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Children’s eyes are special, and they deserve someone who specializes in pediatric eye care. Sanjeev Dewan, M.D. of Ohio Eye Alliance is nearby to help.
Dr. Dewan specializes in eye problems children encounter. He can examine children at any age, even those who are too young to fully participate in their exam. Early detection of vision problems greatly is important as it improves the chances of successful treatment in children.
Strabismus simply means eye misalignment, where the two eyes are looking at different images. In children with strabismus, one eye looks at one object of interest while the other eye points in, out, up or down.
How common is strabismus?
It is estimated that 4% of the U.S. population has strabismus.
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There are many different types of strabismus. Strabismus is most commonly described by the direction of the eye misalignment. Common types of strabismus are esotropia (inturning), exotropia (outward turning), and hypertropia (a vertical misalignment of the eyes).
Strabismus can also be described by its cause. Three of the twelve cranial nerves (III, IV, VI) which arise from the brain and reaching the face are responsible for eye movement can be weak or palsied and cause strabismus. Some examples of this type of strabismus include third nerve (III) palsy, sixth nerve (abducens) and superior oblique (IV) palsy.
Special patterns of strabismus can have unique names such as Brown syndrome and Duane’s syndrome.
Esotropia is inward turning of the eyes (aka “crossed eyes”). Types of esotropia include infantile esotropia, accommodative esotropia (related to farsightedness) and sixth nerve palsy. Exotropia is the term used to describe outward turning of the eyes (aka “wall-eyed”) [See figures 1 and 2].
Fig. 1: Large-angle infantile-onset esotropia.
Fig. 2: Child with exotropia of the right eye.
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The terms hypertropia and hypotropia are used to describe vertical misalignment. Hypertropia is an abnormal eye higher than the normal eye. Hypotropia is when the abnormal eye is lower than the normal eye. The terms can generally be interchanged depending upon which eye is being described.
Most strabismus is the result of an abnormality of the neuromuscular (including brain) control of eye movement. Our understanding of these control centers in the brain remains incomplete. Less commonly, a problem with the actual eye muscle may cause strabismus.
Eye misalignment is a major cause of amblyopia in children. When the eyes are oriented in different directions, the brain receives 2 different visual images. The brain may ignore the image from the misaligned eye to avoid double vision, resulting in poor vision development of that eye. Also, an eye that sees poorly may become misaligned.
Strabismus often occurs in children who are otherwise completely normal. However, disorders that affect the brain such as Cerebral Palsy, Down syndrome, hydrocephalus and brain tumor are more likely to develop strabismus.
Stroke or vascular problems may cause strabismus in adults. Trauma, neurological problems, and Grave’s disease (thyroid eye disorders) are other common causes of strabismus.
Trauma can cause strabismus by:
Brain Damage that impairs control of eye movement,
• Damage of the nerves that control eye movement and/or
• Damage of the eye muscles either directly or secondarily from trauma to the eye socket.
Children with strabismus frequently have an associated condition called amblyopia (lazy eye), although amblyopia can occur without any eye misalignment. Here, one or both eyes have reduced visual acuity.
Amblyopia is decreased vision in one or both eyes due to abnormal development of vision in infancy or childhood. In amblyopia, there may not be an obvious problem of the eye. Vision loss occurs because nerve pathways between the brain and the eye aren’t properly stimulated. The brain “learns” to see only blurry images with the amblyopic eye even when glasses are used. As a result, the brain favors one eye, usually due to poorer vision in the other eye. Another word for amblyopia is often “lazy eye.” It is the leading cause of vision loss amongst children. [See figure 1]
Normal vision develops during the first few years of life. At birth infants, have very poor vision, however as they use their eyes the vision improves because the vision centers in the brain are developing. If infants are not able to use their eyes from various reasons the vision centers do not develop properly and the vision is decreased despite normal appearance of the structures of the eyes.
The most common cause is refractive error in one or both eyes that is not corrected early in childhood resulting in poor development of the visual function in the affected eye/s. This is called refractive amblyopia. Another common cause is strabismus or eye misalignment. This is called strabismic amblyopia.
Rarely there is a structural anomaly that impairs the visual function like a droopy eyelid or opacity in the visual axis like cataract or corneal scar. This is called deprivation amblyopia.
Multiple causative factors can coexist.
There is no surgery to improve the vision for amblyopia. Surgery can be performed to straighten misaligned eyes such as crossing. Surgery to make the eyes straight can only help enable the eyes to work together as a team. Children with strabismic amblyopia still need close monitoring and treatment for the amblyopia, and this treatment is done either before or after strabismus surgery is performed.
Children who are born with cataracts may need surgery to take out the cataracts. After surgery, the child will usually need vision correction with glasses or contact lenses and patching.
If amblyopia is not treated the vision in the affected eye/s will be permanently decreased causing deficits in depth perception and peripheral vision. Moreover, if the good eye becomes injured or affected by a disease, significant lifetime disability may result.
From the American Association for Pediatric Ophthalmology and Adult Strabismus, AAPOS.org.