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Posted on 08-14-2013
Strabismus (eye turn) can occur for no apparent reason as well as along with amblyopia (lazy eye). Strabismus (which can also be referred to as lazy eye by many people) and strabismus surgery (eye muscle surgery) are important topics for behavioral optometrists and the people who come to them for advice and help. I have been working with people who have strabismus, including many who previously had strabismus surgery, for over twenty years. It is exciting to see the improvement in visual performance and general quality of life that takes place over the course of the vision therapy program as these people learn how to use the visual process better. And, as is increasingly uncommon these days, I work with each patient personally at every session so I get to see what’s happening in real time. I have also written quite a bit about strabismus and strabismus surgery over the years, but something a colleague recently posted on a listserve for behavioral optometrists inspired me to share his post and some of my own thoughts on the subject.
July 5, 2012
I recently accompanied a patient of mine to a strabismus surgeon. She happens to be a patient who had failed 2 surgeries and who regained stereovision, through vision therapy. She wears prisms full time right now to avoid double vision. She has made incredible gains and has even written a blog about herself about how empowering vision therapy has made her feel. However, she still has a very large angle and for all sorts of reasons is seeking the opinion of ophthalmologists. I saw that there was no interest whatsoever in exploring the sensory status of the individual. The exam was just prism neutralization of the angle.
Of course her case would mean that certain considerations would need to be made to achieve an optimal result. When I mentioned this, the surgeon said, “Oh! In that case I’ll try to align the eyes exactly. I use a method whereby we can adjust the angle after the surgery.” My patient was asking if he “knew how the outcome would be.” From his answers it became absolutely clear to me that strabismus surgery really is a gamble. Even though we say it all the time, it was quite an experience to hear it from the surgeon’s mouth. They align the eyes and just hope for the best. Some [strabismus surgeries] work some don’t, but the issue of whether it will or will not work is unpredictable.
I concluded that strabismus surgeons rely, for their success, on the neuroplasticity whose existence they deny.
Robert Lederman, O.D.
I’ve been posting chapters of my upcoming book discussing all aspects of strabismus surgery and the alternatives. The book is tentatively titled, Parents, Be Sure To Look Both Ways Before Uncrossing Your Child’s Eyes. I’m writing this book because of my tremendous frustration dealing with doctors who provide strabismus surgery for people whose eyes can’t seem to work as a team and can’t seem to point at the same thing at the same time. Our philosophies couldn’t be more different in regards to what these people need vision-wise and what we can offer them.
While I recognize that there are some people who need strabismus surgery to get their eyes to appear straight to others, I do not agree that everyone who has strabismus is best served by submitting to strabismus surgery. In fact, I have had numerous parents bring their children to me for an evaluation after having been told their child needs strabismus surgery. Many of these parents tell me that the surgeon assured them that there was “nothing wrong with the child’s eye muscles, but that’s how we fix it.” This idea seemed to confuse and worry these parents, who then went in search of an alternative.
I agree that damaged eye muscles are extremely rare. I do not agree with putting so many of these children (and actually people of all ages) through strabismus surgery as a first resort. And, as a behavioral optometrist, I heartily disagree with strabismus surgeons who brush off or express contempt for the value of optometric vision therapy either as a viable alternative to strabismus surgery in many cases or as a vital component to any treatment plan that includes strabismus surgery. Vision therapy is critical to improving the ability of the brain to make the best and most long-standing functional use of any possible positive effects of the surgery. A properly functioning visual system maximizes the potential for the eyes to remain straight. Strabismus surgery without vision therapy is nothing more than a cosmetic procedure. And strabismus surgery, as often as not, results in multiple surgeries when the initial procedure “wears off.” The main reason it wears off is the lack of vision therapy, which enables the person to integrate the changes brought about by strabismus surgery.
I was recently contacted by a 37 year old man who has been wearing lenses to compensate for farsightedness since age 6. He first became aware that he had a cosmetically noticeable three years ago. He was strongly leaning toward surgery, and then maybe vision therapy after the surgery.
I naturally suggested he consider vision therapy before doing anything else. He told me that nobody had been so forthcoming about the guaranteed consequences of surgery (scar tissue, decreased muscle mobility, the likelihood of more surgery to fix the first surgery and the destruction of specialized fibers critical to communication between muscle and brain).
I haven’t seen this gentleman yet; he’s thinking things over. I truly hope he decides to try vision therapy and lenses before he attempts any surgery. I feel very strongly that surgery should not be the first resort for any adult with strabismus. Even if surgery is done, vision therapy should be done first in preparation and then after surgery to maximize the potential of the eyes to remain straight.
Strabismus surgery is primarily, if not exclusively, a cosmetic procedure to make the eyes look aligned. First, the fact that the eyes appear aligned to the average observer does not mean that the eyes are sufficiently aligned. It takes a fairly significant misalignment for an eye turn to become cosmetically noticeable to most people. Second, the fact that the eyes are aligned does not guarantee that they are working in an integrated way at all times, or any of the time.
Another thing mentioned in my colleague’s post is prism. It is common to prescribe compensating prisms for people with strabismus. Compensating prisms merely change the apparent location of whatever is seen through them, possibly enabling someone with strabismus to avoid double vision. This in turn may make it easier to use both eyes in an integrated way, which is of course desirable. I prefer to use compensating prisms only after exhausting all therapeutic options. It is always my hope that through vision therapy and therapeutic lenses a person will be able to use their visual process at a higher level. Nothing works all the time, but it has been my experience that there is no harm in trying vision therapy first and then relying on external “fixes” if necessary.
I have done extensive work with people managing strabismus throughout my years in practice. One of those people was my brother, who had strabismus surgery to straighten his eyes when he was thirteen years old. We all assumed that my brother’s eyes had been fixed since they looked straight. We happened to be watching a 3-D presentation on TV about eighteen years later, just after I graduated from optometry school, and he was unable to experience the 3-D effect. This meant that he was not using both eyes together, since that is how we see 3-D normally. I had him start a vision therapy program with me and within a short period of time he became able to see 3-D fairly well and fairly consistently. That was about twenty years ago. Now he can’t wait for the next 3-D movie to come out. He loves them. If you or someone you know has difficulty appreciating all the new 3-D technology out there, it is likely that you have a visual problem that can be improved with vision therapy. Then you can spend the extra money to see a movie in 3-D; at least you’ll get your money’s worth when you can actually see the 3-D.
Another person with strabismus I worked with was my (step) daughter; we met when she was just five years old. I just wanted to examine her because she had never had an eye exam to that point and I know that all children should have a thorough developmental visual evaluation by the age of five, if not earlier. It turned out her eyes crossed intermittently, sometimes one eye, sometimes the other. Nobody knew there was anything wrong with her eyes since the eye turn wasn’t cosmetically noticeable. It took special testing, the kind behavioral optometrists do routinely, to uncover the visual disturbance that was there, unknown to anyone. It is not in the least inconceivable, had she been seen by a surgeon, that strabismus surgery would have been offered, if not recommended. Shortly after the initial evaluation I had her wearing developmental lenses and doing vision therapy with me for several months. That was eleven years ago. After being homeschooled until the sixth grade, she is now an honor student (has been since starting public school) and made the varsity lacrosse team as a sophomore (even after missing her entire freshman season while rehabbing a repaired ACL). I consider her vision training experience to be a contributing factor in both areas of performance.
I have dozens of stories like these. Vision therapy is almost always beneficial for people with strabismus, whether they have had strabismus surgery or not. Vision therapy can eliminate the need for strabismus surgery in many cases. Vision therapy is likely critical to the long-tem success of any strabismus surgery. In any case, it is almost impossible for vision therapy to be anything but a positive influence on a person’s visual development, performance and comfort.
Further reading on lazy eye: Brief History of Treatment Methods for Helping Lazy Eye from 900 A.D. to Present by Susan R. Barry, Ph.D.
Next time: If It Ain’t Broke, I Still Might Be Able To Fix It
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