little four eyes

Updated: I’ve added Vision Therapy as a choice, but it’s not showing up yet.  It should show up shortly.  Sorry for that, I knew there was something I was forgetting when I hit publish.

One of our readers, Heather, asked if I’d do a poll about how many children with accommodative esotropia end up patching.  I’m expanding the poll just a bit to include other treatment options.

If your child has accommodative esotropia (partial or full), let us know what treatments you’ve done.

Many thanks to Sarah who sent in her account of working with a teacher of the visually impaired. – Ann Z

My nearly four-year-old daughter Isabella has multiple ocular diagnoses: severe hyperopia (farsightedness), astigmatism, mild macular hypoplasia (“underdevelopment of the macula, a small area on the retina responsible for seeing in detail” – read more) , latent nystagmus (“involuntary rapid movement of the eyeball, occurring only when one eye is covered” – read more), and intermittent exotropia (“eyes that turn outward” -  read more).  She began seeing an ophthalmologist at six weeks old and received her first pair of glasses at 15 months. Today at nearly age four, her acuity measures about 20/70 with correction. Isabella also has bilateral sensorineural hearing loss, childhood apraxia of speech (a motor speech disorder),  hypotonia (low muscle tone), and fine and gross motor delays.

Isabella

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Ingrid wrote me with the following question:

I’m wondering if any parents of children with intermittent exotropia notice that their child constantly closes one eye in sunlight? Of all that we go though with Paris’s eyes, including patching, this for me is the thing that bugs me and bothers me the most. Especially as we live in Australia and it is always sunny!As soon as we walk outdoors she closes her exotropic eye, so she is closing it a large part of the day. I have tried sun glasses but she really doesn’t want to wear them. I am thinking of getting transition lenses? Has anyone got any advice on what to do? Is this something that can be rectified. It is really distressing to see her with one eye closed a good part of the day!

Here’s the thing, Zoe does the same thing, though she has esotropia, not exotropia.  Has anyone else noticed this with their child?  We’ve both asked our POs and not gotten much of an explanation.

Yes, we buy every cute glasses-themed T-shirt we see. Busted farmer's hat? Not a typical accessory.

Last night, my daughter experienced double vision. But panic soon gave way to reassurance. It was not a bad thing. Surprisingly, I haven’t lost my mind. (Though if I did, would I know it? Anywho.) Please allow me to explain.

Stella, whose vision I’ve covered here at Little Four Eyes before, just turned three. When she was 18 months old, her accommodative esotropia and anisometropia were discovered and addressed with glasses. Her stylish specs keep her eyes straight–HOORAY! We still patch a little bit, because her left eye is more farsighted than the right and so has slightly lower acuity (really, less than one line difference at last check). We’re finishing up vision therapy. Stella can catch a ball, now without using her chest to corral it. She can snag falling feathers with the grace of a major league outfielder, and hit a birdie with a racket, not so much with grace (yet) but with real and consistent contact. Her peripheral vision was opened up by the vision therapy, and her toe-walking reduced. She’s doing very well, and even asks to do our daily at-home vision therapy activities. Amazing progress all around.

Last night, when I heard her crying out from bed, I blamed the cold she’s been battling. I went in to comfort her and help blow her nose. As I leaned over her, I saw a dazed smile on her face. That’s when she said, “I see two mommies.” I looked more closely, and sure enough, her left eye was turned in. I so rarely see her eyes cross–because she almost always wears her glasses. The sight is still a punch in the gut, but I quickly put the pieces together and saw a big positive.

First off, she has a cold–the stress of illness is what brought out her strabismus out in the first place.

Secondly, she wasn’t wearing her glasses. Spec-free, all bets are off, particularly when she’s studying something up close. At least until age 11 to 13 or so, she’ll need glasses to keep her eyes aligned. The vision therapy helped re-wire her brain to always use her eyes, aligned by glasses, together. If her glasses were on and I saw crossing, only then would I have real reason for concern.

Lastly, and this felt like a big and helpful realization to me: She wasn’t suppressing the weaker eye. She saw double because she was trying to use both eyes as usual. If her weaker eye was being tuned out, she wouldn’t experience double vision. Typically, again thanks to her glasses, her eyes are aligned and work together, enabling great stereoscopy as recently measured by both her new ophthalmologist (who is wonderful) and her developmental optometrist (also super fantastic). It’s no wonder Stella found the double vision amusing and unusual. She’s used to two eyes in concert, not in conflict.

Upon further obsession (err, reflection), I was pleased with how she quickly articulated what was going on. Back when she got her glasses, half a lifetime ago for this three-year-old, she had a relatively good vocab for her age but obviously couldn’t describe her vision to me. She also refused to even look at the feather I held in my hand above her head, nevermind catch one. She’s come a long way!

All that said, last night was a good reminder about how crucial it is for Stella to wear her glasses at all times (sleep, bath, and swimming excluded). I’ll confess that sometimes, upon waking, she comes to our still-darkened room and hangs out in our bed for a bit, usually without her glasses. About time we made “glasses on!” the very first step in our day.

Now, if only she could effectively clean her glasses on her own. This cold is resulting in permanently smeared lenses! (Ew.)

The Treat Game: Stella's baby helps find matches during vision therapy at home

Stella’s developmental optometrist views patching as a first step in amblyopia treatment. Patching (in our case, Magic tape over the lens of the stronger eye) boosts the acuity of the weaker eye. Stella’s lazy eye is growing stronger, and vision therapy is more and more focused on training her eyes to work together for strong binocular fusion, in an effort to encourage stereoscopy, prevent or minimize regression and provide a lasting fix.

Stella’s daily patching time now feels pretty turn-key, even though (as is my nature) I do it on the fly. She does a solid hour, at least, first thing in the morning, kicked off by some video watching. Sometimes it says on and patching is done by late morning. Sometimes patching is completed in two or three chunks. I seize opportunities strategically. If she’s engrossed with a toy that demands a ton of hand-eye coordination, I’ll throw on her patch to give her amblyopic eye a workout. We’ve got patching down! Vision therapy? Or more accurately, getting 20 to 30 solid minutes of vision therapy done at home? Still a challenge. But as her weaker eye improves, the nature of  her vision therapy is changing. The latest exercises seeming to provide more improvement bang for our frustration buck. So we’re trying harder than ever.

Ever since Stella’s vision therapy progress evaluation which showed great gains, we’ve been doing a bit of what Susan Barry discusses on page 150 of Fixing My Gaze: monocular fixation in a binocular field (MFBF). This means that instead of being completely excluded via the patch, the stronger eye is merely put at a disadvantage. Her dominant eye is still able to receive and contribute visual input, allowing the eyes to work together, but the amblyopic eye is forced to do the heavy lifting. Several doctors/researchers, over several decades, have endorsed the effectiveness of this approach (Brock, Cohen and Hess for starters). Our experience with MFBF is limited but growing.

Almost every day, Stella dons a green-tinted patch over her strong eye and watches a video on our TV, the center of which is covered by a transparent red sheet. Her strong eye can’t see what’s in the red area thanks to the green tint, but it can still see what’s going on the periphery. In order to take in all the action and view the complete picture, her un-patched amblyopic eye has to pick up the slack and garner what is usually the most important part of the scene (whatever is centered, like close-ups of facial expressions, etc.). Her eyes are working together but her weaker eye has to perform at a higher level, setting the stage for binocular fusion. This work counts as patching time, so hooray for that!

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This story was sent in by Sheetal.  She’d love to hear from anyone else dealing with intermittent exotropia. – Ann Z

My daughter has intermittent extropia. Her eye drifts outwards intermittently. We discovered it when she was about 7 months, but doctor said not to do anything about it then. We started patching when she was about 1 1\2 years; we patched only one eye (right eye) to make the left eye stronger. We did it for about four months. We went for a follow up in November 2010; she was 2 years by then. Doctor said, he sees the drift and he says he will have to do surgery soon. He also told us that her vision is fine in both the eyes. (20\20)

I really panicked, because though I see the drift in her eyes, I don’t see it all the time and I see it occasionally, maybe 5-10 times a day and it is different on different days. Whenever the drift is there, it stays for few seconds and she corrects it. Drift usually comes when she is looking at certain angle, I don’t see it when she is looking straight at things. So I was completely shaken when doctor said surgery is the only option.

I subsequently took appointment from 2 other doctors.

The second doctor told me that the drift is about 20-25 prism units, but he suggested not to do anything, he is very experienced and he told me to wait, according to him 1\3 of the cases stays the same, 1\3 gets better on their own and 1\3 gets worse. So he told us to keep a watch and I have appointment with him in April. (He also advised is against patching because he of the binocular vision). He also mentioned an interesting fact, that small kids have to look up at everything because their height is small, but as they grow everything is at an eye level and that helps in getting the drift better.

We went to the third doctor and he also mentioned that the drift is about 20 prism units.

He knew my first doctor and he said, he didn’t agree with him as far as the surgery goes, he said surgery is the last option and he recommended to continue patching and suggested pencil pushup exercise.

Now, I am a little relieved that surgery is off for now but am confused that there are different statements from different doctors. Am not sure if whatever I am doing is right, fear of something going wrong is always there.

Now I am patching the right eye for 1 1\2 hours and left eye for 1\2 hour alternate days.

We also try doing the Pencil Pushup exercise with her, we got 100 sticks from dollar store and we stick stickers on the tip and move it from back to front, she does it or few minutes and then looses attention.

Nintendo 3DS, expected to hit stores in March, comes with a vision-related warning

Jessica Gottlieb is a prominent blogger known for sharing strong opinions on motherhood, social media, and other assorted and engaging topics. Her son happens to have strabismus and amblyopia. He visited regularly with a pediatric ophthalmologist from age four months until earlier this month. Now nine years old, his vision has come a long way. He continues to wear an eye patch for a couple hours each day.

I thought the Little Four Eyes community would be interested Jessica’s recent thoughts on a piece of tech news: Nintendo’s 3D Gaming Device Comes with a Warning for Children Under Six. The soon-to-be-released gadget will come with a warning about potential injury to the eyes of children under age six, whose vision is still developing. Jessica has a valid concern about the device and its warning. The reason her son still wears a patch is because, at age nine, his eyes are still growing and changing (per the renowned doctors charged with caring for his vision).  So why does Nintendo set the cut-off age at six when we know that eye development continues beyond then? What is the real risk?

This area of concern seems likely to grow as gaming systems evolve without much regard to their impact on young eyes. As if we didn’t have enough on our parental minds, ay? Extra caution certainly seems warranted, especially when it comes our children with visual issues such as strabismus and amblyopia. Thanks for the heads up, Jessica.

Parents/experts, what do you think? How much do you worry (or not) about the effects of video games and emerging forms of 3D entertainment, and screen time in general?

My daughter is only two and her screen time is generally limited to 30-60 minutes of TV (age-appropriate videos) a day, only while wearing her patch as it helps with compliance to our regimen, but I know this will get trickier as time goes on. What guidelines do you have in place for your child? How have viewing/gaming habits and limits changed or become harder as they’ve gotten older? What have optometrists, vision therapists, or ophthalmologists told you about the impact of TV, computers and video games on your child’s vision?

Vision therapy: Skills and porcupine quills! Stella's first time wearing therapeutic prism lenses.

Last night and this morning, there was a nerve-wracking build-up to Stella’s check-up, wherein her developmental optometrist would gauge how patching and vision therapy have helped Stella, or not. I’ve worked very hard (okay, harder on some days than others) during Stella’s first three months of vision therapy, sometimes pulling my hair out, often swallowing pesky doubts, and occasionally guzzling wine. She’s 27 months old now, and has been such a trooper through glasses, patching and vision therapy. She asks to do certain “eye games” and requests her patch in the morning so she can watch a video (it’s her routine, plus there’s no TV watching without a patch). But she can also be impossibly resistant in that flippant, in-your-face way common to two-year-olds. And Stella’s not the only one with a short attention span! What was I talking about? Oh yeah–this isn’t easy, folks!

I’m proud of Stella regardless, but has all our effort paid off? As we headed out to the doctor’s office, part of me was absolutely certain that yes, her progress has been hit-you-over-the-head obvious and will be decisive and documented for posterity in the history books (or at least Stella’s patient records). But, I’ll be honest. Another part floundered and secretly wondered if we’d been throwing away hundreds of dollars each month.

The verdict: Stella has made solid improvement! Stella’s amblyopic eye is getting stronger and her eyes are working together more effectively. In August, when Stella was 24 months old and had been patching for maybe three weeks, her left eye was judged to be 20/40 [edit: found out at vision therapy that it was 20/80 before patching began]. Her right, 20/20. Since then, her left eye ramped up to 20/30, and her right is still 20/20. Other positive signs: During the exam, Stella’s eyes didn’t cross like last time. She showed much clearer evidence of 3D vision and binocular vision while wearing red/green glasses. These areas still need a lot of work, but Stella’s doctor and I see her first three months of patching and vision therapy as a success.

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This question just came in from Jen.  Anyone out there in a similar situation?  -Ann Z

My daughter was diagnosed at 20 months old and we have been patching since. She was also prescribed glasses a month ago, her prescription is +1.5 ONLY but our doctor says we should give it a shot to see if that will help straighten her eye. So it turns out that the prescription is so low that it does not help her “see” better at all so it’s been a struggle to get her to wear it. I’m just getting frustrated that nothing is helping her yet. She has been a trooper in patching and we just had another baby so there are so much changes in her world. I want to see if there are anyone here with a child in similar prescription and has seen a difference in straightening out the eyes or successful in keep the glasses on?

The chunky funky frames are a slightly higher prescription that we are trying to see if filling her whole script will help reduce the squinting.  Her left eye is looking straighter without having the muscles moved and her right eye is still healing!  The new muscle position is also helping with her academics.  The progress she has made with reading and writing in the last 3 weeks is amazing!!!!