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Aligning eyes: straightening out strabismus - includes related article

FDA Consumer , Nov, 1991 by Dixie Farley

"Why do you have that patch on? Did your eye fall out?" Kindergartner Kimberly May answered the jeer with a shrug. In 1974, it was Kim`s first day of school in Gaithersburg, Md., and she and the boy harassing her were waiting with other children for the building to open. Standing nearby, Kim`s 7-year-old brother Erik replied with gusto: "You dumb thing. She`s got amblyopia, and she needs the eye patch so she can see better. So there."

Although Erik couldn`t explain how Kim`s amblhopia (decreased vision) resulted from strabismus (eye misalignment), he defended his sister with the few terms and facts he`d overheard at home. And although Kim couldn`t find comfort in knowing that many other youngsters wear eye patches for amblyopia, she took heart from her brother`s support.

Strabismus affects approximately 4 percent of U.S. children under age 6. Amblyopia occurs in about 2 percent of the general population.

Anne May, a registered nurse, discussed her daughter`s condition with the teacher, emphasizing that strabismus would not hamper Kim`s ability to do class work. With agreement from Kim and her teacher, May also spoke to the class.

"I told them one eye sometimes is weak but can often be strengthened by patching," May says. "We took the patch off to show them her eye was OK under there. After that, there were only one or two remarks, from students absent that day."

In Kim, strabismus occurred as crossed eyes. In others, it may manifest as eyes that turn out, up or down. Its name can be traced to the Greek word strabismos, to look obliquely or with unstraight eyes; some use the terms "squint" and "lazy eye." Strabismus can disable sight in one eye, yet leave the other with 20/20 vision. Strabismus can be acquired from diverse causes at any age. There are more than a dozen variations. (See accompanying article.)

Sight: A Team Effort

Healthy eyes move together to send similar images along the optic nerve to the brain for fusion into a single 3-dimensional picture at the brain-vision junction, or visual cortex. Toward this end, six muscles (see illustration) attached to the outside of each eye contract and relax to move the eyes in perfect synchronization, permitting fusion, or binocular vision, across a large area of the visual field.

Strabismic eyes, on the other hand, do not move in unison. A muscle may pull too weakly or too strongly against its opposing muscle, creating an imbalance that causes one eye to drift from parallel alignment with its mate; more than one pair of muscles may be imbalanced.

Since each eye fixates on an object at a different point in space, the images received by the brain are dissimilar. The brain is unable to fuse the dissimilar images, resulting in double vision, which can be very disturbing. To avoid this disturbance, the brain may suppress vision in the deviating eye, allowing clear sight to develop solely in the straight eye. Decreased vision in the suppressed eye is called amblyopia. Prolonged amblyopia causes a loss in 3-dimensional viewing and depth perception.

The "squint" or turn usually is constant but may be intermittent and may occur in only one eye or alternate between the two eyes. Vision in people with alternating strabismus generally remains good i each eye individually.

While strabismus clearly stems from muscle imbalance, the causes of such imbalance are many and are not all completely understood.

"There`s a strong genetic influence, but there are also many anatomic and neuromuscular reasons," says John F. O`Neill, M.D., an ophthalmologist (a physician who specializes in eye disease) and director of the Pediatric Ophthalmology and Strabismus Service at Georgetown University`s Center for Sight in Washington, D.C. "One group of children may have eyes that turn, usually inward, from the day they are born. Another group may have perfectly healthy and straight eyes their first few years of life. However, as these children mature and start focusing more carefully on objects, the effort to see clearly causes their eyes to cross. Another group of children with neurologic conditions, such as cerebral palsy, not only may have poor movement of their arms and legs, but the eye muscle system is affected as well."

Strabismus can be associated with many other conditions that cause poor vision in one or both eyes--for example, cataract, Down syndrome, thyroid disese, eye tumor, damage to the fetal central nervous system from toxoplasmosis (a parasitic infection that can pass from the mother during pregnancy), damage to a nerve supplying the eye muscle (perhaps from birth trauma), or eye disuse due to a high refractive error (such as extreme farsightedness) or different refractive errors in each eye (such as nearsightedness in one eye and farsightedness in the other).

Is It Strabismus?

Maybe not. Some children have facial features that make the eyes look crossed when they aren`t, and some normal newborns have a temporary outward drift.

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