Strabismus surgery or Vision Therapy. Whats the better choice at this point

I posted on here last year regarding my exotrophia and got some great
replies, especially from
Neil Brooks. His and everyones elses consensus seemed to be that
surgery was best. Neil
even referred me to Dr. David Guyton at Johns Hopkins who I spoke with
and Dr. Guyton referred
me to a guy here in NYC, Dr. Jay Wisnicki. But due to some personal
and family issues I put
off pursuing anything for the last year and never saw Dr. Wisnicki.
Yesterday I finally made an appointment to see him which is set for
tomorrow but I started reading more about vision therapy and wondered
if I am jumping
the gun on this by pursuing surgery. Should I get evaluated by an
optometrist as well to see if
I am a good candidate for vision therapy or is it going to be a waste
of time. I am more looking for a
good cosmetic result rather than stereoscopic vision for fusion. Will
surgery at this stage of my
life give me a good cosmetic result that will not deviate over time
again or will vision therapy
produce a similar result and maybe even stereoscopic vision? If I can
avoid going under the
knife and get the same or better result than that would be optimal.

Below is a copy of what I originally posted

---------------------
I am 35 years old and have suffered from exotrophia since I was about
6. Prior to that I was 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 in my
right eye. My parents always claimed it only apparent when I am tired
but that is not true. It is exo all the time. From
what my parents told me, Parks also hadsaid I had minor brain damage
and that there would never be fusion. I also recall my mother saying
that they were told that the vision in the right eye, the exo eye,
turns off when I don't use it. Also one of his colleagues said I would
never be able to drive since I had no real depth perception. Well
after the 2 surgeries 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 actually becomes exo. But contrary to what
my parents were told by Parks about one eye being turned off, both
eyes are indeed working simultaneously. 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 back over their shoulder when I talk to them, not to mention
occasionally people will then actually ask me if I am looking at them.
All this 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 noticeable 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,
preferably 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.
-----------------------------------------

On May 8, 12:07 pm, amn0270 <sithlor...@gmail.com> wrote:
> I posted on here last year regarding my exotrophia and got some great
> replies, especially from
> Neil Brooks. His and everyones elses consensus seemed to be that
> surgery was best. Neil
> even referred me to Dr. David Guyton at Johns Hopkins who I spoke with
> and Dr. Guyton referred
> me to a guy here in NYC, Dr. Jay Wisnicki. But due to some personal
> and family issues I put
> off pursuing anything for the last year and never saw Dr. Wisnicki.
> Yesterday I finally made an appointment to see him which is set for
> tomorrow but I started reading more about vision therapy and wondered
> if I am jumping
> the gun on this by pursuing surgery. Should I get evaluated by an
> optometrist as well to see if
> I am a good candidate for vision therapy or is it going to be a waste
> of time. I am more looking for a
> good cosmetic result rather than stereoscopic vision for fusion. Will
> surgery at this stage of my
> life give me a good cosmetic result that will not deviate over time
> again or will vision therapy
> produce a similar result and maybe even stereoscopic vision? If I can
> avoid going under the
> knife and get the same or better result than that would be optimal.
>
> Below is a copy of what I originally posted
>
> ---------------------
> I am 35 years old and have suffered from exotrophia since I was about
> 6. Prior to that I was 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 in my
> right eye. My parents always claimed it only apparent when I am tired
> but that is not true. It is exo all the time. From
> what my parents told me, Parks also hadsaid I had minor brain damage
> and that there would never be fusion. I also recall my mother saying
> that they were told that the vision in the right eye, the exo eye,
> turns off when I don't use it. Also one of his colleagues said I would
> never be able to drive since I had no real depth perception. Well
> after the 2 surgeries 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 actually becomes exo. But contrary to what
> my parents were told by Parks about one eye being turned off, both
> eyes are indeed working simultaneously. 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 back over their shoulder when I talk to them, not to mention
> occasionally people will then actually ask me if I am looking at them.
> All this 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 noticeable 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,
> preferably 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.
> -----------------------------------------

in my opinion its a no-brainer. get the surgery.
if afterwards you want to try to get some improved vision in that eye
with visual training then it will be much easier if the eye is in good
alignment with the other, which it should be after surgery. but the
ability to achieve improved vision with visual training is much lower
in adults than in young children so I'm not sure whether that will
work in any case. and using visual training to achieve a cosmetic
result is not what its intended for, its intended to improve visual
function (acuity, stereopsis, etc).

I'll agree here 100%, vision therapy is not a realistic plan. Vision
therapy works best on "virgin" eyes that have never been operated on
for strabismus surgery. You can train for months or years and never
compensate enough for muscles that were left surgically as too long or
too short.


On May 8, 11:41 am, p.clar...@gmail.com wrote:
> On May 8, 12:07 pm, amn0270 <sithlor...@gmail.com> wrote:
>
>
>
>
>
> > I posted on here last year regarding my exotrophia and got some great
> > replies, especially from
> > Neil Brooks. His and everyones elses consensus seemed to be that
> > surgery was best. Neil
> > even referred me to Dr. David Guyton at Johns Hopkins who I spoke with
> > and Dr. Guyton referred
> > me to a guy here in NYC, Dr. Jay Wisnicki. But due to some personal
> > and family issues I put
> > off pursuing anything for the last year and never saw Dr. Wisnicki.
> > Yesterday I finally made an appointment to see him which is set for
> > tomorrow but I started reading more about vision therapy and wondered
> > if I am jumping
> > the gun on this by pursuing surgery. Should I get evaluated by an
> > optometrist as well to see if
> > I am a good candidate for vision therapy or is it going to be a waste
> > of time. I am more looking for a
> > good cosmetic result rather than stereoscopic vision for fusion. Will
> > surgery at this stage of my
> > life give me a good cosmetic result that will not deviate over time
> > again or will vision therapy
> > produce a similar result and maybe even stereoscopic vision? If I can
> > avoid going under the
> > knife and get the same or better result than that would be optimal.
>
> > Below is a copy of what I originally posted
>
> > ---------------------
> > I am 35 years old and have suffered from exotrophia since I was about
> > 6. Prior to that I was 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 in my
> > right eye. My parents always claimed it only apparent when I am tired
> > but that is not true. It is exo all the time. From
> > what my parents told me, Parks also hadsaid I had minor brain damage
> > and that there would never be fusion. I also recall my mother saying
> > that they were told that the vision in the right eye, the exo eye,
> > turns off when I don't use it. Also one of his colleagues said I would
> > never be able to drive since I had no real depth perception. Well
> > after the 2 surgeries 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 actually becomes exo. But contrary to what
> > my parents were told by Parks about one eye being turned off, both
> > eyes are indeed working simultaneously. 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 back over their shoulder when I talk to them, not to mention
> > occasionally people will then actually ask me if I am looking at them.
> > All this 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 noticeable 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,
> > preferably 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.
> > -----------------------------------------
>
> in my opinion its a no-brainer. get the surgery.
> if afterwards you want to try to get some improved vision in that eye
> with visual training then it will be much easier if the eye is in good
> alignment with the other, which it should be after surgery. but the
> ability to achieve improved vision with visual training is much lower
> in adults than in young children so I'm not sure whether that will
> work in any case. and using visual training to achieve a cosmetic
> result is not what its intended for, its intended to improve visual
> function (acuity, stereopsis, etc).- Hide quoted text -
>
> - Show quoted text -

Thanks for your replies.

So in a nutshell the only way I am going to achieve the cosmetic
result I desire is doing the surgery and the best chance to avoid the
exotrophia reoccurring again down the road is to follow up the surgery
with vision therapy to hopefully develop some degree of fusion or
stereoscopic vision which at this point in my life everyone says is
unlikely, but if I am able to somewhat develop it, it would thus lock
the eyes in position permanently. Am I correct?

Thanks,
Adam

On May 8, 6:47 pm, amn0270 <sithlor...@gmail.com> wrote:
> Thanks for your replies.
>
> So in a nutshell the only way I am going to achieve the cosmetic
> result I desire is doing the surgery

yes

> and the best chance to avoid the
> exotrophia reoccurring again down the road is to follow up the surgery
> with vision therapy

highly doubtful that any exo recurrence would be affected at all by
vision therapy

> to hopefully develop some degree of fusion or
> stereoscopic vision which at this point in my life everyone says is
> unlikely

this is the only effect that vision therapy might have, but as you
say, its unlikely

> but if I am able to somewhat develop it, it would thus lock
> the eyes in position permanently.

don't know for sure but i think there wouldn't be any "lock" at all.

your are what is called an "intermittent exotrope". your eyes have
learned to work separately and fortunately they have developed good
acuity, albeit without any stereopsis. the development of stereopsis
is a very early event in visual development, even preceding acuity.
at your age it is virtually certain that you will not gain any
functional stereopsis. if I were you I would only look forward to a
cosmetic effect.

On 5/8/07 5:37 PM, in article
(E-Mail Removed). com, "(E-Mail Removed)"
<(E-Mail Removed)> wrote:

> On May 8, 6:47 pm, amn0270 <sithlor...@gmail.com> wrote:
>> Thanks for your replies.
>>
>> So in a nutshell the only way I am going to achieve the cosmetic
>> result I desire is doing the surgery
>
> yes
>
>> and the best chance to avoid the
>> exotrophia reoccurring again down the road is to follow up the surgery
>> with vision therapy
>
> highly doubtful that any exo recurrence would be affected at all by
> vision therapy
>
>> to hopefully develop some degree of fusion or
>> stereoscopic vision which at this point in my life everyone says is
>> unlikely
>
> this is the only effect that vision therapy might have, but as you
> say, its unlikely
>
>> but if I am able to somewhat develop it, it would thus lock
>> the eyes in position permanently.
>
> don't know for sure but i think there wouldn't be any "lock" at all.
>
> your are what is called an "intermittent exotrope". your eyes have
> learned to work separately and fortunately they have developed good
> acuity, albeit without any stereopsis. the development of stereopsis
> is a very early event in visual development, even preceding acuity.
> at your age it is virtually certain that you will not gain any
> functional stereopsis. if I were you I would only look forward to a
> cosmetic effect.
>

Prior esotropes who become exotropic later are seldom, if ever, intermittent
exotropes. It is usually a constant exotropia. Intermittency would indicate
fusion most of the time, which prior esotropes normally will not do.

The history is consistent with infantile esotropia. Probably had Parks
medial recessions, was still residual esotrope, and then lateral resections.
It could have been a lateral recession for consecutive exotropia, less
likely. Parks usually did equal balanced surgery split between the two eyes.
(I did some of my training with Marshall Parks, most with David Guyton, and
some with Arthur Jampolsky, all very well-known specialsits).

Surgery will not improve fusion. Whatever stability occurs will not normally
be due to fusion in these cases. I do not have experience with vision
therapy at this age having any effect on the long term alignment.


David Robins, MD
Board certified Ophthalmologist
Pediatric ophthalmology and adult strabismus subspecialty

On May 8, 10:34 pm, "David Robins, MD" <trasha...@bigfoot.com> wrote:

> Surgery will not improve fusion. Whatever stability occurs will not normally
> be due to fusion in these cases. I do not have experience with vision
> therapy at this age having any effect on the long term alignment.
>
> David Robins, MD
> Board certified Ophthalmologist
> Pediatric ophthalmology and adult strabismus subspecialty

Hi Doc,
So being that you say vision therapy won't help long term alignment or
do anything for stereoscopic vision or fusion then basically
I should not waste my time with vision therapy after the surgery,
correct? Basically
it sounds like the cosmetic result I get from the surgery is the most
I can expect at this
stage of my life, which I am not complaining about since a cosmetic
result
is really all I was after anyway. What are the odds that after the
surgery that
my right eye will drift out again as time goes by? Will future
surgeries be in
my future to keep things aligned?

Thanks
Adam

Some stay straight (or cosmetically straight, anyway) for years. Others do
not. I am not says there is zero role to vision therapy, it is just that
most of the people I know do not use it, especially in adults. Ou have to be
careful in this newsgroup, as this is not the opinion of some of the
optometrists.

The reason you probably drifted out now is the overactive inward converging
signals that caused the original crossing are now back to more normal
levels. Meanwhile, the muscles were moved around to compensate for the
overactive signals. Now that they are ore normal, the altered muscles now
angle the eyes out. Realigning the eyes helps, assuming no great change in
the signals. That is the more unpredictable part.

Children with large angle crossing in the office are often striagh to
slightly angles out AT THE START OF SURGERY when the signals are turned off
by the anesthesia and muscle relaxation agents. I often joke to the
anesthesiologist that they have cured my patient before I started operating.

On 5/8/07 7:53 PM, in article
(E-Mail Removed) om, "amn0270"
<(E-Mail Removed)> wrote:

> On May 8, 10:34 pm, "David Robins, MD" <trasha...@bigfoot.com> wrote:
>
>> Surgery will not improve fusion. Whatever stability occurs will not normally
>> be due to fusion in these cases. I do not have experience with vision
>> therapy at this age having any effect on the long term alignment.
>>
>> David Robins, MD
>> Board certified Ophthalmologist
>> Pediatric ophthalmology and adult strabismus subspecialty
>
> Hi Doc,
> So being that you say vision therapy won't help long term alignment or
> do anything for stereoscopic vision or fusion then basically
> I should not waste my time with vision therapy after the surgery,
> correct? Basically
> it sounds like the cosmetic result I get from the surgery is the most
> I can expect at this
> stage of my life, which I am not complaining about since a cosmetic
> result
> is really all I was after anyway. What are the odds that after the
> surgery that
> my right eye will drift out again as time goes by? Will future
> surgeries be in
> my future to keep things aligned?
>
> Thanks
> Adam
>

On May 8, 8:37 pm, p.clar...@gmail.com wrote:
> On May 8, 6:47 pm, amn0270 <sithlor...@gmail.com> wrote:
>
> > Thanks for your replies.
>
> > So in a nutshell the only way I am going to achieve the cosmetic
> > result I desire is doing the surgery
>
> yes
>
> > and the best chance to avoid the
> > exotrophia reoccurring again down the road is to follow up the surgery
> > with vision therapy
>
> highly doubtful that any exo recurrence would be affected at all by
> vision therapy
>
> > to hopefully develop some degree of fusion or
> > stereoscopic vision which at this point in my life everyone says is
> > unlikely
>
> this is the only effect that vision therapy might have, but as you
> say, its unlikely
>
> > but if I am able to somewhat develop it, it would thus lock
> > the eyes in position permanently.
>
> don't know for sure but i think there wouldn't be any "lock" at all.
>
> your are what is called an "intermittent exotrope". your eyes have
> learned to work separately and fortunately they have developed good
> acuity, albeit without any stereopsis. the development of stereopsis
> is a very early event in visual development, even preceding acuity.
> at your age it is virtually certain that you will not gain any
> functional stereopsis. if I were you I would only look forward to a
> cosmetic effect.

my terminology stands corrected. your condition is called
"alternating exotropia" rather than intermittent, unless some of the
time both eyes are in proper alignment.

Dear Sithlor,

You might also contact Dr. Granet at:

http://eyesite.ucsd.edu/faculty/granet.htm

I understand he is an expert on strabismus.

Perhaps Neil Brooks could describe Dr. Granets
work with his strabismus.

Enjoy,

Otis



On May 8, 12:07 pm, amn0270 <sithlor...@gmail.com> wrote:
> I posted on here last year regarding my exotrophia and got some great
> replies, especially from
> Neil Brooks. His and everyones elses consensus seemed to be that
> surgery was best. Neil
> even referred me to Dr. David Guyton at Johns Hopkins who I spoke with
> and Dr. Guyton referred
> me to a guy here in NYC, Dr. Jay Wisnicki. But due to some personal
> and family issues I put
> off pursuing anything for the last year and never saw Dr. Wisnicki.
> Yesterday I finally made an appointment to see him which is set for
> tomorrow but I started reading more about vision therapy and wondered
> if I am jumping
> the gun on this by pursuing surgery. Should I get evaluated by an
> optometrist as well to see if
> I am a good candidate for vision therapy or is it going to be a waste
> of time. I am more looking for a
> good cosmetic result rather than stereoscopic vision for fusion. Will
> surgery at this stage of my
> life give me a good cosmetic result that will not deviate over time
> again or will vision therapy
> produce a similar result and maybe even stereoscopic vision? If I can
> avoid going under the
> knife and get the same or better result than that would be optimal.
>
> Below is a copy of what I originally posted
>
> ---------------------
> I am 35 years old and have suffered from exotrophia since I was about
> 6. Prior to that I was 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 in my
> right eye. My parents always claimed it only apparent when I am tired
> but that is not true. It is exo all the time. From
> what my parents told me, Parks also hadsaid I had minor brain damage
> and that there would never be fusion. I also recall my mother saying
> that they were told that the vision in the right eye, the exo eye,
> turns off when I don't use it. Also one of his colleagues said I would
> never be able to drive since I had no real depth perception. Well
> after the 2 surgeries 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 actually becomes exo. But contrary to what
> my parents were told by Parks about one eye being turned off, both
> eyes are indeed working simultaneously. 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 back over their shoulder when I talk to them, not to mention
> occasionally people will then actually ask me if I am looking at them.
> All this 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 noticeable 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,
> preferably 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.
> -----------------------------------------