Patching the better
seeing eye (the "good" eye) remains the mainstay of
treatment for amblyopia. The idea is to make the "bad"
eye work harder. Patching can be extremely frustrating but can
also be extremely rewarding. It is important to follow the physician's
patching instructions carefully so that the doctor can properly
guide the patient towards a successful experience. Every patient
is different and various patching regimens apply.
At times, other
methods may be used to blur the vision in the good eye. Atropine
(dilating) eye drops are sometimes utilized and if this is appropriate
for your child, the doctor will discuss this further.
The eye patches can be purchased
at the drug store or pharmacy and are usually found in the Band-Aid
section of the store. Coverlet and Opticlude are two brands recommended.
Infants require the junior size and older kids need the regular
size. The skin around the eye that is patched may be sensitive
and become raw. Baby oil or Vaseline should be applied to this
area every night at bedtime. If glasses are to be worn, the patch
goes on the skin and the glasses go over the patch. The patch
should not be placed on the glasses.
Strabismus means
misalignment of the eyes. The eyes can be crossed (esotropia)
or deviate outwards (exotropia) or drift up or down (hyper/hypotropia).
Treatment options include glasses, eye patches, eye drops, prisms,
and eye muscle surgery. Each patient is different and a thorough
examination is necessary to determine the correct treatment course
for that individual.
Esotropia (Crossed-eyes)
Two major types of esotropia exist.
Congenital or infantile esotropia, and Accommodative esotropia.
It is also possible to have a combination of the two.
It is not normal for the eyes
to be misaligned even a bit after 3-4 months of age. When the
eyes are found to be crossing within the first year of life and
the entire eye exam is otherwise normal, this may be congenital
or infantile esotropia. The treatment is usually surgical.
If the eyes are abnormally farsighted,
glasses must be tried even with babies. If the eyes are straight
with the glasses in place, this is called accommodative esotropia
and surgery is not indicated. The eyes are focusing too hard to
see and therefore crossing. No surgery is done because the glasses
will still be needed after surgery to help focus vision. As long
as the eyes are straight WITH THE GLASSES ON, the treatment is
working.
Exotropia (Drifting eyes or wall-eyes)
When one or both eyes tend to
drift outwards, this is called exotropia. The natural history
of this entity is to worsen over time if left untreated. Sometimes,
good control of the eyes can be gained from patching therapy and/or
glasses. If the eyes continue to deviate significantly, surgery
may be indicated.
Adult strabismus is not a cosmetic
defect in that it does not represent a subjective departure from
a patient's concept of beauty nor is it a natural consequence
of ageing. Simply put, straight eyes are normal; non straight
eyes are abnormal. Multiple studies have shown that even adults
without double vision who have longstanding strabismus from childhood
benefit with fusion and an improved ability to use the two eyes
together. Expansion of the visual field after strabismus surgery
is well documented and occurs with poor vision in one eye and
even when there is no expectation of recovery of binocular fusion.
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General Surgical Guidelines. There
are four important goals of strabismus surgery: (1) to restore
binocular fusion and eliminate double vision, (2) to expand the
binocular visual field of patients with esotropia, (3) to improve
visual performance, and (4) to improve psychosocial functioning.
These guidelines are taken from the "Lifelong Education for
the Ophthalmologist'(LEO) Clinical Topic Update on Pediatric Ophthalmology
and Strabismus. This update is from the American Academy of Ophthalmology
and was written in 1996 by Michael X. Repka, M.D., Johns Hopkins
University School of Medicine.
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It is the policy of the American
Association for Pediatric Ophthalmology and Strabismus that strabismus
be recognized as a disease, and that therapy to attempt to treat
this disease does not confer beauty, but attempts to correct abnormal
ocular alignment. Therefore, strabismus surgery is reconstructive
and not cosmetic. Strabismus surgery should be considered at any
age if the treating physician feels that it would be in the patient's
best interest, either to reduce or eliminate symptoms or to attempt
to bring the patient's eyes to or towards normalcy.
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Many patients
go through life not realizing that they can be helped as described
above until knowledgeable medical professionals properly inform
them. In fact, many patients are mis-informed and told that nothing
can be done for them.
About 6% of children are born
with the tear ducts or nasolacrimal ducts
blocked. This creates tearing and discharge and matting
of the eyelashes. The great majority of these will open spontaneously
within the first 6 months of life. Tear ducts massage and antibiotic
drops/ointment are sometimes utilized. If symptoms persist after
6 months of age, a procedure to open the tear ducts is considered.
A standard tear duct probe is
simple and only takes a few minutes. A tiny wire is inserted through
the openings in the eyelids and passed to the tear sac and into
the nose through the tear duct. A harmless colored dye is flushed
through the system and suctioned out the nose to ensure that the
canal is open.
When the procedure is done at
a young age, the success rate is very high. If the child is older,
has already failed a simple probing procedure, or if the child's
tear duct anatomy is not normal, then a different procedure is
needed. This procedure may be a Lacricath, where a probe with
a balloon tip is used to dilate the tear duct. Alternatively,
a silicone tube may be placed within the tear system and removed
at a later date.
Anesthesia for a simple probe
usually consists of just a mask over the nose and mouth and light
gases so the child does not move and feels no pain. The Lacricath
and tube procedures requires a breathing tube because of the chance
of some mild bleeding and because these procedures take more time.
The physician will only perform these
procedures at facilities he feels has expertise and experience in the administration
of pediatric anesthesia.
Back to Top Retinopathy
of Prematurity
The
retina is the inner lining of the eye that functions like the film in a
camera. Blood vessels that nourish the retina are one of the last structures
of the eye to mature, and are barely completely developed even in a full-term
baby.
ROP
is when the blood vessels in the retina develop abnormally in some premature
infants. It is more likely to develop in in the smallest,
most complicated babies. In spite of the best medical care that modern medicine
can provide, ROP still develops in many infants.
When ROP
develops, one of three things can occur:
1) In the
large majority (about 80%) of babies who develop ROP, the abnormal blood vessels
heal themselves during the first year of life.
2) In some,
the abnormal vessels partially heal. These babies are at an increased risk to
develop nearsightedness and need glasses early in life. Also, they may develop
amblyopia or lazy eye or strabismus (misalignment or wandering of the eyes),
There may be scarring of the retina that can cause other vision problems. These
children require regular eye examinations to determine what treatment is needed.
3) In the
most severe cases, the blood vessels develop abnormally and form scar tissue
that can pull the retina off (retinal detachment). This can result in permanent
loss of vision and sometimes blindness. Fortunately, only a small percentage
(about 5%) develops these advanced stages of ROP. Important decisions have to
be made about possible surgical/laser procedures to try to protect vision.
PRE-OPERATIVE
EVALUATION
Please
call our surgical coordinator for instructions.
SURGERY
Eye
muscle surgery has made tremendous advances over the years. The surgery is designed
to put the eyes into a more satisfactory alignment. Eye muscles are attached
outside the eye. Each muscle has partner-muscles and opponent-muscles. The eyes
move when one set of muscles pull and the opposing set relaxes. "Strengthening"
operations make an individual muscle pull more effectively by shortening or
tucking that muscle to reduce its effective length. "Weakening" operations
make an individual muscle pull less effectively by lengthening or "clipping"
or by moving the points of attachment of that muscle closer together.
TECHNIQUE
OF SURGERY
At
no time is the eye removed from its socket. The eye muscles lie beneath the
filmy membrane (conjunctiva) covering the white of the eyes. Small incisions
are made in this filmy membrane to expose the attachment of a muscle or its
tendon to the white part of the eye. These tendons are then moved in a way to
make the muscle effectively longer or effectively shorter. The muscles are reattached
to the white part of the eye (sclera) by stitches (sutures). These sutures are
usually absorbable material not requiring removal. Following surgery, the area
of incision in the filmy membrane and the points where the sutures are placed
may exhibit some redness and swelling. The eyelids are usually not manipulated,
but occasionally following surgery, the eyelids may be transiently discolored
or swollen. Tears are usually blood tinged the first day; tears and secretions
tend to dry and collect on the eyelids.
ANESTHESIA
The
physician will only perform surgery at facilities he feels has expertise and
experience in the administration of pediatric anesthesia.
RESULTS
OF MUSCLE SURGERY
Eye
muscle surgery is not exact, it is approximate. It is based upon average
responses to "shortening" or "lengthening" a given muscle
a set number of millimeters. The average response to "shortening"
or "lengthening" of the eye muscle is predictable. There may be
an over- response or under-response to a given operation.
In
most instances, we plan to achieve with one procedure a satisfactory correction
of the eye muscle problem. Because of varying responses, or because of the magnitude
or complicated nature of the muscle problem, more than one muscle operation
may be necessary. Please do not try to evaluate the outcome of surgery during
the first several days to the first several weeks following surgery. The operated
muscles do not function with full power immediately. Until full function is
regained the eye position may change. It may take 6-12 weeks to regain full
function
RECOVERY
ROOM
Following
muscle surgery the patient will be taken to the recovery room where special
nurses and equipment are available. Here their recovery from deep anesthesia
is supervised
A.
Eating
The
patient may have cracked ice or small sip of a carbonated beverage. Nausea
is frequent after the administration of anesthetics and with eye muscle
surgery. When a satisfactory state of consciousness returns, they are sent
to their own rooms. The parents rejoin them at this time. Large
quantities of fluids or solid foods seem to irritate the stomach in the immediate
post-operative period. Usually the patient is able to resume a regular diet
the day following surgery
B. Bandages
Ordinarily the eyes are not covered. For this
reason, you will be able to see discharge that normally follows surgery.
Discharge may be blood-tinged for several hours. These secretions may be removed
with Kleenex or clean moistened cotton.
C. Tearing
Tearing during the first few days after surgery
may occur and may be bothersome. Sponging with a Kleenex is permitted.
D.
Pain
Generally
there is little or no pain except on extreme movements of the eyes. The patient
learns this and tends to turn the head rather than move the eyes. Tylenol
can be given if there is pain, but blood-thinning medications such as Advil,
Motrin, and aspirin should be avoided.
E.
Activity
The
patient is able to use the eyes the day after surgery. All patients are allowed
up with supervision the same day. Infants and small children may be held in
the parent's arms. Swimming is not permitted for two weeks. Keep soap and
water out of the eyes when bathing.
F.
Glasses
The
eyes are light sensitive following surgery and older patients will appreciate
sunglasses or wide-brimmed hats. Younger patients may choose to close their
eyes to avoid the light. If glasses were worn prior to surgery, they will
probably be continued immediately after surgery. They may be modified at sometime
during the post-operative period.
G.
Medication
Any
regular medication that the patient is taking should be continued upon leaving
the hospital. Occasionally, special additional medicines will be prescribed
for you to take home
POST-OPERATIVE
VISITS
Some
post-operative visits will be scheduled at intervals. If there is any problem
between the scheduled visits, please report that and additional visits will
be arranged. Visits during the weeks following surgery are considered immediate
post-operative surgical care and are covered by the surgical fee.
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Dr.
Miller with one of his patients before surgery.