“Figure that one out … Falls in a well, his eyes go crossed, gets kicked by a mule, they go back to normal.” —Cousin Eddie in National Lampoon’s Christmas Vacation
If, like me, you’re a fan of Chevy Chase, that’s a great line from a hilarious movie. But if, also like me, you have a child who suffers from misaligned eyes or the vision problems that often accompany the condition, the real-life situation isn’t funny and can be a source of stress and worry for concerned parents. The good news is that if caught early, crossed eyes, lazy eyes, and wandering eyes can be treated and ultimately corrected.
What is a Lazy Eye?
The term “lazy eye” is often misused by laymen when describing an eye that drifts inward toward the nose (crossed eyes) or outward toward the ear (wall-eyed), when the medical term for eye misalignment is strabismus. A person who suffers from a lazy eye has a condition known as amblyopia. Kids with amblyopia are looking clearly out of one eye while the other, the lazy eye, rests and remains fuzzy and unfocused. A person with amblyopia frequently also suffers from strabismus—an eye that moves inward or outward—but a child can have amblyopia, an eye that doesn’t work all the time, without any visible signs. On the other hand, a child can have strabismus without any vision problems. There is also a form of strabismus called accommodative esotropia, where one of the eyes turns in due to farsightedness. In this case there is clearly a vision issue which, if left untreated, could lead to blindness in one eye. In a small number of cases strabismus may be a sign of retinoblastoma, a rare form of childhood eye cancer.
Strabismus = Eyes that move independently inward, outward or up and down instead of moving together.
Amblyopia = “Lazy Eye,” a condition where the brain suppresses vision in one eye.
Crossed eyes and drifting eyes affect somewhere around five percent of the population. The condition has been known to run in families, but that’s not always the case. There’s nothing parents can do to prevent strabismus, but there are many ways to correct it.
The first thing all parents should do is get their babies’ eyes examined by a pediatric ophthalmologist. It’s important to have your child seen by a trained eye specialist rather than a pediatrician, because pediatricians frequently misdiagnose true strabismus as pseudostrabismus, where a child’s eyes appear to turn inward because of the shape of their face. Pseudostrabismus is common in newborns because they have fleshy, flat noses and deep eye folds. Dr. Jeffrey Cooper, a pediatric ophthalmologist for the last 30 years, says, “Amblyopia and strabismus cause more visual loss than all injuries and illness in the under 40 group. It’s a major public health concern that’s not acknowledged appropriately by pediatricians.”
I can back up this claim, as I had two pediatricians in two different states dismiss my concerns about my daughter’s wandering eyes. It took a pediatric ophthalmologist less than ten seconds to make my daughter’s eyes drift toward her ears and diagnose her with intermittent exotropia (eyes that move outward like a chameleon). The American Academy of Pediatrics agrees. They recommend that all babies have vision screening (including screening for strabismus and amblyopia) at the earliest possible age, and at regular intervals throughout childhood.
Consider the fact that eyes can move in almost any direction, some or all of the time, and you’ll realize that there are many types of strabismus with infinite degrees of severity. Ophthalmologists must tailor the appropriate treatment to each child, but the tools at their disposal generally include: wearing an eye patch for part of the day to force the weaker eye into doing all the work, placing blurring eye drops in the strong eye for the same reason, using eyeglasses that force the wandering eye to focus, surgery to physically align the eyes, and vision therapy—a specialized set of eye exercises, usually in the form of games for children, that train the eyes to work as a team. Dr. Cooper explains, “If the eyes turn in, patching or drops are used to treat the amblyopia. Some children will have an inward eye turn, associated with them being farsighted, so glasses with bifocals or a special prismatic lens are used to help align the eyes. Large eye turns, caught early in age, are best treated with surgery.”
A child with amblyopia actually possesses a lazy brain, rather than a lazy eye, because for some reason, the brain shuts off power to one eye and uses a single eye to see while the other remains unfocused. Although the most common cause of amblyopia is strabismus, a child can suffer from a lazy eye because of nearsightedness or farsightedness without showing any outward signs. Untreated amblyopia results in permanent vision loss! So how can parents know if their child is seeing clearly if both eyes seem to move in sync and there’s no indication of trouble?
“They can’t. And neither can a pediatrician,” says Dr. Cooper. “Every child should have one eye exam with drops. If we could get every child seen at nine months, we could probably eliminate amblyopia.”
Once a child is diagnosed with amblyopia, the treatment options are similar to those for strabismus: patching or eye drops to force the patient to use the blurry eye more often, vision therapy to train the eyes to work as a team, and possibly surgery to align the eyes if strabismus is the cause of the amblyopia. According to Dr. Cooper, “The earlier you begin treatment, the greater the rate of success. At nine months of age, the chances are extremely high of developing normal vision. However, the success rate decreases with each year and levels out at age six. A younger child can be treated with short-term patching and the right glasses, while an older child needs patching, glasses, and vision therapy.”
Surgery, it should be noted, doesn’t actually cure amblyopia. It’s a cosmetic cure that corrects the strabismus, which causes amblyopia. So a child can come out of strabismus surgery with perfectly aligned eyes that still don’t function together. “People think that if their child has an eye turn and has surgery to correct it, their child has good vision, but it’s not so and the child can develop poor vision the rest of their life,” warns Dr. Cooper. “The brain controls the eyes. If you align the eyes, but don’t fix the brain process, they don’t stay aligned and drift back. So kids with inward eye turns are best treated with glasses, surgery, and vision therapy.” In fact, children who have alignment surgery, but forgo vision therapy to teach the eyes to work together, frequently require multiple surgeries because the untrained eyes regress back to their old positions. Dr. Cooper estimates that it happens about 60 percent of the time.
Patching, glasses, and vision therapy exercises are the only ways to actually train the brain to use both eyes in tandem, and those options require a certain amount of dedication from Mom and Dad to make sure they’re done properly. Young children often balk at wearing an eye patch because it feels weird and hurts to remove. (Imagine having to remove a giant bandage stuck over your eye every day for months.) Older children are embarrassed to wear the patch because of teasing at school. Blurring eye drops help alleviate some of the problems associated with the patch, but young children may fight getting eye drops more than wearing the patch!
Similarly, wearing eyeglasses is hard for anyone to get used to, especially children who don’t understand the benefits. Glasses may be forgotten, removed when the child is out of their parent’s supervision, broken, or lost. Even kids who faithfully wear their glasses are subject to ridicule from classmates.
Vision therapy exercises can be fun and painless, but they require time and travel to the doctor’s office. Although some vision therapy can be performed at home, most doctors require patients to come in for regular office visits because the exercises often require the use of special prisms and lenses. Parents must be disciplined enough to make each office visit, plus make time to sit down with their child for home-based therapy each day.
For more information about strabismus and amblyopia, visit the Strabismus website.