ambliopy and strabismus

I apologize for writing this long story, it's my first time in a web
group and I am hopeful that the more information I provide, the better
the advice you can give me.

My four years old boy was diagnosed with strabismus and amblyopia. He
started crossing (in) his right eye around 3 months ago. The
ophthalmologist prescribed glasses OD +2.25 (sphere) OS +1.75 (+0.25)
and then advised us to patch him 2 hours a day, and do some manual
activities while patched. He has been patched 7 weeks now. His vision
in OS (left, right?) is 20/20 and in the right eye was 20/40, and now
(after patching) is 20/30. However, I still see him failing the tests
with his right eye. I wonder how accurate the numbers are. He also just
failed the 3D test, de one with the fly and the little clowns, but the
doctor said that it is not definitive until he's 5 years old, but I
believe he understands the test. Well, the point is that my wife and I
believe he's no getting better, he is crossing more. Without glasses
he crosses much more now than 3 months ago, and even with glasses he
keeps crossing, but less than without them. Is this normal? is
strabismus something that gets worst with time? Can the glasses be the
cause for the change? In addition, why does the left (stronger) eye
needs +1.75 if it is 20/20? The boy keeps looking over his glasses
(tilting his head forward) every time he needs to see something further
than 3 feet. And what are the chances of him getting better. Are there
really some kids that after a few years of treatment solve the problem
for good and don't need glasses anymore, or they will always need the
glasses but won't have double vision, and will have 3d vision? What
are the chances in statistical terms? I don't even know what to
expect. Part of me wants to believe everything will be alright but I
keep reading and finding out this problem is very complicated and full
of uncontrollable variables and mysteries. What is the normal process
for treatment? patch and glasses may be enough to solve it? How do you
know if the treatment is working? The Doctor says my son was crossing
6-8 and now is 2-4 (with the glasses). But with out them, as I said,
is getting worst. Do you know any top ophthalmologist in the San
Francisco bay area? Stanford, San Jose, Berkeley? I'm not saying his
actual Doctor is not doing her job but I need a second opinion with
someone else knows is really really good. we're not form here so we
don't have a good network to find references. Sorry again for such a
long post. I'll appreciate any answer to my concerns. I'm lucky
there are these groups.

 

The issue here is whether his eyes are straight with the glasses on. If
so, you are at least on the right track.

1) Ignore what happens with no glasses on. At this point, they should
be on full time, NO exceptions.

2) Patching of 2hr per day is pretty well useless. I don't know why
ophthals continue to do this, it is a waste of time in most cases. What
you should be doing is to use atropine drops in his RIGHT eye for about
3 months. This will stimulate the use of the left eye and develop 3D
vision. Patching will not do this, it reinforces monocular vision.

3) Has your son been rechecked for his preccription? You want the
strongest possible prescription in his glasses at this moment. The plus
power is what keeps his eyes straight. It may be bebeficial to get
bifocals if the turn is greater at near than far.

4) Look up www.covd.org to find an optom in your area. Look fror
fellows, they are better skilled.

5) Atropine, Maximum Plus Power, Bifocals, Behavioural Optometrist.

Cheers,

dr grant

 

For a layperson, I know a bit about this. Dr. Grant's spot on.

I might go a step further and ask this of Dr. Grant:

- Bifocals??

- EW contact lenses (hyperopes accommodate less in CLs than in specs)?

- What portion of this is accommodative? Phospholine Iodide?

 

Apologies. I wasn't questioning this. I was suggesting it, but
overlooked that you included it.

 

Thank you both.

Dr Grant wrote:

"What you should be doing is to use atropine drops in his RIGHT eye for
about 3 months. This will stimulate the use of the left eye and develop
3D vision."

His strongest (preferred) eye is the left one. That is the one we're
supposed to penalize with atropine, right? Not the right one.

You mentioned that atropine will be better to develop 3D vision. I have
been reading some lay man articles comparing patching vs. atropine and
have not read about it, would you mind elaborating on that?

Regarding if his eyes are straight with the glasses, let's say that
they are definitively straighter with glasses than without them,
however he still crosses even with the glasses on. What does it mean?

Thanks again

 

Actually most of us DON'T do 2 hrs a day. But there was a recent
well-controlled study from PEDIG (Pediatric Eye Diseases Investigation Group
looking for evidence-based medicine rather than opinions)) comparing 2 hr a
day to 6 hrs a day, with significant improvement at 2 hrs per day. I
personally don't do that, but the study supports it. Therefore, there is
proof that is is not a was of time. Already he has picked up 1 line in just
7 weeks, which is not bad for the first patching session. At 2 hrs a day,
there is minimum reinforcement of monocular vision, anyway. Atropine, which
works all day long every day is a potential source of visual interference
also. I tend to reserve it for kids who are hard to patch or to have some
treatment in school that avoids patching in class.

3D vision will only really happen if he is truly straight, otherwise he will
have the minimal stereopsis of monofixation syndrome, which could have
existed all along, and just now manifesting a larger angle as accomoodative
factors are kicking in.

If he is crossing more when the glasses are off now, I tell parents to
EXPECT this. It is an indication of his igh sensitivity to accommodation
(focusing). When he is used to the glasses relieving the eystrain that is
turning the eyes in, it a a sudden strain when he taking the glasses off.
The inturning is the response to the sudden increase in accommodation effort
that he is then no longer used to (and shouldn't have to be).

My OPINION.

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

 

Good to hear from you again, Doc.

My (lay) thought on Atropine's application in this case was to
prescribe a fully Atropinised Rx for the child, not to use Atropine on
a regular basis.

Thoughts?

 

Thanks again for your answers.

I wrote:

"Regarding if his eyes are straight with the glasses, let's say that
they are definitively straighter with glasses than without them,
however he still crosses, even with the glasses on. What does it mean?"

Anybody has any idea?

As the time goes by, the glasses plus the patching are supposed to make
his eyes straigh?

How long can it take?

Thanks again, you are really helpful

 

The patching is to equalize vision, and eye preference. Doing so may or may
not influence the angle. Equal preference may result in straighter eyes IF
the angle is small and fusion is present.

The glasses are to remove the accommodative component of the crossing. Many
of these still have a non-accommodative component, which the hyperopic
glasses will not straighten. Of course, this is assuming the glasses are
indeed the full hyperopic correction - an atropine refraction is the surest
way to test for that. Once patching is pretty much over, ff the residual
angle is small, some would argue to leave it alone, leave as monofixation
syndrome (small angle esotropia). Others would argue for a small prism in
the glasses top better align the eyes, but in some cases, the eyes just "eat
up" the prism and adapt an increased angle where the residual continues at
the sam small angle, gaining nothing.

If the angle WITH GLASSES is large (>= 15 prism diopters), surgery for that
residual angle is often done. It also depends on the near angle as well, so
cases are individual.

 

Bogo, sorry misread the numbers, the left should have the atropine./

dr grant

 

David,

I have a problem with the PEDIG study, because all the ophthals that
espouse it here are having their kids seen by me after no improvement
in 6 months and going onto atropine and improving in the first month
with me.

My issue is that patching reinforces monocularity, regardless of time,
unless the eyes are straight as you say. Hubel and Wiesel showed that
alternating patching could change cortical cell response from left to
right eye, and when you patch for 2 hours, you force non-preferred
dominance for 2 hours, then preferred eye dominance for the rest of the
day. This results in left eyed cells and right eyed cells, but no
binocular cells.

I used to patch a lot, but my ophthal recommended to refer the kid to
him and get them put on atropine. I did this and we got great results
so I continued to do this. Lionel is a pretty smart guy (I think he has
forgotten more about strabismus than I will ever know) so I listen to
what he has to say. I comanage a lot of my patients with him,
especially if there is the suspicion of surgery needed.

Most of the kids I see are refractive amblyopes so atropine works
brilliantly for them. Strabs are certainly another kettle of fish and
patching is definitely better for many of them (which is probably a
large chunk of your practice).

Cheers,

grant

 

I personally don't find some of the PEDIG study results in my own practice;
ie the 2 hr/day patching as being effective in very many cases. I don't
cling to the PEDIG results very much. It is the parents waving the internet
articles in my face, who do.

Regarding then binocular cells- these are kids who probably suffer from lack
of binocular cells anyway, due to the amblyopia they have had all their
life, probably. My feeling is the short time (relative to their life prior)
we are patching, it probably doesn't make any long-term difference. (Not a
study of course, ...)

A lot of amblyopes I get who ARE refractive have such poor vision starting
out that I se no point in using atropine (ie <20/70 or so). My feeling is
atropine really only works if you can switch fixation at near by blurring
more than the amblyopic eye. I check which eye they are using at near, if I
start atropine. If they still use the better eye, how could it be effective?
Yes, I could remove the plus from the atropined eye, or even go minus, to
penalize more, but it is such a hassle. To check vision in that eye, you
then have to put a trial frame with the correct Rx on. And parents complaint
if you then reorder (expensive) new lenses for less penalization, and then
reorder yet again once the amblyopia treatment is over.

David Guyton at Wilmer (who I trained with) has gone almost entirely over to
atropine. He never could explain to my satisfaction how it could work where
the near preference is not switched, and others besides me wonder, too.
However, my other training with Dr. Jampolsky in San Francisco, used a fair
amount of patching. But he was dealing more with strabismic patients, as you
said.

Bottom line, we still don't scientifically really know which treatment is
best. We may THINK we know, based on logic, however, which is what a lot of
our treatments are based on.

BTW, when you say "Lionel", I presume you mean Lionel Kowal, who we all know
of, and have corresponded with myself. As you said, very smart guy.

 

I agree with you on this. Like I say, I don't get too many strabs as
they get filtered pretty quickly away from optometry in most cases, and
the CET's need patching, glasses and surgery in most cases. I don't
even bother with them in most cases (except for the specs) as they need
surgery in most cases and the doc is usually best placed to determine
this as you are well aware.

Occlusion of any sort is what you are comfortable with. Other optons I
know patch, I find I get crappy results and almost invariably allergy
to the opticlude patches. That really sucks!!!

Yes, it is the same Lionel, I am pretty lucky to have one of his ilk in
my town. He works well with optometry, even when we confound him with
6yo girls with Holmes Aide pupil (which Lionel assures me is
impossible). He did add the pearl that Aide comes from Geelong, 1hr
from Melbourne. I didn't know that.

Cheers

grant

 

Dr. Robins,

Then, instead of two, how many hours of patching per day would you feel
comfortable with?

Regarding Dr. Jampolsky in San Francisco, I'm looking for a Dr. in the
SF bay area, should I try to take my 4 years old kid to see him? Or ask
him for a referral around here?

Thanks again.

Javier

 

I would want to be rechecking his distance script again to make sure it
is strong enough. Also check his near phoria with cover test to see if
he has excessive esophoria at near. This is where bifocals will help if
he has high esophoria.

If he is straight most of the time, then atropine is better than
patching as it will develop 3D vision.

If patching, I find 6hr to full time works better than 2 hr, but with
vision at 20/30, it is at tje stage when I would be looking at
antisuppression treatment with a Bangerter foil (a stick on graded
occluder on the glasses) which is worn full time on the left lens of
the glasses and helps to develop 3D vision as well as improve the RE
vision. The foil drops the LE to around 20/60 to 20/80 on the left eye.
This works if the eyes are nostly straight.

dr grant

 

You don't know how much I value every time you all answer. Thanks

 

You don't know how much I value every time you all answer. Thanks

 

Patching hours really depends on the level of amblyopia, the cause and type
of amblyopia, and whether there is coexsisting strabismus and a possibility
of continued fusion, It is a very individual situation,as far as I'm
concerned.

Thus, it is not how many hours I'd be comfortable with. It ranges from 2 hrs
in a few cases to all day (1 hour off).


Dr. Jampolsky retired from practice a number of years ago.

You might try (all in the CPMC Hospital area on Webster and Clay in SF):
(all excellent people)
Susan Day (in Dr. Jampolsky's old office)
Alan Scott (the other ex-codirector of the Smith-Kettlewell Institute)
Otis Paul
William Good

Where is "around here"?

 

Sorry, around here I meant the San Francisco bay area; SF, Stanford
University, Silicon valley, or even Berkeley or San Jose if necessary,
even when the lat two are a little further.

Thanks

Javier