- Accommodative Esotropia
- Tear Duct Obstruction
Lasik surgery alters the shape and steepness of the cornea to eliminate or decrease the need for glasses or contacts. The eye changes in childhood and into the teens and young adulthood. We do not perform Lasik until the eyes are stable and the prescription is not changing, at least until early 20’s
The eye is like a camera in that the front part of the eye focuses images on the back part of the eye (retina). If the eye is longer or shorter than average, or if the cornea is shaped differently, the image is blurry on the retina. Glasses or contacts correct for the length of the eye and the shape of the cornea, allowing a clear image to get to the retina. Glasses do not ‘weaken’ the eyes. Many people feel they become dependent on the glasses, but this is just that they have become accustomed to seeing clearly and enjoy clear vision.
20/20 vision means that at 20 feet, you can see what the average person can see from 20 feet. 20/200 vision means that at 20 feet you can see what the average person can see from 200 feet away.
As an example, if the vision is less than 20/40, the DMV requires that you have your eyes examined by an eye professional before obtaining a license to make sure that you do not have very compromised vision or deteriorating vision.
The DMV requires 20/200 vision in the better eye as the MINIMUM vision requirement to obtain a driver’s license. They may restrict the license such as requiring glasses to drive, or only allow driving during the day if the vision is poor.
There is no treatment necessary. As the child’s face matures, the eyes will appear straight.
In pseudostrabismus, the light reflex will be in the same location on both pupils. If the child has true strabismus, the light reflexes will be in different locations. Photos where there is “red eye” from a flash camera are the best to assess. Even still, there can be a small amount of strabismus present and this can only be diagnosed on examination by a doctor.
Pseudostrabismus means that although the eyes appear misaligned, they are in fact straight. It is often caused by the baby’s upper facial appearance because the bridge of the nose is flat allowing skin folds to cover part of the white of the eyes making them appear crossed.
If babies don’t clear up by around one year of age, we recommend probing to open it up. The probing procedure is done at an outpatient surgery center, because the baby will require a brief anesthetic given by an anesthesiologist (MD) to allow the probing. A soft metal wire about the size of an earring wire is gently threaded through the duct from the eyelid to open the duct where it is blocked at the bottom. Most babies will clear with doing this procedure. Occasionally the duct will close back up and it is necessary to do further procedures such as placing silicone tubes to hold the duct open for a time, so that it won’t close back up again.
It helps to look at the anatomy of the tear duct system to understand the massage technique. The tear sac is located on the side of the nose by the inner corner of the eye. Often this sac is overfilled with tears since it is blocked at the bottom. Think of the tear sac like a balloon. Gentle but firm pressure is applied from the inner corner of the eye towards the nose, trying to NOT allow the tears and discharge to come back towards the eye, but rather to apply pressure down the duct in an effort to pop open the duct at the bottom. The first push is the most effective. Try to do this every time you change the baby’s diaper. If you put your hands on each side of the baby’s face, you can use your index finger to push towards the nose.
In about 10% of normal newborn babies, the duct that drains the tears from the eye to the back of the nose is blocked at the bottom of the duct. Some babies will open up by themselves or with massage, and some require a probing procedure to open up the duct. Many babies require washing the eyelids with half strength baby shampoo or topical antibiotics for intermittent or chronic infections until the duct opens up.
If there is a vision problem causing the exotropia, then that problem must be addressed. Patching, glasses, and sometimes surgery are some of the treatments used.
Exotropia is the term used when one or both eyes wander outwards. It is often intermittent and worse while looking at the distance, in sunlight, or when the person is ill or tired. Often the person squints in sunlight. Sometimes an eye wanders outward because there is something wrong with the vision in the eye, but more often there is no identifiable cause. Amblyopia (lazy eye) can develop as well. the condition can run in families.
Up to one third of children with crossed eyes will develop a vertical (upward) deviation of one or both eyes. This can be from inattention to that eye, or because of an overacting muscle. Patching or sometimes surgery may be necessary.
Some children will outgrow the glasses as the eyes grow and become less farsighted. This usually does not happen until the age of 9-11 years old. Some children do not outgrow the glasses and do have to wear glasses or contact lenses as adults. Adults can also consider refractive laser surgery if they remain farsighted
Sometimes patching or surgery is necessary in addition to the glasses.
When the glasses are taken off, the child has to focus the eyes to see clearly and you will see the eyes cross. Sometimes you will see even more crossing than before the child got glasses. This is because before the child had glasses, he only made the effort of focusing when it was necessary to see. Now that he has become accustomed to seeing clearly all the time with the glasses, he is less tolerant of the blurry vision and really focuses when they are off to see clearly.
Glasses help by reducing the focusing effort, allowing the child to see clearly reducing or eliminating the crossing.
Accommodative esotropia is a common type of crossing seen in children. The eyes cross when the child makes an effort to focus. One or both eyes may cross, and it may be all the time or only sometimes. It can run in families. Amblyopia (lazy eye) can develop as well. (See Amblyopia.)
Great!! This means the atropine is working! If the amblyopic (weak) eye is straight and the stronger eye is turning, that means the atropine is making the child use the weaker eye, which is the goal of the atropine.
Amblyopia is decreased vision in an eye because of lack of use during childhood. It is a problem of the brain not processing visual information from the eye. It is caused by any condition that interferes with normal visual use of the eye(s) such as strabismus (eyes that are not aligned), refractive errors (strong or asymmetric glasses prescription), or occlusion of the visual axis of the eye(s) such as ptosis (droopy lid) or cataract. Amblyopia can be treated during childhood by forcing the use of the weaker eye. If it goes untreated, the vision loss is irreversible in the older child or adult.
Patching the good eye forces the brain to use the bad eye. Patching may be full time or part time. If it is full time, this means no more than one hour off per day, usually at bath time just before bed. A ‘session’ of full time patching is one week per year of age. For example, 3 weeks for a 3 year old, 6 weeks for a 6 year old. Follow up during full time patching is after each session. Kids that are less than full time patching, are followed up usually after a few months.
Atropine works like patching by blurring the good eye instead of occluding it. If the atropine is used every night, follow up should be in 4-6 weeks. If the atropine is used just the first 2 weeks of each month, follow up is usually after 2-4 sessions (months) of atropine. The dose of atropine is one drop, or ¼ inch of ointment, used either every night, or on a part time basis such as nightly for the first 2 weeks of the month.
Atropine is a medication, and any medication can have side effects. Although it is rare to have side effects from using only one dose every day or two, stop the medication and call your doctor if your child has a rash or a fever while on the atropine. This medication should be kept out of reach of children. If ingested, a bottle of atropine could cause a very small child to become very ill or even die
If the atropine is mistakenly put in the wrong eye, just restart it in the correct eye. It will wear off, and won’t cause permanent damage.
Atropine dilation can last two weeks. The drops we use in the office to check for glasses can last up to 2 days. It will wear off and will not cause any permanent damage.