Muscle Surgery

Amblyopia 

 In some children, sight doesn't develop properly in one eye even though that eye is structurally normal. The condition is called amblyopia (am-blee-OH-pee-uh), and known as "lazy eye" because the eye seems to have lost the desire to see. Since amblyopia causes no discomfort, and the other eye sees normally, the child is not aware that vision has decreased. Amblyopia is often discovered at a vision screening examination at the pediatrician's office or when the child starts school.

What Causes Lazy Eye?

        Each eye sends a similar visual image to the brain, and the brain merges them into a single image. But when the two images are very different from one another, the brain cannot combine them. The result may be double vision. Young children are able to avoid double vision by suppressing -- subconsciously ignoring -- the image from one eye. But eventually that eye may lose its ability to see clearly.

Why Are the Images Different?

        Two common conditions can cause the eyes to send different images to the brain. One is strabismus (misaligned eyes); as one eye looks straight ahead, the other turns in, out, up or down. The other is anisometropia (an-eye-so-muh-TROH-pee-uh), which means that the two eyes have very different optical powers (one may be normal and the other very farsighted or have extreme astigmatism). Structural eye disorders -- cataracts, for example -- can also lead to reduced vision from amblyopia.

        Even if you know that your child has one of these conditions along with poor vision, you still have no way of telling, without an eye examination, whether one eye is truly "lazy."

Treatment

        Once the diagnosis of amblyopia has been made and its cause identified, treatment should be started right away. By starting as early as possible, the amblyopic eye will have

 
 

 its best chance of regaining normal or close-to-normal vision.

 If the cause of the lazy eye is optical, it will be treated with prescription eyeglasses. (Glasses can be worn even by newborn infants.) The vision should eventually improve with the glasses. And though it may not return fully to normal, it often does.

        If the cause is misaligned eyes, surgery may be necessary to straighten them. Surgical success is enhanced when the vision in both eyes is close to normal, so surgery will often be delayed until the amblyopia has been treated. 

 With or without surgery, treatment of amblyopia almost always involves a vigorous program of patching. A patch is placed over the good eye to get your child to begin using the amblyopic eye. That may take a lot of urging and patience, since you will be forcing your child to use an eye that sees poorly, at least initially.

        Instead of patching, another  method occasionally used is to "penalize" the good eye. The pupil may be dilated with cycloplegic eye drops to blur the vision in that eye. This encourages use of the weaker, amblyopic eye.

        The purpose of the patching or other penalization method is to improve vision. It does not eliminate the need for prescription glasses, nor does it, on its own, correct eye misalignment.

Prognosis

        Early identification and treatment of an amblyopic eye is very important. After the age of nine, the poor vision in that eye will probably remain for life. An older child -- or an adult -- who has amblyopia or had previous treatment that did not result in perfect vision, will not achieve perfect vision, even when corrective lenses (glasses or contacts) are worn. With early treatment, however, the chances of improving vision are excellent.

To learn more about Amblyopia and the health care we can provide,

please call us at 208-523-6868

Esotropia      

 The word "esotropia" describes eyes that are not properly aligned: as one eye (the straight eye) looks directly at an object, the other eye turns inward toward the nose (crosses). Esotropia that begins during the first few months of life is called infantile esotropia.

Understanding the Terms

 The term for misaligned eyes of all types is strabismus (struh-BIZ-muss). It is called convergent when one eye turns in toward the nose (converges). In other words, convergent strabismus is another name for esotropia.
        In some cases of esotropia, the same eye always does the deviating; in others, the eyes may alternate, which means that sometimes the right eye turns in while the left eye is straight, and other times the left eye turns in while the right eye is straight. Alternating esotropia can be quite confusing to parents. You notice an eye turning inward, and just when you have concluded which one it is, the other eye seems to be the culprit. 

When to Seek Help

        Children's eyes, to develop normally, must stay aligned and properly focused. If an eye is misaligned and allowed to remain that way, the child is at great risk of losing considerable vision in that eye. This development is called amblyopia (lazy eye). Amblyopia can be reversed if treated early enough.

        As soon as you even suspect that your child's eyes might be crossing or "wandering," no matter how slightly, they should be examined. The sooner treatment is begun, the better your child's chance for achieving normal vision in each eye and binocular depth perception (3-D vision, or stereopsis). No child is too young for an eye examination. If surgical correction becomes necessary, the results are likely to be better when the surgery is done before the second birthday.

Pseudostrabismus

        Sometimes infants, particularly Asian infants, appear to have crossed eyes as they look to one side, though the eyes are actually straight. This is called "pseudostrabismus." The condition occurs when the bridge of the nose is wide and there is an extra fold of skin between the nose and the inside corner of the eye. It tends to disappear as the nasal bones develop, so most children outgrow the pseudostrabismus.

        If you are especially concerned, there are simple tests that can be made to determine whether the apparent strabismus is "pseudo" or real.

Examination

        Your child will have a complete eye examination and refraction (measurement of vision and the optical system). Eye drops will be used to dilate the pupils and temporarily paralyze the eyes' focusing mechanism. The interior of the eyes will be carefully evaluated; eye positions and eye movements, stereopsis, and the ability to recognize double vision will all be checked, depending on the age and cooperation of the child. You may be referred to other medical specialists to check for any other condition that might be associated with the eye problem.

Treatment

        The goals of treatment are to achieve good vision in each eye, a normal appearance, and depth perception. Eyeglasses may be required, even for an infant, because both eyes must see a clear image in order to work together properly.

        Whether or not glasses are prescribed, "patching" is often part of the initial treatment of infants and young children who have developed amblyopia. A patch is placed over the normal (preferred) eye for up to several months, to force the child to use the amblyopic (lazy) eye until vision improves and stabilizes. Patching can be very effective.

        Still, glasses and patching alone are usually not enough. Surgery on the eye muscles may still be necessary to achieve good alignment, even for infants of only a few months of age. Afterwards, glasses may be needed, to help the child develop the ability to use both eyes together. 

Surgery

 Surgery consists of repositioning the eyeball, by tightening some muscles and loosening others, to change their pull on the eye. The procedure usually takes about an hour. A general anesthetic will be used, so your child will be asleep and not feel any pain. After surgery, the eyes will be red, and tears may be tinged with blood. The eyes may be uncomfortable and hard to open for a day or two. Mild pain medication will be given for the discomfort. Most patients return home the same day. There is no need to limit your child's activity, but try not to get water in the eyes. Within two weeks, the sutures will dissolve or fall out on their own, and the eyes will gradually return to their normal appearance. 

 Eye muscle operations are generally quite safe, though they do involve some risk, as does any surgery and anesthesia. If surgery is recommended for your child, the risks will be carefully explained to you along with the potential benefits.

When Is a Second Operation Necessary?

        The goal of surgery is to bring the eyes into parallel alignment. Most of the time the calculated amount of eye muscle tightening and loosening results in good alignment. But every muscle reacts differently to surgery, so it is difficult to accurately predict the final eye position. An under- or overcorrection will sometimes need adjustment. Another factor is that eye movement coordination is partly controlled by the brain, which is not directly affected by the muscle surgery. So even eyes that are successfully aligned may gradually drift inward or outward over time and may require re-aligning.

Prognosis

        Treating esotropia often involves many years of parental and professional commitment and care. The outcome depends on many factors, including type of esotropia, age of onset, and the visual acuity of each eye. With appropriate and timely treatment, most children can attain good eye alignment, comfort, and a highly acceptable appearance. The great majority will gain normal vision, and some will achieve coordinated use of both eyes (binocular fusion and depth perception). 

        Each child's potential for a good result is different. Many do not achieve every benefit, even when eye realignment is surgically successful. Your expectations should always be optimistic, but should also be realistic.

To learn more about Esotropia and the health care we can provide,

please call us at 208-523-6868

Exotropia      

 Exotropia is a term that describes eyes that are not properly aligned. While one eye (the "straight" eye) aims directly at an object, the other eye turns outward. Intermittent exotropia, the most common form, usually begins before school age and is most noticeable when the child is tired or daydreaming. Some children react to the exotropia by closing one eye, especially when they are in bright sunlight.

        Exotropia is not always obvious. But since early treatment may be important, your child's eyes should be examined by a doctor as soon as you even suspect they might be "wandering," no matter how slightly.

Understanding the Terms

        The term for misaligned eyes of any type is strabismus. It is divergent when one eye turns out (diverges), away from the nose. Divergent strabismus is another name for exotropia. Exotropia may be "constant," meaning that the eyes are misaligned all the time, or "intermittent," when they are misaligned only part of the time.

        In some cases, it is always the same eye that deviates; in others, the eyes may alternate -- sometimes the right eye turns out while the left eye is straight, and other times the left eye turns out while the right eye is straight. Alternating exotropia can be confusing to parents. You notice that an eye turns, and just when you have concluded which one it is, the other eye seems to be the culprit.

Examination

        Your child will have a complete eye examination and refraction (measurement of vision and the optical system). Ointment or eye drops will be used to dilate the pupils and temporarily paralyze the eye's focusing mechanism. The insides of both eyes will be carefully evaluated; eye positions and eye movements, stereopsis (3-D vision), and the ability to recognize double vision will all be checked, depending on the age and cooperation of the child.

        You may be referred to other medical specialists to check if any other condition is present that might be associated with the eye problem.

Treatment

        The goals of treatment are to achieve a normal appearance, good vision in each eye, and depth perception. When the exotropia is intermittent, the need for treatment as well as its timing, type and amount depends on a number of factors, such as the patient's age, how far the eyes turn out, and how much of the time the eyes turn out.

        Eyeglasses are prescribed if they improve vision because both eyes must see a clear image for them to work together properly. Since prisms can control the amount and direction the eyes turn, some prism power may be incorporated into the lenses to lessen the effort needed to keep the eyes working together. Eye coordination exercises, called orthoptics, may help improve fusion control when the misalignment is small.

        Eye surgery may become necessary, though it is typically postponed if the eyes deviate less than half the time. Surgery consists of tightening some eye muscles and loosening others, to change their pull on the eyeball. The goal is to bring the eyes into parallel alignment. Muscle operations are generally quite safe, though they do involve the risks of any surgery and anesthesia. If surgery is recommended, these risks will be carefully explained to you along with the potential benefits.

When Is a Second Operation Necessary?

        Most of the time the calculated amount of eye muscle tightening and loosening results in good alignment. But every muscle reacts differently to surgery, so it is difficult to accurately predict the final eye position. An under- or overcorrection will sometimes need adjustment.

        Another factor is that eye movement coordination is partly controlled by the brain, which is not directly affected by the muscle surgery. So even eyes that are successfully aligned following surgery may gradually drift inward or outward over time and may require re-aligning. 

Prognosis

        Without treatment, some patients spontaneously improve with time, others maintain the status quo for years, perhaps indefinitely, and others may get worse. Treating exotropia often involves many years of parental and professional commitment and care. The outcome depends on many factors, including the type, age of onset, and visual acuity of each eye. Each child's potential for a good result is different.

        With appropriate and timely treatment, most children can attain good eye alignment, comfort, and a highly acceptable appearance. Some will also gain normal vision and coordinated use of both eyes (binocular fusion and depth perception); but many do not, even when eye realignment has been surgically successful. Your expectations should be optimistic, but also realistic.

  

To learn more about Exotropia and the health care we can provide,

please call us at 208-523-6868

 
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