Strabismus (Exotropia ) - Advice needed

I would be greatly thankful to you people if I can get any advice,
input, personal comments on my case as described below:

Somewhere in the age of 3-5 years, I had a little accident, jumped
from something high and the edge of my left eye hit the bed post. I
got Strabismus, although somehow it was not noticed or better say not
took care of. In this age, I am 28 now, I really feel it more
difficult at times because of psycological issues like job, marriage,
etc.

In the age of 14, I consulted an eye specialist, and he told me that
my left eye sight was under-developed because of "suppression" and
can't be recovered even through lenses, glasses, or surgery. In
addition, I was informed that I had Exotropia and that if I wished, a
cosmetic surgery was possible. My parents suggested the surgery in
order to atleast look better although even at that time some people
said it's un-noticeable. Now I understand the reason, because it is
intermittent, just disovered it today when I read something about it
on the internet. And this has driven me to post the whole thing on
usenet.

I had the surgery (14 years before), and it was like before, I mean
exotropia was there but maybe to a lesser extent. Just two weeks
before, I had my eyes tested for driving license, my right eye is 6/6
(perfect), and with left eye I can perceive most of what is around me
but cant read except if it is really large(around 6 inch). Even then
its blurred. I dont see double images, except very very rarely when i
engage into some continuous talk or discussion for more than 5-6 hours
and all the time I try to focus other person's face. Even then its
blurred to say the most, I mean I lose fusion but not completely.

I am contented that I cant read with my left eye, but really I wish, I
could look like a normal person. I could look straight into people's
eyes. Is there any hope, can I get straight eyes, for the cosmetic
reasons? Should I go for surgery? Any other excercise, therapy, etc.?

I dont have any other problems. I read a lot, and much faster than any
of my colleauges do, no headaches, use computer a lot, more than 10
hours a day although I fear and never play ball games. The left eye
goes outward around 5-10 degrees but am not certain about the actual
measure. But sure, its not something extreme. I think my left vision
is also improving but at a very very slow rate. 14 years before, I was
not able to make sense of things with it, only distinguished between
day and night but now not only I can walk if I close my right eye but
can even read something as I pointed above.

Thanks for your attention and I look for your valuable remarks.

 

snip: poster has exotropia, amblyopia with suppression and has had one
surgery for exotropia, would like to have cosmetic surgery so that people
don't notice the eye turn

You will need to consult a strabismus surgeon, who will be able to tell you
the odds of having successful cosmetic improvement based on the actual
measurements of your eye.

However, you should know that in cases of deep amblyopia with suppression,
even if the surgery is successful, sometimes the eye will deviate outwards
again after a few years due to the lack of fusion.

Dr Judy

 

Many thanks Dr Judy

I dont know what deep amblyopia is. But sure if I go through surgery,
I would like it to correct the thing for the whole of my life, if
possible. Because I think, the psycological effects of having
strabismus again, after staying aright for some years, would be even
more difficult to handle.

What's you own personal advice in the wake of this situation? Should I
go for it or not?? Well. And also please indicate, if possible, the
probability measure (in percentage) of eye going outward again in some
years after a cosmetic surgery.

Thanks again.

 

The time of the cheats have come.

Now listen to this story, it's so absurd that it is not of this world.

Please Mr. Tom, don't invent such lies, there are gullible people that
may believe in them!

--
If you are interested in learning more about vision and the cure of
imperfect sight by treatment without glasses, contacts or surgery,
please visit http://TheCentralFixation.com or write to me privately.
You can also subscribe to
http://health.groups.yahoo.com/group/PerfectSight/ where you can
download for free the VOLUME ONE of the greatest BETTER EYESIGHT
MAGAZINE, published in 1919 by THE CENTRAL FIXATION PUBLISHING COMPANY.

 

It means the vision in your bad eye is very bad even with glasses.

But sure if I go through surgery,

Depends on the particular details of your eye. Only a surgeon who has
examined you and considered the question of whether surgery is recommended
can answer this.

Well. And also please indicate, if possible, the

Again, only the surgeon who has examined you can give you this data, and it
will be a best guess, not carved in stone.

 

You have to realize how the vision system works. The eyes are held straight
normally because fusion (using both eyes simultaneously together) helps fine
tune the brain's alignment signals that go to the eye muscles. As the eys
drift off from alignment, even microscopically, the erro signal that is
created realigns the eyes.

When there is no fusion from any cause, and from amblyopia specifically in
your case, there is no error signal to drive aligment. The nerve signals are
then bascially free-running, and the brain tries to send the same signals to
each eye. When there is poor vision one eye, it tends to wander out, and the
outward aiming signals gradually increase as compared to the inward aiming
signals, and this drift may continue to change for a long time, may stop
changing, and change again later.

When muscle surgery it done to try to align the eyes, it is operating on
normal muscles that are getting abnormal signals. It is trying to compensate
by weakening and tightening the muscles to offset the abnormal signals.
Yes, when the msucles have taken a "set" due to misalignment for a very long
time, there can be true changes in the stiffness (length-tension curves) of
the muscles due to stretching and contracture.


The goal of muscle surgery in exotropia with poor vision in one eye is to
leave the eyes slightly esotropic (pointed inwards) to allow for expected
future drift outwards. Most bad amblyopes WILL drift out again later on. I
have seen it take many years, or as little as a number of months. No one can
really predict a particular patient's course. They can only say, "In my
experience ...". Most responsible surgeons will tell you that future surger
is to be expected when misalignment recurs. Small amounts of misalignment
can be treated with BOTOX injections, but this technique really depends on
presence of fusion for a long-lasting result. However, I have seen a BOTOX
treatment keep someone happy for several years, til the drift reached a
point that he wanted something done again. Also, depending on the size of
the angle, and since all the surgery would have to be done in that one eye
(as opposed to doing equal surgery both eyes if both had good vision), a
large amount of surgery one eye may cause some incomitance. That is, due to
tightening the inner muscle and weakening the outer muscle creates a
situation where the eye has more trouble looked outwards. This may cause
relative crossing when looking to that side, but is usually not so
pronounced, since people don't spend much time looking far to one side -
they turn their head.

You are looking for a permanent cure, which is not possible. What can hope
for is a relative period of better cosmesis, the details of which can ONLY
be described to you after an exam by the surgeon.

Good luck.


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

 

Dear Dr. Robins

Thank you very much for your detailed answer. It has really helped me
understand my situation. And yes Dr. Judy, my left eyesight is really
bad, as I have already told. I'm not able to do anything useful with
it even with the help of glasses. I simply dont use it.

I wish I could be in States to find a chance to see you, Dr. Robins,
personally regarding my case.

I hope the current ongoing research in this area should be able to
address the issue of strabismus permanently even in adults. Because i
believe, with the available horizontal disparity among both eyes, and
the knowledge of which one is the good eye, and using triangulation
mathematically, it should be possible, to point the second eye to the
same object as well, even without fusion. It may seem a joke at this
time, but in the "not so far future", we should be able to compensate
for those error signals, using bio-micro-controllers, of which I have
a fair idea, sent by the brain rather than fighting with the muscles.

Thanks anyway. I would soon meet some eye (strabismus) specialist here
in Europe but sure will never go for surgery after this helpful
discussion. If he/she recommends any other solution, e.g. as Dr.
Robins indicated of the use of some injection, I would be glad to go
for it, provided it can work with an eye which is taking almost no
tangible action in the vision process.

Tom

 

Yes of course this is possible and done routinely. What is unpredictiable
is whether the operated eye will continue to point at the object in the
absence of fusion. Dr Robins explained this, perhaps you did not
understand that fusion is needed to maintain the alignment.

Dr Judy

It may seem a joke at this

 

Actually, any strabismus surgeon would be able to help you. We all do about
the same things - I don't doing anything "special". Yeah, I'm an engineer,
so I tend to be rigorously obsessive, but other than that ...

You should easily be able to find someone where you are, rather than here in
the San Francisco Bay area. Where do you live?

There is no real ongoing research in strabismus these days, other than
clinical information from academicians in the field. The National Institutes
of Health Nation Eye Institute has newer areas to fund, mainly in genetics
and molecular biology. That is why I left strabismus research at the
Smith-Kettlewell Eye Research Institute about 15 years ago.

The problem is NOT the muscles fighting. It is the brain not sending the
signals due to lack of fusion. Fusion is the area that is poorly understood,
and ever if it were understood, has little hope of correction in adults.
Most eye movement research is aimed at understanding the motor part of the
system, not the fusion. Yes, you can point the eye where you want it, but it
won't lock in and stay there since the feedback loop is not there.

If I were you, I would not be so negative about surgery. It is more powerful
and longer lasting than BOTOX, which while less invasive, is less
predictable and less helpful in these amblyopic situation. Of course, the
safest treatment is always to do nothing - "First, do no harm" , one of the
prime directives in medicine.

 

Not directly on strabismus, but there is plenty going on in orbital
mechanics and the "pulley" system". I would think the better you
understand the orbit, the better Miller's model gets, the better the
outcomes.

Scott

 

I worked directly with Joel Miller in his lab when I was at Smith-Kettlewell
and still keep in touch (we're good friends). I used his computerized
modeling system "ORBIT". He is one of the few strabismus researchers still
getting funded. But this has been going on with him since the early 1980's.
He and Joe Demer at Jules Stein are the collaborators about the pulley
system model, which we were looking at in the late '80s.

Still doesn't help that much for traditional strab problems. What I meant
was, while these models help us understand why some of our procedures do
what they do, there are no "miracles" coming out in strabismus management.

 

This all makes sense but why is it that when an eye is removed, the
muscles keep on doing what they've always done and move with the
remaining eye? Is it simply because they've worked well for so many
years and just carry on doing what they know? Will the brain ever
tell the muscles of the enucleated eye to stop bothering to move or
will they carry on working ad infinitum?

Ann

 

Dear Dr. Robins

Thanks again. Well not so negative about the surgery but lets first
discuss it with some strabismus specialist. And I live in Germany.
Another question is regarding the surgery costs. I can only hope that
my insurance will cover it. I think I have to ask them even before
seeing the surgeon. I am doubtful because the origin of the problem is
prior to the commencement of my policy. But maybe for such chronic
cases they have some different rule.

Tom

 

The brain seens similar signals to the aiming muscles in both eyes,
regardless of whether the eye is still there. Without visual input to change
the ratio, the signals are normally the same for both eyes, by Sthe Law of
Equal Innervation, and the Law of Reciprocal Innervation. This will continue
forever.

 

You may have a problem since it is a "pre-existing condition". However, a
further problem is that most insurance companies consider adults with
strabismus without diplopia as been a cosmetic problem, and refuse to cover
it.

In some instances, our surgeon can argue it is a psycho-social problem in
that it interferes with interpersonal relationships and business
situtations. Sometimes they consider the argument that it may restore some
fusion that has been lost. It usually requests, at least here in the States,
multiple letters to the insurance companies, where they are reviewed by
nurses who refuse the arguments.

I am fortunate because at Kaiser, there is no one higher up to decide what I
can and cannot do, except of course in cases of medical misadventure, etc.,
so I get to do all the adult strab cases that I see fit, without any
pleading. However, with the current trend towards reducing fees by cutting
out some things, this may end up becoming like is is in private practice.


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

 

Oh I see.. thank you.

Ann

 

To consider it "cosmetic" to want to look normal never made sense to me. But
then, insurance companies don't like to pay for anything. In my case, my
eyes turn inward, much more my right eye and it really does effect how I
interact with people. When I engage in conversataion, I always wonder deep
down if others notice, so I have a hard time looking at them. Aside from
that, I have a question on this topic.....my mother smoked while pregnant
with me 47 years ago. Certainly there are lots of poisons in cigarettes and
it must have been worse 47 years ago. I have 4 children, none of whom were
born with crossed eyes like me. Is it possible that my visual defect is
actually a birth defect from her smoking?

 

I don't know of any relationship between smoking and specifically esotropia.
It tends to be genetic, the exact relationship vague.

 

I had a wonderful lunch w/ Joel about four years ago in SF, and he told
some great stories about his mentor--we shared some roots at Hopkins, and
have some mutual friends.. Joe Demer and I share a mentor, separated by
about five years. Tempis fugit-- I must know Joe more than ten years
already.

Scott

 

I guess you're referring to David A. Robinson. I knew him when I was at
Wilmer, where I did my strab fellowship with David Guyton.

You may have also known DavidZee, the neurologist. (We were all in the same
car once for a short trip -all Davids.)

Who was the other mentor you mentioned - Gunther von Norden,
perhaps?