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Medical Forum / General / Vision / April 2005Estropia in Toddler-followup..
Hi everyone. Earlier back in jan we had posted here for help ( http://groups-beta.google.com/group/sci.med.vision/browse_frm/thread/456501f8702 7fdde/e11c0498381eb2ba?tvc=1&q=estropia+toddler#e11c0498381eb2ba) Our 3 1/2 year old seemed to have slightly crossed eyes, so we took him in to be checked and he was diagnosed as farsighted @ +2 , causing " accomodative estropia" and was prescibed glasses. Supposedly, after a month's use he should have less crossed eyes after using the glasses. Well , today we had the followup, and here is what we were told: There is no significant change noted. he sees equally well with or without the glasses, through both eyes, and his estropia is about 35 Degrees. The doctor recommends surgery to correct the 35 degree mis-alignment. The doctor said we could continue the glasses another 30 days and see if they straighten then, but he was certain enough himself to say we could go ahead and schedule surgery immediately. We are really at our wit's end! Our poor little guy faithfully wore his glasses from day one, every waking moment, and now, prefers them on, saying its a little fuzzy without them(:<. Once again , a few questions? 1. If this was a muscular alignment problem, why was it not present from birth? It appeared noticeable around 2 1/2 yrs. 2. The doctor says he would likely NOT need glasses after surgery, or indeed right now. (even noted "no need to continue glasses" on his chart) Has he harmed his eyes, or become dependent on his glasses already? 3.If it appeared to us as a worsening condition, what is to say we go through the surgery and then they start again to cross?? Any input very much appreciated..we are for to try to find a few more opinions, We will try to post back as we know more, Thanks again, G First of all, 35 prism diopters is quite a bit of esotropia. I would imagine that his eye is turned almost all the way in toward his nose. Any person could it. However, I would want to have a few more answers before I submitted my 3.5 y/o to surgery. For a starter, I would want to know if the +2 diopters of farsightedness was the manifest refraction or the cycloplegic refraction. I would also want to know if additional plus could be given in the form of a bifocal, if not in the distance prescription. I would also want to know if the child has a lazy eye, i.e. didn't see as well as the good eye. DrG I meant to say that any person could see 35 diopters of esotropia. Sometimes I don't proofread my posts. DrG He did not say 35 diopters, he said 35 degrees, and then further, he said the muscle moved would need to be moved about 5 mm?? It truley is not very noticeable. I will ask about the 2 types pf refraction and get back.. FYI.. his doctor is a Ped. Opth.--board certified.. G > FYI.. his doctor is a Ped. Opth.--board certified.. It seems that the more the titles, the more the incompetence. >> FYI.. his doctor is a Ped. Opth.--board certified.. > >It seems that the more the titles, the more the incompetence. Signed Rishi, BSc, MS, PhD, MD, JD, CPA, MD, MAI The standard method of determining the degree of misalignment is by using prism. The amount of prism needed to produce alignment of the visual axes is expressed in prism diopters. I assumed that 35 degrees meant 35 prism diopters, which would seem to correspond to 5mm of muscle recession (although I am not a surgeon). By the way, I correctly assumed that the doctor was a pediatric ophthalmologist. As a non-surgeon, I am merely expressing the steps I would take before I recommended surgery for a child of 3.5 years with accommodative esotropia. In other words, I would try to push additional plus. Also, if the turned eye is amblyopic, that needs to be treated. The presence of amblyopia reduces the treatment prognosis for eyeglasses and surgery. Typically, the threshold for cosmesis is about 10-15 prism diopters of strabismus. Less than that is difficult to see by anybody except a trained observer. 35 prism diopters is definitely noticeable, and is a surgical amount of strabismus. Eyeglasses may not ultimately work, but if it were me, I would want to make every reasonable attempt. DrG >The standard method of determining the degree of misalignment is by >using prism. The amount of prism needed to produce alignment of the [quoted text clipped - 15 lines] >surgical amount of strabismus. Eyeglasses may not ultimately work, but >if it were me, I would want to make every reasonable attempt. Doc, How about Phospholine Iodide? Worth looking into?? Neil Never having used phospholine iodide, I cannot say. It is a long-acting anti-cholinesterase that is used not only to treat glaucoma (rarely), but also to treat accommodative esotropia. It does this by reducing the AC/A ratio, or the amount of convergence produced by accommodation. Pilocarpine gel is also used for the same purpose. I guess I am of the older school which favors non-surgical methods prior to surgical methods of intervention for most things, unless there is clear and convincing evidence to the contrary. DrG Phospholine iodide is used as an adjunct treatment for esotropia caused by accommodation, where accommodation-reducing glasses canot be worn due to poor compliance, or where bifocals would otherwise be prescribed, and there is some reason not to use the bifocals. Not at all useful for non-accommodative esotropia. P.I. Has its problems - can cause iris cysts (prevented by concomitant use of phenylephrine drops), and can cause a serious anesthesia reaction if certain drugs are used for emergency surgery and the anesthesiologist doesn't know about the drug being used. Also, it is difficult to titrate this medication, especially since the company stopped making it a few years ago, and only reintroduced one strength at the petition of the pediatric ophthalmology community. I never use it, and know very few people who do. I find it much simpler to use bifocals, where I can wean someone off them later on. David Robins, MD Board certified Ophthalmologist Pediatric and strabismus subspecialty Member of AAPOS (American Academy of Pediatric Ophthalmology and Strabismus) > Doc, > [quoted text clipped - 3 lines] > > Neil > Also, it is difficult to titrate this medication, especially since the > company stopped making it a few years ago, and only reintroduced one > strength at the petition of the pediatric ophthalmology community. I never > use it, and know very few people who do. I find it much simpler to use > bifocals, where I can wean someone off them later on. Where is the science here? Isn't science a reproducibility of facts? It is always an arbitrary choice of the physician, I see. In fact the only true scientific method that works always is Dr. Bates'. > He did not say 35 diopters, he said 35 degrees, and then further, he > said the muscle moved would need to be moved about 5 mm?? It truley is [quoted text clipped - 5 lines] > > G 35 degrees would be even a larger angle, more noticeable than 35 prism diopters. I agree with the other posters, this would be very noticeable to casual observation, a very crossed eye. Is it always the same eye, or does he alternate? Is maybe the angle larger when he views a very close object? I also agree with making sure he's been completely cyclopleged to be sure all the hyperopia is manifested; I'd probably use atropine just to be sure. If he's really only +2 to complete cycloplegia and still has the esotropia, I'd go for the surgery, if it were my child. w.stacy, o.d. Dear Austin, Subject: Different opinions, i.e., second opinions I am an engineer -- not "medical". Since I have BOTH procedures used on me -- I will give you advice from personal experience. (I got into this at the age of about seven -- not three.) I am certain that Ped. Opth. believe in "cutting" the muscle -- but I would attempt to hold off on doing that. I would suggest finding a BEHAVIORIAL optometrist. This approach is slower, and frustrating -- but better in the long-run. This is the "second opinion", and your Ped. Opth. should respect it as such. You can always "cut the muscle" at some later date -- there is no hurry in doing it. You will find very strong opinions on this subject. Good luck. Best, Otis Engineer > I would suggest finding a BEHAVIORIAL optometrist. > This approach is slower, and frustrating -- but better in the > long-run. <snip> > You can always "cut the muscle" at some later date -- there > is no hurry in doing it. Dear Austin, Please disregard Otis's postings. He is not in the medical profession and is not in any position to give medical advice. The above can be construed as medical advice Thank you. Allen > is not in any position to give medical advice. The above can be construed > as medical advice Poor Otis is simply telling you that he has been cheated in his early childhood by some idiotic ocular specialist who destroyed his natural muscles and did not treat him according to science but only to butchery. However, since Dr. Bates gives directions to cure even amblyopia, I don't see any harm in letting the poor eye of the child follow his own course of life. What I have witnessed today with the young lady coming from a -23 D prescritpion gives me once more the easy certainty that Dr. Bates is 100% correct in everything he has written. Following true logic, actual doctors are 100% wrong. > You can always "cut the muscle" at some later date -- there > is no hurry in doing it. Disregard any input from Otis. He claims to be an engineer and admits to no training in eyecare or vision sciences. Why he feels compelled to post on some topic like this escapes me. There actually IS a hurry to figure out the problem. Anyone with a large esotropia can develop site-threatening amblyopia unless it is properly treated. I would follow the good advise you got earlier in this thread. The pertinent question is, what is the cycloplegic refraction-- if it's more than +2.00 then his glasses need to be stronger. If he has a large esotropia remaining even after using the maximum plus spectacle refraction, then surgery is probably indicated. And if his best-corrected acuity now is lower in one eye (meaning he has some measure of amblyopia already) then the importance of fixing the problem becomes more acute. Do not fear surgery-- it is a quite reasonable and safe procedure. Just check that a simple change in his glasses doesn't solve the problem first. You need to take your son to a person who specialises in none surgical correction of strabismus in small children. "Successfull" surgery for strabismus often produces a straighter eye but no normal function of the eye. Nevertheless this is regarded by the surgeon as a successful outcome. See if you can find a behavioural optometrist who specialises in childhood strabismus. > "Successfull" surgery for strabismus often produces a straighter eye > but no normal function of the eye. Nevertheless this is regarded by > the surgeon as a successful outcome. This science is mad of charlatans, con men, and fakes. The problem with this advice is that precious time is wasting. The truth is that the earlier the surgery, the more likely normal binocularity will be established. And if I did get an opinion from a behavioral optometrist, I'd make sure he/she were competent in pediatric strabismus and that he/she had a good working relationship with a pediatric opthalmic surgeon. w.stacy, o.d. > You need to take your son to a person who specialises in none surgical > correction of strabismus in small children. [quoted text clipped - 5 lines] > See if you can find a behavioural optometrist who specialises in > childhood strabismus. oops, that's pediatric "ophthalmic" surgeon... even I make misteaks sumtimes... > The problem with this advice is that precious time is wasting. The > truth is that the earlier the surgery, the more likely normal > binocularity will be established. And if I did get an opinion from a What time is being wasted? The father says the symptom is scarcely noticeable. Also the father says the child --- before he was put glasses on --- was in good shape and could look at things near and close without trouble. Why are you creating unnecessary trouble? But the parents are responsible. If they were more intelligent, they would have done different. > Hi everyone. > Earlier back in jan we had posted here for help ( http://groups-beta.google.com/group/sci.med.vision/browse_frm/thread/456501f8702 7fdde/e11c0498381eb2ba?tvc=1&q=estropia+toddler#e11c0498381eb2ba) > Our 3 1/2 year old seemed to have slightly crossed eyes, so we took him > in to be checked and he was diagnosed as farsighted @ +2 , causing " > accomodative estropia" and was prescibed glasses. Supposedly, after a > month's use he should have less crossed eyes after using the glasses. > Well , today we had the followup, and here is what we were told: What did you think you would have been told??? If the eyeglasses would prove unsatisfactory, of course the idiot doctor would have talked about surgery. Never they would have talked of THEIR OWN ERRORS. > to say we could go ahead and schedule surgery immediately. We are > really at our wit's end! Our poor little guy faithfully wore his > glasses from day one, every waking moment, and now, prefers them on, > saying its a little fuzzy without them(:<. Same old story... Poor guy, he was happy, now he is in misery, now they will operate on him, again another chunk of misery sticking on his soul... > 1. If this was a muscular alignment problem, why was it not present > from birth? > It appeared noticeable around 2 1/2 yrs. This is simple, due to mental strain, have you tried to rock him regulalry as told in the Stories From The Clinic book? > 2. The doctor says he would likely NOT need glasses after surgery, or > indeed right now. (even noted "no need to continue glasses" on his > chart) Has he harmed his eyes, or become dependent on his glasses > already? Of course yes, why are you in the need to ask doctors? Is not your intelligence enough to understand??? > 3.If it appeared to us as a worsening condition, what is to say we go > through the surgery and then they start again to cross?? Of course they will cross again and again as always happens. Doctors do not tell you this, I don't know why. It doesn't matter what he wrote. Just ignore him. He's thousands of miles away and only trying to sell books. The community mental health standards in Italy must be deplorable. There's the old saw about chimpanzees and typewriters that is very apropos for madmen and internet newsgroups. DrG > The community mental health standards in Italy must be deplorable. > > There's the old saw about chimpanzees and typewriters that is very > apropos for madmen and internet newsgroups. Well, I don't know. You don't have a clue. People comes here to get advice, and all that you can do is to recommend: eyeglasses, drugs, surgery. We all know well that: eyeglasses aggravate the symptoms of imperfect sight, once you put them on, when you put them off you see MUCH WORSE than before once drugs are mostly ineffective and create addictions and side-effects, and people become numb surgery is, when it works out fine, just "cosmetic". Do you think you have a good "mental standard" to offer to people by recommending the above treatments??? Because people are gullible, you continue to be in the business, otherwise it would have been different. Anyway, traces are left here, when we will have been proved successful, you will be able to know for yourself how much idiotic you are. Because, if you were right, there would have been non space for me to talk here. The mery fact that I talk here is because you are TOTALLY UNSUCCESSFUL with your clients. I would have no business if you were successful. Do you realize this? You just provided the evidence. Now, if only the Italian authorities would do their jobs... DrG > You just provided the evidence. Now, if only the Italian authorities > would do their jobs... Yes, Mussolini was hanged 60 years ago. What do you want to do now? You should be jailed for your incompetence and malicious treatments. But it is such a great inertia you have got on your side, that nothing will happen. See you later, dear comrade, perhaps in the jail I may teach you how to heal your own vision. > It doesn't matter what he wrote. Just ignore him. He's thousands of > miles away and only trying to sell books. You beat 'em all... |
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