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Medical Forum / General / Vision / February 2006v pattern exotropia and therapy w/ 20/20 vision (help)
My son is 6 1/2 years old. He has seen a pediatric ophthalmology for over 4 years. We were first told that the bridge of his nose is very wide which makes it look like he has strabismus. About one year later we were told he does have strabismus not hte bridge issue. The dr has been treating my son every 6months with simple observation. I went last week and was told that Jacob needs surgery (a little shock) I was told that he has such a mild case that surgery would not be needed now it has become bad enough he needs surgery. I was told that he started at a 10 and has gone from a 15 and is now a 20 (I have no idea what that means and he would not explain it said he would review at the consult prior to surgery) My son has 20/20 vision and does not wear glasses at all and never has and we have never done the patch thing I was told it would not work. (not convinced now). I am told that he has v pattern extropia. I cannot find anything on v pattern. I need to know if anyone can tell me if my son really needs surgery or if therapy which I just found even existed would work. I would alspo like to know a time frame for therapy. It is my understanding my sons case is very mild but Dr. said I need to make a decision within 3-6 months. I have a very small window to work with and I am afraid to let it go to long and to make my current Dr made incase I have to revert to the surgery. He is the best surgeon in my are. Can anyone help. One very concerned Mom thanks Dear Bubo, Subject: Conflicting opinions. I am not a doctor -- but I have had a similar experience. I will be "attacked" because I suggest you undedrstand BOTH the majority opinion -- and the second opinion. The majority opinion is to "cut" the muscle as soon as possible. That is the majority opinion. The second-opinion is to find a "behaviorial" optomterist in the phone book -- and call him. This is the second-opinion -- and I support it. This involves "visual training", and I would take your child to that optometrist for his evaluation. (This statement does not reflect on the "competency" of EITHER OD OR MD). It is just that they have opposite but competent training in these specialities. I personlly believe that the "visual training" (while frustrating) had the better effect. But this decision is yours alone to make. Best, Otis > The majority opinion is to "cut" the > muscle as soon as possible. That > is the majority opinion. Is it? I wonder how you knew that. So would you tell us whether the exotropia was constant, or intermittent? I would think that's important. And of course you considered how often the child experiences diplopia, and how he scores on stereo acuity testing, before making a recommendation. We're so fortunate to have your opinion on this. Your comments clarified so much. -MT Dear Mike, It is intersting how you attack me -- and decline to answer bubo's questions. Otis > It is intersting how you attack me -- and decline to answer > bubo's questions. I don't have enough data to be answering questions. How do you make medical recommendations without data? -MT > It is intersting how you attack me -- and decline to answer > bubo's questions. Dear Mike, I don't have enough data to be answering questions. Otis> Then why do you post here? How do you make medical recommendations without data? Otis> You are confused. I have made A SUGGESTION to bubo THAT IS NOT A MEDICAL RECOMMENDATION!!!! Otis> You do not seem to understand the meaning of these words. Otis> I SUGGESTED that she look for a SECOND OPINION. THAT IS NOT A MEDICAL RECOMMENDATION AT ALL. That is just the idea to be "wise" about these two methods -- with NO ENDORCEMENT OF EITHER METHODS> Otis> I have had BOTH THESE METHODS USED ON ME, (as a 6 year-old child) and so I do have my own personal opinion about these issues. That is why I stated that "I am not a doctor", and you proceed to ASSUME that I have made a MEDICAL recommendaton -- WHICH I HAVE NOT DONE. Otis> Jeeze! Otis -MT The numbers are prism diopters, which is a commonly used measuring nomenclature in strabismus. (The numbers are derived on the optical bench, 1 prism diopter means light deviated 1 cm of axis at 100 cm distance.) To think in degrees, divide the prisms by 2 for a rough approximation. (20 prisms is about 10 degrees.) The prism numbers are marked on the prisms themselves. Some people, particularly in Europe measure in degrees. Usually, surgery is not done for angles less than 15 prism diopters. Since he was originally 10, you would not operate. At 20 , you would. However, I like to wait for the angle to be stable. If it is still increasing, and you operate. The angle may again increasingly angle in after surgery. Stability is determined by repeat measurements over a time. I wait at least 1-2 months between measurements, and like to have 3-4 that are approximately the same. If you measure over too short a time, you won't see the change. Of couse, you may have a very slow increase, and even this length of time may not pick it up. Question is, how long do you wait to be sure it is stable? V-pattern means the eyes angle in more on downgaze and less on upgaze. V-patterrn is a common association with childhood esotropia. If the v-pattern is small (less than 10 prism change from up to down), you can just do vertical transposition of the medial recti when they are operated, moving them down toward the point of the V. If ti is larger, and if there is inferior oblique overaction to explain a larger V-pattern, then one weakens the inferior obliques perhaps in conjunction with the vertical transposition, depending on the change in the V from center to down, and center to up. Patching is not for correction of the angle. It is used for treating amblyopia - unequal vision. If there is amblyopia, it should be treated fully before surgery. Sometimes treating the amblyopia happens to result in better alignment and reducing need for surgery. More often, the angle remains unchanged by the patching. Some kids start out having only pseudostrabismus (the wide bridge illusion of eye crossing), and some may separately have strabismus then, or develop it later. Unrelated to whether or not there was pseudostrabismus. David Robins, MD Board certified Ophthalmologist Pediatric and adult strabismus subspecialty Member of AAPOS (American Association of Pediatric Ophthalmology and Strabismus) > My son is 6 1/2 years old. He has seen a pediatric ophthalmology for over 4 > years. We were first told that the bridge of his nose is very wide which [quoted text clipped - 23 lines] > > thanks DOES THIS MEAN ONLY SURGERY WOULD WORK OR IS THERAY AN OPTION I SHOULD FURTHER INVESTIGATE?? THANK YOU SO MUCH FOR YOU REPLY. >The numbers are prism diopters, which is a commonly used measuring >nomenclature in strabismus. (The numbers are derived on the optical bench, 1 [quoted text clipped - 44 lines] >> >> thanks Dear Bubo, Subject: Recommendations for you to look for the second opinion. I would like to state that I resent the attack by Mike Tyner on my suggestions to you. The turn out to be "classic" recommendations. Each doctor must do as he believes -- and was taught -- and that is only reasonable. I suggested you look for the "second opinion", and Mike Tyner "attacked" me for making that recommendation!!! I had developed slight "strabmismus" (eye turn) as a young child. The result was that I had BOTH procedures used on me. Eye-training (stereo-scope -- and others), and muscle-cut. That does not make me an "expert" in the sense of these two "methods" but I certainly formed an opinion -- that you should become knowledgeable of these issues. MY PERESONAL OPINION (Get it, Mike Tyner?) is that the "training" was "difficult" since I had to be "pushed" to do it. (Children are not at all easy to deal with.) By this I learned to "control" the eye turn -- and I could intentionally "fuse" intentionally. I think that is the better way. You should also monitor your childs "close work" habits, i.e., how close does move his eyes to read, or play with toys. Even at that young age, some kids develop some seriously bad habits (myself included.) But, as Mike Suggested -- find a "vision traning" optometrist, and consult with him. A second-opinion would be of value to you child. Best, Otis > But, as Mike Suggested -- find a "vision traning" optometrist, Mike did not suggest a "vision traning" optometrist, nor a "behavioral" optometrist. And Mike did not trash an entire medical specialty in order to insert his own "Second Opinion." Mike implied that a "third opinion" option may exist - which is _no_ treatment, for the present. Mike also did some research before trying to answer. Does this mean you're going to continue offering your off-the-cuff "Second Opinion" for every new question that pops up? After all, if you answer enough questions, you're bound to get something right eventually. Apologies to Bubo for turning this into a squabble. -MT Otis, are you one of those people who incessantly does air quotes (you know, using 2 fingers of each hand to make bunny ears in the air) when you talk? > The turn out to be "classic" recommendations. > ... the "second opinion", and Mike Tyner "attacked" me [quoted text clipped - 6 lines] > You should also monitor your childs "close work" habits, > But, as Mike Suggested -- find a "vision traning" Also, you constantly tell people to seek the second opinion. What is that? I asked my doctor. I then asked a second doctor for a second opinion. The second doctor didn't say anything close to what you suggest. Should I have asked for THE Second Opinion? Maybe you should refer to this as the "10 thousandth opinion"? -Quick On 1/26/06 5:58 AM, in article 5aefad936c3f4@uwe, "bubo via MedKB.com" <u18066@uwe> wrote: > DOES THIS MEAN ONLY SURGERY WOULD WORK OR IS THERAY AN OPTION I SHOULD > FURTHER INVESTIGATE?? THANK YOU SO MUCH FOR YOU REPLY. Surgery is not guaranteed to work either. In exotropes, it is likely to be reasonably straight with 1 surgery in about 60-70%. If it is intermittent, then orthoptic treatment (what you are calling "therapy") may indeed play a role. I was just explaining measurement and surgery issues. >> The numbers are prism diopters, which is a commonly used measuring >> nomenclature in strabismus. (The numbers are derived on the optical bench, 1 [quoted text clipped - 44 lines] >>> >>> thanks ERROR ERROR ERROR: I misread that it was exotropia, not esotropia. Some overall information, except the surgery is usually done on the lateral recti (outer muscles). For V-pattern exotropia, the vertical transposition of the laterals would be to move them up towards the top of the V; the opposite from V-pattern esotropia. > My son is 6 1/2 years old. He has seen a pediatric ophthalmology for over 4 > years. We were first told that the bridge of his nose is very wide which [quoted text clipped - 23 lines] > > thanks > I need to know if anyone can tell me if my son really needs surgery or if > therapy which I just found even existed would work. I would alspo like to > know a time frame for therapy. It is my understanding my sons case is > very > mild but Dr. said I need to make a decision within 3-6 months. I'm sorry we haven't offered a clear-cut answer. I'm not sure there is one. I'd use the time to seek out a second opinion from a doctor who doesn't do surgery. I've had V-pattern exotropia all my life. The only symptom is a tendency to see double when I look way up. But mine is mild enough that I can compensate (make things single) with effort. It's never been enough of a problem to justify surgery _or_ therapy. If your son is 20/20 in each eye, he doesn't have amblyopia and isn't likely to develop it from intermittent exotropia. Patching is a treatment for amblyopia, so there's no need for patching. The decision to do surgery should be based on symptoms. If he sees double in straight-ahead gaze, or if he develops the habit of tilting his head back, those are clear indications that surgery is warranted. Without those clear-cut symptoms, I'd want an opinion from a competent optometrist who sees lots of children, or in a teaching clinic. If you'll tell us what area you live in, we can make some suggestions. -MT > The decision to do surgery should be based on symptoms. If he sees > double in straight-ahead gaze, or if he develops the habit of tilting [quoted text clipped - 3 lines] > optometrist who sees lots of children, or in a teaching clinic. If > you'll tell us what area you live in, we can make some suggestions. Is there a cosmetic issue, as well? I would think that plenty of folk with big strabismus don't see double, as the brain learns tricks to pick which eye is doing the viewing and suppressing information from the other eye. Some people might not like looking as if their eyes are misaligned all the time, and it could have nothing to do with functionality or binocularity.  SignatureScott Reverse name to reply On 1/26/06 6:43 AM, in article Xd5Cf.615$Nv2.156@newsread1.news.atl.earthlink.net, "Mike Tyner" <mtyner@mindspring.com> wrote: >> I need to know if anyone can tell me if my son really needs surgery or if >> therapy which I just found even existed would work. I would alspo like to [quoted text clipped - 24 lines] > > -MT The decision to operate does depend on symptoms or cosmesis, as above. However, if there is recoverable stereopsis (fusion of images), this should also be taken into account. This is an important part of visual functioning. Many cases this is not an issue, as no fusion is possible, but if it is possible, the longer it stays out, the less likelihood for recovery. So, the recently decompensated strabismic has a greater chance than long-standing ones, and congenital ones rarely have any chance of recovery after 2-3 years old. An intermittent exotrope who is straight at least 50% of the time is still retaining the ability to fuse fairly well. > An intermittent exotrope who is straight at least 50% of the time is still > retaining the ability to fuse fairly well. One other thing is nagging at me. The OP said "we were told that the bridge of his nose was wide, which makes it look like he has strabismus." It's a very convincing illusion, but to me it's always looked like ESOtropia, not EXOtropia. In either case, the key is whether or not it's constant. If so, surgery is much more appropriate. -MT On 1/27/06 6:12 AM, in article mTpCf.6500$rH5.778@newsread2.news.atl.earthlink.net, "Mike Tyner" <mtyner@mindspring.com> wrote: >> An intermittent exotrope who is straight at least 50% of the time is still >> retaining the ability to fuse fairly well. [quoted text clipped - 4 lines] > It's a very convincing illusion, but to me it's always looked like > ESOtropia, not EXOtropia. Certainly, which is why I originally wrote about surgery for esotropia, rather than exotropia! BTW, I have seen the wide bridge/epicanthal folds HIDE an exotropia. That is, they were exotropic on measurement, but the pseudoesotropia of the folds compensated for the visibility of the exotropia, making it look about normal. > In either case, the key is whether or not it's constant. If so, surgery is > much more appropriate. > > -MT > BTW, I have seen the wide bridge/epicanthal folds HIDE an > exotropia. That is, they were exotropic on measurement, but > the pseudoesotropia of the folds compensated for the visibility > of the exotropia, making it look about normal. Good catch! -MT Okay maybe I am just extremly ignorant or very confused. But my son has exotropia with 20/20 vision it is not cosmetic only myself and the doctor really notice it. I can not tell if you are telling me that vision thereapy is an option or if surgry is it. The dr states that vision therapy would not fix his problem. I am going to get a second opinion can you direct me to a few dr's I am in Mogadore, Ohio 44260. Thanks >On 1/27/06 6:12 AM, in article >mTpCf.6500$rH5.778@newsread2.news.atl.earthlink.net, "Mike Tyner" [quoted text clipped - 18 lines] >> >> -MT Dear Bubo, Subject: No one can tell you what to do! Re: The nature of the second opinion. I AM NOT A DOCTOR. But I was a child with "controlled" strabismus, and received BOTH treatments. I am well-aware of the frustration of "vision training" but I personally think it is a good "second opinion". Each doctor must do what he believes is "right". But there is a profound difference in what can be done. I would suggest that you look for a "behaviorial" optometrist" (and I think the initials are COVD) in your general area. You MIGHT find one on your own town. Look in the phone book -- and call them up and talk to them. They will help you if you let them! There is "overt" problems with the eyes -- where "fusion" is broken, and the eye "drifts" either "out" or "in". It is not clear if that is the case with you child. If the eye is visibly drifting "out" then that is strabismus. (I did this myself -- and learned to "control" it through "vision training".) So that is your choice -- in my opinion. We can talk endlessly about it -- but each man will do what he thinks is "right" for your child. He would do the SAME if it were his own child. This does not make either opinion "right" or "wrong" it just tells you there is an anternative. Good luck -- but find that second-opinion optometrist and have him look at your child. It is worth the effort. Good luck, Otis Okay maybe I am just extremly ignorant or very confused. But my son has exotropia with 20/20 vision it is not cosmetic only myself and the doctor really notice it. I can not tell if you are telling me that vision thereapy is an option or if surgry is it. The dr states that vision therapy would not fix his problem. I am going to get a second opinion can you direct me to a few dr's I am in Mogadore, Ohio 44260. Thanks Otis Brown opened his mouth and farted out the following stupid remark: >Good luck -- but find that second-opinion optometrist >and have him look at your child. It is worth the effort. please disregard otis brown. he is a moron and knows nothing about strabismus, myopia or any ophthalmic condition. right now he is under investigation by the State of Pennsylvania for practicing optometry without a license. maybe you can find a second opinion optometrist by looking in the yellow pages under "Optometrist-- Second Opinion". ;) Dear Bubo, Subject: Calling "second opinion" ODs -- total idiots This is why I suggest finding a second-opinion OD who will SUPPORT you rather than calling anyone and everyone a "total idiot" who attempts to help you with this second-opinion. That has been all to "common" in the history of "medicine" -- strong opinions with scant scientific support. Try this site for a CO in Vision Development -- which describes your child. Try to ignore the majority-opinion "rants" that go on around here. http://www.optometrists.org/Boston/articles.html Best, Otis "second opinion" <--- THE Second Opinion "total idiot" "common" "medicine" "rants" Quote count: 5 Post size: tiny -Quick what is a "CO in Vision Development"? oh, i forgot. you are a moron. On 1/31/06 6:09 AM, in article 5b2ea26e52613@uwe, "bubo via MedKB.com" <u18066@uwe> wrote: > Okay maybe I am just extremly ignorant or very confused. But my son has > exotropia with 20/20 vision it is not cosmetic only myself and the doctor > really notice it. I can not tell if you are telling me that vision thereapy > is an option or if surgry is it. The dr states that vision therapy would not > fix his problem. I am going to get a second opinion can you direct me to a > few dr's I am in Mogadore, Ohio 44260. Thanks Don't know anyone in the area there. As a pediatric ophthalmologist, I really don't do any vision therapy. That tends to be confined to some optometrists. HOWEVER, there is vision therapy and there is vision therapy. There are some unscrupulous types who rope you into a year of $10,000 treatments to fix whatever ails you. Those are not the ones you want. You want someone who is skilled at the kind of eye exercises that MAY help certain types of exotropia - some cannot be helped. The person may be a particular type of optometrist, or it may be an orthoptist working for an optometrist of pediatric ophthalmologist. I must say, there are fewer and fewer orthoptists around; most came from Britain. I don't know if they still train any in this country. Regarding surgery, there is in the realm of the pediatric/strabismus ophthalmologist. However, as has been pointed out, many do only surgery, no other treatments. If the exotropia is not cosmetically objectionable, and if it is intermittent, then it may not require any treatment. I would get a second opinion or two. Dear Bubo, The reason I suggest a "Behaviorial" OD is because: He will be "commited" to this "vision therapy". (I would be careful -- because as David Robins says, you can be badly treated $$$ on this issue.) If this Behaviorial OD also agrees that the child requires a rectus cut, then you will feel much better about it. A second-opinion is always good. Your child has nothing to loose. Neither opinion is "right" or "wrong" and that is NEVER my implication. It is more "educational" -- so you feel better about the decision you will be making. Best, Otis Dear Bubo, Here is a website that you might find useful for your child. http://www.eyecaretrust.org.uk/index.php If the condition is mild -- this might be a second-opinion alternative. It pays to consider alternatives. Otis ------------- > My son is 6 1/2 years old. He has seen a pediatric ophthalmology for over 4 > years. We were first told that the bridge of his nose is very wide which [quoted text clipped - 23 lines] > > thanks Otis Brown stupidly typed the following message, further proving that he is a total idiot: >Dear Bubo, > [quoted text clipped - 4 lines] >If the condition is mild -- this might be a second-opinion >alternative. It pays to consider alternatives. gee otis, what a great post. i'm sure bubo really appreciates getting a link to a site in Great Britain. especially since he lives in Ohio you moron. go post in some forum regarding engineering or alzheimers or something. |
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