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Strabismus - Crossed Eyes

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Infants And Children With Crossed Eyes Should Be Examined By A Pediatric Ophthalmologist

Parents often wonder exactly when their child's eyes will align together and work as a team. But not all infant's eyes line up early in life. The American Association of Pediatric Ophthalmology and Strabismus (AAPOS), offers insightful information for parents about strabismus (crossed eyes) in infants and children.

There is usually no cause for alarm if a child's eye strays inward or outward occasionally within the first two months of life. However, any misalignment of the eye after this time period may signify a serious problem. Examination of a child's eyes should begin just after birth. Before leaving the hospital nursery, a baby's primary care doctor should check the red reflex (the red glow from the back of the eye) to be certain light rays are passing into the eyes properly. An abnormality of the red reflex is a cause for alarm, and immediate referral should be made to a specialist in children's eye problems, or a pediatric ophthalmologist.

What is a pediatric ophthalmologist?

A pediatric ophthalmologist is a eye physician and surgeon (Eye MD) who attended medical school, performed an ophthalmology residency in all aspects of eye disease for at least three years and completed a fellowship of at least one year or more in children's eye disorders. Pediatric ophthalmologists are highly qualified to insure proper prevention and care of children's eye disorders. Their intense training makes them the best choice to examine and treat eye problems in children, especially if surgery is required to treat a particular eye problem.

Is it normal for a baby's eyes to cross?

Infant's eyes are often not straight (demonstrate misalignment) in the first couple of months of life during the time that the eye and brain grow and learn to work together. Infants whose eyes are not aligned in the first two months of life must be closely monitored by their primary care doctors. In some cases, crossing may be only occasional and not require any treatment; however, if the misalignment continues, a referral to a pediatric ophthalmologist is highly recommended.

What do we call eyes that aren't in good alignment?

Binocular Coordination: One of the more important visual skills is the ability to coordinate the two eyes together. A child is born with two eyes, but he must learn to team them together. Some children learn to do this properly while others do not. For example, some children develop a problem known as exotropia. Exotropia (wall-eyed) means an eye turns outward. This is not the same as a condition known as esotropia. Esotropia (crossed eyes) is the term used for and eye that turns inward. The educational implication of this particular problem is that a child with esotropia sees things smaller than what they actually are. In order to see an object properly, it is necessary to make the object larger. The only means at the disposal of the child to make it larger is to bring it closer.

Both these conditions are the result of either the brain's inability to control eye alignment or a vision problem. The brain sends an abnormal nerve input to the muscles that move the eyes. Usually but not always poor alignment is an isolated problem and the rest of the brain functions normally. An eye may turn inward or outward as a result of poor vision. The reduced vision may be due to a structural problem in the eye itself or to a need for glasses to correct farsightedness, nearsightedness or astigmatism. If the eyes are not straight by age three months, a child should see a primary care doctor. Yes, sometimes even babies need glasses.

Adequate Convergence: During the act of reading, the demand is for the two eyes to turn inward so that they are aimed at the reading task. If the eyes have a tendency to deviate outward, the child must use excess effort and energy to maintain fixation on the reading task. Most studies have shown that the greater the amount of effort involved in reading, the lower will be the comprehension and the lower will be the performance. When reading, the eyes do not move smoothly over a line of print. Rather, they make a series of fixations looking from word to word. When an exophoria exists, each time fixation is broken and moved to the next word, the eyes will tend to deviate outwards and they must be brought back in to regain fixation. Human nature being what it is, the child generally has an avoidance reaction to the reading task. This is compounded by the fact that anything the child doesn't do well, he would rather not do. This is the child who looks out the window rather than paying visual attention. He is commonly given labels. He is often accused of having a short attention span and not trying. He is told that he would do better if he tried harder, but he has tried harder to no avail. He is often labeled as having dyslexia, minimal brain dysfunction, learning disability, etc. Commonly, he loses his place while reading and/or uses his finger or a marker to maintain his place. While making the eye movements during the act of reading, he might not land on the next word, but rather land a few words further on. Consequently, he commonly omits small words or confuses small words. Often, he just adds a word or two to make the sentence make sense. If the two eyes are pointing at the same point in space, a person will see the fixated object as being single. Double vision or overlapping vision results if the two eyes are not exactly pointing at the same point. Don't expect a child to tell you that his vision isn't clear. He has no yardstick of comparison to inform him that his vision differs from the vision of anyone else.

Will crossed eyes result in double vision?

No, crossed eyes in children do not usually cause double vision. Ocular misalignment may result in poor vision (amblyopia) in the deviating eye. Amblyopia is the leading cause of visual loss in individuals under forty. If treated in the first few years of life, a child's vision can be restored, while failure to detect amblyopia can lead to a lifetime of poor vision in one eye.

Loss of three-dimensional vision (stereovision) occurs when eyes are misaligned. Although a toddler with crossed eyes may function appropriately, many adult tasks require good stereovision for best performance (such as landing a jet plane on an aircraft carrier or driving a fork lift). More important, children with crossed eyes often suffer negative social interaction and may develop poor self-esteem. Eye muscle surgery may be required to restore normal ocular alignment and provide a socially acceptable appearance. Often, but not always, three-dimensional vision can also be restored.

While there may be no cause for alarm if an infant's eyes cross in or out, this problem should not be ignored. The best advice for parents is to visit a primary care doctor or make an appointment with a pediatric ophthalmologist for an eye exam for their child. Children do not have to be able to read an eye chart before they can have a complete eye exam. Early detection is the key to correcting crossed eyes, and most often treatment is very successful. For more information, visit the AAPOS website at http://med-aapos.bu.edu.

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