm splints are available from MEDI-KID Company at 888-463-3543 or on-line by clicking here.

What activity precautions should be taken?

The vision in the amblyopic eye may be quite poor for a while after beginning the patching therapy, so extra precautions should be taken on stairs, playgrounds, bike rides, etc.

What instructions are there for patching?

Dr. Burke will give you instructions on how to treat amblyopia, but it is up to you, the parents, and your child to carry out this treatment. Children do not like to have their eyes patched, especially since they have been depending on the good eye, that is now being patched, to see clearly. But as a parent, you must convince your child to do what is in their best interest. Successful treatment depends on your commitment and involvement as well as your ability to gain your child’s cooperation. Parents play a very important role in determining whether their child’s amblyopia will be improved.

Is there an alternative to patching?

As an alternative to patching, eyedrops may be prescribed to “penalize” or blur vision temporarily the focusing ability in the stronger eye which forces the child to use the amblyopic eye.

Does eye drop therapy work for everyone?

Not all children benefit from the eye drop treatment for amblyopia.

What happens when the vision is maximized in the amblyopic eye?

Once vision has been improved, less hours of maintenance patching or less frequent use of the penalizing eye drops may be required to keep the vision from slipping or deteriorating.

Additional Resources:

Amblyopia
Patching

Dr. Burke is one of Cincinnati’s most trusted resources concerning adult strabismus.

Strabismus is an ocular condition that occurs when the eyes are misaligned and point in different directions from each other. As a result, your eyes do not work together.

Strabismus may occur at any time–infancy, early childhood, or adulthood. When it happens in children, double vision rarely results because the brain is able to process the image from one eye while suppressing the visual image in the other. However, when strabismus presents in adults, double vision may occur.

The most common causes of strabismus in adults: persistence of or recurrence of strabismus that began in childhood, thyroid orbital disease, stroke, head trauma, and diseases that may affect the nerves such as diabetes, myasthenia gravis, multiple sclerosis, and brain tumors.

The main complaint from an adult is that the eyes are visibly in different positions. Adults may be aware of double vision, complain of trouble focusing or eye strain, be aware that images may jump or have difficulty tracking images while reading, and loss of peripheral vision. As they are unable to make direct eye contact with both eyes when looking at other people, many adults feel awkward in social situations often negatively impacting their self-image and self-confidence, interpersonal interactions, and their employment.

The primary goal of treatment is to align the eyes and restore binocular vision. The most common method is surgical realignment where selected eye muscles are repositioned so that the eyes can be rebalanced to work together. Surgery is typically done as an outpatient surgical procedure. People recover quickly from this procedure and are able to return to most normal activities within a week although healing and complete recovery may take a few months. Strabismus surgery is safe, very effective, and enhances your quality of life. In a few instances, additional eye muscle surgery maybe necessary to keep the eyes aligned.

For more information click here.

Dr. Burke is one of Cincinnati’s most trusted resources concerning accommodative esotropia in children.

Esotropia is the medical term for crossed eyes. Accommodation is the powerful force that allows the eyes to focus. When we accommodate on a close target, this powerful focusing force also activates convergence, or turning inward of the eyes to look at or be aligned upon nearby objects. These 2 activities (focusing and turning the eyes inward) are both controlled by the same nerve and happen at the same time. This process is called accommodative convergence.

When these systems become imbalanced, a problem called accommodative esotropia may develop. This focusing related crossing problem occurs in about one out of every 100 children. The most common age of onset is after 12 months and before age 5 years. During the early stages, the child’s eyes may cross only when looking at near targets and is especially noticeable when the child is fatigued or ill. As time passes the problem typically worsens causing the eyes to cross more often.

A child who has accommodative esotropia almost always chooses one eye to keep straight, the dominant eye. The crossed, non-dominant eye almost always loses vision because of disuse. This loss of vision is called amblyopia. Therapy to correct “the lazy eye” is imperative.

Accommodative esotropia is most always treated with glasses. Glasses will only help the child if they are prescribed accurately and worn full-time. The glasses relax the need to accommodate or focus that will reduce the convergence or crossing. Some children with accommodative esotropia may cross their eyes even more when they look at things close up than when they look at things far away. This excessive near crossing may require the use of bifocals to help straighten the eyes at near fixational distances.

Glasses alone may not be enough to straighten your child’s eyes. In up to 30% of cases, eye muscle surgery may be required in addition to the use of glasses. Surgery is only used to treat the crossing that is left-over or not relaxed by the glasses.

Whenever an eye misalignment is suspected, your child should have a complete evaluation by a pediatric ophthalmology specialist.

What is accommodative esotropia?

Accommodative esotropia is a common form of crossed eyes occurring in up to 2% of children and typically developing after 12 months and before 5 years old. Accommodation refers to the powerful force that allows the eye to focus. When we accommodate on a close target, this powerful focusing force also activates convergence, or the turning inward of the eyes to look at or be aligned upon nearby objects. These two activities (focusing and turning the eyes inward) are both controlled by the same nerve and happen at the same time. This whole process is called accommodative convergence. Most children with accommodative esotropia are farsighted. Farsighted children have to use their focusing mechanism inside their eyes (accommodation) more powerfully than do most children. Because the same nerve controls focusing and turning the eye inward, the farsighted child who is working very hard to focus may cross (over-converge) the eyes at the same time. This is called accommodative esotropia or may also be described as focusing-related-crossing.

How is accommodative esotropia treated?

Most children with focusing-related-crossing, or accommodative esotropia, are treated with eyeglasses. The power of the eyeglasses is determined by performing a refraction. In most cases of accommodative esotropia, the focusing muscles inside the eye must be relaxed with eyedrops (cycloplegia) to accurately measure the full amount of the child’s farsightedness (hyperopia). About 75% of children with accommodative esotropia will have straight eyes wearing eyeglasses. Glasses will only help the child if they are prescribed accurately and worn full-time. As soon as the glasses are removed, the eyes will cross again. For this reason your child must wear the glasses during all waking hours. In the remaining 25% of patients, glasses alone may not be enough to straighten your child’s eyes. This type of strabismus is referred to as mixed mechanism esotropia. In these cases, eye muscle surgery may be required in addition to glasses. Eye muscle surgery is only used to treat the crossing that is not relaxed by the glasses (the non-accommodative component). That means your child will continue to need glasses to keep their eyes straight even after surgery (for their accommodative component).

What is mixed mechanism esotropia?

When the crossed eyes (esotropia) are caused by both focusing reason (accommodative) and by a muscular reason (non-accommodative), the crossing is referred to as mixed mechanism esotropia. The accommodative component requires to use of glasses. Surgery is often necessary for the muscular imbalance (non-accommodative) part.

For more information click here.