Paediatric Strabismus – Back To Basics:

Is treatment available for paediatric strabismus?

Yes, treatment is available for children with strabismus. The type of treatment depends on the type of strabismus, and whether any other eye conditions are present. It is important to understand that eye turning in children (paediatric strabismus) is never normal, except in the first three months of life. An eye turn in childhood can affect the development of vision, therefore any child suspected of having an eye turn should be seen by a paediatric ophthalmologist.

Types of childhood strabismus:

The types of paediatric strabismus, or childhood strabismus, are based around the direction the strabismic eye is turning. For example:

Esotropia: Indicates the eye is turning in towards the nose

Exotropia: When the eye is turning out towards the temple.

Hypertropia/hypotropia: Indicates a vertical strabismus where the eye is turning up or down.

There are also quite a few sub-categories of paediatric strabismus that we covered in our overview of strabismus earlier in the week: http://sosdoctors.com.au/strabismus-back-to-basics/

In a nutshell, the most common forms of paediatric strabismus are: Fully accommodative esotropia, partially accommodative esotropia, non-accommodative esotropia, exotropia, intermitent exotropia, and pseudo strabismus.

– Fully accommodative esotropia, partially accommodative esotropia and non-accommodative esotropia: These are all inwards turning eyes (esotropia), and are linked to accommodation. Accommodation is a focussing power of the eye that is strongly linked to convergence. Convergence is where the eyes cross, and is used for many near activities such as reading and screen work. In some children, hypermetropia (far-sightedness) means that an excessive amount of accommodation is exerted from the visual system in order to see clearly. This excessive accommodation causes the eye to over converge, and an esotropia is seen.

– Exotropia and intermittent exotropia: Either a constant or intermittent outwards turn of the eye.

– Pseudo strabismus:  Pseudo strabismus presents to our clinic quite commonly in babies under 12 months. Usually, parents or a caregiver have noticed a turn in either one or both eyes. The turn is usually seen most of the time, and more often is noticed to be an inward turning eye. Pseudo strabismus is in fact not an eye turn at all – it is an optical illusion whereby the excess skin folds around a babies nose give the illusion of an eye turning inwards. Pseudo strabismus can only be diagnosed by a paediatric ophthalmologist when the ophthalmic examination is completely normal. Any young child or baby that is suspected of having strabismus or pseudo strabismus should have a full ophthalmic examination by a paediatric ophthalmologist to ensure normal eyesight development.

Pseudostrabismus

Pseudostrabismus: It looks like the baby’s left eye is turning inwards (a left esotropia), when in fact the eyes are straight.

Signs of paediatric strabismus:

The most obvious sign of a child having strabismus is a noticeable tendency for an eye to drift or turn. This can range from being very obvious (for example a large amplitude, constant eye turn), to occasionally noticed (for example an intermittent, fleeting eye turn), to very subtle and usually only noticed by the main caregiver (for example an eye turn that only happens on looking up to one side).

Other signs include squinting the eyes (furrowing the brow to narrow the eyes when looking at something), closing one eye in bright sunlight, rubbing the eyes, excessive blinking, headaches or complaining of sore, tired eyes.

If you are at all concerned about your child’s eyes, or feel they may have strabismus, it is always best to have their eyes checked with a paediatric ophthalmologist.

Why does it matter if my child has an eye turn?

Paediatric strabismus can have disastrous effects on vision development. An eye that turns, provides the child’s brain with conflicting information. Because a child’s brain is within a plasticity phase known as neuroplasticity, (read more about this here: https://faculty.washington.edu/chudler/plast.html) the child’s brain will often “switch off” the turning eye due to this conflicting information. This “switching off” of one eye is known as amblyopia, and if left untreated, amblyopia can cause blindness in the strabismic eye.

In childhood, amblyopia can be treated using occlusion therapy (often referred to as patching). Patching involves covering up the dominant eye with an eye patch for a few hours each day so that the strabismic eye develops neural connections with the brain, thereby strengthening the vision. For more information on amblyopia, please read our previous post on adult strabismus.

Treatment for paediatric strabismus:

The most important factor in treatment of childhood strabismus hinges around vision development. The priority is always given to developing the vision first, rather than correcting the strabismus. Often these treatments go hand in hand, and can be treated at the same time. Depending on the type of eye turn, we may need to treat the vision first, and then treat the strabismus afterwards.

Here are the most common means of treating paediatric strabismus:

  • Treating amblyopia first (patching). Patching will not directly fix the strabismus of the eye, it aims to correct the vision of the strabismic eye. Often by improving the vision of the eye, we see an improvement to the strabismus of the eye, but it is important to be aware that amblyopia treatment aims to improve vision, not the eye turn.
  • Glasses: Often glasses are prescribed to help manage a paediatric strabismus. Some forms of glasses can help control certain types of eye turns. It is important to note that we will only prescribe glasses where they are absolutely necessary for vision or control of an eye turn.
  • Eye exercises: Eye exercises, often referred to as orthoptic exercises, are only used in select cases of paediatric strabismus. The orthoptists at Sydney ophthalmic specialists are all trained in paediatric orthoptics and will work along side the paediatric ophthalmologist to diagnose and treat strabismus that could benefit from eye exercises.
  • Strabismus surgery: Strabismus surgery is often required for paediatric strabismus. In most cases, all other options are tried first in an attempt to avoid surgery. Your paediatric ophthalmologist will talk to you about the likelihood of your child requiring strabismus surgery. Strabismus surgery for children is performed as a day procedure, but requires a general anaesthetic. Your ophthalmologist will talk you through the steps involved in the surgery. There are also a few very good resources available to explain strabismus surgery to children. Contact our office for further information on this, or visit https://www.amazon.com/Blueberry-Eyes-Monica-Driscoll-Beatty/dp/0929173244 to find a copy of a useful book to read to your child before they have strabismus surgery. We have a few copies of this book that we can loan out to our patients.

Patching

A young baby wearing an eyepatch over the right eye to treat amblyopia in the left eye.

References:

https://aapos.org/terms/conditions/100

https://aapos.org/terms/conditions/21

https://ranzco.edu/ArticleDocuments/233/opa_ranzco_strabismus_surgery.pdf.aspx?Embed=Y

https://www.aapos.org/terms/conditions/9

https://www.aapos.org/terms/conditions/54