Strabismus — Is Surgery Enough?


Today’s guest blogger is Dr. Samantha Slotnick.  Dr. Slotnick, is a Behavioral Optometrist practicing in Hartsdale, NY.   She is also an Adjunct Assistant Research Professor at the SUNY State College of Optometry in NYC.

Eye turns are a common problem affecting about 3% of the population.

Often, when patients with eye turns come to me, they are not aware of any non-surgical options to address their problem. Some of these patients have already had surgery, perhaps unsuccessfully, or they report that the surgery worked for a while, but “didn’t hold.” They’ve often been told in advance that they may need a second or third surgical procedure.

The problem with treating an eye turn (strabismus) with surgery alone is that strabismus is rarely a “muscle-only” problem. Especially after years of living with the eye turn, our highly adaptable brains come up with strategies for coping with information coming from two eyes which do not point in the same direction.

Among these strategies are suppression and anomalous projection (or anomalous correspondence).

-Suppression blocks out information from one eye, which protects the person from experiencing double vision.  Suppression only occurs when both eyes are open.  It takes energy to actively suppress information.

-Anomalous projection (or anomalous correspondence) trains the brain to match up information between the two eyes based on the way they are pointing, rather than on the way the original connections are made between the eyes and the brain. This allows the patient to retain some degree of stereopsis. (Stereopsis is 3-D vision derived from the two eyes seeing the world from slightly different vantage points.)

These two main “strategies” are very helpful for the person with an eye turn … until attempts are made to straighten the eyes.  If surgery is used to straighten the eyes (by relocating muscle attachments), but no attention is paid to the brain’s “strategies,” there is a much lower potential for long term success.

Consider what would happen if the eyes were made to align (surgically), but suppression continued to block information coming from one eye. In many cases, without addressing this protective “strategy,” the brain does not learn to combine the information from both eyes. So, even though surgery moves the eyes so that there will be no conflict between the images from the right and left eyes, there is also no “glue” to keep the eyes aligned after surgery.  In a case like this, the eyes may start to turn again, even after appearing like they were holding straight after surgery.

Now consider what would happen if the eyes were made to align (surgically), but anomalous projection continued to match up information between the two eyes based on the way they had been positioned for years up until the surgery.  In many of these cases, the patient begins to see double after the eyes have been re-positioned.  Even worse, these patients may experience visual confusionVisual confusion is the appearance of two different objects overlapping, as if they come from the same place. The brain now has the same two main options for avoiding visual confusion: suppression and anomalous projection.  Since anomalous projection worked successfully before, these patients may learn to re-assign information based on their new eye positions.  But without the guidance of vision therapy, many of these patients re-establish their eye turn to the same position that their eyes held before the surgery.  Some patients even end up with the eyes switching to turn the opposite way after surgery!

Vision therapy for patients with an eye turn is a rehabilitation process which helps the brain adapt to a change in the relative positions of the eyes.  It trains the brain to make use of information coming from two directions, and to marry the pieces of information into a single image.  It also trains the brain to be flexible in coordinating the eyes over a range of distances and demands.

Ideally, vision therapy for eye turns should be addressed BEFORE surgery is attempted.  Sometimes, successful vision therapy negates the need for strabismus surgery.  Other times, vision therapy prepares the brain so that surgery is successful and will hold.  If surgery is performed, vision therapy should also be conducted AFTER surgery to help stabilize the visual system and maximize the positive outcome.  It takes training to learn to see and appreciate the world in 3-D, especially for patients with a long history of an eye turn.  The long term benefits of vision therapy for eye turns include:

-Less energy exerted when reading:

-More energy available for thinking!

-Less loss of place/ skipping lines

-Better sense of spatial organization:

-Improved ability in sports and athletics

-Easier time parking a car

-Better depth perception:

-Greater accuracy in hand-eye coordination

-More enjoyment of the visual world

-Better use of peripheral vision:

-Easier time “seeing the forest while viewing the trees”

For an appreciation of how life can be changed after vision therapy for an eye turn, I strongly recommend reading “Fixing My Gaze,” by Susan Barry. This first-hand account chronicles the life experience of a person who had an eye turn from infancy, had multiple strabismus surgeries, and did not begin vision therapy for her eye turn until the age of 48.

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123 comments

  1. Fantastic information. We’re posting this on our Facebook page – http://www.facebook.com/thevisiontherapycenter

  2. 54 years ago (age 5), I had my first eye operation for strabismus, and 42 years ago (age 17) I had my second. One year ago (age 58) I began vision therapy. Until then, my world was two-dimensional. After several months of therapy, I saw in 3-D for the first time. I cannot express the excitement, joy and wonder of seeing space between things. Prior to this, things just looked like they were overlapping. I’m still doing vision therapy to further refine my steriopsis. It is a thrilling journey.

  3. Dear Hope,

    Thank you for posting! I am so glad you have found new enjoyment in your life through visual experience. Your story is inspirational.

    May I ask what your expectations were of your second surgery? Did it include a change in function?

    What drove you to begin vision therapy?

    Best regards,

    Samantha Slotnick

    • My expectation was cosmetic. I hoped to have “straight” eyes. And, I did. I did go to an orthoptist after surgery, who told me, “I can probably get your eyes to work together, but you might see double for the rest of your life.” I declined the offer.

      It wasn’t until I read Oliver Sachs’ piece about Sue Barry in the New Yorker, that I realized I was missing something; that I saw the world very differently than most people. After sitting down and crying about this new concept, that I was really deprived of something wonderful, I decided to explore vision therapy. I give great thanks to Dr. Sachs for “opening my eyes” to the possibilities, to Sue Barry for her extraordinary descriptions of her own development of steriopsis; and to my vision therapist, who is helping me broaden my abilities.

  4. Every word wroten here, should to be translated in many languages. If you agree. I will translate your blog in German. I agree in all issues. great job! Joe

    • Dear Dr. Slotnick
      Thank you for this encouraging post!!
      I Just had my third surgery a month ago. This time after two years of vision therapy that taught me how to use both my eyes and after the surgery the surgeon told me to walk around seeing double until my brain will give up one image again… now that I know better I’d do that mistake again.
      But there are so many people that don’t know and this knowledge is so crucial that I’d like translate it to Hebrew and share it in my blog – http://i-two-eye.blogspot.co.il/
      Thank you,
      Shiri

      • Dear Shiri,

        Congratulations on your recent success! It sounds like vision therapy in combination with surgery has provided you with stability and new function in using your vision!

        I greatly appreciate your enthusiasm, and your desire to share what I have written here by translating it into Hebrew.

        I have a colleague in Israel who is an excellent Behavioral Optometrist, Dr. Robert Lederman. Perhaps you have even worked with him, as he and I have discussed vision therapy pre- and post-surgical management for strabismus?

        This blog is officiated by the College of Optometrists in Vision Development; Dr. Lederman and I are both Fellows. It would be my preference to have him review your Hebrew translation for technical accuracy and to post it on *his* website. We would need the translation to link back to the original page, and to reference me as the author, and you as the translator. You can link your blog to Dr. Lederman’s page once it is posted there.

        Thank you for sharing your success, and for striving to help others with similar circumstances!

        Best wishes!
        Dr. Samantha Slotnick

  5. Dear Dr. Samantha,
    This is great stuff, and very important. I especially take to heart your comments regarding AP and Suppression.
    I posted a link to this blog on the Vision Therapists’ Google Group and have asked them to spread the word.
    warmest regards,
    Linda Sanet, COVT

  6. Dr. Slotnick,

    An excellent post. Operating on strabismus without preparing the patient with therapy is a little like throwing a child in the water without teaching him to swim. Some make it; some don’t.

  7. Well presented! Thanks for the information.

  8. Dear Dr. Slotnick,

    This is a great article! Being a Nurse I have frequently seen patients with Strabismus and I feel much more informed. What a logical concept and it is a shame patients are not routinely instructed on this option. It’s not like an Orthopedic Surgeon does a Total Knee replacement and sends a patient home without Rehab Therapy! Eye surgery should be no different! Thank you for adding to my knowledge!

    Sincerely
    Carrie

  9. My two year old has amblyopia and esostrophic strabismus in his left eye, measuring 40; so quite a big eye turn..do you think it’s possible to realign eyes with vision therapy, especially at such a young age? I have been patching his eyes daily and im told today that he has 20/20 vision if that means anything…I would appreciate your views..

    • Dear Irene,

      Thank you for writing about your son.

      I will try to provide some insights that may help you, but I would encourage you to seek out a behavioral or developmental optometrist for specific guidance on helping your son develop binocular vision skills. If you check the “Locate a Doctor” feature through the COVD website (https://covdwp.memberpoint.com/WebPortal/BuyersGuide/ProfessionalSearch.aspx) you will be able to identify someone near you who can help.

      Often, patients with esotropia (an eye turn inward) have what is called a “centration point,” a place very near to their eyes where both of the eyes are aiming at the same point in space. This centration point provides an entry for developing binocular (two-eyed) experience and extending it outwards. You can develop this right away by playing “airplane”-type games with his food. For example, when you bring food on a spoon towards the eyes, very close, so that it looks like his eyes are both pointing directly at the spoon, slowly pull the spoon back and observe if he separates his eyes (“diverges”) in order to keep both eyes on the food.

      An eyeglass prescription may assist your son in relaxing his eyes and developing a range over which he can extend his two-eyed seeing. Again, I recommend consulting with a behavioral or developmental optometrist to obtain an optimal prescription geared to facilitate development. This is not intended as a “corrective” prescription, but rather a “therapeutic” prescription.

      At the age of two, it is not too early to introduce activities and interventions which will help your son to make changes in the way he is using his eyes. Often, with young children, these changes are gradual and subtle, but over a year of therapy I will observe decreases in the total size of the eye turn. While your son may not be quickly and fully remediated, the early experiences in developing binocularity may serve as building blocks towards making progress later, and without the intervention of surgery.

      There are distinct advantages to avoiding surgery altogether: The connections between nerves and the muscles they control remain intact. There is some evidence that in the long run, it is easier to control muscles that have not had surgical intervention.

      Consider esotropia as a binocular (two-eyed) problem. The way towards resolving a two-eyed problem is through two-eyed experiences. Patching, however, *deprives* the brain of two-eyed experiences, and should not be undertaken for prolonged periods. You can reference the Amblyopia Treatment Studies, which are clinical trials showing that (1) extensive patching is not necessary to gain improvements in amblyopia, and (2) patching is best undertaken in short, 30 minute periods with detailed, interactive activities (like connect-the-dots or working on puzzles or manipulative games).

      Amblyopia literally means “lazy eye,” and refers to a reduction in vision potential through an eye. Vision does not fully develop in a “lazy eye” because the eye is not receiving a clear image. This may be due to an eye turn, a high prescription (especially if one eye has a “normal” prescription), or an opacity blocking light through the eye (such as a cataract which is present from birth).

      If your son has attained 20/20 vision with each eye, amblyopia is no longer the primary issue, and he is now likely to switch which eye he views with. I would not continue to recommend patching, with the exception of specific, prescribed activities. Patching may help one eye develop its ability to see on its own, but patching for prolonged periods will interfere with binocular experience.

      There are ways, through vision therapy, to challenge one eye at a time while both eyes are still seeing. These activities are very successful at teaching the brain how to take information from both eyes at the same time, rather than taking turns between the right and left views of the world.

      I hope this provides some perspective on the potential your son has to develop the ability to see with two eyes together. The guidance of a behavioral or developmental optometrist is a critical component of a successful outcome.

      Best of luck!

      Dr. Samantha Slotnick

      • Hi Dr. Samantha Slotnick,
        My daughter just turned 3 and has esotropia. Sometimes her eye turns in more than at other times. Today I noticed her eyes separate as if they were trying to straighten. If you go close to her and have her focus on you, it looks as though she is looking with both eyes at the same time, but I can’t be sure. Are there any other exercises you could recommend to help her? We went to a vision therapy doctor, but after 2 weeks she told us to drop the exercises and try glasses. We tried those for 2 weeks, but they didn’t seem to help much. Now we are considering surgery since we don’t know what else to do. The exercises we tried for 2 weeks were chair spins, walking on a balance beam, and light therapy. I’m not sure if these helped and the doctor seemed to be not so sure either, since she told us to drop them altogether and try glasses. Are there any other exercises we could try? I’ve tried looking online, but can’t find much.
        Thank you, Christine O.

      • Dear Christine,

        I am glad you are seeking input and alternatives before attempting surgery.
        However, I could not in good conscience recommend activities as a “do it yourself” form of vision therapy for a toddler with strabismus. Your observations as a parent are valuable, and you have likely identified areas where your daughter is following you with both of her eyes. Now is not the time to quit!

        I would encourage you to look for a second opinion, and to find a doctor who makes you feel comfortable with the management s/he can offer.
        You can use the “Doctor Locator” functions on covd.org or oepf.org. If you would like to post a city/region, I can try to obtain a more specific recommendation for you.

        Best wishes,
        Dr. Slotnick

      • Hi Dr. Slotnick,

        Thanks for the kind reply. We are looking for another doctor to do vision therapy exercises for my daughter. We live in Scranton, PA in the Northeast PA area. Let me know if you can recommend anyone. We are willing to travel an hour or 2 for the best care.

        Thanks so much!
        Christine

      • Dr. Samantha Slotnick
        I was reading about how you recommend not patching that much. My daughter had eye surgery 4 months ago. Before surgery, one eye went out a bit about 30 to 50% of the day. Especially when she was tired. This was not really noticeable to most people either. After surgery, her eyes are crossing in. One more than the other, and almost all the time!! Her condition worsened with surgery. I am so upset as you can imagine. She doesn’t seem to be using her eyes together very much at all. Maybe a few seconds or minutes a day. Instead of going the surgery route, we are going to a developmental optometrist for vision therapy. He is a fellow covd. My daughters vision in both eyes are fine according to him. He said to only patch 2 hrs a day, opposed to the ophthalmologist who told us 8 hrs a day. We went to another developmental optometrist who said to patch 6 hrs a day to strengthen the weaker eye (her amblyopia one). I don’t know who to go with and who is more experienced…don’t know what you think. Both doctors are extremely thorough and very good!!

      • Dear Sheri,

        I would lean toward the Fellow of COVD, who is recommending less time patching. It’s great that you have options, and you can certainly go with your gut on which is a better match for you and your family.

        I am glad you are leaning away from surgery at this point, and I hope your daughter is able to make the changes in her use of her eyes so that surgery is no longer indicated.

        Thank you for sharing about your daughter. It is frustrating to learn of cases where a patient has only an occasional eye turn outward, is treated with surgery, and winds up with a full time eye turn inward and esotropia.

        Best,
        Dr. Samantha Slotnick

  10. Hi, my 4 year old son has had strabismus surgery a year ago. Mostly corrected now but may need fine-tuning surgery.
    At a recent check-up with an expert orthoptist at Sydney Hospital, he failed a 3D vision test.
    The orthoptist said that he will never be able to see 3D as that develops earlier and once that period is missed it’s impossible to develop later. That depressed me and my wife.
    I see blogs where people say they developed 3D vision later after strabismus correction.
    Could the orthoptist be wrong? Our next appointment with the opthalmic surgeon isn’t until June 2011

  11. Hello, James,

    Sorry for the delayed response.

    I would not take your orthoptist at his/her word with the negative prognosis on 3D vision. However, you may need the assistance of someone who takes a different approach to visual processing. I recommend you seek an opinion from a behavioral optometrist. Try the website for the Australian College for Behavioral Optometrists: http://www.acbo.org.au/

    I have asked for specific recommendations on doctors from my colleagues. If you would like to provide your email address, I will send you a recommendation directly.

    Best of luck!

    Dr. Samantha Slotnick

  12. Dear Dr Slotnick

    Thank you for your comment and kind wishes. I’m glad there may be some hope for my son developing 3D vision. I will check out the website for the Australian College for Behavioral Optometrists: http://www.acbo.org.au/
    My email address is jmoshide@ozemail.com.au

  13. My daughter (age 13) is facing her 7th (yes, 7th) strabismus surgery in the next couple months. We have switched surgeons prior to the last one, and I do have confidence in our new dr.’s abilities. But I am truely curious about eye therapy. I have to believe that there are options out there other than surgery over and over and over again that will help to prevent this issue. Or things that can be done post or prior to help strengthen the muscles so we can get off this roller coaster – she does not deserve this!!. She was born 4 weeks early with Pulminary Atresia, so we had to get her heart issues under control before addressing the eyes. Her first surgery wasn’t until she was 1 1/2 – which I understand is a little late for the best results. Before we go into this next surgery, I do have alot of questions for our dr., and would appreciate more inforamtion on eye therapy so that I can discuss intelligently with him. Thank you,

    • Dear Vicki,

      Please, PLEASE seek out the opinion of a behavioral optometrist before following through with this 7th surgery. It is not about your surgeon’s abilities. It is about your daughter’s ability to make sense of images from two different eyes into a single, whole picture.

      ==> No surgeon can do this for her. <==

      This visual fusion goes on in the BRAIN, not at the eyes.

      This is why, I repeat: NO SURGEON CAN DO THIS FOR HER.

      I am glad you are asking questions and looking for help.

      If your daughter has re-adapted an eye turn SEVEN times, and if you do not change your course of care now, I would bet money on her re-adapting an eye turn an eighth time.

      She is telling you something: She does not know how to put the images together. So she is preferring to pull them apart.

      She requires a different approach.

      She requires Optometric Vision Therapy for strabismus.

      If you would like to provide an email address or your location, I can offer a specific recommendation for a behavioral optometrist near you. Otherwise, try locating a doctor on
      http://www.covd.org
      OR
      http://www.oepf.org.

      Best wishes,

      Dr. Samantha Slotnick

      • Thank you all for your comments and suggestions. We are in Norfolk, Virginia, and would be willing to travel to see someone for a consult. I would love a recommendation. We CANNOT keep going on this train.

        V.
        tv.townsend@verizon.net

  14. Dear Vicki,

    In addition to the excellent comments offered by Dr. Slotnick, a few other points to consider. At this juncture your daughter likely has so much scar tissue from prior surgical procedures on her eye muscles that if we were talking about muscles elsewhere in the body anyone doing further surgery without consideration of non-surgical therapeutic options might be guilty of malpractice. For many reasons, eye muscle surgeons ignore all of the points that Dr. Slotnick raises in her original post, and in her caution to you. In addition to the sources she provided from COVD and OEP, here is a brief overview from the American Optometric Association:
    (http://www.aoa.org/x4700.xml)
    ————————————————-
    Prism lenses are special lenses that have a prescription for prism power in them. The prisms alter the light entering the eye and assist in reducing the amount of turning the eye has to do to look at objects. Sometimes the prisms are able to fully compensate for and eliminate the eye turning.

    Vision therapy is a structured program of visual activities prescribed to improve eye coordination and eye focusing abilities. Vision therapy trains the eyes and brain to work together more effectively. These eye exercises help remediate deficiencies in eye movement, eye focusing and eye teaming and reinforce the eye-brain connection. Treatment may include office-based as well as home training procedures.

    Eye muscle surgery can change the length or position of the muscles around the eye in an attempt to better align the eyes. Eye muscle surgery may be able to physically align the eyes so they appear straight. Often a program of vision therapy may also be needed to develop a functional improvement in eye coordination and to keep the eyes from reverting back to their previous condition of misalignment.
    ————————————————-
    For more information on how surgeons provide selective information about multiple eye muscle surgery outcomes, see:

    http://www.strabismus.org/surgery_crossed_eyes.html

    • Dear All, Since I last wrote, it was determined that Terry, my son, still had a problem after 2 ops on his right eye. Our surgeon convinced us that a third op on the good left eye was needed to balance out the right eye. We went along with that because there was a suggestion that it might restore binocular vision. The third operation failed and now he has esotropia in the left eye. The surgeon is regarded as the best in Sydney, Australia and he was surprised and suggested Terry needed a 4th operation 9on the left eye). He asked me for permission for a second opinion from his practice partner and his practice partner agreed on a 4th operation. As my wife is Japanese, she wanted opinions from Japan. The first Japanese specialist suggested prism glasses before deciding on a 4th operation. The second Japanese specialist agreed with glasses. When we returned to Sydney with those opinions, the surgeon agreed on a trial of glasses but gave him mild prescription glasses and not prism glasses. We are to return for a review in a few months but the trial is supposed to last for one year. I have yet to take him to a behavioural optometrist but after the review, I will look for one.I appreciate the kind help of Dr Slotnick and apologise for not acting on her advice sooner.

      • Dear James,

        Thank you for sharing your story. I am sure many can learn from the challenges you have been facing with your son.

        Please keep us informed after you take your next steps!

        Best wishes,

        Dr. Samantha Slotnick

  15. Strabismus surgery is seldom as successful as we would hope it to be. Please see. Maino D. The number of placebo controlled, double blind, prospective, and randomized strabismus surgery outcome clinical trials: none!. Optom Vis Dev 2011;42(3):134-136. at http://www.covd.org/Portals/0/OVD/42-3/Editorials/OVD%2042-3%20Journal_Editorial_Maino_web.pdf

    • Thanks for the article – the more I read about vision therapy the more I am wishing I had known about this a long time ago. We have an appt for my daughter in 2 weeks with a dr. that has been doing vision therapy for about 20 years. But I have a concern – I don’t want to alienate our surgeon in the process of finding out more information about an alternative course of action. I believe that ultimately we may need to have both professionals working together for the best possible outcome for my daughter. I will be setting up an appointment with our surgeon to go over what has been done in the past and what he hopes his suggested upcoming surgery will provide and discuss the fact a that surgery after surgery after surgery doesn’t seem to be effective. Are my concerns legitimate, or am I worrying about something that i don’t need to be? Any suggestions would be appreciated.

      • My opinion is that you need to act in your best interest. It may be useful to have surgical support in the future, after she has learned how to fuse visual information with her brain FIRST. At that time, I agree, the best option is to have the two doctors co-managing care, communicating with each other. In cases where a surgeon has accepted input from me, it has worked out in the patient’s best interest EVERY TIME.

        In many strabismus cases where the patient has never had vision therapy, the surgeon tends to leave the eyes slightly crossed, as this is not cosmetically noticeable, and the patient often learns to suppress the vision from one eye. Surgeons tend to perform this over-correction of a tendency for the eyes to turn outward as a way to try to prevent the eye from drifting again. However, if a patient doesn’t adapt to this posture, the eyes will re-adapt a turn (sometimes turning even farther inward, sometimes turning outward again).

        Your daughter is an example of a patient who is not independently “figuring out” how to use her eyes together when they point straight. SO, she has re-adapted the turn SEVEN TIMES.

        Once a patient has optometric vision therapy, they learn to start using visual information from a larger area of their retinas. They learn to process information simultaneously between the two eyes. Optometrists may use tools, like prisms, lenses, filters and occlusion to help a patient change how they process visual information. At times, the patient can use their eyes as a team with the help of glasses, but they cannot keep their eyes straight without glasses.

        To help reduce the amount of motor work the patient must do to hold their eyes straight, sometimes a surgery is recommended as a part of therapy.

        In these cases, by co-managing, the optometrist can inform the surgeon about the muscle skills the patient has developed, and what the patient is capable of doing. When I have been able to co-manage a strabismus patient THROUGH surgery, my patients have done well and been successful cases. Usually, after surgery, a bit more therapy helps the patient stabilize their visual system (similar to having physical therapy after any orthopedic surgery to relearn how to use the body with the surgical changes).

        However, I have had three cases in the last three years where a surgeon has performed surgery on vision therapy patients without the input of the managing optometrist, and the patient has been left with double vision and a whole new set of challenges to work through after surgery.

        This is because optometric vision therapy helped the patient learn to use both eyes as a team, so they were no longer likely to suppress an eye. As I explained above, the surgeon frequently over-crosses the eyes, because this stabilizes many strabismic patients who have never had surgery or therapy. However, patients who have learned to use their eyes as a team know how to make fine adjustments to keep their eyes coordinated, providing them with single vision while both eyes are working. It is much easier for people to pull their eyes closer together (converge their eyes) if they are left slightly under-crossed after surgery than to learn how to spread the eyes apart (diverge the eyes) if they are left slightly over-crossed after surgery. This is the OPPOSITE of what is usually recommended for strabismus surgery, with patients who have never had surgery or therapy. Hence, co-management is always the best approach. When professionals are working in your best interests, they will not be so ego-driven as to refuse co-management.

        As a health care professional involved in a patient’s case, I always appreciate a patient’s phone call to let me know that they are exploring some options and alternatives, and that they appreciate the help and counsel I have offered to date. Keep in mind, “doctor’s orders” are really doctor’s recommendations. Your surgeon should be happy to be available to you as YOU wish and when you ask for support. You are not obliged to more. This person is a medical professional, not a personal friend. You do not to be concerned that they will hold a grudge because you didn’t do exactly as they recommended when they recommended it. There is no reason to think that delaying a plan for surgery will result in them closing the door on you or your daughter.

        Good luck, and please come back and keep this blog informed of your daughter’s progress!

        Dr. Slotnick

  16. Thanks for the article Dr Maino, after reading it I will need a heck of a lot of convincing to let Terry have a 4th operation.

  17. I have touched base with Rosemary Paynter, a lecturer/behavioural optometrist at the University of New South Wales (my alma mater). I’ve forwarded to her all of Terry’s summaries contained in the surgeon’s referrals and the Japanese opinions. We hope to have an appointment in her clinic in a few weeks. Like Vicki, I hesitate to tell the surgeon but hopefully he will take it well. Once there is an update, I will post it. Thanks again Dr Slotnick (if you are interested in getting a copy of Terry’s summaries I can send them to you via email)

    • Hi James

      Im from Sydney Aust too and have a similar
      problem to yours with my daughter. Just wondering how did everything go with Terry and any updates? Best of luck!

      • Hi Anna
        It’s nice to know you are from Sydney too. Who is your daughter’s surgeon? We go to Dr Frank Martin who is a nice man but last week he said the glasses Terry tried haven’t worked. In 6 weeks we go back to him for eye patch test again. It looks like he wants to go ahead with the 4th surgery which is scary since the first 3 ops corrected somewhat but not all. He still tilts his head sideways to see properly. We are told that he will never get 3D vision as he lost the window period as a baby to develop it. But since coming to the COVD blog, I’ve been given hope. Dr Slotnick recommended that we see an Australian behavioural optometrist. I found one at the University of NSW Optometry Clinic as I mentioned in my other replies. Rosemary Paynter made us hold off until tomorrow (May 2) because her students do the therapy under her guidance. As the semester started in March, she didn’t want fresh students to evaluate Terry so she wanted us to wait until now. I think the therapy is free except if there are things we need to buy. If you get back to me, I can give you details of the UNSW clinic. I’ve used it before and it’s a world class facility. My local optometrist sent me there for tests for myself because they have the advanced instruments. Even though students do a lot of the tests, they are very closely supervised by the professors. Also on the COVD blog I came across a video by Dr Sue Barry. She didn’t develop 3D vision and as an adult, vision therapy helped her gain 3D vision. The video was very moving.
        Anyway, keep in touch.
        James jmoshide@ozemail.com.au

  18. At age 4, my son has already had two eye muscle surgeries to correct esotropic strabismus (diagnosed at 4 months) by one of the most highly reccommended surgeons in the Northwest. Although we researched and asked about non-surgical options, we were told that he would not be a candidate for vision therapy because of his young age and that the sooner we do corrective surgery, the better. Because we were taking him to a highly reputable pediatric eye institute, we perhaps mistakenly accepted that evaluation and went ahead with the surgeries. His eyes still drift and the doctor does not believe that he is using them together, and still we have been told that vision therapy is not likely to help. We even called a local vision therapy clinic, and were told directly by the doctor that because he has already had surgery, vision therapy won’t be effective and essentially turned us away without ever seeing my son. I’ll also add that from my understanding, he is not a particularly extreme case. In fact, often as I watch him play, I could swear that his eyes are moving together in correct alignment. The more I research, the more I find all these success stories, and the more I feel like I have to persue vision therapy options in spite of the doctors who are nay-saying. Has anyone else had this experience, or can someone tell me what I am missing that makes my son’s case different enough to put him in “non-candidate” status?

  19. It does not sound like your son’s case is a non-candidate case. Many times doctors are confused by eye turn (strabismus) cases as they look at the eye turn of the patient as the problem. Surgery is often recommended as the only solution. It is also commonly thought that there is a developmental window when this surgery needs to be done before irreversable blindness will be the result. What we have found out is that the eye turn for the young patient is not the problem. The eye turn is actually a symptom of the problem due to eye teaming coordination not being present. The finding is that the eye turn is a “brain coordination” problem and not an “eye muscle” problem. To prove this theory, if you cover one eye, the other eye has full motion in all areas of gaze and functions normally. The problem only exists when both eyes are open and are not coordinated together. Vision therapy is based on walking the patient through those developmental stages again and guiding this normal coordination to develop. It is like teaching someone how to ride a bicycle. The person trying to learn bike riding coordination only learns by getting on a bike and riding it. We use training wheels to give the patient the experience of what it feels like to peddle and balance at the same time. Once that coordination develops from the continued experience of riding the bike, the training wheels can be removed and the person has this coordination for a life time. Our training wheels in vision therapy are lenses and prisms used during therapy which gives the patient the experience of using both eyes together to experience fusional eye teaming and depth perception. This experience can take as long as nine months to a year with the patient experiencing both in office and at home procedures of vision therapy. Please go to http://www.COVD.org to find a doctor of optometry who is board certified in this specialty that is near by where you live.
    Dr. Brad Habermehl

  20. Hello everyone, my 9 year old son has constant alternating esotropia with good vision. He had it since about 18 months (this is when we noticed it) and he had patching which led to the right eye becoming stronger and him alternating. Glasses do not help him. He had a highly traumatic birth (lacking oxygen, intensive care, neonatal seizures). However he has had a hard time being bullied/teased since about age 4 and especially since about age 7. It is heartbreaking.The squint is very noticable. We saw a local vision therapist (in the UK) who said that as my son has NO 3d vision at all the only way to straighten is surgery. I am stuck now as to whether to go ahead with the surgery for cosmetiic reasons to stop my son being continually called such names as ‘freaky eyes’. Please can anyone advise whether surgery is the way to go. Thank you.

    • Hi Jem,
      Strabismus can have profound effects on children in more ways than we sometimes think about. I would like to suggest that you have your son examined by a developmental optometrist before he has surgery. The doctor may tell you the same thing– that surgery is the best option– but therapy AFTER the surgery may be just as important. Lining the eyes up cosmetically is an important first step, but these children still have to learn to see straight! Their brains need practice to learn how to coordinate the two eyes. Unless this can be learned, there is a strong possibility of the eyes turning in again. Good luck!
      Dr. R. Mozlin

    • Hi Jem,

      I just would like to underscore Dr. Mozlin’s recommendations. Your first, best step is to look for a behavioral or developmental optometrist near you. If you would like to provide a city, I will ask my colleagues for a recommendation for a doctor nearby.

      It is possible that your son does not currently appreciate “3D Vision,” but this CAN be learned. I believe it would be to his benefit to attempt therapy before surgery, as this will provide prognostic information. As Dr. Mozlin stated, surgery may not be successful if your son has a strong desire to avoid using the eyes as a team. Many such patients will re-establish an eye turn after surgery, unless they receive intervention which helps train them to use the information from the two eyes together. This is not supported by patching in this phase of therapy.

      Optometric Vision Therapy can help your son learn how to use two-eye information, even before surgery, with the help of special tools (such as prisms and filters as part of a therapy program). You may still consider surgery if needed, and if you do, it will be important to continue with therapy afterwards in order to integrate two-eye seeing at a more proficient level.

      I hope this is helpful. Let me know if you would like me to help you find a recommendation. You may also check with http://www.OEPF.org.

      Best wishes,
      Dr. Samantha Slotnick

  21. Thank you both so much for the reply and very useful advice. I live in Manchester, UK. If you have any details of anyone in this area that would be great thank you. I will continue to seek a developmental optometrist before deciding on surgery and definately afterwards as well. Thanks again for your time, Jem.

    • Hi Jem,

      I have received recommendations from colleagues on your side of the pond.

      They recommend you get in touch with Dr. John Glover. His website is here: http://www.parkvision.co.uk.

      I exchanged a brief email with Dr. Glover, and he would be able to take on your son’s case.

      Good luck!

      Dr. Samantha Slotnick

  22. Dr Slotnick, Thank you so much for that information I will go and check out the website now. Really appreciate your time and help, Jem.

  23. Thanks so much for this very supportive thread. I just read Jem’s question and I so much understand the child: I also had a very large angle esotropia more or less from birth. I get totally mad when people refer to it as a cosmetic problem, if the child is seeing well. It is a major social handicap. The amount of bullying, sniggering, gazing from strangers that you get while having one eye far in and a bit upwards causes extreme psychological pain, and it gets worse during teenage years when everyone is totally focused on what they look like, girls maybe more than boys but still. I know this very well because I went around with it until I was 16, believing it could be fixed, and I definitely developed some kind of social phobia because of it.

    When I finally got to surgery, at 16, the doctors said I had developed anomalous correspondence, and there was a very big difference between the eyes also in nearsightedness (-8 on one eye and -2.5 on the other). They basically said that if they straighten the eyes, I could get either blind on one eye or see double for the rest of my life. So they straightened the eye just a bit, but I was left with both a slight “shade” on one of the eyes (double seeing) and with a very noticeable squint. No one ever suggested vision therapy (this was in Sweden in the 80s). I lived like that for a long time, 35 years. It is very limiting when you meet strangers, in all sorts of situations. It makes people uncomfortable and it is not a hit if you are looking for contacts with the other sex, to put it mildly, at least not if it is as noticeable as mine.

    Now, 6 months ago, I found a specialist here in Israel where I live who said she thinks I can have surgery and it will be OK. I decided to go for it. The first week I saw very, very double, really two people standing beside each other instead of one. The worst thing was that the double picture wasn’t straight, but diverged further away…one road, one straight line, looked to me like a V. I bumped into things. But I consciously trained to see things as one, and the brain adjusted very quickly. It was very, very tiring and I slept a lot. After one week I could drive a car again, and after a month I felt I was almost back to what I was before as far as functioning goes – reading, driving, working. Still, I see double on both eyes, although I often don’t seem to notice it, and then I think “wow, I don’t see double anymore”! and in that instant, I recognize the “other” image. But in spite of all this I am very pleased I did it. For myself. For that little girl who didn’t want anything in life more than being like all the others, not constantly being reminded that she had “freaky” eyes that made people uncomfortable. Now, I am going to look for vision therapy (having read “Fixing my Gaze”) even if I don’t have much hope ever to see 3D.

    After this long post, here is my real question: in a case like mine, with large angle esotropia, anomalous correspondence, surgically straightened eyes with remaining diplopia on both eyes (which I often don’t notice while using the left eye, the strong eye), is there a point in trying vision therapy or will it complicate matters further??

    thanks
    Anna

    • Yes, Anna, you may appreciate life-changing functional improvements.
      I can enthusiastically recommend Dr. Robert Lederman to help you: http://www.ledermanvision.com/english/about.php.

      Congratulations on the progress you have already begun to make independently. That is a positive prognostic indicator, as far as I am concerned.

      Good luck.
      Dr. Samantha Slotnick

  24. Surgery is not always the answer… If anyone were to be interested in reading about my long journey of overcoming double vision: http://livingwithdiplopia.posterous.com. It’s been a hell of a ride but I’m getting (relatively) close. :)

  25. All your post are evry helpful but I feel so overwhelmed by it all. My 2 year old daughter was diagnosed with intermittent strabismus. She doesn;t show it all the time only when tired or sick. My question is does surgeory help in this case? Her optomologist says she’s 20[20 and her brain is sending messages to her eyes. We did pathing but he told us to scale back its not needed at this point. Pkease help

  26. I have gone through two surgeries so far and wear glasses all of the time.I was told that my “glasses keep my eye straight” but when I become tired a significant difference can be seen. I have never heard of any type of vision therapy. I am in the military now and am limited to some jobs because of my glasses. I just recently began looking into trying to find a way to fix my eyes without having to use glasses. Is it too late to try the therapy? If not about how long would it take and how should i go about trying to find a way to find it? Or do I need to restart the entire process all over again. I had already accepted the fact that I would never see in “3D” until I had started to hear about this and now it feels as if there is still some hope to be able to see “normally” and at this point I am willing to try just about anything to see as everyone else does not to mention it would help me excel in my career leaps and bounds past whet my limitations are even though my brain has found a way of coping since never having the ability to optically judge distance. Thank you for any help you can offer.

    • Hello Brad, it is never too late to try to regain or enhance your vision. It is very difficult to determine how long a therapy program might take and how successful it might be without having any information about you and your vision. There are now more optometrists working in the military and the VA with soldiers and veterans with significant visual problems associated with trauma. These optometrists would be well-versed in treating your binocular vision problem. If you need to find a doctor outside the military, then try the Locate a Doctor function on COVD’s website. Good luck on your journey. https://covdwp.memberpoint.com/WebPortal/BuyersGuide/ProfessionalSearch.aspx

  27. I wanted to share our son’s visual miracle with you. My son was in a car accident 14 years ago suffering severe Brain Injury and among the many vision problems he had was that the two eyes were not functioning in sync. He had headaches, nausea, spacial issues like bumping into things, could not read for extended periods of time, couldn’t see in 3D and more. Eye doctors at the time reccomended Surgery but added the outcome might worsen my son’s vision. We opted not to have Surgery. Almost two years ago we brought my son to an Optometrist who perscribed prism lens for one eye and a variety of vision therapies at home. I can’t tell you all the incredible improvements this has made in the Quality of Life, my son is experiencing. All the above problems are almost non existant. He can read for hours, play tennis, shoot baskets, play video games, ride in a vehicle for hours and do so without headaches, nausea, and frustration. I would encourage others to get the advice of a Vision Therapist before having Surgery.

  28. 9 hours ago my 4 years old son had an eye surgery on his right eye, which was turning in a lot since about 1 y.o. of age. ….. 4 hours after surgery he was able to open eye without crying and squinting and i saw that the eye was not aligned with the other eye.
    i cried and blamed myself that i decided to do surgery (i hoped at least for cosmetic result). i put my child through such a procedure and results are not what we hoped for.
    his vision in the right eye is poor. since he was around 2 y.o. we tried patching and glasses, he still wears lglasses. NOW I NEED TO KNOW if there is still hope and chance for improvement of the vision and/or positioning of the eyes for him? i will not do repeat surgery, at least not till if he asks for it when he is older.
    i should have looked at vision therapy before when i was searching web for anything i could find about srtabismus. i spent hours and days reading, but sadly i didn’t look in to it…..

    it makes so much sence now, that how many repeat surgeries are needed – because eye turns in not because of the muscle problem, but because of the brain signals, and obviously eye will turn in/out again because brain signals were not changed. root of the problem is in how brain tells our eyes to work. and that brain will turn eyes again the way it tells them to work, regardless of what corrections were done cosmeticly.

    i wish i could give my eye to my child.

    and another question – if i see now couple of hours after strabismus surgery that eye still turns in, does it mean surgery was not succesful or might it be that the eye still might be getting in place hours after surgery? i think i know the answer… but maybe not.

    • Dear ksenia,

      I’m so sorry that you are only now looking for alternatives to surgery. I can see by your post that you really do understand the role of the brain in helping the eyes work as a team.

      In answer to your questions:
      First, it is possible that within a few days after surgery, when he is able to start using his eyes to see and gather information, his eyes may look more aligned. Without aiming for something, it is not likely that his eyes will appear “straight” just on lifting the lids. This may or may not be sufficient to gain the results you desire for him, and it may be, as you suggest, purely a cosmetic improvement. If he does not learn to make use of the eyes as a team in the new posture, he is likely to either suppress the eye and/or develop a turn again (in or out).

      Second, it is possible that he can learn to use his eyes as a team post-surgery. I would encourage you to take your son to a behavioral optometrist within the next week or two. Right after a surgery, there is more room for plasticity– for the brain to make changes before it develops new habits with the new eye posture.

      If you would like to let me know where you are (city/state), I can offer a recommendation for a doctor nearby. Or, you can try the doctor locator functions at covd.org or oepf.org.

      Best wishes to you and your son in getting the care you need!

      Dr. Slotnick

      • Dr. Slotnick, thank you so much for your very quick reply. It took me some time to stop worring so much about surgery after it was done and to start looking for the vision therapist and do not give up.
        I did find one close to home, but i still would like you to recommend us another one or two behavioral optometrist that you know of. I want to have two or three opinions and see what they think about our situation.
        We live in Mineola, New york.
        And thank you so much for helping us all.

  29. I have a very basic question about vision therapy for Strabismus and I hope Dr Slotnick can answer it.

    I fully agree and understand the fundamental premise of vision therapy for strabismus. But it seems like vision therapy would involve the patient to follow instructions. So at the outset it seems like it is a feasible option for a patient old enough to have the ability to follow instructions. It does not seem very feasible for a young patient (say less than 2 years).

    My son is 16 months old now and has been crossing his left eye since he was 10 months old. His eye power is +3.5 on the left eye and +2.5 on the right eye. He wears glasses and the degree of crossing has reduced with the glasses on, but there is still residual crossing that we see. We also patch his right eye (strong eye) so that he does not develop ambyopia due to his crossing. It seems like we are heading towards a strabismus surgery as the only option.

    For a child of his age, I suppose there are certain activities that one can do to help his binocular vision development. Since he does not have the cognitive power to understand all that we tell him and then follow it, it becomes difficult to follow a full-blown vision therapy program. I would hate to wait till he gets older to act on his problem as well. My question is very simple and straightforward.

    How can vision therapy help someone who is only 16 months old. I believe that it can help patients who are 4 years or older for sure.

    Thanks

    • Hi Ram,

      I am glad you are exploring these options now.

      You are right, the nature of a vision therapy program designed for an adult would be very different than for an infant. But there is a LOT that can be done to support your son’s binocular development with minimal higher-order cognitive input!!

      I would also caution that once you perform strabismus surgery, the ability of the person to gauge feedback from those eye muscles will be impacted.

      I would strongly recommend finding a behavioral/developmental optometrist to work with your son. It would not likely be a weekly program for a 16 month old. In my office, we would spend a few visits together, developing activities that you could then work on at home. I would vary visit frequency depending on the the amount of responsiveness of the patient, the needs of the parents, the potential for prescription modification, etc.

      Regarding the use of patching, let me give you an analogy:

      If you have a sports team with two athletes, and one of them is a really good player, while the other is uncoordinated, what are your options for developing the team?

      One option is to leave them both on the field. In this case, the strong player makes all the plays, and the weak player doesn’t get very involved. (This is the equivalent to no intervention, no patching, no therapy.)

      Another option is to bench the strong player and only play the weak player. This may make the weak player better, but when the strong player gets back on the field, as usual, he takes over and doesn’t pass to the weak player. (This is the equivalent of prolonged patching of the dominant eye as the only active intervention.)

      If you really want to optimize the team, you may need to do some pointed development of the weak player (remedial practices). (This is the equivalent of very brief periods of patching of the dominant eye while conducting pointed exercises with the non-dominant eye (remediation).)

      BUT… your best bet is to play BOTH players while creating a disadvantage for the strong player (for example, the strong player would have a hand tied behind his back, but the weak player could use both hands). This way, you level the playing field, and train the two players to work together as a team. (This is the equivalent of following brief periods of patching with *binocular* activities in which the dominant eye gets a reduced view (with a blurring or colored filter, for example), and the non-dominant eye gets a visual advantage.)

      Vision therapy for toddlers needs to be a bit like a 3-legged race. The brain has to get involved in order to get the eyes coordinated and working together as a team.

      I hope this gives you some encouragement. It sounds to me like your son has intermittent use of his eyes as a team already. What you need are some specific, team-development activities!

      Best of luck!

      Dr. Slotnick

  30. Thanks Dr Slotnick for the explanation. It seems logical and makes sense.

    Can you throw some light on what might cause a child who was looking straight for a while to start crossing his/her eyes. How much does the degree of farsightedness contribute to it.

    Thanks

    • Hi Ram,

      It has to do with the interaction between the focusing system and the eye-teaming system. These two processes are neurologically cross-linked. So when the brain begins to be able to handle better control of the focusing system (which develops greater accuracy later than the eye-teaming system), there is some tendency to slip out of alignment in order to get a clearer image in focus on the retina. It does relate to the far-sightedness, which requires a greater amount of focusing effort.

      The good news is, with the right balance of lens compensation and the development of focusing-and-eye-teaming flexibility, the patient can often learn how to maintain both, rather than sacrificing one for the other. Better results can be obtained with earlier intervention. Delaying intervention may result in other adaptations (which are discussed in the original column.)

      For a more specific opinion, find a doctor near you!!

      Best,
      Dr. Slotnick

  31. I’m 16 and have had amblyopic strabismus as long as I can remember, and recently got what is only my first strabismus surgery after my parents deciding against it as a child – I was getting eye patched at the time and they were told the procedure was solely cosmetic, and were therefore more worried about the visual aspect of things. However, I still have amblyopia, and am aware that this is probably permanent. My surgery went okay, but my eye is slightly undercorrected and due to my amblyopia I’m worried about it returning to how it was(even worse than at present) in the future – I came across this article while trying to find information on the recurrence of strabismus and it intrigued me. Would visual therapy work if I had amblyopia(my good eye is 6/5 best corrected, whereas my amblyopic eye is 6/12 – I see peripheral vision out of it constantly, however, and can occasionally focus on something with it if it’s in the right side of my field of vision, although it causes slight double vision when I do so), and how do I go about getting/doing it? Would I need to find someone who specialises in this, or is it something one can do alone? If the former, who must I go about contacting? Sorry for having so many questions, but I’ve never heard anything about this before so I have my fingers crossed.

    Thanks

    • Dear Thomas,
      Sorry for the delayed response!

      I’m really glad you are exploring your options, and I encourage you to find a behavioral optometrist near you. From your description, you can very likely be helped!

      You use 6/6 notation rather than 20/20, so I know you are not in the United States. One good site to look for a behavioral optometrist near you is http://www.oepf.org. If you would provide your location, I can request a more specific recommendation from my colleagues on behavioral optometrists near you.

      From your description you are making use of binocular vision in the form of Anomalous Projection. It sounds like you are using central vision from your dominant eye, and peripheral vision from both. When you switch to using your non-dominant eye, you are using central vision from both eyes. Because they are not aligning now, you are seeing double.

      Prognostically, this is a good sign, because it means that you are using both eyes, even though they are not aligned perfectly. With the right combination of activities and material support, your brain can likely be trained to make better use of the vision in both eyes. A behavioral optometrist will need to evaluate you to be more specific about your potential. They may also recommend a trial course of therapy to see if you are responding well to treatment. If you can learn to use both eyes as a team, you will have a much lower likelihood of re-creating the eye turn.

      Best of luck, and let me know if you’d like a more specific referral.

      Dr. Slotnick

      • No problem, I’m glad to have any kind of response because it’s a very exciting opportunity for me! Even the surgeon who corrected my eye has told me that no sort of binocular vision or perception of depth can be developed by anyone past the age of 6 years.

        You’re right about me being from outside of the States: I’m from Liverpool, United Kingdom. I’ve had no look with online searches so if you could find any sort of recommendation for me it’d be greatly appreciated! I’d love to explore this possibility if possible, even if it means waiting a while until I’m slightly older and have easier access to an optometrist.

        That description of anomalous projection describes what I’ve always experienced pretty well. my central vision has never came from my right (non-dominant) eye.

        I have one further question. If I were to attain binocular vision, or at least better use of my eyes in combination with each other, would images appear less focused permanently due to my non-dominant eye being 6/12 vision best corrected, or would images still be clear/would my lazy eye’s acuity improve along with the teamwork of my eyes?

      • Dear Thomas,
        Your question about reduced vision in your non-dominant eye: Yes, it is likely to improve with vision therapy, but I could not hazard a guess as to how much.

        I am looking into more specific recommendations for a doc in your area…

        Best,
        Dr. Slotnick

      • Hi Thomas,
        I have a strong recommendation for a Doc in Manchester– seems that is closest. Have a look at Dr. John Glover’s website: http://www.parkvision.co.uk

        Best!
        Dr. Slotnick

  32. i am 50 years olld. My strabismus return over 20 years ago. At the time , i am been tod that I wasn’t agood candidate for another surgery due to scars tissue. I have lost my vision on that crossed eyes and my pupil is retracted on that same eyes. Could vision therapy will help my eye to straighten evenso my vision is almost inexistant. on that eyes. I live in Canada and if it will be a posibility , I will sign up for vision therapy. Please respond.Thank you

  33. Dear Rosy,

    Thank you for reaching out to me.

    Your situation sounds somewhat complicated, with a combination of medical and functional issues.

    You will need a firsthand evaluation, and maybe even a 2nd or 3rd opinion before you find a doctor who can help you.

    Scar tissue can be made more pliable with exercises that stretch and move the eyes. However, surgery may no longer be a good option for you because of it.

    When you are evaluated, the doctor who sees you will need to determine if your vision in the affected eye is reduced only centrally, or if your peripheral vision is affected as well. When you say that “your vision is almost nonexistant,” your doctor needs to find out exactly what that means clinically.

    However, the good news is, even a blind eye can be trained to move in different directions with motivation from both the patient and the doctor, and with the support of biofeedback methods. For example, when we *hear* something to one side, we have reflexes that move both our neck and our eyes in order to look at what is making that sound. Your doctor can help you use alternative neurological pathways to help you gain control over where your eye is pointing, even with poor sight.

    I would encourage you to try to find an optometrist who is motivated to help you. This means that the doctor is either (1) willing to refer you to a behavioral optometrist, or (2) willing to work with you on a trial basis to see if you can make some changes.

    You can start with http://www.oepf.org or http://www.covd.org to find a doctor near you. If you would like to provide your province and city, I may be able to offer a more specific recommendation for a behavioral optometrist near you.

    The most important component to your success will be your motivation AND your doctor’s motivation.

    Lastly, I offer Optometric consulting support via Skype to work with colleagues who are *willing* but not yet ready to take on challenging cases like yours. If you find a doctor who is willing to try to help you but is hesitant, you can show them this blog and see if they would like to work with me as part of a treatment team.

    I wish you the best of luck finding the professional near you who is willing to help!

    Sincerely,
    Dr. Slotnick

  34. Hi can u recommend a a behavioral optometrist based in singapore? My daughter has alternating estropia since she was 3m old. She just turned 7months and I hope to do more beforee surgery is scheduled

  35. My 5 year old was diagnosed with esotropia at 3 months and surgery was immediately recommended. We asked for a review by a vision therapist, but the recommendation still came back for surgery (50 prism diopters). He has since had 2 surgeries. At the follow up appointment for each one, we were told that alignment looked good, but within a couple weeks the crossing creeped back. We have asked our opthalmologist at every turn whether vision therapy might help, and have been told basically, “don’t waste your time and money…its not proven to work”. This is of course a maddening response in general, but the deeper pain of it is that we truely can’t gamble we don’t have, as an appoinment to just get in the door and meet the vision therapist was quoted at $550.00, with weekly treatments of up to 40 weeks at $250 pet treatment (after a long run around where the center led us to believe it might be possible that insurance would cover it). We’ve looked extensively, and have yet to find an insurance plan that would cover vision therapy. So here’s my question….how are people affording to even try vision therapy? Do you know of any loopholes, studies, angles, clinics, youtube tutorials….anything that would make vision therapy accessible to a family living on a teacher’s income? We live in Corvallis, Oregon

    • Dear Lana,
      Sorry to hear about your struggle.
      You may try to obtain Care Credit as a means of managing this health-related issue financially.

      You should be searching for a behavioral (or developmental) Optometrist (as opposed to a vision therapist).

      In the Eugene area, Carol Marusich, O.D., M.S., F.C.O.V.D., and Margaret Foley, O.D., F.C.O.V.D., are both highly trained.
      Heading North to Silverton, Terri Vasche, O.D., F.C.O.V.D. has a large practice which can take care of your child.

      Patients with esotropia have a medical diagnosis, so you may be eligible for partial reimbursement, depending on your insurance. Even if the office does not accept assignment, you may be able to submit for support out-of-network and reduce the overall cost to you.

      I hope this is helpful, and that you continue to get the care you need!

      Best wishes,
      Dr. Slotnick

  36. Dear Dr. Slotnick,

    Thank you so much for your site and for your kindness and generosity towards everyone reaching out to you.

    I have a four year old daughter with intermittent esotropia. Her regular ophthalmologist, after trying glasses (which didn’t work) and some patching (which did actually help a little) suggested more patching and surgery. At this point I researched visual therapy and we began working with an acclaimed visual therapist.

    That was about 5 months ago. I’m sorry to say my daughter’s condition appears to have gotten worse. Now both eyes are turning in (before she mostly favored one eye. I understand this is not necessarily negative, as it means that both eyes are working, but it also doesn’t seem positive), and the degree of the inward turn is more severe. It is also more constant. This was verified by her original ophthalmologist who has examined her several times and who came to these conclusions empirically.

    It has been an incredibly challenging 5 months and very difficult to assist a 4 year old in doing daily eye exercises when she does not have the comprehension to understand “long-term benefits.” We worry that the process of getting her to do her eye exercises (we try to keep it light, but often must submit to cajoling, bribing and threatening) is effecting her behavior and self-image.

    Our original ophthalmologist is now strongly recommending surgery without delay and my husband is inclined to do it as well. I don’t want to do it, but I must admit that she seems to be regressing instead of progressing.

    I am hopeful that the visual therapy prior to surgery will help her brain make the connection post-surgery. My questions are: Is it dangerous to wait too long with intermittent esotropia? Shall we continue visual therapy post-surgery? Should we wait until she is more mature to attempt it? How much time is reasonable to expect some gains in ocular alignment with visual therapy? Our surgeon claims he leaves no scar tissue behind, is this possible?

    Thank you so much for any feedback you are able to give.

    Best wishes,
    Ruby

  37. Hello Dr Samantha

    I am based in London, England and have been following this brilliant blog. My 9 year old daughter Rosie has accommodative esotropia in her right eye. She had surgery on both eyes aged three to loosen the inner eye muscles and reduce the turn. After what appeared to be initial success she has had post operative drift so that now her turn is measuring 18. The Dr is suggesting further surgery is needed and I am very nervous about going ahead with this having read your advice to others on this blog. Some days Rosie’s turn is worse than others and the measurements can vary between 12 and 18 at different appointments. The problem I have is finding a behavioural optometrist in the UK that would be able to help Rosie with her eye problem. It seems like the UK is behind the US in this respect. We have also be actively warned away from using this route by the hospital who say it is dangerous and will result in double vision. I am guessing we need to take a leap of faith! I also have a four and a half year old boy with the same problem. He is in his maximum prescription but still has an eye turn and the Dr is now saying surgery is our best option. Any advice you can give would be greatly appreciated

    Kim

    • Dear Kim,
      Sorry for the delayed reply; my original response did not post!

      I am glad you are putting the brakes on rather than looking to continue with the surgery route. The variation you observe in her turn angle implies some binocular use of her visual system, depending on the visual situation and on her stress level.

      There are several behavioral optometrists in your area. You can see their addresses here: http://www.babo.co.uk/babo-members-south-east/

      I surveyed some colleagues, and received several strong endorsements for Dr. Henry Kahan from among those listed.

      Regarding your concerns about double vision: There is much greater likelihood of causing double vision after surgery relocates the eyes without changing the way the brain was using the information coming through the eye-channels.

      Doctors who specialize in working with strabismus can create a controlled environment so that the patient learns how to use information from both eyes as a team before pushing them to do so in a real-world environment.

      I hope you are able to find a doctor who earns your confidence in working with both of your children.

      Best wishes,

      Dr. Samantha Slotnick

      • Hello Dr Samantha

        Thank you so much for your reply. I am delighted to say we have found a behavioural optometrist in North London, Smita Trivedi and we are booked to see her with both my 9 year old and 4 year old in early April. She has been incredibly helpful already and I am looking forward to exploring the non surgical route with her. My four year old is wearing a weaker old prescription at Smita’s advice and already his eye turn has reduced from 40 to 30 and his eye turn is alternating in this prescription which is encouraging. It is early days but it is remarkable to have seen such a change even before starting treatment!

        Best wishes

        Kim

      • Wow! Kim, that’s fabulous!

        Thank you so much for sharing your good, promising news!

        Please do keep us posted here when you have progress to report. There is a community of people who may find hope after learning of your experiences!

        Sincerely,

        Dr. Slotnick

  38. Hello Dr. Samantha,

    My one year old has be diagnosed with 4th nerve palsy on his left eye since he was six months old. His head is constantly tilting to the right side and the doctor said this is to avoid seeing double vision. The eye doctor said there is nothing we can do except for eye muscle surgery when he reach 3 years old. After doing a lot of research online, I found out about vision therapy. My question is that will vision therapy help in my son’s case?

    • Dear Yan,

      From your description, your son is using information from both of his eyes.

      It is possible that he turns his head to avoid double vision. It is also possible that he turns his head so that he can use both eyes together when in that head-turned posture. The head turn more likely is counteracting the lack of muscle use of the left superior oblique muscle.

      The question you may need to learn is whether your son has a palsy or just a paresis (weakness of the nerve). Many, many patients with paretic 4th cranial nerves establish large ranges of single and clear binocular vision without surgery.

      I would recommend finding a behavioral optometrist who may be able to provide special glasses with prisms to help reduce the head turn. It is possible that some home activities can also be recommended to help your son continue to use both eyes as a team. You have plenty of time to consider options other than surgery!

      You may also want to consider visiting a chiropractor who specializes in pediatrics and infant care. The way your son is continually keeping his head turned may have impacts on his postural development. I have also read of instances where the improvement of nerve support through chiropractic adjustment can help improve the use of cranial nerves and the visual system as well.

      Good luck!

      Dr. Samantha Slotnick

  39. Dr. Slotnick,

    Can you recommend a vision theropist in the DFW area or direct me to a source where i can research a good professional? I went to the COVD database but the closest recommended doctor was 4hrs away in Austin.

    My 6yo has had two procedures for strabismus and is being recommended a third. We asked after both initial procedures about the likihood of success and were told 95%. I’m growing wary of this surgon, however, after reading that success rates are only 70%.

    Also, is it possible that genetics may be a factor that rules out either an invasive or non-invasive approach?

    Many thanks!

    • Dear Frustrated,
      I asked my colleagues for a recommendation in your area, and I received a resounding response endorsing Dr. Charles Shidlofsky.
      Neurodevelopmental Sensory Enhancement Center
      5934 W. Parker Rd
      Plano, TX 75093
      Phone: 972-312-0177

      Regarding genetics: I believe the plasticity of the brain trumps genetics every time. Genetics provides a predisposition. But there are many factors which interact to make us who and what we are.

      Good luck!

      Dr. Slotnick

      • Thanks so much. We were told that this latest surgery was resulting from a newly detected genetic issue. I don’t want to fully dismiss the surgeon, but am increasingly skeptical of all of the unique factors that are associated with my daughter which are only solved by a silver-bullet surgery. i won’t dismiss surgery altogether, but need to explore other options.

        Thanks again,
        Will keep you all posted on how this turns out.

  40. Dear Susan:

    I’m writing to you from Santiago, Chile. I have strabismus since I remember, I got a surgery when I was 3 years old, then my eyes started to look to different directions again (this time less than the first time and to other directions). The minute I read this I was so happy that I have a chance to fix my problem, all of my ophthalmologist tell me that I don’t have a cure, it will only be cosmetic and they’re right they can’t fix the problem but because they don’t know about this.

    PS: I can look in 3D movies sometimes but only If concentrate in looking with both eyes and sometimes it works

    Now I would LOVE to give a try with Optometric Vision Therapy for strabismus. I don’t care if I have to travel to USA, I know it will be worth it. :’) Just dreaming to fix my problem, no more headaches or getting tired after reading, and think about looking in 3 D sounds like a dream.

    Could you recommend me a vision therapist that will worth visiting him/her from Chile that can help me fix my problem?

    Thank you and God bless you (:

    • Dear Maria,

      I am so glad to provide hope. I will research with my colleagues and try to find a recommendation for you!

      Dr. Samantha Slotnick

      • Thank you Dr. Samantha you don’t even imagine how happy I am!, Thank you for giving new hopes!

      • Dear Maria,

        I have spoken with several colleagues, and to their knowledge, this sort of care is not found in Chile.

        I do have some doctors to whom I can refer you in Ecuador and in Brazil. I realize, both options are very, very far away, but perhaps closer than the USA. Would you like their contact information? Would you prefer to come to the USA? If so, is there a region of the country where you have some relatives?

        Dr. Samantha (no, not Susan, but I have been called worse…) :)

      • Hi again, thank you so much for your help (:

        I was thinking that If you could refer me somebody (doesn’t matter where) that would be ideal for my “problem” Then the travel won’t be a problem cause it will worth it :) , so if you have a colleague in USA that will be ideal for me, please tell me :)

        PS: Sorry again, I got confused with the Fixing my gaze’s author, Susan Barry, I was so happy when I read this blog that I didn’t realize what I wrote!

        Thanks again and God Bless you!

    • Dear Maria,

      I am so excited to share a solution for you!

      I have just been in contact with a colleague of mine who is an outstanding, capable and caring clinician, Dr. Pauline Buck. Her office is in Miami, Florida. She works with many patients who are from South America, and maintains support at a distance. I am confident that you and she will be a “good match”!

      Please email her at paulinekbuck@bellsouth.net to follow up!

      And *please* keep us posted on your progress!

      Best of luck!!
      Dr. Samantha Slotnick

      • Thank you Dr Samantha!! I’m sorry for the delayed reply, I’ve been really busy these days! I can’t believe I have a chance to fix my problem, and it’s all thanks to you and your beautiful blog!

        I’m going to contact Dr Pauline and i’m going to tell you how it went!

        Thanks again
        God Bless
        Maria

      • Marvelous, Maria! Please, keep us all posted!

        All the best,
        Dr. Samantha

  41. Sorry, I was so happy that I wrote Dear Susan instead of Dear Samantha ! My bad it’s just that this are such a great news for me, sorry again (:

  42. Dr. Shotnick,
    I had eye surgery when I was 4 years old and after that I had about 1 1/2 years of eye patching. I am now 32 and saw a doctor about vision therapy today. After his evaluation, he determined that therapy would not be a benefit since there is no eye teaming at all. He stated that the only thing he could recommend is another surgery. Cosmetically I am interested in having another surgery but at the same time I really wanted to gain some depth perception. Is my only opinion surgery at this point? Just looking for some input. Thank you.

  43. I’ve spent so long being angry about my visual issues and am so grateful that you’ve shared this information.

    I spent my childhood having multiple surgeries for my eyes, thinking that each cosmetic fix corrected the problem (even though the correction never stuck). After my third or fourth surgery, my left eye stopped going all the way to the left, creating a very awkward look when I tried to view something to my left, and my central focus became off as well. (My weaker left eye, which my eye doctor always kept as a lesser prescription to keep my right eye dominant, kept moving back inward.)

    At some point while I was 27, I decided to try to not hide behind glasses and got a prescription for contacts. I noticed almost instantaneously that my eyes were straighter in contacts, which gave me hope to research more ways to correct my eyesight. That was when I discovered vision therapy.

    I wanted to laugh and cry when I realized what vision therapy could do. I actually did cry – a lot – right in front of the doctor when she said she could help me. I also wanted to scream at my surgeon, who had previously told me there was nothing that could be done because surgery was the only option and it would only make things worse, due to the tightening of my muscle.

    I’ve been going to vision therapy since July of 2012, and while my eyes aren’t perfect yet, their alignment is much better, my left eye has regained some movement, and I’ve seen some depth and 3D. I have a long journey ahead of me, but being able to look at people in the eye has been a major improvement.

    I hope your post will help others find the happiness that I’ve had. I only wish I’d discovered vision therapy much, much sooner.

  44. Hello from Sydney, Australia. My 9 year old son developed an inward eye turn 6 months ago for reasons unknown. (I suspect it was due to hard knocks on the football field, since the turn developed right after football season). When we first saw our paediatric ophthalmologist in December 2012, his eye turn was measuring 30. She recommended glasses for vision training. He does have 20/20 vision out of both eyes, although his right eye is slightly stronger than his left eye. His left eye is the one with the noticable turn inward. He is also seeing double with objects in the distance. By March 2013 his turn was measuring 80, so the glasses had not been helpful. The Doctor sent us for an MRI to rule out anything sinister. The MRI was all clear, thank goodness. The Doctor then recommended surgery, which was booked for the end of April 2013. I did enquire about vision therapy as an alternative to surgery, but the Doctor dismissed it and thought it would not be helpful in his case. The Doctor had us patch his right eye for 2 hours a day leading up to surgery. The day of surgery, his eye was back to measuring at 30. The Doctor was pleased that it had improved, but still recommended surgery. Originally the surgery was just going to be for the Left eye, because the turn in that eye had become so severe. With the improvement, she said she could operate on both eyes, in a less invasive surgery that had better overall results. I was a little confused as to why we were still operating if the patching seemed to be giving us positive results, but I went with the experts advice and opted for surgery. Now 4 weeks after surgery, his eye turn is back (now measuring 60!) and his double vision has not improved. The Doctor has put him back into his glasses, which he hates. I now want to look into vision therapy, which I should have done from the beginning. Based on his case history, can you recommend anyone in Sydney? I am feeling very defeated and upset that I let my son go through such a big procedure, without getting any positive results out of it. Thanks for any help or advice!

    • The College of Optometrists in Vision Development is an organization of professionals who specialize in the diagnosis and treatment of visual conditions that can have significant impact on the lives of our patients. This includes very complex disorders such as strabismus and amblyopia. Our goal is to reach out to patients and potential patients around the world to help them make better decisions when seeking eye and vision care. Due to the complexity of these conditions and the uniqueness of every person’s visual and health status, we cannot offer diagnosis or treatment advice in response to comments or questions on this blog. We would strongly encourage you to consult with an optometrist near you for the proper diagnosis and management of the possible visual dysfunctions you describe. You can start your search here. Best wishes on your journey!

    • Hi Megan, I’m from Sydney and I can sympathise with you as the three surgeries on my son Terry were not as successful as expected. The surgeon was shocked himself at the failure of the third operation on the good eye to balance out the bad eye. He asked us for permission to get a second opinion. Both surgeons want a 4th operation and we said “Whoa!”. The surgeon’s surprise was a concern for us as he is probably the leading surgeon in Sydney. We have since had two opinions from different specialists in Japan who suggested we try glasses and other things before resorting to further surgery. Terry was assessed at the University of NSW to see if he would be a candidate for vision therapy. They said “no”. But we didn’t give up. Through this blog we were put in touch with Liz Jackson. We are very happy with her. She disagreed with the UNSW assessment. I found out later that Terry’s surgeon exchanges patients with Liz. She also teaches at the UNSW Optometry faculty. Since starting vision therapy Terry has developed some 3-D vision. Terry is now co-managed by Liz and his surgeon. Liz Jackson’s practice is called Visual Potential Optometrists and is at 2/166 Maroubra Road, Maroubra Junction NSW phone is 9344 9119. Most of her visits are covered by Medicare and the vision training part is not covered but we are out of pocket about $15 per session. I hope this is helpful. James

  45. Great post! Thank you for all the very helpful information

  46. hello ,i am 23 years old from india. my right eye is deviated outwards and downwards if i am not wearing my glasses(-2.25 d for left eye and 0 for right eye)for far distance and if i wear my glasses,they look almost straight for certain distance,still little bit downward and if i look to very close objects(with in 1mtr)my right eye turns inwards and down.i had surgery at age 4,as a pin hit into my eye ball…again i had surgery at the age of 16,due to retinal detachment….my right eye has extreme blurred vision,doctors prescribe no power glasses for my right eye mentioning it to be useless. will it be possible to straighten my eye????i have also noticed one thing that if i keep on increasing the power of my left eye(let say 0d to -4d),my right eye starts turning from out wards to extremely inwards….i have never undergone any surgery for my strabismus,can this be treated through vision therapy,if yes then plz suggest me some doctors from india.

    • The College of Optometrists in Vision Development is an organization of professionals who specialize in the diagnosis and treatment of visual conditions that can have significant impact on the lives of our patients. This includes very complex disorders such as strabismus and amblyopia. Our goal is to reach out to patients and potential patients around the world to help them make better decisions when seeking eye and vision care. Due to the complexity of these conditions and the uniqueness of every person’s visual and health status, we cannot offer diagnosis or treatment advice in response to comments or questions on this blog. We would strongly encourage you to consult with an optometrist near you for the proper diagnosis and management of the possible visual dysfunctions you describe. You can start your search here: http://locate.covd.org/. This includes international doctors. Best wishes on your journey!

    • Hello bibs,

      I am sorry you have had such struggles with your vision over so many issues.

      You really do need to be evaluated by a behavioral optometrist to determine if there are ways in which you can learn to have better control over your vision and visual processing. It is not just a muscle issue. Your brain needs to learn to work with the information from both eyes in order to help you hold them straight.

      I do not know of any doctors in India who practice in this field, but I will send a request to my colleagues to see if we can help you take a first step.

      Best,
      Dr. Slotnick

  47. Our son who is 14 months old now, was cross eyed since he was two months old and at that time the pediatrician had asked us to wait until he turned six months old as sometimes this could be false strabismus. When my son turned six months old, she advised us to see an Ophthalmologist and he told us that our son is cross eyed, near sighted and also has retina issues. When he was 8 months old, we saw a retina specialist and he confirmed that our son has a slight retinal detachment and vitrectomy has to be done. He underwent that surgery when he was 9 months old and then the Ophthalmologist gave us his prescription for glasses (-10 for both the eyes) and he has been using these glasses for over a month now but we do not see any drastic improvement in his cross eye problem. Also, my son wears the glasses only when he is out from the house (which is around 45% of the total time when he is awake).
    We have already seen the Ophthalmologist again and he was recommending a surgery for his cross eye problem and also told us that this has to be done before he turns two year old. We have asked for sometime until mid of Sept 2013 before we again visit the Ophthalmologist and take a final decision for surgery. I have been reading articles on internet about the strabismus surgery and many people have mentioned vision therapy as an option for cross eye problem. I wanted to take advice from you if this can be an option for our 14 months old son as he is so young? Also, do you have any names for the vision therapists that you can recommend to us for a patient as young as our son? We stay in Hyde Park, Chicago.

  48. Hello

    My 21 month old son has recently had surgery on both eyes for strabismus. He’s just had a follow up appointment with the consultant who has told us he’ll never have 3D vision. I came across this thread whilst trying to understand how he will see the world. I was surprised to see that we should be doing some kind of visual therapy to help him, our consultant didn’t say a word about this! Can you tell me whether we have experts in the UK on this kind of therapy? I’ve tried looking but it’s a bit of a minefield!

    Many thanks, Sarah

  49. Hi Dr Slotnick,
    I am happy to have found this website. I was hoping to get a recommendation from you for a behavioural optometrist in Sydney, Australia.
    I will tell you a bit about my story. A couple of years ago I noticed my turned eye, 6 months after having my second child at age 38. I saw an opthamologist who did not help. I went to a neurologist and had many tests done and still nothing. My right eye turns out slightly. I have double vision. I do however think I had intermittent eye turning on very rare times when I would look out of the corner of my left eye for some time. I am wondering that as I aged it just suddenly got worse? Anyway, I need to see someone and hope you can recommend what I should do next. I would really appreciate that.
    Thanks,
    Sofia

  50. Hi
    Pretty good post. I just stumbled upon your blog and wanted to say that I have really enjoyed reading your blog post.

  51. Thank you for all the information in your blog. My 9 month old daughter had surgery 5 days for infantile esotropia. It was intermittent and now I’m upset that we did the surgery. We patched for about 6 weeks (1 hour everyday for 2 weeks, then 2 hours a day for 4 weeks). Then the “good eye” started turning in as well, and even started turning upward as she looked inward. Post-surgery the Opthamologist said her eyes are straight when she tracks him holding a pen light, but when she’s not focused on anything her “good eye” now turns the opposite direction and I can’t even tell where she’s looking! I’m second guessing myself whether we should have done the surgery. Will this correct itself? …and why is there now an eye turn upward? I wish I could go back in time and cancel the surgery! Any feedback would be greatly appreciated.

    • The College of Optometrists in Vision Development is an organization of professionals who specialize in the diagnosis and treatment of visual conditions that can have significant impact on the lives of our patients. This includes very complex disorders such as strabismus and amblyopia. Our goal is to reach out to patients and potential patients around the world to help them make better decisions when seeking eye and vision care. Due to the complexity of these conditions and the uniqueness of every person’s visual and health status, we cannot offer diagnosis or treatment advice in response to comments or questions on this blog. You might consider reaching out to a COVD member directly. Perhaps our membership directory can help you find a doctor: locate.covd.org Good luck on your journey!

  52. Great post! Been reading a lot about this surgery recently. Thanks for the info!

  53. Dear Samantha,

    I broke into tears after finding this website. My 3.5 year old son has just undergone his second surgery for what has been labelled Brown’s syndrome with intermittent exotropia and it has been a failure. Me and my partner did not want to undergo a second surgery (the first surgery was performed when he was 2- and appeared successful however after a few days proved a complete failure and in fact has created new problems). Both me and my partner were convinced that there must be some sort of behavioural therapy that we could do with our son but every doctor we spoke to told us it would be of no use. This did not stop our search for a different approach. We tried Osteopaths, had an MRI done to check for any nerve damage (there was none) and I eventually found a behavioural optometrist close by. Reading this person’s website I was so excited to hear someone talk about an approach to eye problems that did not involve surgery however when we got our child assessed by this person, she shrunk into her shell when told who our opthalmologist was and advised us that he was the best and to take whatever his advice was. We were very disheartened and still not convinced. Then only a month ago our son was invited to be part of a Strabismus Society meeting where doctors from around the world and country (we are in Australia) convene and observe ‘live patients’ and then discuss at length what they believe the problem of each patient is and the actions that should be taken. Every doctor in the room (6 specialists and another 100 doctors) agreed that radical, urgent surgery was needed for our son (complete severing of the Left Superior Oblique and recess/resect of the medial and lateral muscles of the left eye). After this conference and after hearing all these concurring opinions we reluctantly decided to go ahead with surgery- however we chose to separate the procedures so as to assess the outcome of the first- That is, we only had the LSO surgery. There has been no improvement whatsoever and we are devastated to only now learn that our instincts were right. One of our biggest concerns for our boy is his severe head tilt that has since returned only days after surgery(that the severing of the LSO was supposed to ‘fix’). He is only able to use both eyes properly in this, what can only be called, deformed position. Both eyes are developing normally in terms of vision but as you so often say in this blog, they are not working TOGETHER. We have tried our own types of behavioural vision therapy that remarkably seem to have very short term immediate results in terms of the head tilt and binocular vision. The surgery was performed 5 days ago and we are only too aware of how precious this time is post-operatively in terms of physical therapy. Can you please recommend someone we can talk to? We live in Melbourne, Australia but are happy to travel- anywhere.

    With many many thanks in advance,
    Kind Regards,
    Paula and Antony

  54. It is very informative and unique. You have explained it very well. I would like to read more articles like this.Thanks for sharing.

  55. Dear Dr. Slotnick

    I would like to join my voice to the rest bellow and thank you for this article.
    My daughter 2.5 years now was born with a sixth nerve palsy in the right eye. She was a premature baby of 35 weeks pregnancy. No cause was determined in regards of the pre-term labour. Rayana (my daughter) had both lung hemorrhage and brain hemorrhage within two days after her birth. She stayed for 9 days in the NICU till all cleared up and Drs permitted us to take her home. We have checked her sight immediately after she was cleared out of the hospital and the ophthalmologist assured us that her sight was very good due to the conditions she has been through. 6 months later I sensed something was wrong with her vision as she used to have a head turn and her right eye would not turn towards the outside whenever she want to look that way. We took her again to the ophthalmologist where he discovered her sixth nerve palsy. At the age of 1 year and 3 months she underwent a surgery to straighten her eye. The surgery went well thank God. We asked the doctor if there were any vision therapy that we should let rayana go under but he said that the problem is with the nerve not the muscle, and that as long as the nerve is already dead then there is no vision therapy needed. We have regular check ups with the ophthalmologist, however I would like to know if she would still need any kind of vision therapy especially pertaining to future matters such as reading and driving etc. Even if she seems as normal after the surgery with no head tilts at all and being able to focus well to grab anything.

    Thank you again Dr. Slotnick
    Best regards
    Rita Rehani

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