Kudos to Antonio Chirumbolo and the many students at optometrystudents.com for this interview with my friend and colleague, Dr. Ken Ciuffreda. This interview provides many “jumping off” points for discussions about vision therapy, traumatic brain injury and research. In fact, something in that interview sent me down to the library to find an article that was published in 1958.
Fourteen minutes into the interview, Dr. Ciuffreda refers to the 1961 study by Dr. William Ludlam on “The Orthoptic Treatment of Strabismus: A Study of 149 Non-Operated Unselected Concomitant Strabismus Patients Completing Orthoptic Training at the Optometric Center of New York.” In this study of the effectiveness of vision therapy (orthoptics) for the treatment of strabismus, 76% of the patients achieved a “functional cure.”
That rang a bell somewhere in the optometric filing cabinet inside my brain, and I went in search of “Flom’s Criteria.” Published in 1958 in the American Journal of Optometry, Dr. Merton Flom discusses “The Prognosis in Strabismus.” He begins that discussion by distinguishing between a functional cure and a cosmetic cure. After all, how can you determine the prognosis for a certain treatment unless you know what it is you hope to achieve with that treatment.
A functional cure of strabismus restores normal binocular vision to the patient: clear, comfortable single vision at all distances, stereopsis (depth perception), and the ability to maintain binocular vision 95% of the time when moving the eyes through the world in 3 dimensions. The patient may require lenses and even small amounts of prismatic correction to achieve this functional cure.
Dr. Sue Barry, who achieved a functional cure for her strabismus at age 50 through a vision therapy program, describes her experience: “For the first time, I could see the volumes of space between different tree branches, and I liked immersing myself in those inviting pockets of space. As I walk about, leaves, pine needles, and flowers, – even light fixtures and ceiling pipes – seem to float on a medium more substantial than air. Snow no longer appears to fall in one plane slightly in front of me. Now, the snowflakes envelope me, floating by in layers and layers of depth. It’s been seven years since I gained stereovision, but ordinary views like these still fill me with a deep sense of wonder and joy.”
The prognosis for a functional cure is dependent upon many factors: does the eye turn in or out, all the time or intermittently, is there amblyopia or other adaptations to the eye turn, is the magnitude of the eye turn large or small, how motivated is the patient to achieve a functional cure? In some cases, the prognosis for a functional cure is poor, or vision therapy has been unsuccessful. Then the discussion changes to considering a cosmetic cure.
A cosmetic cure occurs when the strabismus is no longer noticeable. A functional cure invariably includes a cosmetic cure, but a cosmetic cure does not assure a functional cure. A cosmetic cure is the goal of strabismus surgery, and more often than not, this can be achieved. However, without improved function (a functional cure), the cosmetic cure may not last. The eye turn may return at some point, and a second surgery may be recommended.
When considering the options to “cure” your strabismus, first consider what type of cure you hope to achieve. Which options are more likely to help you and what is the prognosis for achieving that goal?
Dr. Flom summed it up quite well…..
“When the prognosis is based on good judgement and is tempered with an evaluation of the patient as a human being, it becomes an invaluable aid in recommending the kind of treatment for a strabismus.”
Read more about strabismus here.