Strabismus surgery. Am I a good candidate?

Hello
I am 35 years old and have suffered from exotrophia since I was about
6. Prior to that I esotrophic. I had 2 surgeries when I was a child on
both eyes in the mid 1970's. Dr Marshall Parks in Washington D.C. did
both. Not sure if each surgery was on one eye or if he did both eyes
both times One was at about age 3. The other at about age 6. While
the eso that I had with both eyes was gone I was left with exo. From
what my parents told me, Parks said I had minor brain damage and that
the eyes would never fuse. He also told that the brain turns the vision
off in the eye that it is not using. One of his collegues said I would
never be able to drive since I had no real depth perception. Well after
the 2 surgeriest my parents did not pursue any more treatment after
that so I suspect Parks did all he could do. I also wore glasses for a
short time around age 4 or 5 not for my vision which was 20/20 but what
I suspect was to help to correct the crossed eyes.

So growing up from then on I've lived with my right eye turned out most
of the time. My left eye which I use 95% of the time is straight as
long as I am focusing with it. I have the ability to switch eyes and
focus with the right eye but I have to consciously force myself. When I
do this the left eye becomes exo. But contrary to what my parents were
told by Parks about one eye being turned off, both eyes are indeed
working simultaniously. The eye that I am not focusing with simply
turns outward and acts as peripheral vision on that side but it is
clearly still working. Oh and I had my eyes checked recently and I
still have 20/20 vision.

I was picked on growing up and as I entered adulthood I became very
self conscious of it to the point where I have a difficult time looking
people in the eye I don't know really well. Interviews are a nightmare.
I know people see it because I constantly get people looking looking
back over their shoulder when I talk to them. That makes me even more
self conscious and I break eye contact from then on, usually looking at
them in brief glances, turning my head so I am looking at them more
from the corner of my eye which makes it less noticable or rubbing my
right eye. Anything to make them not notice. I do this with most
people, even those who may not notice. It made me getting ahead in life
hard.

Now I want to pursue strabismus surgery but I want to be sure I make
the right decision on the choice of doctor and that the surgery is
worth while. From what I wrote I was hoping maybe someone here,
preferrably an eye doctor could give me some advice as to whether
surgery is going to work for me cosmetically, don't care if fusion ever
occurs though it would be nice. Also would I benefit from vision
therapy/exercises. Also I want to find a good qualified and surgeon in
the NYC area who has a alot of experience in adult and childhood
strabismus surgery. Hope someone here can help.

Thanks in advance,
Adam

Adam-

I'm certainly not an eye doctor, but your post has been gathering dust,
so I'll take a stab at it....

(E-Mail Removed) wrote:
> Hello
> I am 35 years old and have suffered from exotrophia since I was about
> 6. Prior to that I esotrophic. I had 2 surgeries when I was a child on
> both eyes in the mid 1970's. Dr Marshall Parks in Washington D.C. did
> both

Theoretically, Parks was the best strabismusologist of his time. While
I *did* see him myself (as a patient), he did not perform any of my
three strabismus surgeries.

>. Not sure if each surgery was on one eye or if he did both eyes
> both times One was at about age 3. The other at about age 6.

If he got you straight, I'm not sure it would matter whether he cut one
or both, especially if only one eye was turned.

> While
> the eso that I had with both eyes was gone I was left with exo. From
> what my parents told me, Parks said I had minor brain damage and that
> the eyes would never fuse.

This is interesting. Were you ever evaluated by a neurologist?

I'm going out on a limb here, but ... in *congenital* (now called
"infantile") esotropes -- people born with an inward eye turn (that's
me), it's very normal for the brain's "fusional mechanism" not to
develop. In other words, if you're born withOUT an alignment disorder,
your brain learns to fuse the two images that the eyes send, creating
stereoscopic vision and depth perception. Presumably, this happens
early.

Parks likely meant that your fusional mechanism may not have developed
properly. Mine didn't. The problem with this is: that fusional
mechanism in the brain is sort of a "notch," making it far more likely
that your eyes will maintain their correct alignment. Without that
neurological facility for fusion, it seems very likely that the eyes
will drift, even after excellent *mechanical* alignment due to surgery.

> He also told that the brain turns the vision
> off in the eye that it is not using.

It *can*, but it doesn't have to. In my case, I either alternated
between eyes or *occasionally* used both, resulting in double vision
(prior to each surgery).

> One of his collegues said I would
> never be able to drive since I had no real depth perception.

Nah. People with only one eye can drive legally and their depth
perception is likely to be worse than yours.

> Well after
> the 2 surgeriest my parents did not pursue any more treatment after
> that so I suspect Parks did all he could do. I also wore glasses for a
> short time around age 4 or 5 not for my vision which was 20/20 but what
> I suspect was to help to correct the crossed eyes.

Very possible that they put you in prism glasses to correct a residual
(leftover) alignment issues.

> So growing up from then on I've lived with my right eye turned out most
> of the time. My left eye which I use 95% of the time is straight as
> long as I am focusing with it. I have the ability to switch eyes and
> focus with the right eye but I have to consciously force myself. When I
> do this the left eye becomes exo. But contrary to what my parents were
> told by Parks about one eye being turned off, both eyes are indeed
> working simultaniously. The eye that I am not focusing with simply
> turns outward and acts as peripheral vision on that side but it is
> clearly still working. Oh and I had my eyes checked recently and I
> still have 20/20 vision.

Do they check your vision with your eyes dilated??

> I was picked on growing up and as I entered adulthood I became very
> self conscious of it to the point where I have a difficult time looking
> people in the eye I don't know really well. Interviews are a nightmare.

That's a b**ch. I understand.

> I know people see it because I constantly get people looking looking
> back over their shoulder when I talk to them. That makes me even more
> self conscious and I break eye contact from then on, usually looking at
> them in brief glances, turning my head so I am looking at them more
> from the corner of my eye which makes it less noticable or rubbing my
> right eye. Anything to make them not notice. I do this with most
> people, even those who may not notice. It made me getting ahead in life
> hard.
>
> Now I want to pursue strabismus surgery but I want to be sure I make
> the right decision on the choice of doctor and that the surgery is
> worth while. From what I wrote I was hoping maybe someone here,
> preferrably an eye doctor could give me some advice as to whether
> surgery is going to work for me cosmetically,

Most strabismus surgeons use, as a guide, a minimum of about 12
diopters deviation from straight before surgery is indicated. Two
things have changed in the last 30 years that make the likelihood of a
successful outcome better than your last surgery:

1) Prism Adaptive Trials (where appropriate). This is where they put
you in prism glasses of gradually increasing strength, trying to find
out if you have more deviasion (exotropia) than ... um ... meets the
eye. Your convergence mechanism may be struggling to straighten your
eyes, leading to less apparent deviation than is actually present. PAT
can elicit this;

2) Delayed Adjustable Suture technique. Theoretically, I invented this
;-) They do the surgery, then--after a few days' healing to allow
swelling to go down, they *then* adjust the sutures to optimize
alignment.

> don't care if fusion ever
> occurs though it would be nice. Also would I benefit from vision
> therapy/exercises. Also I want to find a good qualified and surgeon in
> the NYC area who has a alot of experience in adult and childhood
> strabismus surgery. Hope someone here can help.

I know this isn't NYC, but the best guy I know of in the Northeast is
David Guyton at Johns Hopkins:

http://www.hopkinsmedicine.org/wilme...vs/Guyton.html

If you can't see him, perhaps he can recommend somebody -- maybe even
one of his former fellows -- in your area. I'd definitely start with
an evaluation by a top-notch strabismus ophthalmologist, asking him or
her about the vision therapy first. That may be something appropriate
for you, but--from what I gather about your situation--surgery is far
more likely.

Again ... it's really critical to remember: if you were born
cross-eyed, there's every reason to believe that--even after an
outstanding surgical result--your eyes may drift again.

Best of luck, Adam.

Neil

you've received a pretty good reply from neil brooks. he obviously has
experience in the problem from a patient standpoint and has pretty good
technical knowledge on the subject as well.

there is a strabismus surgeon who sometimes posts on this forum-- dr.
robbins i believe is his name. perhaps he will chime in. if not then
repost your question with his name in the title and i bet he'll catch
it.

what is your acuity in each eye separately? i am interested
specifically in knowing what the acuity is in the deviated eye (with
the best optical correction).

i think it is unlikely that you have had any "brain damage". you may
have had some lose of acuity in the deviated eye (amblyopia) and most
certainly your motility mechanisms are abnormal. i wouldn't consid
this to be brain damage in the sense of the word that most people use.

people who see with only one eye do have depth perception, but not
stereopsis which requires binocular vision. a large percentage of the
population is monocular and it doesn't affect your ability to drive
safely or obtain a drivers license.

keep looking for more information. i think much of what you have been
told is not entirely accurate since its old hand-me-down information
from doctor-to-parent-to-child. time also has a tendency to distort
what was actually said. you are more "normal" than you think, and
having vision in one eye is not a serious handicap. help with
straightening your deviated eye is readily available.

if your deviated eye has poor acuity as i suspect, what you are looking
for is a cosmetic solution. that is certainly achievable. i recommend
finding a good strabismus surgeon as you intend on doing. it also
wouldn't hurt for you to just book an appointment with the closest
strabismus specialist right away and then come armed with a lot of
questions. your understanding of your situation and your options will
increase exponentially after you leave.

good luck

retinula o.d. ph.d.

On 4/2/06 8:57 AM, in article
(E-Mail Removed). com,
"(E-Mail Removed)" <(E-Mail Removed)> wrote:

> you've received a pretty good reply from neil brooks. he obviously has
> experience in the problem from a patient standpoint and has pretty good
> technical knowledge on the subject as well.
>
> there is a strabismus surgeon who sometimes posts on this forum-- dr.
> robbins i believe is his name. perhaps he will chime in. if not then
> repost your question with his name in the title and i bet he'll catch
> it.
>
> what is your acuity in each eye separately? i am interested
> specifically in knowing what the acuity is in the deviated eye (with
> the best optical correction).
>
> i think it is unlikely that you have had any "brain damage". you may
> have had some lose of acuity in the deviated eye (amblyopia) and most
> certainly your motility mechanisms are abnormal. i wouldn't consid
> this to be brain damage in the sense of the word that most people use.
>
> people who see with only one eye do have depth perception, but not
> stereopsis which requires binocular vision. a large percentage of the
> population is monocular and it doesn't affect your ability to drive
> safely or obtain a drivers license.
>
> keep looking for more information. i think much of what you have been
> told is not entirely accurate since its old hand-me-down information
> from doctor-to-parent-to-child. time also has a tendency to distort
> what was actually said. you are more "normal" than you think, and
> having vision in one eye is not a serious handicap. help with
> straightening your deviated eye is readily available.
>
> if your deviated eye has poor acuity as i suspect, what you are looking
> for is a cosmetic solution. that is certainly achievable. i recommend
> finding a good strabismus surgeon as you intend on doing. it also
> wouldn't hurt for you to just book an appointment with the closest
> strabismus specialist right away and then come armed with a lot of
> questions. your understanding of your situation and your options will
> increase exponentially after you leave.
>
> good luck
>
> retinula o.d. ph.d.
>


Actually, I am a former David Guyton fellow at Wilmer. However, I learned a
lot from Marshall Parks during my residency in Washington. But, I learned a
LOT MORE during the time I spent in Dr. Arthur Jampolsky's offices in San
Francisco (while I was next door doing muscle research at the
Smith-Kettlewell Institute, of which Dr. Jampolsky was the director).

I don't have much to add to the this tread. Most of the pertinent points
have already been raised. Doing another surgery will likely get a better
alignment, but since there is no fusion, it is not guaranteed to stay
straight over the long haul. The cosmesis may be better, though. Certainly
adjustable suture technique is de rigeur here, as previously operated muscle
don't follow the usual muscle surgery (Parks) tables. As Dr. Jampolsky used
to say, when I asked him how much surgery he would do for a certain angle,
his answer was : "enough". This is determined in large part by how the
muscles feel, and the eye aligns mechanically during surgery. It does not
take into account the innervational forces that change once awake.


David Robins, MD
Board certified Ophthalmologist
Pediatric and adult strabismus subspecialty
Member of AAPOS
(American Association of Pediatric Ophthalmology and Strabismus)

Thanks everyone for your replies. I have another question. I've been to
3D movies and while I have the special glasses on the double image
isn't there, I always assume I am not really seeing the 3D effect
because I only work with one eye and as I understand it both eyes must
work to get that effect. Occasionally I swear I see the objects comin
at me :-) but most of time while the audience is ooing and ahhhing and
grabbing at the air I'm not seeing anything dramatic if at all.
Without the specials glasses on I can plainly see the images on the
screen are doubled which is supposed to be the case. But with the
glasses on looking at the screen I don't see that double image.
Shouldn't I! I thought for the glasses to work I had to have fusion,
which is what I thought combined that double image, and remember my
eyes are not even looking in the same direction at the same time. How
can my brain be fusing the double image into one? This confuses me. Oh,
to enforce that point, when using binoculars I can only see out of one
side at a time depending on which eye I switch to, but not both sides.
As mentioned originally, the unused eye whichever at that moment, just
goes exo. So whats the deal with the 3D appearing to work somewhat?

Thanks again,
Adam

(E-Mail Removed) wrote:
> Thanks everyone for your replies. I have another
> question. I've been to 3D movies and while I have the
> special glasses on the double image isn't there, I always
> assume I am not really seeing the 3D effect because I
> only work with one eye and as I understand it both eyes
> must work to get that effect. Occasionally I swear I see
> the objects comin at me :-) but most of time while the
> audience is ooing and ahhhing and grabbing at the air I'm
> not seeing anything dramatic if at all. Without the
> specials glasses on I can plainly see the images on the
> screen are doubled which is supposed to be the case. But
> with the glasses on looking at the screen I don't see
> that double image. Shouldn't I! I thought for the glasses
> to work I had to have fusion, which is what I thought
> combined that double image, and remember my eyes are not
> even looking in the same direction at the same time. How
> can my brain be fusing the double image into one? This
> confuses me. Oh, to enforce that point, when using
> binoculars I can only see out of one side at a time
> depending on which eye I switch to, but not both sides.
> As mentioned originally, the unused eye whichever at that
> moment, just goes exo. So whats the deal with the 3D
> appearing to work somewhat?

Ok, I don't have a clue but I wanted to make my guess
before someone actually answers...

Ummm, I believe the 3d glasses work on color/spectrum
filtering. One side blue? one side red? The images on the
screen are slightly displaced. one image you see primarily
with one eye and the other image ou see primarily with the
other eye. Varying the displacement of the images works
with your depth perception to give the 3d effect. It wouldn't
work in black and white. It makes sense that you see fine
through the glasses but don't get the 3d effect.

-Quick
>
> Thanks again,
> Adam

On 3/30/06 4:23 PM, in article
(E-Mail Removed). com,
"(E-Mail Removed)" <(E-Mail Removed)> wrote:

> Hello
> I am 35 years old and have suffered from exotrophia since I was about
> 6. Prior to that I esotrophic. I had 2 surgeries when I was a child on
> both eyes in the mid 1970's. Dr Marshall Parks in Washington D.C. did
> both. Not sure if each surgery was on one eye or if he did both eyes
> both times One was at about age 3. The other at about age 6. While
> the eso that I had with both eyes was gone I was left with exo. From
> what my parents told me, Parks said I had minor brain damage and that
> the eyes would never fuse. He also told that the brain turns the vision
> off in the eye that it is not using. One of his collegues said I would
> never be able to drive since I had no real depth perception. Well after
> the 2 surgeriest my parents did not pursue any more treatment after
> that so I suspect Parks did all he could do. I also wore glasses for a
> short time around age 4 or 5 not for my vision which was 20/20 but what
> I suspect was to help to correct the crossed eyes.
>
> So growing up from then on I've lived with my right eye turned out most
> of the time. My left eye which I use 95% of the time is straight as
> long as I am focusing with it. I have the ability to switch eyes and
> focus with the right eye but I have to consciously force myself. When I
> do this the left eye becomes exo. But contrary to what my parents were
> told by Parks about one eye being turned off, both eyes are indeed
> working simultaniously. The eye that I am not focusing with simply
> turns outward and acts as peripheral vision on that side but it is
> clearly still working. Oh and I had my eyes checked recently and I
> still have 20/20 vision.
>
> I was picked on growing up and as I entered adulthood I became very
> self conscious of it to the point where I have a difficult time looking
> people in the eye I don't know really well. Interviews are a nightmare.
> I know people see it because I constantly get people looking looking
> back over their shoulder when I talk to them. That makes me even more
> self conscious and I break eye contact from then on, usually looking at
> them in brief glances, turning my head so I am looking at them more
> from the corner of my eye which makes it less noticable or rubbing my
> right eye. Anything to make them not notice. I do this with most
> people, even those who may not notice. It made me getting ahead in life
> hard.
>
> Now I want to pursue strabismus surgery but I want to be sure I make
> the right decision on the choice of doctor and that the surgery is
> worth while. From what I wrote I was hoping maybe someone here,
> preferrably an eye doctor could give me some advice as to whether
> surgery is going to work for me cosmetically, don't care if fusion ever
> occurs though it would be nice. Also would I benefit from vision
> therapy/exercises. Also I want to find a good qualified and surgeon in
> the NYC area who has a alot of experience in adult and childhood
> strabismus surgery. Hope someone here can help.
>
> Thanks in advance,
> Adam
>

I trained some with Marshall Parks in the 80;'s. Dr. Parks usually operated
both eyes (medical rectus recession) for esotropia. If it recurred, he
usually operated both eyes (lateral rectus resection). However, if the
overly strong inwards brain signals weaken with age, and become more normal.
The now operated muscles now let the eyes turn outwards. This is not an
uncommon problem. I would try to get hospital records of the surgeries, so
it is obvious exactly what had been done. Hopefully they still exist.

By the way, I don't know why anyone would say you couldn't drive because of
lack of depth perception. This is not a requisite for driving. A lot of
people drive who are in your exact situation, since they have adapted to the
lack of depth perception.

While you may feel both eyes are being used simultaneously, they aren't or
you would have double vision constantly. There is a supression scotoma,
where PART of the vision is turned off,in the brain, to help keep diplopia
at bay.

Repairing this cosmetically is not that difficult, virtually any strabismus
surgeon can. It is easier if the old records show what was done. I don't
know anyone in particular in the NYC area, however.

In article <C05F385F.78FD1%(E-Mail Removed)>,
"David Robins, MD" <(E-Mail Removed)> wrote:

> On 3/30/06 4:23 PM, in article
> (E-Mail Removed). com,
> "(E-Mail Removed)" <(E-Mail Removed)> wrote:

> > off in the eye that it is not using. One of his collegues said I would
> > never be able to drive since I had no real depth perception. Well after

> By the way, I don't know why anyone would say you couldn't drive because of
> lack of depth perception. This is not a requisite for driving. A lot of
> people drive who are in your exact situation, since they have adapted to the
> lack of depth perception.

As I have posted before, my wife is blind in one eye. I'm not, but I
only use one eye. We both have valid driver's licenses.

--
Dan Abel
(E-Mail Removed)
Petaluma, California, USA