Pediatric Eyecare

Amblyopia

What is Amblyopia?

Amblyopia is the medical term for poor vision in one or both eyes that is not the result of an eye disease or injury. It is sometimes referred to as “lazy eye.” The eye itself is actually healthy and normal in this condition. Amblyopia is fairly common, affecting about 2%-4% of the population. Amblyopia occurs during early childhood, when the visual system is still developing and vulnerable to disruption. Poor vision occurs because something has interfered with the normal development of vision in the eye, causing a “blurry” image to be seen by that eye. The most common causes include strabismus (misaligned eyes) and a large difference in the refractive error (the prescription) between the two eyes.

If the eyes are not aligned properly or “crossing,” they each perceive a different target. The brain is presented with two completely different images and cannot fuse them together into one clear image. It’s as if the eyes have completely confused the brain. Since we could not function while seeing two different images all the time—constant double-vision, if you will—the brain automatically “shuts off” or ignores one of the two images so that we can function. This suppression of one eye leads to amblyopia or permanent poor vision if left uncorrected.

Likewise, if one eye is much more farsighted, nearsighted or astigmatic than the other eye (even though the eyes, in this case, are aligned and focused on the same target), then the brain is presented with one very sharp image and one very blurry image. If the difference is great enough the brain once again cannot knit these two images together into one clear image—they’re too different. To avoid visual confusion the brain subconsciously ignores or “turns off” the blurrier eye. In each of these examples the eyes themselves are not diseased. There are several other problems that can cause amblyopia, but these are far less common. They include such conditions as congenital cataracts and congenital droopy eyelid (“ptosis”), which physically obstruct vision in one or both eyes.

For more information on amblyopia, contact Dr. Bianchi, one of the premier child eye surgeons in New Jersey now practicing at our laser eye surgery and vision correction center, Westwood Ophthalmology.

Early Diagnosis is Key

Amblyopia only happens in childhood during the so-called critical period of visual development—the first 7-9 years of life. During these early years the immature visual system consisting of the eye and certain parts of the brain are actively developing. If anything interferes with the creation of a focused, clear image in one eye during this period of time, the brain may start to ignore or suppress the blurry eye in favor of the clearer eye as described above. If the blurred image is not corrected by age 7 or 8, poor vision in that eye may become permanent. Once the critical period of visual development is over, no eyeglasses or surgery can recover lost vision due to amblyopia. The visual loss has then become “locked in” by the brain. That is why it is so important to identify amblyopia in young children, so that we may correct it and recover lost vision before it’s too late.

Why does amblyopia matter? Most importantly, it may lead to irreversible vision loss in one or both eyes. This leaves the patient with only one good seeing eye. If anything were to happen to the good eye in the future, the patient would be left severely visually impaired. Vision loss could also prevent development of normal depth perception. Vision must be good and equal in both eyes in order to see in three dimensions. There are some occupations that require perfect depth perception. An amblyopic patient might be prevented from entering these fields.

If you suspect your child suffers from amblyopia, it is imperative you immediately contact one of the experienced child eye surgeons in your area. In Westwood, New Jersey, our laser eye surgery and vision correction center has one of the region’s top child eye surgeons now on staff. Dr. Bianchi will perform a thorough eye exam on your child and design a customized treatment plan aimed at preventing permanent vision loss.

Treatment of Amblyopia

The good news is that with early intervention Dr. Bianchi can restore vision in an amblyopic eye—in many cases to a perfect 20/20. Often eyeglasses are necessary, but the mainstay of treatment for amblyopia is patching of the stronger eye. By forcing the child to use the weaker eye, vision slowly improves over the course of weeks to months. The duration of patching each day may range from a couple of hours to all waking hours, depending on the severity of the amblyopia.

Surgery may be necessary early on for such things as cataracts and droopy eyelids. Surgery to straighten misaligned eyes, however, is typically performed after patching treatment has been carried out to improve vision in the amblyopic eye.

There are also special eye drops available (Atropine) that significantly blur the stronger eye and can be used just like patching therapy. These drops, however, do have systemic side effects and take significantly longer to improve the vision than patching. Typically, eye drops are reserved for patients who cannot tolerate patching therapy.

Success in treating amblyopia depends primarily on the severity of the amblyopia and the age of the patient when it is discovered. Earlier is definitely better in amblyopia treatment. Recent studies, though, have shown that even young teenagers can show small improvements in vision in amblyopic eyes with patching.

Your child should have his or her vision screened by the pediatrician when they are first able to reliably communicate verbally—usually around the age of 3 or 4. If a problem is discovered they should be referred to an ophthalmologist for further evaluation. Only a thorough evaluation from an ophthalmologist comfortable with and experienced in the care of children can rule-out more serious eye diseases and make the diagnosis of amblyopia.

If your child suffers from amblyopia, contact Westwood Ophthalmology to arrange an appointment with Dr. Bianchi.

Strabismus

What Is Strabismus?

Strabismus is the medical term for misaligned eyes. The eyes may become misaligned horizontally or vertically for a variety of different reasons. When the eyes are turned inward the condition is referred to as “Esotropia.” When the eyes turn outward it is called “Exotropia.” One eye may appear to be turned in or out most of the time, or the deviating eye may alternate. In most cases of strabismus the eyes and the eye muscles are perfectly healthy.

The true cause of this family of disorders is not fully understood, but it appears to be neurologic in origin, representing an imbalance in the brain circuits that control eye movements and alignment. It often appears that one eye is predominantly involved or to blame in these conditions, but it’s important to understand that the disorder actually involves both eyes. Eye movements are very highly coordinated by the brain, with each eye very closely linked to the movements of the other. It’s like a very sophisticated ballet. If anything should go wrong with one eye, the opposite eye is automatically affected and involved. The majority of strabismus occurs during childhood, but it may happen to adults, too. The causes, however, are very different in these two groups of patients. The condition is most often congenital or of unknown origin in otherwise healthy children. Diabetes, thyroid disease, head trauma, strokes and tumors are a few of the more common causes of adult-onset strabismus.

For more information on strabismus or to arrange an appointment with one of the top child eye surgeons in the northern New Jersey area, contact our laser eye surgery and vision correction center.

Early Detection is Key

Strabismus is serious because it may lead to loss of vision in one eye and also prevents the development of normal binocular vision. Poor vision in one eye may develop because the brain may start to ignore the image from the misaligned eye (amblyopia). In order for the eyes to work together and see in three dimensions (depth perception) they must be aligned on the same visual target. The brain then combines these two pictures into one three-dimensional image that gives us depth perception.

When the eyes are misaligned the brain is presented with two very different pictures that it cannot combine into one image. The brain responds by ignoring one of the images to avoid visual confusion. The child then loses depth perception and may also lose vision in the “ignored” eye. If a child reaches the age of 7 or 8 with eyes that are not aligned, he or she may never develop normal depth perception. If strabismus occurs in an adult patient it often causes disabling double-vision. It is also clear that the abnormal appearance of misaligned eyes can have a significant social impact on a patient’s life. Self-esteem as well as work and personal relationships can be adversely affected by this condition.

A child’s visual system is actively developing up to about the age of 7 or 8. Vision or depth perception that has been lost due to strabismus can be regained if appropriate treatment is received before this window of time closes. Treatment to restore normal alignment can generally regain some, if not all, depth perception if it is performed before that critical age has passed. In general, the earlier the alignment is restored the better the visual outcome.

Because early detection directly affects the success of the strabismus treatment, you must seek qualified medical care for your child upon the first signs of a visual disorder. It is important you receive care from one of the experienced child eye surgeons in your area. New Jersey ophthalmologist Dr. Bianchi is a specialized pediatric ophthalmologist experienced in the diagnosis and treatment of strabismus. He will perform a thorough eye examination on your child in order to detect the presence of any disorder and recommend an appropriate course of treatment.

Treatment of Strabismus

The treatment offered depends on the kind of strabismus a child has. Some forms of strabismus respond to eyeglasses alone and others require surgery. Some require both. Occasionally, even bifocal glasses are necessary. Often patching will be necessary to treat amblyopia that is commonly associated with strabismus.

Prisms ground into eyeglasses may be able to correct small misalignments in adults, but surgery is required for moderate to large deviations. Many doctors have told their adult strabismus patients for years, incorrectly, that surgery won’t help them or would only be “cosmetic.” In fact, surgery on adults has real medical benefits: eliminating double vision, improving depth perception and enlarging the field of vision.

Many patients report improved self-esteem, communication skills, job opportunities, reading and driving with successful treatment. If you believe your child suffers from one of these disorders, contact Dr. Bianchi in Westwood, New Jersey at our modern laser eye surgery and vision correction center, serving the Pascack Valley area for over 25 years.

Adult Stabismus

Strabismus is the medical term for misaligned eyes. The majority of strabismus occurs in children, but a large number of adults are also affected by strabismus. Many have been told by their physicians, incorrectly, that "nothing can be done" about the misalignment, or that it is "too late." This is simply not true. Surgical and other treatments are available for adults with strabismus, too. Ophthalmologists like Dr. Bianchi who specialize in pediatric ophthalmology and strabismus routinely care for adults with strabismus as well.

Adults get strabismus for very different reasons than children. Usually it is the result of medical or neurological disease. Sometimes it is the result of childhood strabismus that went untreated. Diabetes, thyroid disease, myasthenia gravis, major head trauma, strokes, and brain tumors are the most common disorders that cause strabismus in adults. Rarely, strabismus may result from damage to the eye muscles from surgery around the eye, such as cataract or retinal surgery.

Strabismus in adults usually causes double-vision, which can be quite disabling. Even when double-vision is not present, strabismus can prevent patients from making direct eye contact with both eyes, often making social interactions awkward. Studies have shown that strabismus can have a negative impact on employment and social opportunities. Adults with this disorder do not have to suffer these negative consequences when surgery can improve or restore normal ocular alignment.

Some forms of adult strabismus are temporary and resolve spontaneously. Nerve palsies are an example of this kind of transient strabismus, and are particularly common in diabetics but may also result from serious head trauma. The use of patches and prisms can help relieve double vision while the nerve palsy resolves. This may occur over a period of weeks or months. Sometimes the strabismus does not resolve completely and surgery is necessary. A strabismus specialist can also help determine when further studies like an MRI are appropriate.

Strabismus resulting from neurologic conditions or thyroid disease is typically permanent and will not improve on its own. If the misalignment is small, prisms in glasses can often eliminate double-vision. However, larger misalignments require surgery. The strabismus specialist operates on the eye muscles, tightening, loosening or repositioning them to improve alignment. These same day surgeries are usually performed in an operating room under general anesthesia. No patches are put on the eyes afterwards and vision is generally not affected by the surgery. The patient can usually return to normal activities within a few days. Some forms of strabismus benefit from the use of an adjustable suture technique which allows the surgeon to fine-tune the alignment once the patient has recovered from anesthesia. Such a technique is generally not possible in children.

The risks of strabismus surgery are relatively few and uncommon. Vision loss is extremely rare but has been reported. Anesthesia reactions, infection, persistent or new double vision, and under- or over-correction of the misalignment are the primary risks. Each individual case of strabismus is unique, and the risks of residual misalignment will vary from patient to patient, but the vast majority of patients enjoy improved, more normal alignment and relief of associated symptoms like eye fatigue and double-vision. In some instances we can even restore binocular depth perception. Adults do not have to live with the discomfort and problems caused by misaligned eyes. Please call our North Jersey vision care center to see which treatment options may be right for you. Dr. Bianchi is fellowship-trained in the field of adult strabismus and has performed many successful eye muscle surgeries on adults.

Tear Duct Obstruction

Congenital blockage of the tear ducts is one of the most common problems in pediatric ophthalmology. The proper medical name for the disorder is "Congenital Nasolacrimal Duct Obstruction." It is thought to affect as many as 75% of newborns, though only about a third will show visible symptoms. Typically, the condition presents with chronic tearing as well as mucus mattering of the eyelashes and eyelids on the side of the obstruction. The infant's eyelids are often "stuck shut" with caked mucus upon waking each morning. The eyelid skin can develop a dermatitis, becoming very red and raw from the chronic irritation. The blockage is usually present from birth or very shortly thereafter. Chronic infections of the tear duct may accompany this disorder. Fluctuating symptoms are a hallmark of this disorder, with the symptoms often resolving completely for days, then returning again in time. This reflects the fact that there can be varying degrees of obstruction, ranging from partial to complete. As annoying as this condition can be, it does not pose a serious threat to a child's vision.

Tears normally drain through two small "puncta" or openings located in the corner of each eyelid (upper and lower) by the nose. They then pass through a small canal within each eyelid called the "canaliculus" and are collected in the "lacrimal sac" (tear sac) located just beneath the skin by the side of the nose. The lacrimal sac connects to the actual tear duct ("nasolacrimal duct") which runs through the bone and drains into the nasal passages. This is why we get the "sniffles" when we cry. The tears ultimately end up in our nose. The obstruction is most commonly due to a thin membrane of tissue that blocks the tear duct at its far end, where it drains into the nose and throat.

Fortunately, by one year of age the vast majority of these membranes will regress on their own. The tearing and crusting symptoms then simply disappear. There is some evidence that "massaging" the tear sac during the first few months of life may also help relieve the obstruction. The theory is that pressure exerted from the top of the system with the fingers can force fluid through the membrane and break it open. Your ophthalmologist may instruct you on how to properly massage the tear sac. Antibiotic eyedrops are often used for short periods as well to treat recurrent infections of the system. If the obstruction does not resolve spontaneously by the baby's first birthday, or if the blockage is especially severe, surgical probing of tear duct is often recommended. A thin, soft, blunt probe is threaded through the system and creates an opening in the obstructing membrane. Fluid is then flushed through the system from the top to ensure that it is open. In most cases this is done in an operating room under general anesthesia. It is typically a very quick and low-risk procedure with a very high success rate. There may be some blood-streaking of the tears and a mild bloody nose following the procedure. There is a small chance that the obstruction may recur following a probing. Sometimes a second probing is necessary if that happens, often using balloon dilation of the duct or the use of plastic tubes to keep the system open.

If you suspect your child has a tear duct obstruction, please call our office to schedule a consultation with our pediatric ophthalmologist so that he may determine the appropriate course of treatment.