A Parent Guide to Strabismus, Eye Muscle Surgery and Vision Therapy
The surgeon told us, "There is nothing wrong with your child's eye muscles, but that's how we fix it." Anonymous Parents, after a strabismus surgery consult for their cross-eyed child
Eye muscle surgery for strabismus is one of the most commonly performed procedures involving the eyes. Parents seeking advice on what to do when their child's eyes appear poorly aligned are often told that strabismus surgery is the only solution. That is, unless they are fortunate enough to get an opinion from a behavioral optometrist. Behavioral optometrists offer non-invasive vision therapy, which is clinically proven and highly successful, as the treatment of choice for poorly aligned eyes. Sometimes vision therapy alone is enough to get the eyes straight without the need for surgery. Behavioral optometrists understand that eye muscle surgery is sometimes necessary. Very few strabismus surgeons understand that vision therapy is critical if the eye muscle surgery is to be truly successful and long-lasting. They certainly ignore the fact that vision therapy can prevent the need for eye muscle surgery in many cases. Statistics show that at least 20-30% of those having eye muscle surgery need more than one operation, and at least 20-30% of those need more than two eye muscle surgeries. Eye muscle surgery has a much greater chance of long-lasting success when vision therapy is part of the treatment. Strabismus surgery should almost always be a last resort, not a first resort, and never without vision therapy. Surgeons will probably not tell you this.
I am currently working on a book (to be published in late 2014) meant for parents who are confronted with the decision of whether or not to pursue strabismus surgery (eye muscle surgery) for a child whose eyes don’t seem to be pointing at the same thing at the same time. This condition, technically referred to as strabismus, is often referred to as lazy eye. In fact, it is very unlikely that there is anything wrong with the eye muscles of someone with strabismus. Such eye teaming problems usually occur because the brain has not figured out how to integrate the two eyes together. Just a quick aside – an eye that has trouble coordinating with its partner should never be thought of as lazy. It is more productive to think of this eye as acting heroically by getting out of the way so the person can be more visually comfortable and more effective, with less effort and stress. The term lazy should be reserved for doctors who refuse to understand or learn that there are safe and effective treatments available to people of all ages with eyes that do not work well together. Surgery should only be considered in dire circumstances and in most cases should be the treatment of last resort, not the first thing we think of when an eye is not straight.
Children with esotropia (convergent strabismus) – an eye that turns in and those with exotropia (divergent strabismus) – an eye that turns out usually end up seeing an ophthalmologist to determine if strabismus surgery is required. Most of these children do not see a behavioral optometrist in the early stages of the decision making process. This is very unfortunate. Behavioral optometry offers a non-surgical, non-invasive alternative to strabismus surgery. I have worked with children as young as two years of age and adults in their eighties to help them learn how to use their two eyes together more efficiently. Behavioral optometrists like myself use therapeutic lenses and vision therapy to help the brain learn how to use the two eyes in a more integrated way. The eyes are more likely to remain straight when they are working together consistently.
I wanted to make this information available through my website without waiting for the book to be published for those in immediate need of this information. Surgeons will not provide non-surgical options to parents in distress. The vast majority of them insist that strabismus surgery is the only option. It rarely is. Surgeons seem more inclined these days to tell parents that there is nothing wrong with the child’s eye muscles, but that strabismus surgery is the only effective treatment. It is not. Optometric vision therapy has a long track record of successfully treating all types of strabismus without surgery. Vision therapy is totally non-invasive and safe. Strabismus surgery is extremely invasive, irreversible and guarantees damage to the eye muscle that is targeted by the surgery. Parents cannot rely on the word of experts alone. They must do some research and weigh all the options themselves. I am hoping to add to the existent information to make options available that are often hidden from view.
Parents, Always Look Both Ways Before Uncrossing Your Child’s Eyes
by Steve Gallop, O.D.
Do you know someone whose eyes look kind of funny? When you look at them does it seem that one of their eyes is looking at you as the other eye gazes at their nose or at some unknown object off to the side? Do you get an uncomfortable sensation when you speak to them face to face, uncertain of how to look at them? Many people have difficulty using their eyes as a team. Sometimes it appears obvious, sometimes not. Most of us have had the experience of seeing someone who has an eye that doesn’t seem to be aiming where it should. If this is confusing or uncomfortable for us imagine what it might be like for them.
Do you yourself have an eye that wanders? Are you self-conscious when other people look at you? Do you worry that they keep thinking about which eye they should look at and where your other eye is looking? Do you get frustrated when you look in the mirror and see one eye is not cooperating? Have you considered having surgery to straighten that eye? Are you worried that surgery is dangerous? Do you wonder if it really works or if there is some better alternative? There is usually more than one way to solve a problem and getting two eyes that don’t seem to be coordinating with each other is one of those problems.
Although we have two eyes, they need to work as a single unit. They must move, aim, and focus in unison at all times in order for the visual process to function as it was meant to function. There are many levels of eye teaming difficulty, from the very mild – where the eyes look normal and straight – to the very obvious degree described above, where it is obvious to any casual observer that the two eyes are not looking at the same thing at the same time.
These problems can and often do remain undetected, or at least not properly addressed, for a person’s whole life in more subtle cases.
The more severe cases of eye teaming problems are easily noticed by others. We all know or have seen someone who has one eye that appears to turn in a different direction from the fellow eye. These problems can and often do remain undetected, or at least not properly addressed, for a person’s whole life when there is no cosmetic aspect to the eye teaming difficulty. A person may have various complaints regarding comfort and/or efficiency in these cases. It is entirely possible that these people would be surprised to learn that there was some problem with their vision because often they can see clearly, either with or without glasses or contact lenses, and because they have never been exposed to any way of seeing other than what they have known throughout their lives. They have not been given any options to explore because most eye care professionals have intentionally decided to ignore these kinds of issues and therefore are likely to miss the opportunity to assist these people in achieving a higher level of visual performance and greater visual comfort. The main reason for this is that most eye doctors are comfortable with the idea that their main task is for people to see clearly – nothing else really matters, except that the eyes themselves are free of disease or damage.
People with subtle eye teaming issues may have any of a number of complaints they don’t realize are related to how their visual system is working. Complaints such as double vision, trouble reading, poor handwriting, headaches, eye fatigue, dry eyes, poor coordination, etc. These complaints will never be attributed to the actual causes, which are often eye teaming and/or focusing problems, without a proper evaluation by a Behavioral Optometrist. The vast majority of people fitting this description can achieve excellent improvement in performance and comfort by working with a behavioral optometrist who offers vision therapy and therapeutic lenses as treatment.
Many people are unaware that their vision is not working properly, since they have nothing to which they can compare it. They may simply avoid activities that cause discomfort, frustration or fatigue, or they may not realize that the symptoms they experience are visually related. Still others have long-term, constant, nagging problems that are frequently written off by their doctors as either insignificant, imaginary, or totally unrelated to their “eyes.” People in this category are also very likely to benefit from what behavioral optometry has to offer.
The following pages will, for the most part, be dedicated to the more severe cases. That is, those whose general cosmetic appearance has been affected by the eyes’ extreme inability to work properly as a team.
It is those who have cosmetically noticeable eye turns who are most likely to wind up consulting a surgeon. Surgeons are unlikely to consider alternative possibilities for straightening the eyes, especially since they are convinced that surgery is the only known treatment for the condition. Unfortunately even in the twenty-first century, the most well-known and probably most common primary intervention remains eye muscle surgery. These surgeries are touted as cures for cosmetically misaligned eyes, but unlike most other cosmetic surgeries, eye muscle surgery is covered by medical insurance. I believe this is because there is a pretense that by making the eyes look straight they will automatically work together. Nothing could be further from the truth. The ability of the two eyes to work as a cohesive unit is just one complex aspect of an even more intricate visual process as will be shown throughout this book.
These surgeries rarely, and then mostly by chance, result in a properly functioning visual system. Some surgeons even claim that eye muscle surgery can also cure amblyopia – commonly known as lazy eye Although the term lazy eye can also be used to describe an eye that does not look straight, it is usually meant to refer to an eye that cannot see 20/20 – usually much worse. Amblyopia is a condition where one eye cannot see as well as the other eye no matter what lens is tried.
Behavioral optometrists expect the visual system to perform at a high level throughout our lives.
A properly functioning visual system is one that includes consistent high level eye teaming with excellent depth perception. The visual system is meant to continue operating at a high level indefinitely. Unfortunately, eye muscle surgeries are routinely sold to the public as the only way to fix the problem. These pronouncements are often accompanied by warnings that not submitting to the procedure could result in blindness in the affected eye. In addition, it is common for surgeons to present other types of intervention as experimental, ineffective and/or dangerous quackery.
Every year thousands of children and adults are diagnosed with conditions known as crossed eyes, wall eyes, or lazy eyes. The technical term is strabismus, when the two eyes are obviously not pointing at the same place at the same time. Esotropia is when one or both eyes appear to cross improperly, exotropia is when one or both eyes tend to inappropriately turn away from each other. There is also vertical strabismus where one eye aims higher than the other, though this is less common and rarely severe enough to present a cosmetic problem – the most famous exception being Abraham Lincoln; in fact the sculptor of the Lincoln Memorial was so keen on detail and accuracy that you can see this in the statue.
All cosmetically noticeable eye turns are frequently treated by surgical means. One or more eye muscles may be shortened or lengthened to alter the cosmetic alignment of the eyes. Some surgeons prefer to operate on the problematic eye, some on the other eye and some will operate on both eyes. There are numerous techniques and procedures available. While the quality and safety of these procedures has improved over the years, there has been little change in the philosophy of most surgeons who are diagnosing and treating these conditions, and therefore little change in the quality of the outcomes.
This surgery-based philosophy presumably maintains that there is some problem with the eye muscles when the two eyes are not aiming properly. While eye muscle damage can actually happen, it is quite rare. Many people experience less than satisfactory results after surgery because of the limitations of this philosophy. Problems may surface immediately following the operation, or may take several years to become noticeable. At this point I am referring to eye alignment problems. Eyes that appear straight immediately after surgery only stay that way for about fifty percent of people who have eye muscle surgery.
Actually, the need for multiple operations is quite common when the standard medical/surgical approach is taken. Many people have unsatisfactory results from eye muscle surgery because surgeons treat the eyes as mechanical devices, not as part of an intricate visual process that mostly occurs in the brain.
When a surgically straightened eye un-straightens again surgeons simply see this as an indication of the need for further surgery. Actually, the need for multiple operations is quite common when the standard medical/surgical approach is taken. Unfortunately, because of differing philosophies, all these people must continue with their vision as it is, or attempt further surgery, unless they are fortunate enough to find a doctor who understands their problems from a different perspective. They need a doctor who knows how to work with them to achieve improvement through non-surgical means- a Behavioral Optometrist. This book addresses all these issues as well as presenting alternatives for treating these conditions before surgery, instead of with surgery or after surgery.
One problem that arises initially, in most cases, is that parents and patients seeking guidance and help are given limited information. People generally seek a specialist when a vision problem is significant enough to cause concern. This is particularly true when the problem is cosmetically apparent. Such cases include eyes that turn in or out, and/or a significant difference between the two eyes’ ability to see clearly. Most people seek expert advice in such cases and often end up in the office of an ophthalmologist. An ophthalmologist is a medical doctor, a specialist highly trained in diagnosing and treating all eye diseases, typically using invasive measures such as medication or surgery. The other branch of eye care professionals are optometrists. An optometrist is a doctor trained in diagnosing and treating a variety of eye health problems. Optometrists are permitted to use medications to treat certain common conditions, but none are permitted to perform surgery. In some states, they are permitted to do some types of laser surgery but it varies from state to state.
Optometrists and ophthalmologists are licensed to prescribe lenses and treat functional and developmental vision problems like strabismus and amblyopia. In fact, the lines of distinction are becoming increasingly blurred as optometrists continually expand their scope of practice in the direction of ophthalmology. An important distinction must be made when choosing a professional to evaluate, diagnose and provide treatment options when dealing with the types of functional and developmental vision problems that are so often treated with eye muscle surgery.
Anyone considering eye muscle surgery for themselves or their child should consult a Behavioral Optometrist to get a broader understanding of how the visual process works and how surgery fits into the bigger picture. Many eye teaming problems can be corrected, or greatly reduced through non-surgical means.
There is a specialty area within optometry known as Behavioral or Developmental optometry. Behavioral optometrists specialize in diagnosing and treating functional and developmental conditions of the visual system. These doctors will treat such visual problems without the use of surgery and in most cases without drugs. In those cases where surgery is unavoidable for one reason or another, these doctors will work with the patient before and after surgery to optimize the outcome whenever possible.
The conditions at issue here are known as binocular vision problems, that is, problems with the way the eyes work as a team. I am mainly going to address the various types of strabismus and amblyopia. It is rare that both eyes are amblyopic but this can occur. Cases requiring surgery make up a minority of such vision problems, and developmental/behavioral optometrists believe non-surgical options should be investigated before deciding on the need for surgery. Many eye teaming problems can be corrected or greatly reduced through non-surgical means (lenses, prisms, and vision therapy), which will be discussed later. Because of these other safer and non-invasive options, surgery should be a last resort in most cases, although many who are considered experts, in particular ophthalmologists, feel that it is a first choice, or frequently, the only choice. In fact, eye muscle surgery is the second most common eye surgery performed.1,2
One thing we do know is that the visual process is not an eye process, but more a brain process. The visual process is pervasive in human behavior and development.
Vision is a complicated process that is not fully understood by most of the public. In fact, even though vision is the most studied and well understood of all our senses, science still does not fully understand the entire process of vision. One thing we do know is that the visual process is not an eye process, but more a brain process. The visual process is pervasive in human behavior and development. The eyes themselves are fairly complexstructures, but their main purpose is to absorb light, convert that light into chemical signals and then into electrical signals that travel to and from many parts of the brain and body. It is important to think in terms of seeing with our brains rather than with our eyes. It is also important to understand that the primary purpose of the visual process is to direct action.
The visual process develops, and continues to do so throughout our lives. The visual process is learned and therefore trainable at any age.
Before we go any further I would like to explain my working definition of the term vision. Actually, I will generally avoid the term vision. I will replace it with visual process since most people, including most eye care professionals, already have their own definition of the word and consider vision to be nothing more than the ability to see clearly. The visual process is much more than that. It is a dynamic process that occurs in the brain. The visual process develops, and continues to do so throughout our lives. The visual process is learned and therefore trainable at any age.
The visual process is about deriving meaning and directing action in response to light entering the eyes. Reading a series of letters on a wall chart is nothing more than a measurement of eyesight or visual acuity, which isonly one of many important aspects of the visual process, and in many cases, it is not even the most important. The visual process is tied in to the way we see the world, the way we think about the world, and the options that seem available to us as we go through life. It is intimately related to our overall development and our performance in school, work, sports and recreation. We are more dependent on the visual process as a means of interacting with our environment than with any of our other senses. As behavioral optometrists have understood for almost one hundred years, the visual process is pervasive in human behavior.
Our two eyes must function as a single unit to provide comfortable, effective input. Consistently reliable input is necessary for optimal information processing and meaningful, accurate responses. The ability of the eyes to coordinate, that is, binocular vision or eye teaming, is what allows us to perceive things as being three dimensional, and to understand, and make sense of the space that surrounds us, as well as the people and things with whom we share that space at any given time. For example, if the eyes are not coordinating properly, a person may experience double vision. As you can imagine, this is very disruptive and troubling to the person.
Poor eye teaming leads to errors in judging distances and depth (space) whether or not there is double vision. This in turn affects the way we move through a room, play with toys or other people, color within the lines and every activity that requires us to move any part of our body with some purpose in mind. This is especially important for driving a car. If we cannot accurately judge space, our reactions to traffic or parking situations will be less than optimal. The accuracy of eye teaming is critical in reading, writing and learning in general. Good eye teaming is also important for athletic performance.
Poor eye teaming can cause people to feel insecure in social situations. People with noticeable eye turns are often self-conscious. And people feel awkward around them because it can be strange to look someone in the eye while watching the other eye look elsewhere. People with eye teaming problems often find it difficult to make or maintain eye contact even with family members. So the visual process is often a critical aspect of human social behavior and development.
Many of these people would be considered candidates for eye muscle surgery, but have managed to overcome their visual problems non-surgically, or have found higher level improvement by adding vision therapy to other treatments.
Over the years, behavioral optometrists have worked with countless people of all ages, with all types of functional vision problems. Our experiences in working with people in this way have shown that there is almost always potential for meaningful improvement in visual function and development. This includes children with various learning problems, people with eye turns, lazy eyes, and those who have suffered brain injuries or are living with various developmental and/or neurological deficits. Many of these people would be considered candidates for eye muscle surgery, but have managed to overcome their visual problems non-surgically, or have found higher level improvement by adding vision therapy to other treatments.
Behavioral optometrists have also had the good fortune to be able to help those who have had eye muscle surgeries that did not turn out as hoped. These people were suffering on a daily basis because of the inability of their eyes to work together and sought specialized care to make them more comfortable. The goal of this book is to provide more comprehensive information than is typically offered about the available options. It is also my goal to provide an overview of the factors affecting visual function, an understanding of the ways good visual performance and comfort can be achieved, and the personal thoughts of some people who have had experience in all these areas.
Feel free to contact Dr. Gallop in Broomall, PA (Delaware County) for any specific questions you may have or to make an appointment.
Dr. Gallop specializes in working with people of all ages including children with strabismus, learning problems, reading difficulties and children on the autism spectrum.
Further reading on strabismus and strabismus surgery:
by neurobiologist Susan R. Barry, Ph.D. and Rachel Cooper