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Posted on 09-10-2015

Strabismus, Autism Spectrum Disorder and Attention Deficit Hyperactive Disorder

I guess I should thank my colleague Shirley Ha for sharing this very short article entitled RISK FACTORS FOR ESTROPIA from EUROTIMES columnist Priscilla Lynch. It was interesting, but also somewhat frustrating. The article presents a brief summary of the Strabismus Keynote Lecture by Lionel Kowal, MD (from Australia) at the 2015 World Congress of Pediatric Ophthalmology and Strabismus (WCPOS) in Barcelona. Dr. Kowal explained that conditions such as attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), or the drugs that are used in their treatment appear to be risk factors for esotropia (crossed eyes).

This should raise red flags if at all true, though Dr. Kowal admitted there was “remarkably little data.” While it is certainly common for children with these conditions to have visual problems, including esotropia, the idea that conditions like ASD and ADHD could be leading to visual dysfunction is hard to imagine. It is much less difficult to imagine that medications these children are put on could be disrupting the visual system, as so many medications do. The most likely scenario is that the affected children already had undiagnosed, perhaps more subtle (though no less disruptive) visual conditions that worsened to the point of being too obvious to ignore because of the medications.

Dr. Kowal recommended staying the course as far as treating esotropia surgically and warned his audience to be careful when trying new technologies and procedures. I’m not sure if this was in reference to vision therapy (which is not new, but completely safe) or things like injecting botulism toxin into eye muscles, or implanting magnets into the muscles and surrounding structures in lieu of surgery. My experience shows that strabismus surgery should almost always be more of a last resort, and the idea that strabismus might be medically induced, puts such cases squarely in this category. Vision therapy would be a much better first choice in cases like this since there is clearly no muscle damage involved.

Behavioral optometry does recognize a relationship between visual conditions like esotropia and ASD. We have had many decades of experience treating such visual conditions in children with ASD, ADHD and countless other global diagnoses. Successful treatment of these visual conditions very often results in improved development, behavior and overall performance.

It’s just so frustrating to know that some doctors continue bending over backwards to avoid admitting that there is a wealth of clinical data and experience in treating strabismus. I suppose that they believe that they are the only ones qualified to treat strabismus, but the fact is that vision therapy can often eliminate strabismus without surgery. Research has also shown that people who undergo strabismus surgery have better long-term results when vision therapy is part of their treatment.

Kowal told attendees that strabismus remains a very challenging condition, despite all the advances in ophthalmology, and the fact that it is the most common eye condition in children. (I must add here that I do not accept the premise that strabismus is an "eye condition" since it is most often a very treatable glitch in the brain and not a broken eye.) Kowal added, "The stuff we do is very difficult to do, and it requires a lot of practice and many years to become an expert, and the more expert you become the more uneasy you become that you don’t know enough.”

The important work of surgeons like Dr. Kowal would become much easier, more successful and more fulfilling if they would work alongside behavioral optometry. Behavioral optometrists using vision therapy and appropriate lenses have a long, excellent track record of treating strabismus and all other functional/developmental visual conditions. Anyway, if you know an eye surgeon, or anyone who is thinking about how to deal with strabismus (at any age) tell  them about my new book, "A Parent Guide to Strabismus, Eye Muscle Surgery and Vision Therapy."

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