This blog has been adapted from ‘The Sandwich Approach to Vision Therapy and Strabismus’, on The VisionHelpBlog, Dr Leornard Press OD FAAO FCOVD, Nov 2019

Imagine eating each of these separately: a leaf of lettuce, a few spicy pickles, a meat or vegetarian patty, a spoon of ketchup, a sesame bun and then two slices of cheese? …. Probably not great!

However, when you combine all of these items into a hamburger – together they become one of life’s most delicious treats … that’s the ‘sandwich’ effect!

What do sandwiches have to do with vision therapy?

Dr. Nancy Torgerson, together with the surgeon Dr. Thomas Lenart, reports that the term “sandwich approach” seems to be gaining traction for the combination of vision therapy and strabismus (eye turn) surgery are found to boost clinical outcomes in certain cases.

The ‘sandwich’ approach might consist of vision therapy before surgery to optimize sensory readiness for motor fusion, and/or after the surgery to stabilize or safeguard binocular vision.

To date there have been isolated case reports in the literature on using sandwich approaches of combining optometric vision therapy to provide a more optimized outcome of strabismus surgery.

As an example, Northwest Eye Surgeons posts on its website: “The goal of strabismus treatment is to improve eye alignment so that the eyes work together (binocular vision). Treatment addresses the underlying cause and may include eyeglasses, eye exercises, prism therapy, vision therapy and/or eye muscle surgery….”

How does vision therapy work?

Vision therapy works by teaching the brain to blend the information from the two eyes.

Many times, vision therapy can even align the eyes without surgery. 

In other cases, vision therapy is performed after surgery to help keep the eyes aligned and to further improve 3D vision, depth perception for sports, school, and driving.

In vision therapy programs various exercises are conducted to help the brain and eyes to improve eye coordination.

Strabismus affects not only how children and adults look, but see as well. Successful eye surgery along with vision therapy can help align eyes and create two-eyed depth perception for seeing the three-dimensional world.

A compendium from the Royal College of Ophthalmologists already notes the role of non-surgical exercises in the treatment of convergence insufficiency, distance esotropia and symptomatic phorias.

There are positive signs that eye doctors are appreciating the combination of vision therapy with strabismus surgery to deliver the optimum vision for patients … just one more ‘sandwich’ we can all enjoy!

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Sixth nerve palsy, also called abducens nerve palsy, is a rare condition that occurs when the sixth cranial nerve, also called the abducens nerve, becomes damaged.

Each year, around 11 in 100,000 people are diagnosed with sixth nerve palsy. 

The sixth cranial nerve is responsible for sending signals to the lateral rectus muscle. This small external eye muscle attaches to the outer side of your eye and turns your eye outward, away from your nose.

When the sixth cranial nerve becomes damaged, it prevents the lateral rectus muscle from contracting and results in an inward eye turn (esotropia) and double vision.

What causes sixth nerve palsy?

Sixth nerve palsy is generally diagnosed in adults above the age of 70, when diabetes (23%) and hypertension (20%) are most prevalent. Sixth nerve palsy can also be present at birth, or result from trauma or medical condition. However, in up to 30 percent of cases, the underlying cause of sixth nerve palsy is unknown.

The most common causes of sixth nerve palsy include: 

• Diabetes
• Hypertension
• Skull fracture or TBI
• Stroke
• Lyme disease or other infection
• Brain tumor
• Nerve inflammation
• Multiple sclerosis
• Meningitis

If you notice any changes to your vision, schedule an appointment with an eye doctor as soon as possible. 

SEE RELATED: Neuro-Optometric Rehabilitation FAQs 

What are the symptoms of sixth nerve palsy?

Depending on the underlying cause of the condition, sixth nerve palsy can affect either one or both eyes.

Double vision is the most common symptom of sixth nerve palsy, especially when both eyes are open, when looking at distant objects or when looking in the direction of the affected eye.

Strabismus, or an eye turn, is another common symptom of sixth nerve palsy that causes the affected eye to turn toward the nose.

Types of sixth nerve palsy

There are two different types of sixth nerve palsy:

1. Isolated sixth nerve palsy occurs without any additional symptoms, usually as a result of any of the following conditions:

• Injury
• Viral illness
• Hypertension
• Diabetes

2. Non-isolated sixth nerve palsy occurs when additional symptoms appear as well, including any of the following:

• Eyelid droop (ptosis)
• Fever
• Headache
• Nausea and vomiting
• Hearing loss
• Facial weakness
• Decreased facial sensation

How is sixth nerve palsy diagnosed?

To obtain a diagnosis of sixth nerve palsy, your doctor will conduct a thorough medical history, and a physical and neurological exam. If your doctor suspects sixth nerve palsy, you will be referred to an eye doctor for further testing.

Brain imaging and blood tests may be required as well, to rule out a range of possible conditions that may be causing your symptoms.

How is sixth nerve palsy treated?

Treatment of sixth nerve palsy will depend on its underlying cause, but may include:

• Vision therapy
• Antibiotics to treat a bacterial infection
• Corticosteroids to reduce inflammation
• Surgery or chemotherapy to eliminate a tumor

Vision therapy is an effective treatment option for some patients with acquired sixth nerve palsy, as it can help to improve eye movements and reduce or even eliminate double vision. 

In some cases, there may not be a specific treatment for the underlying cause. However, if the condition is due to a virus or following a trauma, symptoms from sixth nerve palsy may improve on their own within a few months.

To promote healing and improve vision, your eye doctor may recommend any of the following treatments:

• Eye patching to correct double vision
• Prism lenses to help improve binocular vision
• Botox injections to temporarily paralyze the unaffected eye muscle and improve eye alignment
• Eye muscle surgery to realign the eyes

Surgery is usually only recommended as a last resort if all other treatments prove to be unsuccessful.

LEARN MORE: Guide to Vision Therapy

If you notice any changes to your vision, especially double vision or an eye turn, schedule an appointment for an eye exam.

The sooner you receive a proper diagnosis, the greater your chances of achieving optimal treatment results.

The post Sixth Nerve Palsy appeared first on Optometrists.org.

Third nerve palsy, also called oculomotor palsy, occurs when the third cranial nerve becomes injured or diseased.

The third cranial nerve controls the actions of four external eye muscles. These muscles are responsible for turning the eye inward, moving the eye upward and downward, and rotating the eye downward and outward toward the ear.

The third cranial nerve also controls pupil constriction, upper eyelid position and eye focusing abilities.

As the third nerve controls many of the eye’s muscles, palsy of this nerve can result in complete or partial paralysis of the eye muscles.

A complete paralysis of the eye muscles generally leads to an outward and downward eye deviation, while a partial paralysis leads to an outward eye turn.

Similarly, a complete paralysis of the eye muscles typically results in a complete closure of the eyelid, while a partial paralysis usually results in a droopy eyelid.

What are the symptoms of third nerve palsy?

• Double vision (diplopia)
• Eye misalignment (strabismus)
• Droopy eyelid (ptosis)
• Enlarged pupil that does not react normally to light
• Tilted head posture to compensate for binocular vision difficulties

If you experience any of the above symptoms, contact an eye doctor near you.

SEE RELATED: Vision and Brain Injuries

What causes third nerve palsy?

Third nerve palsy may be congenital or acquired. While the cause of a congenital palsy may not be identifiable, an acquired palsy may result from:

• Birth trauma
• Head injury
• Infection
• Vaccination
• Migraine
• Brain tumor
• Aneurysm
• Diabetes
• Hypertension

How is third nerve palsy diagnosed?

An eye doctor may be able to diagnose third nerve palsy, but may refer you to a neuro-ophthalmologist or neurologist for confirmation.

A series of diagnostic tests, including a neurological exam and MRI or CT scan, will be performed in order to effectively identify a third nerve palsy.

How is third nerve palsy treated?

Unfortunately, treatment for congenital third nerve palsy has yet to be discovered.

If the palsy is acquired, treatment will depend on the underlying cause of the condition.

Surgery may be recommended if a tumor or aneurysm is pressing on the nerve, to relieve the pressure on the nerve and promote healing.

To reduce or eliminate double vision and improve eye alignment, the following treatments may be recommended: 

• Vision therapy
• Patching one eye to improve binocular vision
• Prism lenses to reduce or eliminate double vision
• Eye muscle surgery to realign the eyes
• Eyelid surgery to correct the ptosis

Vision therapy is an effective treatment option for some patients with third nerve palsy, as it can help to improve eye movements and binocular vision.

If you notice any sudden changes to your vision, especially double vision or an eye turn, schedule an eye exam as soon as possible. 

LEARN MORE: Guide to Vision Therapy for Adults

The sooner fourth nerve palsy is diagnosed, the greater your chances of optimal treatment results.

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Fourth nerve palsy, also known as superior oblique palsy or trochlear nerve palsy, occurs when the fourth cranial nerve becomes diseased or damaged.

The fourth cranial nerve controls the actions of the superior oblique eye muscle. This external muscle runs from the back of the eye socket to the top of the eye, and is responsible for turning the eye inward and downward.

What causes fourth nerve palsy?

Fourth nerve palsy can be congenital or acquired.

According to a study conducted by the American Academy of Ophthalmology (AAO), the most common type of fourth nerve palsy is congenital (49%), followed by hypertension (18%) and trauma (18%).

Concussions and whiplash are the most common causes of injury to the fourth cranial nerve.

Poor blood flow related to diabetes is another common cause of nerve injury or disease.

Although less common, fourth nerve palsy can also be caused by:

• Vascular disease related to diabetes, that leads to a reduced blood supply to the nerve.
• An aneurysm that is pressing on the nerve and decreasing blood flow to the nerve.
• Increased pressure inside the skull that is pressing on the nerve.
• Stroke
• Brain tumor

Idiopathic fourth nerve palsy occurs when there is no known cause for the nerve paralysis.

What are the symptoms of fourth nerve palsy?

Fourth nerve palsy generally affects only one eye, but it can affect both eyes as well.

The most common symptoms of fourth nerve palsy include:

• Double vision (diplopia) when both eyes are open.
• Strabismus, or an eye turn that causes the affected eye to turn upward.

Other symptoms can include:

• One iris appearing higher than the other
• Tilting the head to compensate for binocular vision difficulties
• Pain above the eyebrow

If you experience any of these symptoms contact an eye doctor near you.

SEE RELATED: Third Nerve Palsy

How is fourth nerve palsy diagnosed?

To diagnose fourth nerve palsy, your eye doctor will first conduct a full medical history.

Your eye doctor will then examine the functioning of the cranial nerves by looking at the position of the eyes at rest, and then evaluating eye movements as an object is followed with the eyes.

Your eye doctor may also assess how your pupils react to light, measure the pressure within your eyes, and examine the back of your eyes with a slit lamp.

Since a range of medical conditions can cause double vision, your doctor may refer you for further testing to rule out any other serious conditions.

These tests may include:

• Blood tests
• Brain imaging
• Eye ultrasound
• Nerve stimulation tests

How is fourth nerve palsy treated?

The treatment options for fourth nerve palsy depend on the underlying cause of the condition.

When fourth nerve palsy is idiopathic or caused by an injury to the nerve, it may improve on its own after several months.

Surgery may be required if something is pressing on the nerve, in order to release the pressure and promote healing.

To reduce or eliminate double vision and improve eye alignment, your eye doctor may prescribe any of the following treatments: 

• Vision therapy
• Prism lenses to eliminate double vision
• Eye patching to improve binocular vision
• Surgery to realign the eyes

Vision therapy is an effective treatment option for some patients with fourth nerve palsy, as it can help to improve eye movements and binocular vision.

Your eye doctor may also refer you to a neuro-ophthalmologist, an eye doctor who has undergone extensive training to diagnose and treat various complex conditions and diseases of the nervous system.

LEARN MORE: Guide to Vision Therapy

If you notice any sudden changes to your vision, especially double vision or an eye turn, schedule an eye exam as soon as possible. 

The sooner fourth nerve palsy is diagnosed, the greater your chances of optimal treatment results.

The post Fourth Nerve Palsy appeared first on Optometrists.org.

Strabismus, also known as “crossed-eyes” occurs when the two eyes are unable to achieve proper alignment to focus on an object. One eye is generally able to look directly at the object, while the other eye turns in a different direction.

Strabismus affects up to five percent of the population.

Strabismus surgery involves loosening or tightening the eye muscles in order to achieve proper alignment of the eyes. This type of surgery is recommended for all types of eye turns, including esotropia, exotropia, hypertropia, and hypotropia.

How effective is strabismus surgery?

Strabismus surgery is effective 80-90 percent of the time. Some patients, depending on their age and type of strabismus, will require multiple procedures for optimal results.

Will strabismus surgery give me clear vision?

If you or your child has been diagnosed with strabismus, surgery is an effective way to improve eye alignment.

However, it is important to understand that while surgery will correct the eye turn to help your eyes appear aligned, it cannot stimulate the two eyes to work together for clear vision. 

Therefore, your eye doctor may recommend a program of vision therapy to improve eye coordination and eye teaming skills— which will also ensure that the eyes remain aligned.

What is a recession procedure?

A recession is used when the muscle is too tight. This procedure involves relocating the muscle to a different area— detaching the affected extraocular muscle from the eye and reattaching it farther back on the eye. By altering its position, the muscle is weakened, leading to improved alignment.

What is a resection procedure?

A resection is used when the muscle is too weak to hold the eye in its proper place, and consequently causes the eye to turn. This procedure involves strengthening the extraocular muscle by shortening it, and then reattaching it to its original position.

What is an adjustable suture procedure?

This procedure is performed following a recession or resection procedure in which adjustable sutures were used. During this procedure, the surgeon adjusts the sutures that hold the extraocular muscles in place, and either tightens or loosens them to improve the surgical results and achieve optimal alignment.

This surgery is generally only performed in adults, as the patient remains awake during the procedure with only a local anesthetic. For children with strabismus, a regular suture is typically used.

All sutures will dissolve on their own within about six weeks.

Contact an eye doctor near you to learn more about strabismus surgery and to discuss if this procedure is best for you or your child.

SEE RELATED: What Is Intermittent Strabismus?

Is strabismus surgery safe?

Yes.

While all surgical procedures carry a risk, the risks associated with strabismus surgery, including infection, bleeding, or excessive scarring, are low. The main risk of strabismus surgery involves under correction or overcorrection. Complications that lead to vision loss are very rare.

Will I be awake during surgery?

While most children undergo general anesthesia, adults are usually given the option for conscious sedation with a local anesthetic.  The surgery is performed in a hospital or surgical center, and is typically an outpatient procedure.

What to expect after strabismus surgery

After strabismus surgery, your eyes will look red and feel sore. Some people experience a foreign body sensation in which they feel like something is stuck in their eye. This is due to the sutures and will disappear as the sutures dissolve in the next six weeks.

You may notice blood in the inside or outside corner of your eye, in the surgical area— this is normal and will subside within two to three weeks.

Other symptoms you may experience in the first few days after surgery include:

• Swollen eyelids
• Light sensitivity
• Mild blurry vision
• Double vision

Many eye doctors will prescribe an antibiotic eye drop or ointment to be used for a few days post-surgery— be sure to use your medication as directed by your doctor to avoid post-surgical complications.

For the first few days following surgery, expect to be off your feet and resting. Your doctor will let you know when it is safe to resume normal activities— usually within a few days post-surgery.

Caution: Avoid saunas, hot tubs, and swimming pools for three weeks after surgery to reduce your risk of infection.

Which symptoms indicate a problem?

Watch for signs of an infection or slipped muscle within the first week after surgery:

• Vision loss
• Increasing redness
• Green discharge
• Severe pain during eye movement
• Inability to move your eye

If you notice any of these symptoms, contact an eye doctor or emergency medical services immediately.

How do I know if the surgery was successful?

The first few days after surgery will provide a good indication of the success of the surgery. However, eye alignment can change over time and the final outcome of the surgery may not be confirmed until your eye has healed, typically around six weeks post-surgery.

Most children under the age of 10 will need multiple procedures to obtain optimal results.

LEARN MORE: Guide to Eye Turns

Schedule an appointment with an eye doctor to discuss any concerns you may have about an eye turn or strabismus surgery.

The post Strabismus Surgery appeared first on Optometrists.org.

A: No.

Strabismus treatment options depend on the type of strabismus— direction of eye turns, angle of deviations, the presence of convergence insufficiency, double vision, or amblyopia (lazy eye), etc.

Non-surgical treatment such as glasses, prisms, and vision therapy are available, and can lead to improved vision and eye alignment.

Q: Will eye muscle surgery always be successful?

A: No.

Eye muscle surgery may help to realign the eyes, however, the surgery cannot restore the connection between the eyes and the brain which is vital for vision.

This explains why the eyes often “go back” or deviate again after surgery.

Numerous peer-reviewed scientific studies report success rates for eye muscle surgeries, ranging from 30 percent to 80 percent success.

In those studies, success is sometimes defined as cosmetic improvement only— the eyes maintained a straight and aligned appearance, but improved vision was not achieved.

Clearly, it is important to determine whether surgery is being recommended for the purposes of cosmetic improvement only.

Q: How many eye muscle surgeries will be needed?

A: Often, many surgeries are needed.

If your surgeon has recommended initial eye muscle surgery, ask how many surgeries! The surgeon should be very clear as to the possibility that repeat surgeries could be recommended down the road.

Good cosmetic alignment is often only achieved after two or three surgical procedures are performed.

Q: Can a developmental optometrist be helpful?

A: Yes.

Effective surgical intervention to gain the use of both eyes, requires not only perfect alignment but also an eye doctor who knows how to stimulate the two eyes to work together.  It is therefore often recommended to have a pre- and post-surgical consultation with a developmental optometrist.

Surgery, if necessary, should be coordinated with the developmental optometrist who is knowledgeable in visual development.

If the goal is for improved binocular vision, a developmental optometrist will work to improve binocular vision with the use of lenses, prisms, and vision therapy.

During the critical period, if therapy is not initiated immediately following surgery, the chances of success can diminish. Pre-surgical consultation and stimulation by the optometrist are also helpful.

Schedule an appointment with an eye doctor near you to discuss treatment options.

SEE RELATED: Strabismus Surgery

Q: Does the age of the patient matter?

A: Sometimes.

Age does have an impact on whether surgery is appropriate.

Early occurring constant strabismus is the one type of strabismus which might need early surgery to eliminate the eye turn.

For other types of strabismus, especially intermittent, don’t allow a surgeon to rush you into surgery based on statements about age. Surgeons are experts in surgery and may often fail to fully explain all treatment options.

In all cases, we recommend that you seek a second opinion (preferably from an optometrist who offers vision therapy).

Q: Can vision therapy help?

A: Yes.

Vision therapy deals with two parts of the visual system:

• Motor- enables the two eyes aim accurately
• Sensory -enables unification of the two images into one 3D image in the brain (stereopsis).

You must have motor control and alignment in order to make the eyes see properly. Often, eye turns that develop before age two, may have good motor alignment without the ability to have stereopsis. If you have an eye turn, it is beneficial to work closely with a behavioral or developmental optometrist to discuss the appropriate treatment methods.

If your child has been diagnosed with an eye turn, contact an eye doctor to discuss all of your concerns.

LEARN MORE: Guide to Eye Turns

Your child’s binocular vision is essential for meeting all of life’s demands.

The post Strabismus FAQs appeared first on Optometrists.org.

Lazy eye can be treated through different means— depending on the type, severity, and age of the patient.

Traditionally, it has been thought that lazy eye treatment should begin before a child reaches around eight years old, however recent research shows that even after this age, lazy eye can be successfully treated. That being said, the earlier the condition is diagnosed, the better the treatment outcome will be.

Corrective eyewear

The first criteria to treat amblyopia is to ensure that each eye has the highest visual acuity possible. Amblyopia that develops as a result of an underlying refractive error typically responds well to corrective eyewear, which allows the lazy eye to gain the best vision possible, and “get used to” seeing the world more clearly.

According to the Pediatric Eye Disease Investigator Group (PEDIG) research, 77 percent of children with refractive amblyopia showed improved visual acuity within fifteen weeks of wearing corrective eyeglasses.

This research indicates that passive treatment using only eyeglasses, can improve visual acuity. However, the eyeglasses alone do not treat the underlying problem.  Therefore, a treatment program of vision therapy is usually prescribed to retrain the eye-brain connections of the lazy eye.

Vision therapy

The most common treatment for amblyopia is vision therapy, which may be recommended in combination with other treatments.

Vision therapy is highly successful for the improvement of visual acuity, binocular vision, visual processing abilities, reading fluency and depth perception.

Modern-day techniques used in vision therapy have shown that optimal long-term results can occur when the two eyes are trained to work together (stereopsis).

Stereopsis develops a deeper neurological connection between the two eyes and the brain.

Vision therapy programs to treat amblyopia may include:

• Accommodation (focusing)
• Fixation (visual gaze)
• Saccades (eye jumps)
• Pursuits (eye tracking)
• Spatial skills (eye-hand coordination)
• Binocular vision (the eyes working together)
• Stereopsis (3-D vision)

A vision therapy program may include the use of lenses, prisms, filters, occluders, and other specialized equipment designed to actively make the lazy eye work. Each vision therapy program is customized to the specific needs of the patient.

Games and activities incorporated into vision therapy may include coloring in special workbooks, dot-to-dot drawing, word games, building blocks, and more. In recent years, advanced digital therapies such as virtual reality games have turned vision therapy activities into interactive and exciting exercises!

Many times, home practice will be recommended to reinforce the office-based treatments. The length of the program depends on the severity of the diagnosis and patient compliance, but most therapy programs range from several weeks to several months.

Contact an eye doctor near you who has experience treating lazy eye with vision therapy to help improve your vision.

SEE RELATED: Until What Age Can a Lazy Eye Be Treated?

Eye patching

Eye patching, usually recommended within a personalized vision therapy program, involves placing an eye patch over the stronger eye— forcing the lazy eye to work and develop a better connection to the brain.  Through patching of the “good” eye, the brain will begin to acknowledge and interpret visual signals coming from the lazy eye, thereby recovering vision.

The length of this treatment method depends on the extent of the vision, the age of the child, and how long the lazy eye has been present.

Please note, total eye occlusion of the stronger eye is necessary, without any light filtering through the patch.  Decorated eye patches are available for children, to encourage them to wear the patch. Additionally, there are patches that attach to an eyeglass lens, if your child wears eyeglasses.

How many hours/day does your child need to wear an eye patch?

In the past, doctors would recommend full-time patching for lazy eye treatment, for up to 6 or 8 hours every day. However, this recommendation often led to poor patient compliance because of social stigmas and daily hardships.

• Eye patching for moderate lazy eye, for two hours per day with one hour of near vision exercises, is just as effective as patching for six hours per day or even full time patching.
• 62% of patients that patched for two hours per day showed improved visual acuity within about four months of treatment.

Similarly, in cases of severe amblyopia, six hours of patching per day has been shown to be as effective as full-time patching.

Atropine eye drops

Similar to eye patching, atropine eye drops are typically used in combination with a vision therapy program. The drops are applied in the non-affected eye in order to blur vision, and force the lazy eye to become stronger— thereby strengthening the eye-brain connection.

Many parents find the eye drops to be less conspicuous than eye patching, but the drops can cause physical discomfort such as stinging and blurry vision— which may result in inadequate patient compliance.

The good news is that recent research conducted by the PEDIG team has shown that daily use of atropine drops are not necessary for noticeable improvement of vision in moderate to severe amblyopia.

The study reveals that only using the drops on weekends shows equal amounts of improvement.

This finding will likely result in increased compliance and satisfaction with the treatment.

Surgery

In general, if the eyes are aligned then eye surgery is not recommended.

However, if the amblyopia is a result of an eye turn (strabismus), surgery (sometimes even multiple surgeries) may be required to realign the eye muscles and correct the eye turn, in order to improve eye alignment.

About 1.2 million ocular surgeries of these types are performed in the U.S. every year — making it the third most common type of ocular surgery in the country. This surgery can be performed on both children and adults, and is a one-day outpatient procedure with a relatively short recovery period of just a few days.

There are two types of strabismus surgery:

• A recession is performed when the ocular muscle is detached from its original place, and reattached away from the front of the eye, in order to weaken the muscle.
• A resection is performed when a portion of the muscle is removed to strengthen the remaining portion of the muscle.

Surgery for lazy eye treatment may improve vision, but it is not guaranteed to do so. Sometimes, the surgery can improve eye alignment, but the eye-brain connection still requires strengthening —resulting in continued vision problems.

That being said, surgery in combination with eye patching or vision therapy has been shown to increase the patient’s chances of achieving binocular vision.

Which treatment option is right for you?

Your eye doctor will provide all of the information you need to know about lazy eye, and the treatment option best suited for your needs.

In most cases, vision therapy will be recommended for children with a lazy eye— if an eye turn is always present, surgery may be recommended as well.

Many times, adults who suffer from lazy eye will also benefit from vision therapy, even though the program might take longer.

LEARN MORE: Vision Therapy for Lazy Eye

Schedule an appointment with a vision therapy eye doctor near you to start treatment which will improve your binocular vision.

The post How Is Lazy Eye Treated? appeared first on Optometrists.org.

Exotropia is a eye turn where one eye points outwards, this may be noticed while the child is looking at distance objects, near objects or both.

There are two types of exotropia:

• Constant
• Intermittent

Constant exotropia

This occurs when the eye turn is present all of the time, at all distances. This type of strabismus occurs less frequently than the intermittent type.

Treatment for this condition should be prescribed early in order to recover proper binocular vision. Vision therapy, with or without eyeglasses, eye patching, drops, or surgery is the most effective approach in treating constant exotropic strabismus.

Intermittent exotropia

This the most common form of exotropia, occurs when the eye turn is only present occasionally. In many cases, the eye turn may only be visible during stressful situations or when the person is tired or ill— this can lead to a late diagnosis since the vision condition is difficult to notice.

On a positive note, when the eye turn is only occasional, the visual system, including the eye-brain connection, can continue to develop and allow for some development of binocular vision and depth perception.

What are the symptoms of exotropia?

Symptoms of exotropia may be exacerbated by prolonged reading, desk work, and computer use.

The most common symptoms of exotropia are:

• Outward eye turn
• Blurred vision
• Diplopia (double vision)
• Eyestrain
• Headaches
• Avoidance or inability to focus while reading
• Motion sickness

If you experience any of these symptoms contact an eye doctor near you, to help treat exotropia.

SEE RELATED: What Is Strabismus (Crossed-Eyes)?

Can intermittent exotropia be caused by convergence insufficiency?

Yes.

An outward turn of one eye that occurs only when focusing on near objects can be a symptom of Convergence Insufficiency (CI), another common binocular (two-eyed) vision problem.

If left untreated, CI can eventually lead to an eye turn and intermittent exotropia.

Convergence Insufficiency is the most common type of visual-motor problem in children— with a reported 5 to 13 percent prevalence among children and adults.

The condition can cause eyestrain, blurry vision, double vision (diplopia), and/or headaches— which can lead to academic and athletic challenges. According to the National Institutes of Health/National Eye Institute, the best treatment for CI is vision therapy.

How is an intermittent eye turn diagnosed? 

Intermittent eye turns can be difficult to detect because of their occasional appearance. Additionally, an outward eye turn typically only appears when the child is fatigued, anxious, or ill. However, with the use of specialized equipment, your doctor will determine the functional integrity of your child’s visual system.

Treatment of intermittent exotropia

Intermittent exotropia should be treated immediately, as any misalignment indicates that the eye-brain connection is not working effectively.

The most successful treatment for strabismus is vision therapy, usually with other means such as eye patching, eyeglasses, and surgery. Vision therapy treats the underlying cause, improves the eye-brain connection and retrains visual skills necessary for binocular vision.

Vision therapy or surgery?

In a comparative study using both Optometric and Ophthalmological journals, vision therapy had an overall success rate of 78 percent, when compared to surgery that held a success rate of 48 percent.

Vision therapy is also effective in improving the developments of the neural pathways and the eye-brain connection, both before and after surgery.  Surgery should be used as a last resort only for large angle intermittent exotropia. Patients with a significant large angle eye turn can benefit from surgery because the eye will appear aligned— increasing confidence in social situations.  However, surgery does not usually improve visual function, and is therefore typically combined with vision therapy.

Even an occasional eye turn can impact relationships

An early diagnosis of an eye turn, even if it only appears on occasion, is beneficial to your child’s social performance— alleviating social discomfort or low self esteem that can be caused by the condition.  Personal relationships can be significantly impacted, especially if an outsider doesn’t know that the person suffers from an occasional eye turn.

The eye turn can be present only sometimes during a conversation— presenting as lack of eye contact and causing the person to appear as if he is distracted or not interested in the conversation.

LEARN MORE: Guide to Eye Turns

If you suspect that your child is suffering from an eye turn, schedule an eye exam as it is important to diagnose and treat the condition as early as possible.

The earlier the condition is diagnosed, the earlier your child can begin a personalized vision therapy program and be on their way to improved binocular vision.

The post What Is Exotropia? appeared first on Optometrists.org.

The condition can be constant or intermittent and cause an individual to appear “cross-eyed”.

There are four different forms of esotropia:

• Congenital (infantile) esotropia
• Esotropia with amblyopia
• Accommodative esotropia
• Partially accommodative esotropia

Does your infant appear crossed-eyed?

Only 23 percent of infants are born with eyes that appear perfectly straight and aligned, so there is no need to panic if your newborn appears to have an eye turn!

Most infants are born with misaligned eyes, with one eye usually turning outward, appearing “crossed eyed”. Within the first three months of age, the eyes gradually straighten as they begin to develop the neural connections with the brain and work together as a coordinated team.

It is also common for infants to appear as if they have esotropia, because the bridge of the nose is not yet fully developed.  As the bridge of the nose develops, more of the white of the eyes, the sclera, becomes visible on the nasal side, enabling the eyes to appear more aligned.

Congenital (infantile) esotropia

Infantile esotropia is a significant inward turn of one of the eyes during infancy, typically as a result of hyperopia (farsightedness).

This condition usually appears when the infant is between two and four months of age. A baby with infantile esotropia typically looks with one eye, while the other eye looks inward towards the nose, this is called cross fixation.

The primary concern with infantile esotropia is that the condition will inhibit the development of the two eyes to work together as a team— resulting in either reduced, or complete absence of binocular vision and depth perception.

Furthermore, poor eye coordination can lead to atypical gross motor development— preventing the infant to reach important developmental milestones.

According to the American Optometric Association (AOA), children who have had significant hyperopia during infancy are at a higher risk of developing strabismus and amblyopia (lazy eye) by the age of four.  Moreover, the presence of anisometropic hyperopia, which is farsightedness with an unequal refractive error in both eyes, further increases the risk of the child developing strabismus and amblyopia.

How is infantile esotropia treated?

If the infant presents with a constant, significant inward eye turn, then surgery (which may include several procedures) may be required. However, the chance of developing binocular vision with surgery alone diminishes with age.

Therefore, even with multiple surgeries, an older child with infantile esotropia might appear as if his eyes are aligned, but normal binocular vision has likely not been achieved.

In this case, vision therapy to improve eye teaming, eye tracking, stereoscopic vision, and 3D depth perception should be provided.

In less severe cases, eye doctors may recommend prisms, eyeglasses, or occlusion (taping the inner third of eyeglass lenses) to reduce the tendency of the eye to turn inward. Additionally, vision therapy may be recommended to treat the underlying causes of the eye turn.

Schedule an exam with a vision therapy eye doctor and to start improving your child’s vision.

SEE RELATED: What Is Accommodative Esotropia?

Esotropia with amblyopia (lazy eye)

Children with strabismus and lazy eye must be identified and treated at a young age to increase their chances of restoring normal visual acuity.

Treatment for lazy eye typically involves eye patching of the stronger eye which forces the turned lazy eye to develop greater strength. Surgery (sometimes involving multiple procedures) may be recommended for a significant eye turn to re-align the eyes— though vision usually remains blurry even after surgeries. For this reason, vision therapy is typically prescribed to treat the visual pathways and reestablish the eye-brain connections.

Accommodative esotropia

Clear vision of close objects requires our eyes to converge (aim both eyes inward at the same time) in order to properly focus, or accommodate. Too much focusing power may lead to an inward turn of the eyes.  If an inward eye turn is only noticed at around two years of age, it may be a result of poor integration of the accommodative system with the eye alignment (binocular) system.

Corrective lenses for treatment of accommodative esotropia 

If the eye turn only occurs when focusing on close objects then wearing glasses for near vision may be effective at reducing or eliminating the esotropia.

In these cases, the eye turn is noticed when the child is playing with small objects, making eye contact, coloring, looking at picture books, and participating in other close vision tasks.

Additionally, if a child is significantly farsighted (hyperopia), an inward turn of the eye may even occur when focusing on distant objects, such as a television. In this case, corrective eyeglasses may be sufficient in treating the esotropia.

A bifocal or multi-focal corrective lens may be prescribed if the amount of inward turn is greater for closer objects than farther ones. When the eyes are aligned by corrective lenses they may spontaneously begin to work together. If this doesn’t occur, then a vision therapy program can help to improve visual skills and clear binocular vision.

Vision therapy for treatment of accommodative esotropia

Consistent eye turns cause the brain to actively ignore visual information coming from the affected eye (suppression), in order to prevent double vision.  During vision therapy, your doctor may recommend occlusion of the stronger eye (using an eye patch) to retrain the brain and eliminate suppression.

Vision therapy is highly effective for the improvement of visual skills such as eye teaming, depth perception, and stereopsis— all necessary for clear binocular vision.

Esotropia that occurs intermittently does not usually require long term treatment. In this case, corrective eye wear may be recommended along with vision therapy, to improve ocular muscle coordination and eventually eliminate the bifocal.

Patients with accommodative esotropia should never undergo eye muscle surgery to eliminate the need for eyeglasses, as it can cause significant focusing problems with age.

Partially accommodative esotropia

In some instances, part of the inward turn is due to basic esotropia, while an additional amount is due to the effects of accommodation.

For partially accommodative esotropia, most eye doctors typically recommend eyeglasses (to reduce some of the eye turn) in addition to vision therapy (to retrain the visual centers of the brain).

Surgery can be another treatment option to address the non-accommodative portion of the esotropia. However, surgery alone rarely results in clear binocular vision.  For this reason, vision therapy will most likely be recommended for full recovery of binocular vision.

Eyeglasses and vision therapy are the most effective treatments for esotropia.

LEARN MORE: Guide to Eye Turns

Schedule a comprehensive eye exam with your optometrist to obtain a proper diagnosis of esotropia and begin an appropriate treatment plan.

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