Peds Eye Brochure

7/28/2019 Peds Eye Brochure

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PEDIATRIC

Eye CareAmblyopia, Strabismus and Orthoptics

Binocular vision adds depth to life.


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Amblyopia, Strabismus and Orthoptics

TABLE OF CONTENTS2 How the eyes work

3 What is strabismus?4 How is strabismus managed?

5 Will glasses help my child?

5 Does a turned eye cause double vision?

6 Will eye exercises help?

7 What is amblyopia?

8 How is amblyopia treated?

9 Occlusion (patch) therapy

10 Adjustment to the patch

10 Tips to avoid skin irritation

11 Patch removal

11 What do I do if my child removes the patch?

12 Using the lazy eye

12 Effect of the patch on the better eye

13 When to call your eye doctors office14 How long will my child need to wear the patch?

14 What if my child must wear the patch while at school?

15 Atropine treatment for amblyopia

16 How will I get the atropine drop into my childs eye?

17 What to expect from the drops

18 Unusual reactions

18 How long do I continue giving the drops?

19 Eye muscle surgery (strabismus surgery)

20 How the eye muscles work

21 Surgical procedures

22 Operation details, case study

24 Anesthesia

25 Possible complications

27 Post-operative care


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Binocular vision is the ability to use both eyestogether, and it is one of the components of depth perception.

Our goal is to restore or maintain binocular vision and to maximize

the best possible vision in children who have amblyopia, strabismus,

cataracts, glaucoma, or other eye problems through combined

ophthalmic and orthoptic treatment. This brochure is designed toanswer common questions about this specialized type of treatment.


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How the Eyes WorkThe two eyes are coordinated by a central area in the brain and move togetherin a way that is similar to the front wheels of a car. One wheel cannot be

moved without the other one moving. Likewise, you cannot move your left eye

independently of the right eye. If one of your car wheels is bent inward, you can,

by turning the steering wheel, make it straight. However, the previously straight

wheel will now be turned in. The same concept of movement applies to the eyes.

Thus, while it may appear that the right or the left eye is misaligned, it is really

a problem between the two eyes. An eye muscle problem may be corrected by

operating on either eye or, more commonly, on both eyes.

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normal binocular function

Like a steering wheel controls

the front wheels of a car, thebrain coordinates normal eye

movement.


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What is strabismus?Strabismus is the medical term for misalignment of the eyes. It is

a Latin word meaning to look askance or sideways. It refers to

the problem of the eyes not working together and one eye turningin, out, up or down. Approximately four percent of children in the

United States are affected by strabismus. There are various reasons

for this condition, ranging from a need for glasses to ocular (eye) or

neurological abnormalities. A parent or close relative is often the first

to notice a vision problem. When a vision problem is suspected, a

complete eye examination should be arranged as soon as possible.

Early detection and management are important for best results.

strabismus

Photo provided by CanadianOphthalmological Society(www.eyesite.ca)


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How is strabismus managed?The Duke Pediatric Eye team includes pediatric ophthalmologists,orthoptists, and technicians. Orthoptists specialize in identifying eye

muscle imbalances and examining children with eye problems. They

assess visual acuity in infants and children, measure ocular deviations,

and evaluate eye movements.

The level of the examination will be adapted to your childs ability to respond. We

obtain much useful information through observation of your childs visual behavior.

Although responses are helpful, verbal ability is not necessary to complete an

accurate eye examination.

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eye examination

An eye exam will be

conducted to evaluate your

childs eye movements.


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Will glasses help my child?

Some children have an inward turning

eye (crossed eye) that is due strictly

to farsightedness (accommodative

esotropia). They must use extra

focusing power to see clearly. Without

glasses, one or both eyes turn in. Corrective lenses relax this extra focusing

power so that the eyes stay straight. Glasses with or without bifocals are the

best solution.

Children who have an occasional outward drift of one eye when tired may benefitfrom glasses with minus power that help them to keep their eyes straight.

Glasses may be needed to provide clear vision and eliminate blurring, squinting,

or abnormal head positions.

Does a turned eye cause double vision?

When a childs eyes do not work together as a team, he/she will look at an

object with one eye while the other eye looks at something else. The image from

the wandering eye causes double vision. But the brain, by a technique called

suppression, switches off the wandering eye. Thus, younger children rarely have

double vision.

Older children and adults with newly acquired eye muscle problems often report

double vision. Sometimes double vision may be treated with the use of prisms that

adhere to or are incorporated into a pair of glasses.

glasses

Patient before (left) and

after (right) glasses.


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Will eye exercises help?

Eyestrain and fatigue when reading may indicate a convergence problem.

Measurements by one of our professionals can determine if your child will benefit

from eye exercises. Simple near-point exercises can be done even with young

children. A computerized convergence program was developed for older children

and adults. Go to www.computerorthoptics.com for an online description of

this technique.

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Eye exercises, such as a computerized convergence

program, may prove beneficial.

Photo provided by Channel Island Design (www.cid.cc) & HTS, Inc.(www.computerorthoptics.com)


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How is amblyopia treated?Amblyopia (lazy eye) is by far the greatest cause of treatable vision loss in

the United States. A child with amblyopia may lose vision in the affected eye

permanently if the situation is not corrected early. Treatment is more difficult and

less effective with children older than 9 or 10 years of age. If your child is diagnosed

with amblyopia, an individual active treatment program will be designed. This

program may involve one or more of the following: eyeglasses, patch therapy, eye

drops that dilate the pupil, and in some cases a contact lens. Your ophthalmologist

and orthoptist will give you specific information about the treatment for your child.

8Patch therapy is frequentlyused in the treatment of

amblyopia.


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patch therapy

Occlusion (Patch) TherapyIn order to improve your childs vision, you may be instructed to

patch an eye. Patching is a common method of treatment forthe various types of amblyopia. This type of visual loss cannot be

corrected by glasses alone or with surgery. The treatment is effective

when it forces the child to use the lazy eye by patching the good

eye. Patching is most effective in young children, but can also

help improve vision in the early teen years. Untreated, amblyopia

cannot be reversed, and the visual loss becomes permanent. Clear

instructions, reasonable expectations, patience and consistency are all

part of the comprehensive approach to your childs eye care.


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Adjustment to the patchAll children who are patching have similar problems. It is uncomfortable and

sometimes difficult to adjust to wearing a patch. Your child may not see well at

first, and this can be frightening. However, it does not hurt, and it does not damage

your childs normal eye. It is the best thing to do to preserve vision for a lifetime.

For that reason, it is important that your child wear the patch as directed.

(You will receive instructions on how often to patch your child.)

Tips to avoid skin irritationThe patch must be of an adhesive type that sticks to the face. A pirate patch withstrings or elastic is NOT advised. Be sure that the patch sticks firmly to the skin for

the duration of patching time. The narrow end of the patch is placed toward the

nose and the broad end away from the nose.

Patches come in regular and junior sizes and may be purchased at drug stores or

through the Internet:

www.fresnelprism.com

www.ortopadusa.com

Ask for a sample to determine the best fit for your child. Although eye patches are

hypoallergenic, some children develop mild skin irritation from wearing the patch.

The broad area can be trimmed with scissors so that less adhesive contacts the face.

The patch may be rotated slightly so that the same part of the skin is not always

under the adhesive. To protect the skin and decrease irritation, you may apply Milk

of Magnesia with a cotton ball to the skin area where the patch will stick and allow

it to dry completely. Be careful not to get Milk of Magnesia into the eye. Then apply

the eye patch as usual.

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Patch removalRemoving an adhesive eye patch can be uncomfortable and distressing to the

parent and child. Try to remove the patch slowly while applying pressure to adjacent

skin to lessen pulling. Soaking the patch with cool water before removal is also

helpful. Another method is to rub petroleum jelly into the adhesive portion of the

patch. Let the petroleum jelly soak in for about 30 minutes before gently pulling off

the patch. The skin surrounding the patched eye can be treated with any skin care

product to lessen skin irritation. Avoid getting any product into the eye.

What do I do if my child removes the patch?If your child removes the patch before the full amount of time that he/she is

supposed to wear it, immediately replace it with a new patch. Refocus your childs

attention with a toy or game in order to help to distract him or her from awareness

of the patch. Be persistent. Since the patch is not painful, most children will wear

the patch once they realize that their parents intend for them to wear it, and that

it will be replaced. Thin adhesive covers (Tegaderm Transparent Dressing, 6cm x

7cm) can also be placed over the patch to make it more difficult to rub off. Youngchildren can be discouraged from removing the patch by placing them in mittens or

pediatric arm restraints. See Pedi-Wrap catalog at www.pediwrap.com or call the

Duke Pediatric Eye Clinic for assistance.

Pediatric arm restraints, such

as Pedi-Wraps (pictured), can

be used to discourage childrenfrom removing the eye patch.

Photo provided by The Medi-Kid Co.(www.pediwrap.com)

patch therapy


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Using the lazy eyeWhile your child is wearing the eye

patch, he/she should be encouraged to

use the other eye as much as possible.

To shorten the patching period,

encourage your child to participate

in detailed busy work such as paint-

by-numbers, connect-the-dot books,

coloring, writing, drawing, and tracing.

Effect of the patch on thebetter eyeSometimes the deviation seems to

switch eyes or get worse with the

patch. This is normal and only means

that the lazy eye is now being used

so that it stays straight while the other eye turns. This indicates that the patchingprogram is having an effect. Improving vision in the weaker eye is the first step.

The deviation can be dealt with when the lazy eyes vision has recovered. Keeping

return visits is important so any changes can be tracked.

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Activities such as coloring can

help your child use his or herother eye and shorten the

patching period.

Photo provided by the National Eye Institute(www.nei.nih.gov)


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When to call your eye doctors officeSome slight redness of the eye is common because children frequently rub the

eye or the patch. Extreme redness, accompanied by discharge, should be reported

immediately to your eye doctor. If at any time during the patching routine your

child contracts measles, chicken pox, poison ivy, or any other type of skin eruption

around the eye, DISCONTINUE the patching and CALL the Pediatric Eye Clinic at

919-684-0010 or 919-684-0560.

patch therapy

Call your eye

doctors office

should you notice

extreme redness

or skin eruptions

around the eye.


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How long will my child need to wear the patch?

Patching will be continued until there is no further improvement in visual activity oruntil your child uses one eye equally as well as the other. It is impossible to predict

how long this will be for each child, but it typically lasts for several months with

some less intense patching thereafter. Patching could be one of the most important

steps in the treatment of your childs eye condition. Do not become discouraged!

No matter how difficult it may seem, the long-term results are well worth it.

What if my child must wear the patch while at school?Some children will need to wear the patch at school or at the day care facility. If

your child removes the patch frequently at home, this will probably also happen at

school. Make sure your childs teachers understand the importance of the patch.

Provide them with extra patches so they can be replaced at school when needed.

Please help your older child to deal with the comments that others will make about

the patch. Just as a leg cast and crutches help while a broken bone is healing, theeye patch is a short-term way of helping your child to have better vision for life.

Practice an answer to any questions that will satisfy the questioner and make your

child feel positive about the process. For example, when asked What is that on

your eye? the response could be Its a patch to make my weaker eye stronger.

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Your child may need to wear the

eye patch while at school. Notifying

teachers and discussing situations

with your child can help make

things easier.


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Atropine Treatment for AmblyopiaAtropine drops may be used to treat your childs amblyopia. Atropine

blurs vision in the better-seeing eye and encourages use of the eyewith poor vision and improves vision in that eye over time. Atropine

may be used in addition to or as an alternative to traditional patching

therapy. Because atropine cannot be removed once applied, it is a

good treatment option.

atropine treatment


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How will I get the atropine drop into my childs eye?

Have your child lie down on his/her back, looking up at the ceiling. Hold the eyelidsapart and let one drop fall anywhere between the eyelids. If the child is frightened,

try giving the drop before he or she wakes up. In some children, it is necessary for

one adult to hold the child while the other gives the drop. Eventually a routine will

be established. Be sure to wash your hands after applying the drop so that you do

not accidentally get any medication into your eyes. Also, take care not to get any of

the drops in your childs other eye.

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To get the atropine drops in your childs eye,

hold the eyelids apart and place a drop into

the eye. Be careful not to get any drops in

the other eye.


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What to expect from the drops

Unlike other types of eye drops, atropine usually does not sting. These drops causethe pupil (black center of the eye) to become very large. Your child may notice

that close objects are blurred. This is the normal effect of the drops and may last

for up to a week following one drop of atropine. Your child may also be bothered

by bright sunlight. Sunglasses or a broad-brimmed hat may be worn outdoors on

sunny days to avoid discomfort.

Since atropine blurs the vision of the better eye for near work, this forces the child

to use the weaker eye for reading, drawing, etc. Allow your child to hold reading

material close or to lean close to the desk. If your child attends school, please

notify his/her teacher of the eye treatment. In some cases, reading glasses may be

prescribed for using the better eye while at school.

atropine treatment

Atropine drops cause the

pupil to become very large.


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Unusual reactions

Rarely, a child may develop redness and swelling around the eye, fever, or a redwarm face and neck. If this occurs, STOP using the drops and contact our office.

Be sure to keep the atropine drops out of the reach of children. If a child drinks

atropine from the bottle, give syrup of ipecac and contact an emergency room

immediately.

How long do I continue giving the drops?Atropine treatment may be continued for weeks or months, depending on your

childs age and the severity of the vision loss in the amblyopic eye. Keep using

the drops as instructed until the next appointment day unless your doctor says

differently. For any other questions, please call the Pediatric Eye Clinic at

919-684-0010 or 919-684-0560.

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Atropine treatment may

be continued for weeks

or months.


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Eye Muscle Surgery(Strabismus Surgery)

Many patients with eye deviations will eventually need an operation

to align the eyes. The goals of surgery are twofold. The first is to

change the present eye alignment in such a way as to enable the

brain to use both eyes together. This may reestablish binocular

function. The second is to improve the appearance so that the eyes

look straight and move together. The chances for achieving these

goals are influenced by the size and complexity of the eye deviation,the age of onset, types of previous treatment, quality of binocular

function (depth perception), and the compliance with pre- and post-

operative therapy.

The results of strabismus surgery are not always perfect because human tissue

varies from individual to individual. Therefore, it may take more than one operation

to achieve the goal of straight eyes. The success rate varies from 50 to 90 percent,depending on the type of operation and condition of the eyes. In some cases the

surgery may be performed in steps, with the first operation designed to correct

only part of the problem. A second or even third operation may be necessary to

deal with any residual misalignment or to correct another aspect of the problem.

Sometimes the correction of one problem will uncover a second problem that was

not apparent before the surgery.

The purpose of this discussion is to acquaint you with

the facts about strabismus surgery. With vigorous

and complete treatment the results are usually

extremely gratifying.

An operation may eventually

be needed to align the eyes.


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How the eye muscles workEye muscle surgery involves either weakening or strengthening the muscles that

control eye movement. There are six muscles that attach to the outside surface of

the eyeball and control the movement of each eye. Four of these muscles are called

rectus muscles and their functions are very straightforward. The superior rectus

muscle attaches to the top of the eye and pulls the eye up. The inferior rectus

muscle attaches to the bottom part of the eye and pulls the eye down. The medial

rectus muscle attaches to the side of the eye closest to the nose and pulls the eye

in. The lateral rectus muscle attaches to the outside of the eye closest to the ear

and pulls the eye out.

Two additional muscles (the oblique muscles) have very complex eye movement

functions. The superior oblique muscle attaches to the top back part of the eye and

runs through a pulley near the top part of the nose. This muscle pulls the eye down

when the eye is looking toward the nose. The inferior oblique muscle attaches to

the bottom back part of the eye and pulls the eye up when it is looking toward thenose. Their primary function is torsion, the inward and outward rotational balance

of each eye.

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eye muscle surgery

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Surgical procedures

Strabismus surgery consists of two general types of operations. One is aweakening procedure of the muscle which is called a recession, and the other is a

strengthening procedure which is called a resection. The technique for doing these

operations is as follows: the eye muscle is reached through a small cut through

the conjunctiva, which is a thin whitish skin over the surface of the eyeball. The

conjunctiva is the part of the eye that gets red and bloodshot when the eyes are

irritated. The eye muscles are immediately beneath this conjunctival tissue. Incisions

through the skin of the face or the eyelids are not necessary to reach the eye

muscles.

A common misconception is that the eye is removed from its bony cradle called

the orbit and placed on the face during the operation. This is not true. The eye

muscles are located approximately 1/4 of an inch from where the clear dome (called

the cornea) meets the white tissue of the eye (called the sclera or conjunctiva).

Therefore, it is not difficult to get to the eye muscles while the eye remains in its

usual position.

eye muscle surgery

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AnesthesiaOne of the risks of strabismus surgery is undergoing anesthesia. With todays

techniques and equipment, this risk is extremely small. The risk of a serious

complication in a healthy child is approximately 1 in 500,000. It is safer in the

operating room having a strabismus operation than it is riding in a car on a four-

lane highway. Every effort is made to ensure that the patient is in the best physical

condition before he/she undergoes anesthesia. Prior to surgery you may be asked

to obtain certain blood work, tests, and X-rays as deemed necessary (usually not

necessary for healthy children). The anesthetic concerns for strabismus surgery are

different from most other types of surgery. Most patients are healthy, the operationis usually short, and major body systems are not involved. Potential anesthetic

problems are minimized. The surgery is most often done as an outpatient. This

reflects the relative safety and ease of recovery from general anesthesia used for

eye surgery. Since eye surgery is elective, any condition that would increase the

risk of complications from anesthesia must be eliminated prior to surgery. This is

especially important in children. Conditions such as ear ache, pneumonia, flu-like

symptoms, or GI problems will result in postponement of the surgery until they

have been treated. It is safer to delay the surgery than to operate on a child or anadult who is sick. The anesthesiologist will talk to you prior to the surgery and it is

important that you discuss with him/her any questions that you may have regarding

the anesthesia.

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Possible complicationsDuring surgery every effort is made to reduce the likelihood of problems. However,

during the course of any surgical procedure problems may arise. It is the surgeons

responsibility to minimize these problems in the operating room. After the surgery,

it is the patients (or parents) responsibility to follow carefully the instructions

and treatment prescribed. The most frequently encountered complications are as

follows:

1. Overcorrection/undercorrection: This is not really a complication but

is instead an undesirable outcome. Overcorrection or undercorrection of amisalignment may occur in the eyes being repaired. An overcorrection would be

to make an eye turn out that previously turned in. An undercorrection would be

an improvement in the alignment of the eyes but the eyes are still turned in. This

failure to achieve optimal alignment occurs anywhere from 2040 percent of the

time and may result in the need for the use of glasses, special eye drops, prisms, or

an additional surgical procedure.

2. Infection: Infection may occur in the immediate post-operative period, butfortunately this is extremely rare. The ocular tissues are highly vascular and this

usually aids in the prevention of this problem. You will be given instructions with

regard to the use of antibiotics and in the care and use of the eyes in the immediate

post-operative period. A post-operative visit will be scheduled to detect any early

signs of an infection. Severe infection inside the eyes can result in loss of vision.

Fortunately, this is very unusual after strabismus surgery.

As with any surgical procedure,

while every effort is made to prevent

problems, complications may arise.

eye muscle surgery

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3. Bleeding/Retinal detachment: A small bleed into the eye may occur which

normally resolves without intervention. Rarely (approximately one out of 10,000) a

retinal detachment can result which will require further surgery to repair.

4. Slipped muscle: The suture used to attach the eye muscle to the eye is

extremely strong. However, in a rare situation the suture may break, which

can cause the muscle to slip or become detached from the globe. This requires

immediate surgery to reattach the muscle. Fortunately, this also rarely happens.

5. Loss of vision: Permanent loss of vision from eye muscle surgery occursapproximately in one out of 10,000 eye muscle operations, or less. The cause is

usually internal eye infection (endophthalmitis), internal eye hemorrhage, or retinal

detachment. Early detection and treatment can save vision.

6. Double vision: In the immediate post-operative period it is not unusual for

the patient to see double (called diplopia). The eye muscles are sore and are not

working correctly, or occasionally the eye position has been changed enough so

that the brain processes two images instead of one. The double vision normallyresolves within days to weeks, and in some cases it is desirable immediately after

the surgery. Persistent double vision, however, may require additional intervention

if it does not resolve in an appropriate period of time. Every effort is made to try to

anticipate whether this will occur so that you or your child can be prepared in the

immediate post-operative period.

7. Change in refraction: Changes in eyeglass prescriptions may be necessary after

eye muscle surgery due to slight alterations in the shape of the eye or cornea. This

may not be permanent and new glasses will usually correct any refractive changes.

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Post-operative careInstructions for post-operative care will be given at the time of the surgery. Eyes

vary in appearance and comfort depending on the type of operation and how much

surgery was done. You can expect the eyes to be somewhat sore and irritated for

at least several weeks after the operation. The conjunctiva will be red and swollen,

and it may feel like you have sand or other foreign objects in the eye. Sometimes

the upper and/or lower lids will retain fluid and swell. This usually resolves within

several days. If both eyes are operated on, neither eye will be patched. If, however,

just one eye is operated on, a patch will often be used to increase comfort.

It is recommended that most people remain out of work or school for a few days

to one week following the surgery. While you may be able to resume your activities

within a day or two, it is better to plan for a longer recovery period in case it is

needed. Specific details for how to take care of the eyes are given on the post-

operative eye care information sheet.

The two basic rules that should guide activities for the first week after surgery are:

1. Nothing gets in the eye(s)including rubbing eye(s) with your hands

2. Avoid any possible injury to the eye(s)

If you apply these two rules to the planned activity and neither is an issue, then

the activity is okay. Otherwise, DONT DO IT! Questions about additional issues not

covered here may arise. Please feel free to contact your doctor prior to surgery in

order to get these questions answered.

Call the Duke Pediatric Eye Clinic at 919-684-0010 or 919-684-0560.

eye muscle surgery

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Binocular v is ion adds depth to l ife.

Duke Pediatric Eye Care Facility

Faculty:

Edward Buckley, MDLaura Enyedi, MD

Sharon Freedman, MD

David Wallace, MD, MPH

Tammy Yanovitch, MD

Terri Young, MD

Orthoptists:Lois Duncan

Sandra Holgado

Namita Kashyap

Ivonne Rodriguez

Tech Staff:Courtney Fuller

Cassandra Headen

www.dukeeye.org

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