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

Discussion in 'Laser Eye Surgery' started by amn0270, May 8, 2007.

  1. amn0270

    amn0270 Guest

    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.
    amn0270, May 8, 2007
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  2. amn0270

    p.clarkii Guest

    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).
    p.clarkii, May 8, 2007
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  3. 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.
    doctor_my_eye, May 8, 2007
  4. amn0270

    amn0270 Guest

    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?

    amn0270, May 8, 2007
  5. amn0270

    p.clarkii Guest

    highly doubtful that any exo recurrence would be affected at all by
    vision therapy
    this is the only effect that vision therapy might have, but as you
    say, its unlikely
    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.
    p.clarkii, May 9, 2007
  6. 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
    David Robins, MD, May 9, 2007
  7. amn0270

    amn0270 Guest

    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
    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?

    amn0270, May 9, 2007
  8. 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

    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.
    David Robins, MD, May 9, 2007
  9. amn0270

    p.clarkii Guest

    my terminology stands corrected. your condition is called
    "alternating exotropia" rather than intermittent, unless some of the
    time both eyes are in proper alignment.
    p.clarkii, May 9, 2007
  10. amn0270

    otisbrown Guest

    Dear Sithlor,

    You might also contact Dr. Granet at:

    I understand he is an expert on strabismus.

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


    otisbrown, May 9, 2007
  11. amn0270

    amn0270 Guest

    I just want to hear different opinions from various professionals so I
    have some
    clearer understanding of what I am dealing with
    Thats interesting. So you are sort of saying that if Dr Parks had not
    done surgery and my
    eyes alone that is possible that my original esotrophia would have
    diminished to a more
    near proper alignment as I got older. I was looking at some old photos
    of me that were taken
    within a couple years after my second surgery and I notice my eyes are
    in pretty good alignment but by the age of maybe 7 or 8 it seems that
    the exotrophia became apparant and sorta hit the point where it is
    today by my teens.

    What do you think the odds of me developing permanent doublevision
    after surgery are? I don't wear glasses now and don't want to have end
    up having to after surgery to correct that. I have 20/20 vision at
    this point and though I usually focus with my left eye most of the
    time, my right eye which spends most of its time exo works nearly
    identically well though I have to force myself to switch to it.
    amn0270, May 9, 2007
  12. amn0270

    Neil Brooks Guest

    I'm sorry to see you back ;-)
    Somebody on another forum chastised me for continuing to state that
    I'm not a doctor; nonetheless ... I'm not a doctor. David Robins
    knows more than I ever will about strabismus generally. I believe
    I've simply come to learn a LOT about MY eyes ... how well that all
    translates is debatable.

    Now ... all that said ... it seems you'll be seeing the surgeon
    today. My $0.02--in stream-of-consciousness style is:

    - post the results of Dr. Wisnicki's evaluation here. Include
    everything. I'd want to know the difference, if any, between your dry
    (no drops) and wet (cycloplegic drops used) refractions, your angle of
    deviation in every direction, and at far AND near. I imagine all of
    this would be information that Dr. Robins could use, too;

    - You saw 20/20 last year, but ... you're getting older <grin>. This
    means there could still be an accommodative component that should be
    isolated to understand its impact, if any, on your eye turn
    (particularly if you DO go the surgical route);

    - I think you're a candidate for Prism Adaptive Trials. Essentially,
    it's a technique--based on the theory that you can "have" MORE
    deviation than your eyes seem to manifest. They push increasing
    amounts of prism on you, over time, until it looks like they've
    elicited ALL the deviation;

    - Sadly, =I= don't believe that there's much hope that you or I are
    going to get a result--either surgically OR with vision therapy--
    that's going to "lock" our eyes into a straight alignment. The fact
    that we were born with the deviation seems to mean that the neurologic
    mechanism for fusing the images (stereopsis) never properly
    developed. Had we had intensive vision therapy at very young ages,
    this might be different.

    - However ... just because adults are NOT the best candidates for VT
    doesn't mean it won't have ANY positive effects for you. The primary
    issue (to me) is: how big IS your turn right now (in diopters). If
    you're exo- enough that you're a surgical candidate (likely something
    like 12d or more), then I'm betting that vision therapy won't be able
    to "teach you" to overcome THAT big of a hurdle. IF, on the other
    hand, you ARE a surgical candidate, and you DO have a successful
    surgical outcome, then ... why NOT try VT?? It's like cutting up a
    child's steak into bite-sized pieces for them. The slab of meat is
    just too difficult for their little, not-yet-developed bodies. A big
    deviation is something that OUR brains can't process ... or, at least,
    not as readily as those whose fusion mechanisms developed properly.

    - Whether or not you /need/ glasses ... how about a pair of really
    stylish frames with lightly tinted lenses? It might make the turn
    less noticeable to most who are talking to you. I've learned
    something over decades of living with this: we ARE hypersensitive to
    the reactions of others, AND they ARE reacting. Depending on the
    degree of turn, you may be a candidate for prism glasses ... yet
    again. Large amounts of prism involve metric tons of lens--a worse
    cosmetic result than you have--but maybe yours can be "optically
    straightened" with a reasonable amount of prism, well made, in a high
    index lens, and look darned good. The downside here, IMO, is that
    taking them off and putting them on CAN "visually bother" people. It
    bothers me. I live with it.

    - David Granet? Well--though I think Otis Brown is an early-onset
    Alzheimer's candidate with additional psychological issues too
    numerous to list--Dave Granet's good. He's incredibly bright, young,
    creative, and not quite as set in his ways as, say, Parks was when =I=
    saw him. Once you get your results from today's visit, if you want to
    send them to me (neil zero five zero two at yahoo dot com), I'll put
    the two of you together.

    - EVEN IF you had a "perfect" surgical result, IMO, you will NOT
    maintain alignment over the years WITHOUT some sort of VT and/or
    glasses to take care of any refractive error that could be influencing
    your alignment picture (again, the cycloplegic refraction would help
    to inform this). Whether or not the VT will allow you TO maintain
    alignment is still a crap shoot. If you don't have the locking /
    mechanism/, then you can't lock the eyes in place. Period. VT MAY be
    able to find, and develop, the locking mechanism. It probably won't
    hurt anything.

    - I'm a surgical candidate AGAIN due to my exo- (was always eso-
    before the surgeries). I'm in no hurry, though ... it's making my
    life worse, too (for complex reasons that long-time viewers already
    know all too well). Some of us "need" surgery every five-ish years.
    I may come around to that, but not today.

    So, in summary:

    - post your results. That should help everybody give you better info

    - consider some glasses for now, even if it's just to improve cosmesis

    - if you're a TRUE infantile esotrope, you're likely NOT to get a
    permanent fix out of anything, but VT may help you MAINTAIN alignment
    if surgery is indicated, performed, and gets your deviation down to a
    small-ish number

    - prisms may be an option--an option in lieu of surgery, or an option
    after surgery (it's science AND art. The skill of the surgeon is even
    MORE critical when you don't have that locking mechanism well in
    place). Basketball analogy: for most people, the surgeon just needs
    to hit the rim. For you and me, it's gotta' be allll net.

    Hope that helps. I hope today's appointment goes well.

    Get back to us, huh?

    Neil Brooks, May 9, 2007
  13. Most people in this situation won't see double if they are not seeing double
    with the eyes exotropic. As a child, with the esotropia, the brian also did
    not see double, and adapted to that.

    HOWEVER, I have seen a few adults break out of their suppression and see
    double even if they weren't operated on. However, this is uncommom.

    Regarding the issue of Parks and the surgery - one doesn't look forward to
    30 years after surgery and avoid doing it. Yes, some do drift out as I
    mentioned, but I have seen others stay fairly straight permanently. While
    Parks wasn't God (although he might have thought he was at times ...), he
    established a lot of the principles that guide us today. We are looking out
    the retrospectoscope here postulating what would have happened if you were
    never operated, and of course, that isn't fair.
    David Robins, MD, May 10, 2007
  14. amn0270

    amn0270 Guest

    Thats what I was told by Dr. Wisnicki Wednesday, though he said it is
    not uncommon to experience some doublevision temporarily, right after
    surgery but that it will usually go away after a few days or so..
    amn0270, May 12, 2007
  15. amn0270

    amn0270 Guest

    I don't have the info you asked for because I didn't see your reply
    until after I already saw Dr. Wisnicki and I never thought to ask him
    for the information. The visit itself went great. He was a real nice
    guy and did not make me feel like simply another car on the assembly
    line. He said that the deviation substantial enough that he highly
    doubted VT or prisms would be able to correct it because it was so
    large, so not sure if the Prism Adaptive Trials you mention would be
    much help. And I will not wear glasses if it would be required
    forever. If it was simply for treatment for a year lets say than I
    would consider it but I really don't want to have to hide my eyes
    behind glasses for the rest of my life simply to keep them
    cosmetically aligned. This is more because I simply hate the way I
    look in glasses. Dr. Wisnicki was very honest with me about the
    possible outcomes of surgery. He explained the negatives and the
    positives it. Explained that in rare cases after surgery the
    correction ends up being so minimal that I could feel that it was a
    waste and that in really rare cases it could actually make it worse.
    He said fusion after the surgery is highly unlikely and has seen what
    could be classified as a small degree of fusion develop only in about
    2 of his adult patients over the years so he told me not to expect it.
    I told him I did not care as I was only interested in the appearance
    factor at this point. He also made it clear that deviation could occur
    again down the line which would require further surgery if I wanted to
    keep things aligned. He didn't seem to feel VT after surgery would
    have any benefit either from the standpoint of helping lock the eyes
    in alignment. Oh and just as last year I do still have about 20/20

    While I did go ahead and book the surgery for June 7th, I am going to
    see a optometrist next Friday just to see what he has to say. I found
    one near me that does vision therapy. I suspect the surgery will still
    wind up being the best route to a good result but figure I'd get an
    opinion from the other camp..

    Somebody on another forum chastised me for continuing to state that
    I'm not a doctor; nonetheless ... I'm not a doctor. David Robins
    knows more than I ever will about strabismus generally. I believe
    I've simply come to learn a LOT about MY eyes ... how well that all
    translates is debatable.

    Now ... all that said ... it seems you'll be seeing the surgeon
    today. My $0.02--in stream-of-consciousness style is:
    amn0270, May 12, 2007
  16. amn0270

    John H. Guest

    True, double vision does occur but typically recedes. Also, there can be
    benefits in improved vision from the surgery, up to 40% of adults have
    demonstrated improvements:

    The Goal of Adult Strabismus Surgery Is Not Cosmetic


    Arch Ophthalmol.1999; 117: 250


    BY Marilyn B. Mets MD,* Cynthia Beauchamp MD, AND Betty Anne Haldi CO


    Introduction: This is a retrospective study to determine the preoperative
    and postoperative binocular status of adults who

    have undergone surgical correction of strabismus.

    Methods: A list of all consecutive adult patients who underwent surgery for
    strabismus between June 1990 and

    December 2001 (surgery performed by M.B.M.) was compiled, and their medical
    charts were reviewed. Patients were

    included if their charts were available for review and if information on
    binocularity was recorded. Binocularity was measured

    by the Titmus stereo test, Worth 4-dot test, or synoptophore. Improvements
    or decreases in stereo acuity were

    noted 6 weeks postoperatively and at the final office visit. Prism
    management was incorporated preoperatively and/or

    postoperatively in some of our patients. A total of 112 patients underwent s
    urgery for strabismus. Of these, 72 patients,

    aged 16 to 80, were included; 24 were excluded because their charts did not
    contain any information on stereo acuity at

    least 6 weeks postoperatively or they were lost to follow-up after surgery,
    and 16 were excluded because their charts were

    unavailable from storage.

    Results: A variety of surgeries were performed, the most common being a
    bilateral medial rectus recession. Eleven

    patients required a second surgery, and two required a third surgery.
    Overall, 30 (42%) of the 72 patients improved in

    binocular function, 38 (53%) remained the same, and 4 (5%) had decreases in
    their stereo acuity.

    Conclusion: The benefits of surgical correction of strabismus in adults
    include improvement in binocular function, as

    seen in 42% of the patients in the study.

    Trans Am Ophthalmol Soc 2003;101:201-208
    John H., May 13, 2007
  17. amn0270

    amn0270 Guest

    I wanted to let everyone know where I am with my Strabismus. I had my
    surgery Thursday and it went well. He only had to adjust the right
    eye, which is the turned one, though he said prior to surgery that
    depending on the scar tissue from my previous surgeries he might have
    to adjust the left eye if he could not get a perfect alignment with
    the right eye alone. Thankdully that was not the case and he got a
    perfect horizontal alignment. Now 3 days later I looked more closely
    at the result and am noticing something. It seems that there is still
    vertical deviation upwards. The pupil touches the top lid of the eye
    rather than being centered in the eye. I had this vertical deviation
    all along and the Dr Wisnicki was aware of it. I am seeing him for a
    post-op followup tomorrow so I need to address this with him. My hope
    is that this is now simply an artifact of the healing process and that
    the eye will center itself as the swelling goes down. Is this post-op
    vertical deviation normal during healing or is it actually simply
    still poor vertical alignment. If it is is than I guess another
    surgery would be needed.

    amn0270, Jun 10, 2007
  18. amn0270

    Neil Brooks Guest

    Interesting, Adam.

    Again: I'm not a doctor....

    First, congrats on having the horizontal component all nailed down.
    Since--as you know--it's a bit of an art--that's a great outcome.

    Since it was there before, this CAN, typically, be addressed with the
    surgery you just had--often by transposing the cut muscle a few
    millimeters upward or downward before it is re-attached. If you have
    the pre-op notes and the notes from the surgery, you'll probably learn
    more about what you came IN with, and about what, if anything, was
    done during the surgery to address the vertical component.

    The vertical component--diopter for diopter--is harder for us to
    overcome than the horizontal. We generally have greater accommodative
    amplitudes in the horizontal axis than we do in the vertical.
    Therefore, if you have, for example, 6-8d of outward turn, you may be
    able to compensate for it without difficulty.

    Conversely, you may NOT be able to overcome, say, FOUR diopters of
    vertical deviation. There's just not a vertical-compensation
    mechanism that's comparable to the nexus of convergence and
    accommodation that's already built into our brain.

    That said: I've always advocated that you need to get as MECHANICALLY
    straight as they can get you FIRST. After that (that may be where you
    are now), you may want to explore vision therapy to help increase your
    vergence amplitudes, better enabling you to compensate for the
    residual deviation. You would want to be closely monitored, during
    vision therapy, by your strabismus ophthalmologist.

    Though vision therapy isn't highly likely to HURT your situation, you
    wouldn't want to regress at all FROM the vision therapy.

    As to reduction in the deviation when the swelling goes down: I hope
    Dr. Robins will chime in, but my LAYPERSON'S guess is that a bit of
    change after 3-5 days is possible, but that probably no dramatic shift
    will occur.

    I hope it all works out well for you.

    Neil Brooks, Jun 10, 2007
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