Binocular vision adds depth to life.

Eye Care
Amblyopia, Strabismus and Orthoptics

PEDIATRIC

Amblyopia, Strabismus and Orthoptics

TABLE OF CONTENTS
2 3 4 5 5 6 7 8 9 10 10 11 11 12 12 13 14 14 15 16 17 18 18 19 20 21 22 24 25 27 How the eyes work What is strabismus? How is strabismus managed? Will glasses help my child? Does a turned eye cause double vision? Will eye exercises help? What is amblyopia? How is amblyopia treated? Occlusion (patch) therapy Adjustment to the patch Tips to avoid skin irritation Patch removal What do I do if my child removes the patch? Using the lazy eye Effect of the patch on the better eye When to call your eye doctors ofce How long will my child need to wear the patch? What if my child must wear the patch while at school? Atropine treatment for amblyopia How will I get the atropine drop into my childs eye? What to expect from the drops Unusual reactions How long do I continue giving the drops? Eye muscle surgery (strabismus surgery) How the eye muscles work Surgical procedures Operation details, case study Anesthesia Possible complications Post-operative care

Binocular vision is the ability to use both eyes

together, and it is one of the components of depth perception. Our goal is to restore or maintain binocular vision and to maximize the best possible vision in children who have amblyopia, strabismus, cataracts, glaucoma, or other eye problems through combined ophthalmic and orthoptic treatment. This brochure is designed to answer common questions about this specialized type of treatment.

How the Eyes Work

The two eyes are coordinated by a central area in the brain and move together in a way that is similar to the front wheels of a car. One wheel cannot be moved without the other one moving. Likewise, you cannot move your left eye independently of the right eye. If one of your car wheels is bent inward, you can, by turning the steering wheel, make it straight. However, the previously straight wheel will now be turned in. The same concept of movement applies to the eyes. Thus, while it may appear that the right or the left eye is misaligned, it is really a problem between the two eyes. An eye muscle problem may be corrected by operating on either eye or, more commonly, on both eyes.

Like a steering wheel controls the front wheels of a car, the brain coordinates normal eye movement.

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normal binocular function

Photo provided by Canadian Ophthalmological Society (www.eyesite.ca)

What is strabismus?
Strabismus is the medical term for misalignment of the eyes. It is a Latin word meaning to look askance or sideways. It refers to the problem of the eyes not working together and one eye turning in, out, up or down. Approximately four percent of children in the United States are affected by strabismus. There are various reasons for this condition, ranging from a need for glasses to ocular (eye) or neurological abnormalities. A parent or close relative is often the rst to notice a vision problem. When a vision problem is suspected, a complete eye examination should be arranged as soon as possible. Early detection and management are important for best results.

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strabismus

How is strabismus managed?

The Duke Pediatric Eye team includes pediatric ophthalmologists, orthoptists, and technicians. Orthoptists specialize in identifying eye muscle imbalances and examining children with eye problems. They assess visual acuity in infants and children, measure ocular deviations, and evaluate eye movements.
The level of the examination will be adapted to your childs ability to respond. We obtain much useful information through observation of your childs visual behavior. Although responses are helpful, verbal ability is not necessary to complete an accurate eye examination.

An eye exam will be conducted to evaluate your childs eye movements.

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eye examination

Will glasses help my child?

Some children have an inward turning eye (crossed eye) that is due strictly to farsightedness (accommodative Patient before (left) and esotropia). They must use extra after (right) glasses. focusing power to see clearly. Without glasses, one or both eyes turn in. Corrective lenses relax this extra focusing power so that the eyes stay straight. Glasses with or without bifocals are the best solution. Children who have an occasional outward drift of one eye when tired may benet from glasses with minus power that help them to keep their eyes straight. Glasses may be needed to provide clear vision and eliminate blurring, squinting, or abnormal head positions.

Does a turned eye cause double vision?

When a childs eyes do not work together as a team, he/she will look at an object with one eye while the other eye looks at something else. The image from the wandering eye causes double vision. But the brain, by a technique called suppression, switches off the wandering eye. Thus, younger children rarely have double vision. Older children and adults with newly acquired eye muscle problems often report double vision. Sometimes double vision may be treated with the use of prisms that adhere to or are incorporated into a pair of glasses.

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glasses

Will eye exercises help?

Eyestrain and fatigue when reading may indicate a convergence problem. Measurements by one of our professionals can determine if your child will benet from eye exercises. Simple near-point exercises can be done even with young children. A computerized convergence program was developed for older children and adults. Go to www.computerorthoptics.com for an online description of this technique.

Eye exercises, such as a computerized convergence program, may prove benecial.

Photo provided by Channel Island Design (www.cid.cc) & HTS, Inc. (www.computerorthoptics.com)

What is amblyopia?
When a young child uses one eye predominately and does not alternate between the two eyes, the prolonged suppression of the nondominant eye by the brain may develop into amblyopia. Amblyopia is sometimes referred to as lazy eye, but it is more than just an eye problem. The visual portion of the brain is suppressed and vision actually decreases in the unused eye. There are different causes of amblyopia:
Misalignment of the eyes with one eye not being used properly A need for glasses that has not been corrected Glasses are needed because one eye is out of focus The presence of a cataract (an opacity of the lens inside the eye) that distorts light images from properly focusing on the back of the eye, preventing good vision from developing for that eye A droopy or enlarged eyelid that covers the pupil and blocks the vision in that eye In some cases there may be more than one cause.

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amblyopia

How is amblyopia treated?

Amblyopia (lazy eye) is by far the greatest cause of treatable vision loss in the United States. A child with amblyopia may lose vision in the affected eye permanently if the situation is not corrected early. Treatment is more difcult and less effective with children older than 9 or 10 years of age. If your child is diagnosed with amblyopia, an individual active treatment program will be designed. This program may involve one or more of the following: eyeglasses, patch therapy, eye drops that dilate the pupil, and in some cases a contact lens. Your ophthalmologist and orthoptist will give you specic information about the treatment for your child.

Patch therapy is frequently used in the treatment of amblyopia.

Occlusion (Patch) Therapy

In order to improve your childs vision, you may be instructed to patch an eye. Patching is a common method of treatment for the various types of amblyopia. This type of visual loss cannot be corrected by glasses alone or with surgery. The treatment is effective when it forces the child to use the lazy eye by patching the good eye. Patching is most effective in young children, but can also help improve vision in the early teen years. Untreated, amblyopia cannot be reversed, and the visual loss becomes permanent. Clear instructions, reasonable expectations, patience and consistency are all part of the comprehensive approach to your childs eye care.

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patch therapy

Adjustment to the patch

All children who are patching have similar problems. It is uncomfortable and sometimes difcult to adjust to wearing a patch. Your child may not see well at rst, and this can be frightening. However, it does not hurt, and it does not damage your childs normal eye. It is the best thing to do to preserve vision for a lifetime. For that reason, it is important that your child wear the patch as directed. (You will receive instructions on how often to patch your child.)

Tips to avoid skin irritation

The patch must be of an adhesive type that sticks to the face. A pirate patch with strings or elastic is NOT advised. Be sure that the patch sticks rmly to the skin for the duration of patching time. The narrow end of the patch is placed toward the nose and the broad end away from the nose. Patches come in regular and junior sizes and may be purchased at drug stores or through the Internet: www.fresnelprism.com www.ortopadusa.com Ask for a sample to determine the best t for your child. Although eye patches are hypoallergenic, some children develop mild skin irritation from wearing the patch. The broad area can be trimmed with scissors so that less adhesive contacts the face. The patch may be rotated slightly so that the same part of the skin is not always under the adhesive. To protect the skin and decrease irritation, you may apply Milk of Magnesia with a cotton ball to the skin area where the patch will stick and allow it to dry completely. Be careful not to get Milk of Magnesia into the eye. Then apply the eye patch as usual. 10

Patch removal
Removing an adhesive eye patch can be uncomfortable and distressing to the parent and child. Try to remove the patch slowly while applying pressure to adjacent skin to lessen pulling. Soaking the patch with cool water before removal is also helpful. Another method is to rub petroleum jelly into the adhesive portion of the patch. Let the petroleum jelly soak in for about 30 minutes before gently pulling off the patch. The skin surrounding the patched eye can be treated with any skin care product to lessen skin irritation. Avoid getting any product into the eye.

What do I do if my child removes the patch?

If your child removes the patch before the full amount of time that he/she is supposed to wear it, immediately replace it with a new patch. Refocus your childs attention with a toy or game in order to help to distract him or her from awareness of the patch. Be persistent. Since the patch is not painful, most children will wear the patch once they realize that their parents intend for them to wear it, and that it will be replaced. Thin adhesive covers (Tegaderm Transparent Dressing, 6cm x 7cm) can also be placed over the patch to make it more difcult to rub off. Young children can be discouraged from removing the patch by placing them in mittens or pediatric arm restraints. See Pedi-Wrap catalog at www.pediwrap.com or call the Duke Pediatric Eye Clinic for assistance.

Pediatric arm restraints, such as Pedi-Wraps (pictured), can be used to discourage children from removing the eye patch.
Photo provided by The Medi-Kid Co. (www.pediwrap.com)

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patch therapy

Using the lazy eye

While your child is wearing the eye patch, he/she should be encouraged to use the other eye as much as possible. To shorten the patching period, encourage your child to participate in detailed busy work such as paintby-numbers, connect-the-dot books, coloring, writing, drawing, and tracing.

Effect of the patch on the better eye

Sometimes the deviation seems to switch eyes or get worse with the Photo provided by the National Eye Institute patch. This is normal and only means (www.nei.nih.gov) that the lazy eye is now being used so that it stays straight while the other eye turns. This indicates that the patching program is having an effect. Improving vision in the weaker eye is the rst step. The deviation can be dealt with when the lazy eyes vision has recovered. Keeping return visits is important so any changes can be tracked.

Activities such as coloring can help your child use his or her other eye and shorten the patching period.

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When to call your eye doctors ofce

Some slight redness of the eye is common because children frequently rub the eye or the patch. Extreme redness, accompanied by discharge, should be reported immediately to your eye doctor. If at any time during the patching routine your child contracts measles, chicken pox, poison ivy, or any other type of skin eruption around the eye, DISCONTINUE the patching and CALL the Pediatric Eye Clinic at 919-684-0010 or 919-684-0560.

Call your eye doctors ofce should you notice extreme redness or skin eruptions around the eye.

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patch therapy

How long will my child need to wear the patch?

Patching will be continued until there is no further improvement in visual activity or until your child uses one eye equally as well as the other. It is impossible to predict how long this will be for each child, but it typically lasts for several months with some less intense patching thereafter. Patching could be one of the most important steps in the treatment of your childs eye condition. Do not become discouraged! No matter how difcult it may seem, the long-term results are well worth it.

What if my child must wear the patch while at school?

Some children will need to wear the patch at school or at the day care facility. If your child removes the patch frequently at home, this will probably also happen at school. Make sure your childs teachers understand the importance of the patch. Provide them with extra patches so they can be replaced at school when needed. Please help your older child to deal with the comments that others will make about the patch. Just as a leg cast and crutches help while a broken bone is healing, the eye patch is a short-term way of helping your child to have better vision for life. Practice an answer to any questions that will satisfy the questioner and make your child feel positive about the process. For example, when asked What is that on your eye? the response could be Its a patch to make my weaker eye stronger.

Your child may need to wear the eye patch while at school. Notifying teachers and discussing situations with your child can help make things easier.

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Atropine Treatment for Amblyopia

Atropine drops may be used to treat your childs amblyopia. Atropine blurs vision in the better-seeing eye and encourages use of the eye with poor vision and improves vision in that eye over time. Atropine may be used in addition to or as an alternative to traditional patching therapy. Because atropine cannot be removed once applied, it is a good treatment option.

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atropine treatment

How will I get the atropine drop into my childs eye?

Have your child lie down on his/her back, looking up at the ceiling. Hold the eyelids apart and let one drop fall anywhere between the eyelids. If the child is frightened, try giving the drop before he or she wakes up. In some children, it is necessary for one adult to hold the child while the other gives the drop. Eventually a routine will be established. Be sure to wash your hands after applying the drop so that you do not accidentally get any medication into your eyes. Also, take care not to get any of the drops in your childs other eye.

To get the atropine drops in your childs eye, hold the eyelids apart and place a drop into the eye. Be careful not to get any drops in the other eye.

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What to expect from the drops

Unlike other types of eye drops, atropine usually does not sting. These drops cause the pupil (black center of the eye) to become very large. Your child may notice that close objects are blurred. This is the normal effect of the drops and may last for up to a week following one drop of atropine. Your child may also be bothered by bright sunlight. Sunglasses or a broad-brimmed hat may be worn outdoors on sunny days to avoid discomfort. Since atropine blurs the vision of the better eye for near work, this forces the child to use the weaker eye for reading, drawing, etc. Allow your child to hold reading material close or to lean close to the desk. If your child attends school, please notify his/her teacher of the eye treatment. In some cases, reading glasses may be prescribed for using the better eye while at school.

Atropine drops cause the pupil to become very large.

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atropine treatment

Unusual reactions
Rarely, a child may develop redness and swelling around the eye, fever, or a red warm face and neck. If this occurs, STOP using the drops and contact our ofce. Be sure to keep the atropine drops out of the reach of children. If a child drinks atropine from the bottle, give syrup of ipecac and contact an emergency room immediately.

How long do I continue giving the drops?

Atropine treatment may be continued for weeks or months, depending on your childs age and the severity of the vision loss in the amblyopic eye. Keep using the drops as instructed until the next appointment day unless your doctor says differently. For any other questions, please call the Pediatric Eye Clinic at 919-684-0010 or 919-684-0560.

Atropine treatment may be continued for weeks or months.

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Eye Muscle Surgery

(Strabismus Surgery)

Many patients with eye deviations will eventually need an operation to align the eyes. The goals of surgery are twofold. The rst is to change the present eye alignment in such a way as to enable the brain to use both eyes together. This may reestablish binocular function. The second is to improve the appearance so that the eyes look straight and move together. The chances for achieving these goals are inuenced by the size and complexity of the eye deviation, the age of onset, types of previous treatment, quality of binocular function (depth perception), and the compliance with pre- and postoperative therapy.
The results of strabismus surgery are not always perfect because human tissue varies from individual to individual. Therefore, it may take more than one operation to achieve the goal of straight eyes. The success rate varies from 50 to 90 percent, depending on the type of operation and condition of the eyes. In some cases the surgery may be performed in steps, with the rst operation designed to correct only part of the problem. A second or even third operation may be necessary to deal with any residual misalignment or to correct another aspect of the problem. Sometimes the correction of one problem will uncover a second problem that was not apparent before the surgery. The purpose of this discussion is to acquaint you with the facts about strabismus surgery. With vigorous and complete treatment the results are usually extremely gratifying. 19
An operation may eventually be needed to align the eyes.

How the eye muscles work

Eye muscle surgery involves either weakening or strengthening the muscles that control eye movement. There are six muscles that attach to the outside surface of the eyeball and control the movement of each eye. Four of these muscles are called rectus muscles and their functions are very straightforward. The superior rectus muscle attaches to the top of the eye and pulls the eye up. The inferior rectus muscle attaches to the bottom part of the eye and pulls the eye down. The medial rectus muscle attaches to the side of the eye closest to the nose and pulls the eye in. The lateral rectus muscle attaches to the outside of the eye closest to the ear and pulls the eye out. Two additional muscles (the oblique muscles) have very complex eye movement functions. The superior oblique muscle attaches to the top back part of the eye and runs through a pulley near the top part of the nose. This muscle pulls the eye down when the eye is looking toward the nose. The inferior oblique muscle attaches to the bottom back part of the eye and pulls the eye up when it is looking toward the nose. Their primary function is torsion, the inward and outward rotational balance of each eye.

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Surgical procedures
Strabismus surgery consists of two general types of operations. One is a weakening procedure of the muscle which is called a recession, and the other is a strengthening procedure which is called a resection. The technique for doing these operations is as follows: the eye muscle is reached through a small cut through the conjunctiva, which is a thin whitish skin over the surface of the eyeball. The conjunctiva is the part of the eye that gets red and bloodshot when the eyes are irritated. The eye muscles are immediately beneath this conjunctival tissue. Incisions through the skin of the face or the eyelids are not necessary to reach the eye muscles. A common misconception is that the eye is removed from its bony cradle called the orbit and placed on the face during the operation. This is not true. The eye muscles are located approximately 1/4 of an inch from where the clear dome (called the cornea) meets the white tissue of the eye (called the sclera or conjunctiva). Therefore, it is not difcult to get to the eye muscles while the eye remains in its usual position.

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Operation details
If a recession is planned for a particular muscle, this means that it will be detached and moved back approximately 1/4 to 3/8 of an inch and reattached to the eye. This movement from its original position to one further back on the eye has a relaxing effect on the muscle and allows the eye to come into a straighter position. Stitches used during surgery are later absorbed. There are no stitches that have to be removed at a later date. In a resection or strengthening procedure, a 1/4 to 3/8 inch piece of muscle is removed and the muscle is reattached at its original location. The distance that the muscles will be moved is normally determined before the surgery. The technique takes a great deal of skill to move the muscles correctly and is best performed by a doctor who specializes in this type of surgery. The time estimated for the actual surgery is about 20 minutes per muscle. It does not include the time necessary for falling asleep and waking up.

During surgery, the eye is left in its orbit, and no incisions to the eyelids are necessary.
Reproduced, with permission, from Wilson FW, Practical Ophthalmology: A Manual for Beginning Residents, 4th Edition, American Academy of Ophthalmology, 1996.

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The following is an example of a patient who required eye muscle surgery.

Case Report: Ryan is a two year old who was noted to have crossing of the left eye at the age of one. He was diagnosed with esotropia (an inward deviation of the eyes) and surgery was recommended. The operation can be done in one of several ways. Remember, while it appears looking at Ryan that his left eye is the problem, it really is a misalignment of the two eyes together. The fact that we see the left eye turned in means that Ryan is looking at us with his right eye most of the time. If we cover his right eye, he will move his left eye from its turned in position, to straight, to look at us. Now under the cover, the right eye will be turned in. We can operate on the right eye, or the left eye, or both eyes. One of three operations will be recommended. The rst would be an operation on the left eye only. This would involve weakening the left medial rectus (the inside muscle which is pulling the eye in) and strengthening the left lateral rectus (the outside muscle which is not pulling hard enough) to bring the eye to a straight-ahead position. Secondly, a similar operation could be performed on the right eye. That procedure would involve weakening the right medial rectus and strengthening the right lateral rectus muscle to rebalance the alignment between the two eyes. A third operation, the one most commonly used for this particular problem, is to weaken the medial rectus muscle on each eye. There are many additional types of eye muscle operations, and the principles are the same. Muscles are basically strengthened or weakened depending on the particular problem in order to get the eyes into the ideal position.

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Anesthesia
One of the risks of strabismus surgery is undergoing anesthesia. With todays techniques and equipment, this risk is extremely small. The risk of a serious complication in a healthy child is approximately 1 in 500,000. It is safer in the operating room having a strabismus operation than it is riding in a car on a fourlane highway. Every effort is made to ensure that the patient is in the best physical condition before he/she undergoes anesthesia. Prior to surgery you may be asked to obtain certain blood work, tests, and X-rays as deemed necessary (usually not necessary for healthy children). The anesthetic concerns for strabismus surgery are different from most other types of surgery. Most patients are healthy, the operation is usually short, and major body systems are not involved. Potential anesthetic problems are minimized. The surgery is most often done as an outpatient. This reects the relative safety and ease of recovery from general anesthesia used for eye surgery. Since eye surgery is elective, any condition that would increase the risk of complications from anesthesia must be eliminated prior to surgery. This is especially important in children. Conditions such as ear ache, pneumonia, u-like symptoms, or GI problems will result in postponement of the surgery until they have been treated. It is safer to delay the surgery than to operate on a child or an adult who is sick. The anesthesiologist will talk to you prior to the surgery and it is important that you discuss with him/her any questions that you may have regarding the anesthesia.

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Possible complications
During surgery every effort is made to reduce the likelihood of problems. However, during the course of any surgical procedure problems may arise. It is the surgeons responsibility to minimize these problems in the operating room. After the surgery, it is the patients (or parents) responsibility to follow carefully the instructions and treatment prescribed. The most frequently encountered complications are as follows: 1. Overcorrection/undercorrection: This is not really a complication but is instead an undesirable outcome. Overcorrection or undercorrection of a misalignment may occur in the eyes being repaired. An overcorrection would be to make an eye turn out that previously turned in. An undercorrection would be an improvement in the alignment of the eyes but the eyes are still turned in. This failure to achieve optimal alignment occurs anywhere from 2040 percent of the time and may result in the need for the use of glasses, special eye drops, prisms, or an additional surgical procedure. 2. Infection: Infection may occur in the immediate post-operative period, but fortunately this is extremely rare. The ocular tissues are highly vascular and this usually aids in the prevention of this problem. You will be given instructions with regard to the use of antibiotics and in the care and use of the eyes in the immediate post-operative period. A post-operative visit will be scheduled to detect any early signs of an infection. Severe infection inside the eyes can result in loss of vision. Fortunately, this is very unusual after strabismus surgery.
As with any surgical procedure, while every effort is made to prevent problems, complications may arise.

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3. Bleeding/Retinal detachment: A small bleed into the eye may occur which normally resolves without intervention. Rarely (approximately one out of 10,000) a retinal detachment can result which will require further surgery to repair. 4. Slipped muscle: The suture used to attach the eye muscle to the eye is extremely strong. However, in a rare situation the suture may break, which can cause the muscle to slip or become detached from the globe. This requires immediate surgery to reattach the muscle. Fortunately, this also rarely happens. 5. Loss of vision: Permanent loss of vision from eye muscle surgery occurs approximately in one out of 10,000 eye muscle operations, or less. The cause is usually internal eye infection (endophthalmitis), internal eye hemorrhage, or retinal detachment. Early detection and treatment can save vision. 6. Double vision: In the immediate post-operative period it is not unusual for the patient to see double (called diplopia). The eye muscles are sore and are not working correctly, or occasionally the eye position has been changed enough so that the brain processes two images instead of one. The double vision normally resolves within days to weeks, and in some cases it is desirable immediately after the surgery. Persistent double vision, however, may require additional intervention if it does not resolve in an appropriate period of time. Every effort is made to try to anticipate whether this will occur so that you or your child can be prepared in the immediate post-operative period. 7. Change in refraction: Changes in eyeglass prescriptions may be necessary after eye muscle surgery due to slight alterations in the shape of the eye or cornea. This may not be permanent and new glasses will usually correct any refractive changes.

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Post-operative care
Instructions for post-operative care will be given at the time of the surgery. Eyes vary in appearance and comfort depending on the type of operation and how much surgery was done. You can expect the eyes to be somewhat sore and irritated for at least several weeks after the operation. The conjunctiva will be red and swollen, and it may feel like you have sand or other foreign objects in the eye. Sometimes the upper and/or lower lids will retain uid and swell. This usually resolves within several days. If both eyes are operated on, neither eye will be patched. If, however, just one eye is operated on, a patch will often be used to increase comfort. It is recommended that most people remain out of work or school for a few days to one week following the surgery. While you may be able to resume your activities within a day or two, it is better to plan for a longer recovery period in case it is needed. Specic details for how to take care of the eyes are given on the postoperative eye care information sheet. The two basic rules that should guide activities for the rst week after surgery are: 1. Nothing gets in the eye(s)including rubbing eye(s) with your hands 2. Avoid any possible injury to the eye(s) If you apply these two rules to the planned activity and neither is an issue, then the activity is okay. Otherwise, DONT DO IT! Questions about additional issues not covered here may arise. Please feel free to contact your doctor prior to surgery in order to get these questions answered. Call the Duke Pediatric Eye Clinic at 919-684-0010 or 919-684-0560.
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Binocu la r vision adds depth to life .

Duke Pediatric Eye Care Facility

Faculty:
Edward Buckley, MD Laura Enyedi, MD Sharon Freedman, MD David Wallace, MD, MPH Tammy Yanovitch, MD Terri Young, MD

Orthoptists:
Lois Duncan Sandra Holgado Namita Kashyap Ivonne Rodriguez

Tech Staff:
Courtney Fuller Cassandra Headen

www.dukeeye.org
1/2008