Page 23 - May 2024 SAM PDF

EYE CARE AND
EYE CARE AND EYE CARE AND
QUALITY OF LIFE
QUALITY OF LIFE QUALITY OF LIFE

t’s a busy Tuesday in the Pediatric Ophthalmology clinic. Our first others, particularly with regard to getting the dilating eye drops, but
appointment involves a worried mother of a 6-month-old boy who most all can be coaxed through their examinations through a mixture
Iis concerned that he may have crossed eyes. After the usual com- of spinning light toys, movies on the television in the room, singing and
plete eye examination and refraction (checking for a need for glasses), various other distractions.
the child is found to have only epicanthal folds but not true esotropia. Around lunchtime, adult strabismus patients are scheduled. These
The mother is reassured that he has normal eyes and no treatment is patients can have quite complicated forms of strabismus, with etiolo-
needed at this time. She is given a pamphlet with photos to demon- gies ranging from broken-down childhood strabismus, restrictive or
strate the difference between pseudostrabismus and true esotropia, and mechanical problems such as scarring from previous trauma, retinal or
the child is scheduled for a six-month follow-up with the Orthoptist to glaucoma surgeries, or Graves’ disease. Others may have extraocular mus-
double check the eye alignment before discharging the patient. cle weakness due to cranial nerve palsies, damage due to neurological
The next patient has a similar presentation. The 7-month-old girl’s problems such as tumors, or neuromuscular issues such as myasthenia
parents note that the family has been seeing the left eye crossing con- gravis. Examination of these patients can be quite time-consuming, and
stantly since the child began to make good eye contact. After a similar often starts with an extended examination of their eye alignment with an
examination, she is found to have a large angle of esotropia (crossing of Orthoptist prior to meeting with the Pediatric Ophthalmologist. Addi-
the eyes), along with amblyopia in the left eye, but an otherwise normal tional workup is often needed, including imaging and laboratory studies.
eye examination. The family is counseled that she has infantile esotropia Each patient is counseled at length regarding treatment options. While
and amblyopia. Because the right eye is becoming preferred, the parents observation is almost always an option for adult strabismus patients,
are given patching over that eye to correct the amblyopia. Older chil- most have chosen to come to a pediatric office because this was no lon-
dren with amblyopia may also be treated with atropine drops, but in ger working well for them and they are seeking other treatment options.
younger children, patching is more frequently used. The parents are also These can include prism glasses, particularly for elderly patients with
cautioned that it is very likely that she will require strabismus surgery diplopia who normally wear glasses and have only small eye deviations.
to correct the eye alignment once the vision is equal in the two eyes. Many of the adult patients, however, ultimately opt for surgical cor-
They are also informed that sometimes more than one surgery will be rection to correct functional problems such as double vision, eye strain
necessary. Follow-up is scheduled in two months to recheck vision with or fatigue, or social issues such as being asked who they are talking to, or
the Orthoptist. why they aren’t making eye contact with someone. Interestingly, many
Later in the morning, a 3-year-old boy is brought in for the new of these patients are quite surprised to hear that surgical correction is an
onset of crossed eyes. He has no other neurological issues and is doing option, as they have been told for years that they are “too old” for stra-
well developmentally. His examination shows intermittent crossing of bismus surgery, though that is rarely the case. We have corrected patients
the eyes but also, he is found to have a high degree of hyperopia (far- as old as 90 years old, surgically, in order to improve their double vision,
sightedness) at +5.00 diopters in each eye. Discussion with his fami- which will hopefully improve their quality of life, restore the ability to
ly includes the fact that normal farsightedness is no more than about drive in some cases, and reduce the likelihood of falls due to stumbling.
+3.00 diopters at this age, and his excessive farsightedness is causing the When necessary, strabismus surgery is performed as an outpatient
intermittent crossing. Fortunately, this is usually easily corrected with procedure. Both general and local anesthesia are options in adults,
glasses to eliminate the need for focusing, and the patient is unlikely to though children are routinely done with general anesthesia. Surgeries
require surgical correction. He will be seen for follow-up in a few months are generally quick, lasting under 20 minutes of surgical time per muscle
to ensure that the eyes are straight with glasses and the vision is equal, corrected, plus anesthesia time. Patients generally only require topical
but as long as both of these are the case, no additional treatment will be treatment postoperatively, along with acetaminophen or ibuprofen for
required. pain. Patching is normally not necessary for children, though adults
As the day progresses, another family presents with a concern that may be patched overnight. The only statistically significant risk is that
their 7-year-old girl’s eyes are drifting out intermittently, which has been the patient may require additional surgery in the future, though for the
occurring for a while but has worsened recently. Examination confirms majority of patients, only a single surgery is necessary.
that their suspicions are correct, with an otherwise normal examination. After a long but interesting day in clinic, the staff and doctors go
For this patient, the ability to control the drifting, or the lack thereof, will home tired but satisfied with the problems solved today, and looking
dictate the treatment plan. As long as the child has good control of their forward to new patients that will present tomorrow. Sometimes allevi-
eye alignment, then observation is prudent. If the control is poor, or is ating the parents’ concerns is even more of a challenge than keeping the
worsening over time, then various options for treatment are available. For children calm and distracted, but this can normally be overcome with a
younger children, a trial of alternate patching may help them to recognize little extra time and a few more answered questions. At the end of each
Pediatric Ophthalmology and Strabismus: the deviation when it is present, and therefore control it more effectively. day, the challenges of treating the patients (and sometimes the parents,
Overminus glasses (overcorrection of nearsightedness to induce focusing too) provide a challenging and rewarding experience that keeps us com-
and convergence of the eyes) can also sometimes be helpful but ultimately, ing back day after day.
Little Patients, Not So Little Problems surgical correction is an option if control remains poor.
During the day, nearly 100 patients may pass through visits with the
multiple providers in the clinic, with strabismus, amblyopia and other Charles S. McCash, MD, specializes in Pediatric Ophthalmology
By Charles S. McCash, MD problems as varied as childhood cataracts, glaucoma, tear duct obstruc- and Eye Alignment Disorders at the Children’s Eye Center of
tions, chalazia, retinoblastomas, orbital cysts, ptosis and various other South Texas. Dr. McCash is a member of the Bexar County
eye problems. Some kids are more agreeable with the eye exam than Medical Society.

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