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Medical Forum / General / Vision / October 2004strabismus
I'm not sure if anyone can help me here, but I can't seem to find any info anywhere else. My 7 yr old son had eye surgery 3 wks ago to correct his strabismus (his eyes were turning in). This is his 2nd surgery, the 1st one was done about 3 yrs ago. This surgery involved tightening the muscle on the outside of his eye. The redness has really faded, but his eyes seem to be overcorrected - they are now going out. He saw his opthalmologist at 2 wks post surgery, and we were told it can take up to 8 wks to heal. His eyes never looked this way after the 1st surgery so I am very concerned. Is there any exercises he can do to help get his eyes lined up properly? Is this normal 3wks post-op, or are we looking at another surgery? Thanks for any input. Tightening surgery is always less predictable than weakening, which is why the first surgery was to weaken the inner muscles. Part of the reason the tightening is less predictable is that the muscles stretch out somewhat after surgery. Therefore, a small overcorrection is reasonable starting out. It is true the roughly final angle may not be obvious until 6-8 weeks after, and nothing can be done while you are waiting. Is the the balance of muscle forces and the reconfiguration of the muscles that determines the final alignment. Sometimes a lot can happen between the 3 and 6-8 week followups. Another surgery is not an impossibility, but you have to wait and see. The standard amount of surgery for the angle is a guide, and different patients react differently to the same amount of surgery, which unfortunately cannot be determined in advance. David Robins, MD Board certified Ophthalmologist Pediatric and strabismus subspecialty Member of AAPOS (American Academy of Pediatric Ophthalmology and Strabismus) On 10/26/04 8:41 PM, in article ba5daa9c.0410261941.46dd78b9@posting.google.com, "danielle" <wildman@dwave.net> wrote: > I'm not sure if anyone can help me here, but I can't seem to find any > info anywhere else. My 7 yr old son had eye surgery 3 wks ago to [quoted text clipped - 8 lines] > normal 3wks post-op, or are we looking at another surgery? Thanks for > any input. "danielle" wrote >> I'm not sure if anyone can help me here, but I can't seem to find any >> info anywhere else. My 7 yr old son had eye surgery 3 wks ago to [quoted text clipped - 8 lines] >> normal 3wks post-op, or are we looking at another surgery? Thanks >> for any input. David Robins, MD responded: > Tightening surgery is always less predictable than weakening, which > is why the first surgery was to weaken the inner muscles. Part of the [quoted text clipped - 10 lines] > different patients react differently to the same amount of surgery, > which unfortunately cannot be determined in advance. Dr. Robbins, A couple of quick questions, if I may: 1) Prism Adaptive Trials?? Since this is surgery #2, perhaps there is more eso- than "meets the eye." 2) Delayed Adjustable Suturing?? If it wasn't used, perhaps it should be discussed if, indeed, a third surgery is considered. 3) Would it be important to know whether this child was an infantile esotrope? If he is not, then isn't it likely that he has developed enough of a fusion mechanism that vision therapy might be a better approach to take care of post-op exo- than a third surgery, especially if the residual exotropia is less than 8-10d? ISTR that vision therapy has a higher success rate with exo- than esotropia, no? 4) If this child is also a high-plus, it would seem very, very important to get this exotropia tamed, even if prisms were necessary Thanks, Neil > "danielle" wrote > [quoted text clipped - 51 lines] > > Neil Thanks for all the info - 1) what is Prism Adaptive Trials - I'd appreciate any info on this? 2) NO, he did not have delayed adjustable suturing. I just recently read about it and I would definitely ask about it if he indeed needs a 3rd surgery. 3) I assume by infantile esotrope, you are asking if he had this problem as an infant. Yes - he was a preemie (3 months early), so this is actually a common problem. His pediatrician dismissed it, telling me it was normal for a baby's eyes to turn in. It became very apparent on photos, which led me to consult a ped opth. He tried patching and bifocals, which helped somewhat - but still did not correct the problem. I really wish he would have had treatment before age 2, but much time was wasted! So at age 3, he had his 1st surgery. It was successful, that is with his glasses on, his eyes were straight. 3 yrs later, they started going in again - which leads us to his present surgery. 4) What is high plus - I really want to do everything possible to avoid surgery. Is there any place you can direct me to on good vision therapy? His opth did tell me to do exercises where he needs to focus on an object and bring it into his nose, so he looks cross-eyed, and hold it. His right eye always tends to pop right back into that far off position, he cannot hold it in. Is there any other good vision exercises he can do? Thanks so much for your input! On 10/27/04 9:04 PM, in article ba5daa9c.0410272004.31a2adf@posting.google.com, "danielle" <wildman@dwave.net> wrote: >> "danielle" wrote >> [quoted text clipped - 54 lines] > Thanks for all the info - > 1) what is Prism Adaptive Trials - I'd appreciate any info on this? Prisms on eyeglasses are used to see what angle the eyes want to be at in order to fuse - often a larger angle than the apparent angle seen. Used in potential fusers. Infantile esotropes have usually no significant fusion, hence PAT is not used for this. > 2) NO, he did not have delayed adjustable suturing. I just recently > read about it and I would definitely ask about it if he indeed needs a > 3rd surgery. See y reply to Neil. He is far too young to allow standard adjustable sutures. > 3) I assume by infantile esotrope, you are asking if he had this > problem as an infant. Yes - he was a preemie (3 months early), so [quoted text clipped - 7 lines] > straight. 3 yrs later, they started going in again - which leads us > to his present surgery. It is common not to get to the steady-state before age 2 with premies - too much changes going on. You only operate once it is stable, with glasses, and patching is over. Typical infantile esotropes are stable, and not glasses dependent, and ready for surgery by as early as 6 months, typically at about 1 year. Premies often are not. > 4) What is high plus - I really want to do everything possible to > avoid surgery. Is there any place you can direct me to on good vision [quoted text clipped - 3 lines] > far off position, he cannot hold it in. Is there any other good > vision exercises he can do? High hyperopia - farsighted. Probably the glasses you have are hyperopic, but Neil was talking about high powers (ie over 6D or so. When looking through the lateral part of the lens, this creates a prism effect, adding to the misalignment of the eyes angled out. Really only an issue of there is fusion to be gained, not really in infantile eso cases. Vision therapy I feel has no real use in cases like this, as there is no eye-to-eye cooperation to begin with. Trying to break down supression and get both eyes "turned on" at the same time has led to cases of incurable diplopia, so I would not try. What the opht is trying to do now is get hm to probably try to stretch those outer muscles that were operated in, in the hope this lengthens them a bit during the healing period. Can't hurt, but I can't say what the chance is that it will help, either. No other exercises I'd recommend. You have to wait and see where the final result ends up. > Thanks so much for your input! Danielle wrote: > 1) what is Prism Adaptive Trials - I'd appreciate any info on this? Dr. Robins explained this concept in his other post. I was also an esotrope at birth. The first two surgeries helped me for a while, but my eyes kept going back. PAT showed that there was about 2.5 times more esotropia than was measurable in 'traditional' ways. The third surgery used the PAT results to guide how much to tighten the muscles. My eyes (looking straight ahead) were finally straight, have stayed straight, and no longer see double. Unfortunately, at near, I am also exotropic now--a bad thing in my case.... > 2) NO, he did not have delayed adjustable suturing. I just recently > read about it and I would definitely ask about it if he indeed needs a > 3rd surgery. I would discuss this with your son's ophthalmologist in light of the (very valid) issues that Dr. Robins raised. Let's hope there /is no/ third surgery. > 3) I assume by infantile esotrope, you are asking if he had this > problem as an infant. Yes - he was a preemie (3 months early), so [quoted text clipped - 7 lines] > straight. 3 yrs later, they started going in again - which leads us > to his present surgery. My story was pretty similar. From my understanding, though: don't beat yourself up. Congenital esotropia really limits a child's ability to learn proper fusion (using two eyes as a team). If that fusional mechanism isn't there, it's really unlikely that it will ever be developed. In other words, I'm not sure that much could have been done if the problem were addressed any earlier. Hopefully, you'll take that as "good" news. > 4) What is high plus - I really want to do everything possible to > avoid surgery. Is there any place you can direct me to on good vision [quoted text clipped - 3 lines] > far off position, he cannot hold it in. Is there any other good > vision exercises he can do? As Dr. Robins said, high farsightedness. Here's why I ask: As we look at near objects (reading), a farsighted person has to accommodate (focus), and turn their eyes inward toward the object (converge). If your son is farsighted, the postoperative exotropia means that he will have to work just /that much/ harder to read (more focusing, more converging). In other words, the eyes are now turned out beyond normal. They have a longer way to go to converge. This is something to track very closely. The way to minimize that burden is through a combination of eye exercises (geared toward increasing his fusional and accommodative abilities) and adjusting the prescription in his spectacles to minimize his need for accommodation at near. Stop me if this is getting technical and I'll rephrase. Also, if your son /is/ highly farsighted, there's a very strong case to be made that he should be in contact lenses, rather than eyeglasses. Let me jump ahead here: I would think it would add much to the conversation if you could post your son's prescription (the way it's written for eyeglasses), and--perhaps--give us some idea of what his 'esodeviation' (strabismus) figures were, both before and after the surgery. In other words, was he eight diopters esotropic ("8d ET") before?? Again, I'm /not a doctor/, but would be interested in understanding more of your son's situation. Finally, where are you, geographically? I have a great deal of respect for the doctors on this newsgroup . . . and I've seen and talked with many in the past . . . .but the guy I go to (In San Diego) is the one I've known for six years, the one I've trusted to perform surgery on me, and the one to whom I've referred my friends' kids when they have strabismus issues. If you're interested in a second opinion, it's never bad to visit San Diego ;-) > Thanks so much for your input! Danielle--along with the caveats I gave on my response to Dr. Robins . . . I care. I wish I knew then what I know now. I wish the doctors knew back then all that they know now. Your son's /not likely/ to be a fighter pilot or professional tennis player, but that doesn't mean he shouldn't have a normal, happy, productive life. If there's anything I can add to maximize the chances, I'd be more than happy to. Best, Neil "neil0502" <neil0502@yahoo.com> wrote in news:wA9gd.36145$QJ3.23726 @newssvr21.news.prodigy.com: > Your son's /not likely/ to be a fighter pilot > or professional tennis player, I'm not sure about the tennis player thing. There are many cues of depth, binocular fusion being only one of them. Further, vergence is slow compared to other eye movements, and I'm not sure its fast enough to deal with a fast tennis ball. There might be some field of view problems, like a shortened nasal field in the viewing eye, but I'm not sure how important binocularity is for a tennis pro, at least from the depth perception standpoint. Scott I have no fusion and when I was too young to realize this was my situation, I tried playing tennis and couldn't. In fact, I was partnered with a good player whose dominant arm was in a cast and she was still better than I was with my dominant arm. I could not play volleyball either. Though I can see a ball traveling in the air, I have no idea if it is 5 feet infront of me or heading 5 feet behind me. So, I took up running, swimming, and biking. I have become a rather proficient distance swimmer (and have no problems doing fast flip-turns off the wall probably more from feel of timing than visual cues)--endurance sports are something I may never have done if I became a tennis player. One can only wonder how much something like this eye condition molds us--quite a bit I think, but not necessarily for the worse. > "neil0502" <neil0502@yahoo.com> wrote in news:wA9gd.36145$QJ3.23726 > @newssvr21.news.prodigy.com: [quoted text clipped - 11 lines] > > Scott "MSEagan" wrote (responding to Scott Seidman) I have no fusion and when I was too young to realize this was my situation, I tried playing tennis and couldn't. In fact, I was partnered with a good player whose dominant arm was in a cast and she was still better than I was with my dominant arm. I could not play volleyball either. Though I can see a ball traveling in the air, I have no idea if it is 5 feet infront of me or heading 5 feet behind me. So, I took up running, swimming, and biking. I have become a rather proficient distance swimmer (and have no problems doing fast flip-turns off the wall probably more from feel of timing than visual cues)--endurance sports are something I may never have done if I became a tennis player. One can only wonder how much something like this eye condition molds us--quite a bit I think, but not necessarily for the worse. As a person who also has no fusion and has had three strabismus surgeries, I was letting Scott slide ;-) I couldn't agree /more/ with your last statement. My activities of choice: bicycling, mountain biking, rollerblading, scuba diving, hiking, running, swimming (see a 'ball' in here yet??), windsurfing (uh, not lately, but....), etc., etc. You're absolutely right: throw me a ball and it's going to hit me! Entertaining for the spectators, but gets old for me. Part of one season as the water polo goalie in high school proved that pretty well. Glad you've found your niche. I hope this seven year old boy finds his as well. Neil > As a person who also has no fusion and has had three strabismus > surgeries, I was letting Scott slide ;-) I still think you'd be surprised by the amount of "normal" people walking down the street who have poor fusion and never even noticed it. As a strabismic, though, you're facing some extra problems-- you supress vision in one eye so as not to see double, so your visual field is compromised, particularly to the nasal side of your viewing eye. This might be as damaging to activities, if not more so, than a lack of fusion. Scott > Danielle wrote: > [quoted text clipped - 84 lines] > > Neil Thanks so much for your concern. My son's prescription is a little hard to explain. His first ped opth moved out of the area, and I did not care for the dr who took over. He was recommending surgery again and changed his prescription to: Spherical-Distance- R +150 L +150, Cylinder R +50 L +50, Axis R 95 L 88. ADD-R +250 L +250. He wore these glasses for the next year, however, I didn't want to rush into another surgery, so the following year I took him to another ped opth for a 2nd opinion (there are only 2 ped opth in our area). My son would never look through his bifocal, so the new dr told me he didn't need them, since he didn't look through them. He got a new prescription (which, I'm sorry - but I cann't locate at the moment). We went back in 3 mths to see if his strabismus was improving or getting worse. My son took his eye test with his glasses on and totally failed it, he also tended to look over the top of his glasses a lot because he obviously could not see through them. He took the test with no glasses and got everything right. So now, the dr decides he doesn't need any glasses at all, they weren't correcting the strabismus - it was exactly the same with or without the glasses. He stressed surgery was the only way to go to get his eyes property aligned. So, here we are now, almost 4 wks post-op. My son is not wearing any glasses at the moment. I won't know the final figures for his strabismus until his 6 wk post-op appt. Honestly, today is the worst his eyes have looked. It's making reading and school very difficult, since he is seeing double. I really hope things start improving for him in the next 2 wks. Sorry to make this so long, I wish I lived by San Diego, but I'm not even close, I'm about 4 hrs away from Chicago. If you can think of any good questions to ask his dr, please let me know. Thanks! Danielle [QUOTE] Thanks so much for your concern. My son's prescription is a little hard to explain. His first ped opth moved out of the area, and I did not care for the dr who took over. He was recommending surgery again and changed his prescription to: Spherical-Distance- R +150 L +150, Cylinder R +50 L +50, Axis R 95 L 88. ADD-R +250 L +250. He wore these glasses for the next year, however, I didn't want to rush into another surgery, so the following year I took him to another ped opth for a 2nd opinion (there are only 2 ped opth in our area). My son would never look through his bifocal, so the new dr told me he didn't need them, since he didn't look through them. He got a new prescription (which, I'm sorry - but I cann't locate at the moment). We went back in 3 mths to see if his strabismus was improving or getting worse. My son took his eye test with his glasses on and totally failed it, he also tended to look over the top of his glasses a lot because he obviously could not see through them. He took the test with no glasses and got everything right. So now, the dr decides he doesn't need any glasses at all, they weren't correcting the strabismus - it was exactly the same with or without the glasses. He stressed surgery was the only way to go to get his eyes property aligned. So, here we are now, almost 4 wks post-op. My son is not wearing any glasses at the moment. I won't know the final figures for his strabismus until his 6 wk post-op appt. Honestly, today is the worst his eyes have looked. It's making reading and school very difficult, since he is seeing double. I really hope things start improving for him in the next 2 wks. Sorry to make this so long, I wish I lived by San Diego, but I'm not even close, I'm about 4 hrs away from Chicago. If you can think of any good questions to ask his dr, please let me know. Thanks! Danielle [QUOTE] Danielle, I need to reiterate: I'm not a doctor. I welcome the input of Dr. Robins or others (especially if anything I say is in error). I'm puzzled that your seven year old son was put in bifocals. That implies that his ophthalmologist feels your son has a dysfunctional accommodative (focusing) mechanism--relatively unusual for a seven year old, I would think. Have the doctors dilated his eyes (to perform what's called a 'cycloplegic refraction')? The dilating drops--preferably stronger drops, like Atropine or Homatropine--paralyze the muscles that allow a person to focus (the ciliaries). In this condition, they can truly measure just how farsighted your son is. This seems to me to be a relatively important diagnostic step. If your son is trying too hard to focus (accommodating), this could also cause his eyes to turn inward more than they should (esotropia). It would /not/ be uncommon for a seven year-old with your son's stated prescription /not/ to /need/ his glasses to read a distance eye chart. He is, after all, farsighted. His problem would come in when he attempts to read books, use the computer, work on a puzzle, etc. Again, this is where he'd have to both focus /and/ converge (turn his eyes inward)--now a bit more difficult now because his eyes turn /outward/. Certainly, you have to let the results of the surgery 'settle' a bit more before you know where you stand. If he's still seeing double, you're obviously going to have to take further steps--whether that be prisms, eye exercises, or additional surgery. His brain hasn't learned to shut down one image (neither has mine). In some ways, that's worse. In my case, we eventually got my eyes straight enough that my mind didn't 'appreciate' two separate images . . . but it took quite a lot of doing. Esotropia and exotropia are what's called 'horizontal deviations.' Have the doctors also checked your son for '-tropias?' These (hypertropia/hypotropia) are vertical deviations--an eye is slightly high or slightly low. These are a little more difficult to work with, and they tend to prevent fusion from developing, but they can be managed with prisms. I'm not saying it's a likely primary issue, but it should be checked. Other questions: - Is your son's deviation the same at near as it is at far? Is it the same in all positions (looking up, down, left, right, and everywhere in between)? - Has his alignment been measured when his eyes were dilated (cycloplegia)? Is there a difference between the dilated and non-dilated numbers? - Does the doctor think there is a problem with his accommodative mechanism? If not, wouldn't bifocals be unusual at age seven? - What about contact lenses (http://www.revoptom.com/archive/issue/ro09f7.htm)? I think it's well worth your while to educate yourself. Here are a couple of links that I think you'll find helpful: http://snipurl.com/a54o http://snipurl.com/a54p They're a bit technical, but they're /very/ good sources. I've been seen by, or spoken with, several of these authors. They're highly qualified. A little knowledge can certainly be a dangerous thing, but I think you need information to help you make good decisions regarding your son. Nearer to Chicago, huh? How about Michigan. UofM has a fine center: http://www.kellogg.umich.edu/patientcare/clinic.specialties.html#pediatric So does Kresge Eye Institute (Detroit). In fact, Dr. Jo Isaacson is still there. He operated on me in 1967!: http://www.med.wayne.edu/kresgeeye/online/main.html Don't you worry about being wordy. This is your son. I'm 40, but my mother still worries about my eyes ;-) Neil On 10/28/04 9:27 PM, in article zEjgd.36382$QJ3.27956@newssvr21.news.prodigy.com, "neil0502" I say is in error). > I'm puzzled that your seven year old son was put in bifocals. That implies > that his ophthalmologist feels your son has a dysfunctional accommodative > (focusing) mechanism--relatively unusual for a seven year old, I would > think. Actually, it is done for high AC/A ratio (accommodative convergence / accommodation ratio). This is an extremely COMMON problem in kids. That is, their distance correction makes them straight at far, but they still cross at near, wearing the full cycloplegic refraction. In most cases, by reducing the accommodation at near, you can reduce the near crossing and make it straight by proper choice of bifocal power. This is different from reading bifocals to read because of near blur due to poor accommodation, which is what you seem ot be thinking of. True, a 7 year old should not have a problem focusing at near. But, some do - the optometrists call it accommodation infacility, or accommodative insufficiency if worse. Some kids, especially when going thru growth spurts, seem to have trouble reading, and a lower power reading glasses gets them through the few months that this seems to take to get back to normal. neil0502 wrote:. >> I'm puzzled that your seven year old son was put in bifocals. That >> implies that his ophthalmologist feels your son has a dysfunctional >> accommodative (focusing) mechanism--relatively unusual for a seven >> year old, I would think. > Actually, it is done for high AC/A ratio (accommodative convergence / > accommodation ratio). This is an extremely COMMON problem in kids. [quoted text clipped - 11 lines] > power reading glasses gets them through the few months that this > seems to take to get back to normal. Got it. Thank you. On 10/28/04 8:10 PM, in article ba5daa9c.0410281910.4a3b50c9@posting.google.com, "danielle" <wildman@dwave.net> wrote: >> Danielle wrote: >> [quoted text clipped - 115 lines] > If you can think of any good questions to ask his dr, please let me > know. Thanks! Danielle The Rx is a low plus, which is why the glasses made no difference in the angle. In a few cases, it can even in this low Rx. Bifocals are only helpful if the eyes are (almost) straight in the distance, and cross at near, and if the bifocals then make the eyes straight at near also. If the eyes are significantly crosses in the distance, even if the bifocals make the increased near crossing less, it won't make them straight, so they are of little if any value in that case. At this point there is really nothing else to do besides wait and see what happens at the end of the 6 weeks. If he is double, wouldn't hurt to patch one eye or blur it (frosted scotch tape on the eyeglass) especially in school. Probably won't influence the angle one way or the other. > Dr. Robbins, > > A couple of quick questions, if I may: > > 1) Prism Adaptive Trials?? Since this is surgery #2, perhaps there is more > eso- than "meets the eye." PAT testing works when there is some fusion confounding the esotropia measurements, typically with acquired strabismus, causing undermeasurement of the angle. This results in too little surgery, and persistent esotropia after surgery. In this case, the eyes are overreacting to the surgery which is the opposite. > 2) Delayed Adjustable Suturing?? If it wasn't used, perhaps it should be > discussed if, indeed, a third surgery is considered. Can't do it at this young age. Most adjustable sutures are done once awake, and are limited to cooperative patients (ie over 13 years old or so), as it is uncomfortable - you are pulling on the sutures on the eye to adjust the angle in the office, and then tying it. I make angle measurements like I always do, using prisms while they look at the eye chart. I use this in almost all adult patients, not in children. Some do attempt something like this in kids. They wake them up in the recovery room and just look at them. Then, the anesthesiologist puts them back under, in the recovery room, and the angle sutures are changed and/or tied. Problem is, there are very few OR's where they will allow this to happen in the recovery room - it is not set up to administer anesthesia. Also, the angles are not really measured, and it is a guesstimate. Plus, it is usually done when the child is still very groggy, and this can cause angle that do not represent what they would be when fully awake. I have never done this, and I know only a few who have managed to get this by the regulators. > 3) Would it be important to know whether this child was an infantile > esotrope? If he is not, then isn't it likely that he has developed enough > of a fusion mechanism that vision therapy might be a better approach to take > care of post-op exo- than a third surgery, especially if the residual > exotropia is less than 8-10d? ISTR that vision therapy has a higher success > rate with exo- than esotropia, no? Fusion exercises work in some cases, but "vision therapy" is not always that. I myself don't have experience with vision therapy. > 4) If this child is also a high-plus, it would seem very, very important to > get this exotropia tamed, even if prisms were necessary If this child is high-plus, glasses would make him look through a base-in prism, true. However, it sounds like he used to be straighter, and went more eso, so there is probably little, if any, fusion. In that case, most likely doesn't much matter what the prismatic effect is. > Thanks, > > Neil DANIELLE: I'll respond to your e-mail as well. Again, I'm not a doctor--just a long-time eye patient who's had three strabismus surgeries (and a host of other issues that resulted from eye alignment, etc.) myself. The /medical/ advice has to come from the Dr. Robinses (and others) of this world and your son's ophthalmologist. I've learned quite a bit on the way, but . . . a little knowledge can be a dangerous thing. Hopefully, I can raise some issues that may benefit your son in the long term, but I don't call the shots. You and your son's doctors do. Neil0502 wrote: >> A couple of quick questions, if I may: >> >> 1) Prism Adaptive Trials?? Since this is surgery #2, perhaps there >> is more eso- than "meets the eye." > PAT testing works when there is some fusion confounding the esotropia > measurements, typically with acquired strabismus, causing > undermeasurement of the angle. This results in too little surgery, > and persistent esotropia after surgery. In this case, the eyes are > overreacting to the surgery which is the opposite. Thank you. Obviously, we haven't heard the near vs. distant alignment preoperatively. Assuming it was concomitant, I'm thinking this second surgery may have overshot, possibly by quite a bit. I was raising the PAT concept as a way of adding more science to the art. But you're right: it's after the fact. >> 2) Delayed Adjustable Suturing?? If it wasn't used, perhaps it >> should be discussed if, indeed, a third surgery is considered. > Can't do it at this young age. > [quoted text clipped - 15 lines] > would be when fully awake. I have never done this, and I know only a > few who have managed to get this by the regulators. Sigh. I get it. Thanks. >> 3) Would it be important to know whether this child was an infantile >> esotrope? If he is not, then isn't it likely that he has developed [quoted text clipped - 3 lines] >> vision therapy has a higher success rate with exo- than esotropia, >> no? > Fusion exercises work in some cases, but "vision therapy" is not > always that. I myself don't have experience with vision therapy. Fusion exercises is what I was implying. I was hoping that (if there had ever been fusion and the residual exo- was low enough) this child could build his fusional amplitudes and avoid a potential third surgery.... >> 4) If this child is also a high-plus, it would seem very, very >> important to get this exotropia tamed, even if prisms were necessary > If this child is high-plus, glasses would make him look through a > base-in prism, true. However, it sounds like he used to be > straighter, and went more eso, so there is probably little, if any, > fusion. In that case, most likely doesn't much matter what the > prismatic effect is. I was also thinking about /reading/. If this child is exotropic post-op, /and/ is a reasonably high hyperope (I'm thinking +4d or higher), would there not be a significant additional strain to read (triad of accommodation)? My point here is that it may be important to get this child into full plus (again, assuming hyperopia) correction, fusional amplitude exercises, and possibly prisms (hopefully to be reduced or eliminated on the success of the fusional work) to reduce the likelihood of further binocular dysfunction or accommodative issues down the road. Thoughts?? Thanks, Dr. >> If this child is high-plus, glasses would make him look through a >> base-in prism, true. However, it sounds like he used to be [quoted text clipped - 14 lines] > > Thanks, Dr. Actually, reducing the plus migh be used here, using accommodative convergence to get the exo smaller, but can't reduce the hyperopia by more than maybe 3 D. I would assume glasses were used before and after surgery, as is the general rule. Fusional amplitude exercises work is there is fusion, and from the sound of this case, there probably is no real fusion. In most cases I've seen, fusion exercises are not of real use. Unless the angle gets to be small, prisms are also not helpful even if there was fusion, as large prisms cause too much distortion. In smaller angles, prisms are of use if there really is fusion, and low fusional amplitudes that cannot maintain alignment alone. As long as the angle is less than about 12 prism diopters postoperatively, this is in the range for some peripheral fusion, the only kind of fusion most of these cases have. >>> If this child is high-plus, glasses would make him look through a >>> base-in prism, true. However, it sounds like he used to be >>> straighter, and went more eso, so there is probably little, if any, >>> fusion. In that case, most likely doesn't much matter what the >>> prismatic effect is. Neil0502 wrote: >> I was also thinking about /reading/. If this child is exotropic >> post-op, /and/ is a reasonably high hyperope (I'm thinking +4d or [quoted text clipped - 5 lines] >> fusional work) to reduce the likelihood of further binocular >> dysfunction or accommodative issues down the road. > Actually, reducing the plus migh be used here, using accommodative > convergence to get the exo smaller, but can't reduce the hyperopia by [quoted text clipped - 9 lines] > postoperatively, this is in the range for some peripheral fusion, the > only kind of fusion most of these cases have. Ah, true: putting more plus on an exotrope pushes the eyes further out, complicating the problem (why I don't like to wear additional plus to try reading....). In cases of low fusion and relatively small-angle deviations, prisms might only be useful, then, for cosmesis? Thanks. On 10/29/04 7:57 AM, in article tTsgd.2111$zx1.1269@newssvr13.news.prodigy.com, "neil0502" . > Ah, true: putting more plus on an exotrope pushes the eyes further out, > complicating the problem (why I don't like to wear additional plus to try [quoted text clipped - 4 lines] > > Thanks. Prisms can reduce/eliminate diplopia when there is low fusion and small angle deviation, where diplopia is a problem. If no diplopia, no need for prism usually. |
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