It Could Be Your Eyes

Is Surgery The Only Option For My Child?

• Dr. Juanita Collier, MS, OD, FCOVD • Season 1 • Episode 25

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Today we discuss strabismus, an eye turn condition. We explain the various treatment options, including patching, penalization, surgery, and vision therapy and highlight the  importance of developing binocular vision.

We also cover the social and psychological impact of strabismus, the goals of treatment, and the considerations parents should make when deciding between surgery and vision therapy for their kids.
There's a great need for the two eyes to work together when treating strabismus and there are various aspects of visual function that should be considered, such as tracking skills, focusing power, depth perception, and processing abilities. The role of vision therapy in addressing these areas and improving overall visual performance is crucial.

In this episode you’ll hear about:

(00:52) What is strabismus and what are the treatments.
(02:01) Patching or Occlusion Therapy.
(03:46) Penalization. 
(05:06) Why is it important to treat strabismus? 

  • The mental, social and academic impact
  • Driving Issues
  • Amblyopia

(09:48) Goals to aim for as a parent when treating their kids’ strabismus.
(16:07) Asking the right questions to know if surgery is the right choice.
(21:18) How to access the research and integral information about strabismus.

(23:02) Why 4d Vision Gym is your best choice for vision therapy.

Read the episode transcript here

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Dr. Juanita Collier: Welcome to the It Could Be Your Eyes podcast. I'm your host, Dr. Juanita Collier. Through my decades of work in the field of vision, I have met thousands of patients, parents, educators, therapists, and doctors searching for solutions to the seemingly unsolvable. Challenging traditional medicine's new normal?

We'll uncover that the root cause isn't necessarily what you thought it might be. It could be your eyes. 

Hi, and welcome back to It Could Be Your Eyes. I'm your host, Dr. Juanita Collier, and this is Jessica Liedke.

Jessica Liedke: Hi there!

Dr. Juanita Collier: And today we are talking all about strabismus. So strabismus is an eye turn, so sometimes you'll see people who have an eye turn in or out or up or down or maybe a combination of a few of those and we really wanted to kind of get down to what exactly is strabismus, what are the treatment options, why do you need to treat it, what happens if you don't treat it, and really kind of if you're thinking about different treatment options, what questions you should ask the provider.

Jessica Liedke: When we think about strabismus, we've seen a lot of different treatment options, and they range anywhere from kind of a passive patching or occlusion to a more active penalization or surgery or vision therapy, which is obviously what we do most frequently in our office. And so occlusion oftentimes takes place with patching and you might see little kids kind of walking around with, it looks like a pirate patch or a big bandaid over one eye.

And the idea is that you occlude or cover the better seeing eye, quote unquote, so that the weaker eye, quote unquote, can learn how to see better. 

Dr. Juanita Collier: So if we kind of do like a little bit of a history lesson, back in the day, what they would do is they would patch for the entire day. Then they went to 12 hours. Then they went to the school day. Then they cut it down to six hours. Then they cut it down to two to three hours, but active patching, meaning that you're doing near work when you're patching, or some people would have kiddos like on a tablet or something else. That's horrible for your eyes, um, while they were patching.

And then, now, the research shows that patching actually is not effective because it doesn't build up the binocularity. So, the two eyes working together, meaning that after you take the patch off of the lesser seeing eye, the better seeing eye just takes over anyway. And so, while it does help with um anything ever happening to the better seeing eye, when both eyes are open, you're not using that eye that wasn't patched.

Jessica Liedke: And I can speak from experience as a little kid who was patched for hours at a time. It is not fun. Kids don't like to do it. It feels kind of punitive, like you're in trouble, like, you know, you're trying to play, you're trying to be a kid, and you can't see. And you're used to seeing, you're used to being able to see just fine, and then you put on this patch, and all of a sudden you're taking away, like, your primary guiding sense.

And it's very disorienting, and it's, it's almost scary. It doesn't. feel good. So a lot of parents find a lot of resistance when they're trying that with their kids. Then that kind of makes it even harder to make progress too. 

Dr. Juanita Collier: Most people end up hitting a wall when it comes to thatching because eventually the kiddo kind of gives up or the parents give up because the kiddo is so resistant to it. 

Jessica Liedke: You gotta pick your battles as a parent, right? Another thing that's similar to patching is called penalization, and so they will use specialized drops that go in and actually paralyze the focusing system of the quote unquote better seeing eye, so it's just like putting an actual patch on, but it's chemically driven. 

Dr. Juanita Collier: And so the drops that they usually use are atropine. With that, they do what's called atropine penalization. So you put that drop in in your kiddo's eye every day. And so what happens is it makes that eye so blurry that the other eye is supposed to take over. That's a better option than patching because there's still information coming into the better seeing eye.

And so both eyes are working at the same time. You're not saying, like, only when this eye is completely blocked off will I use the lesser seeing eye. You are getting some binocular information in and some, some doctors do prefer to go that route. 

Jessica Liedke: A very common option for treating strabismus is surgery. So we're going to take a deeper dive into what strabismus surgery actually is, what it looks like, and some of the benefits and the complications of strabismus surgery in a little bit. And of course, we also treat strabismus with vision therapy. Again, another one that we're going to get into in a little bit, but before we do, why is it important to treat strabismus, Dr. Collier? Why not just live with an eye turn? 

Dr. Juanita Collier: Well, I think that, you know, just socially, a lot of people who have a visible eye turn are self conscious about it. And so, you know, they might tend to not want to make eye contact or look away from people when they're talking to them and things of that nature.

And then, you know, it's not like everybody in the world is nice and understanding. So sometimes people have to deal with bullying and things of that nature. What a lot of our adults will tell us is when people are looking at me, they don't know which eye to look at. And so that's, uncomfortable and it makes people self conscious.

Just from kind of like a psychosocial perspective, the treatment of strabismus is extremely important for your psyche. Then, we look at, especially with vision therapy, we look at how is it affecting their performance. Working with kiddos, we think about their academic performance. When they're reading, are they seeing double?

Are the words moving? Are they having difficulties actually taking in the information appropriately and being able to process it when it's coming in so confusing? Then when they get a little bit older, we want to think about driving and what's their depth perception like, are they able to stay in their lane when they're driving?

Are they able to really judge how quickly somebody is stopping in front of them? And do they have the appropriate eye hand coordination that's required? And usually if you don't have appropriate eye hand Eye teaming, it's difficult to tell exactly how quickly you need to stop. And so a lot of that driving tends to be a little bit jerkier.

And then we also see difficulties with parallel parking and things of that nature. So when we're thinking about our kiddos who are 16 years old getting out on the road, it gets. Concerning thinking about what their depth perception might be and how they'll react to a situation when, you know, they're on the highway and things are moving really, really quickly and they have no idea what's going on around them and being able to understand their surroundings appropriately.

Then we think about also from more of a scientific perspective, amblyopia. So like Jess was saying with the patching, what we're trying to avoid with patching or penalization or vision therapy is we want to make sure that both eyes can see and can see clearly ideally 2020 or better. And what happens is if your eye is turned for a long enough period of time, your brain will actually make the information coming into that eye very blurry.

And it'll make it so that you don't have the receptors in your brain to appropriately process clear information. That eye being turned for so long then starts to develop a whole new neurological pathway where the brain is not seeing clearly out of that eye and is unable to see clearly out of that eye.

The other issue that you can have with amblyopia is If the prescription in one eye is so strong, then it makes it so that the patient will handle amblyopia, meaning that their vision is not correctable down to 20 20. So that's also a concern. And then our biggest concern with that, like we were saying before, is that if something were to ever happen with the better seeing eye, then you're left with an eye that may be possibly legally blind or something of that nature.

So we would definitely want to make sure we get as. good of vision as possible in each eye. 

Jessica Liedke: Exactly. You know, I just want to make a point too that you said, you know, there are social implications to having strabismus and I was just reading some research the other day that said that children with strabismus face more than just their peers judging them and maybe not being very kind, but they actually surveyed teachers and they took pictures of children that had been digitally altered. So they, they had a picture of one child with like quote unquote straight eyes and the picture of the same child with a digital eye turn. And they asked teachers to rate like how well they think these children are going to behave in class, how smart they think they're going to be, how capable they think they're going to be, and they actually ended up rating the children with strabismus as being less friendly, less smart, less a pleasure to have in class. Oh, wow. And that's coming from the teacher perspective. So it's it kind of even goes a little bit deeper than just having to face bullies, which is really unfortunate. But that's just the world that we're we're living in... 

Dr. Juanita Collier: and how your teacher thinks of you it definitely determines a lot. And so, you know, I know that the teachers that were like, Juanita, you can do this. You got this and really expected a lot from me were the ones that got the most out of me. So I think that that's very. interesting to think about teachers kind of having that subconscious bias.

Jessica Liedke: Yeah. We know we need to do something about this. We have a child that has a strabismus. We gotta do something about it. So what sorts of goals of strabismus treatment should a parent be aiming for or looking for in options when they're considering how to treat their child's strabismus? 

Dr. Juanita Collier: I think that what we want to look at first in our office is we want the two eyes to be able to function together and team appropriately.

And so when we're thinking about vision therapy, what we do is we start with the basics. So the foundation of everything is being able to move the eyes in the same direction at the same time, nice and smoothly without any tracking difficulties so that the person can read across the page without any issues.

And so the first thing we're going to do is make sure that their tracking skills are equal between the two eyes. Then, we want to look at their focusing power. So, how well can they make and keep things clear at different distances? Now, oftentimes what we'll see is there's one eye, the better seeing eye, that can track really, really well and can increase and relax its focusing power really, really well, and then the other eye doesn't.

Even when we're thinking about cosmetically aligning the two eyes, if one eye is that much less skilled than the other eye, the brain's not going to put the effort into using that other eye. And so what we need to do is really make sure that the skills are as close to each other as possible. And what most people don't kind of think about when they're looking at, like, having a child with an amblyopic eye or a lazy eye is that the better seeing eye oftentimes doesn't see that well either.

They might be seeing lower down on the chart, but their tracking skills might not be great. They're just better than the other eye. Or their focusing power might not be great. It's just better than the other eye. Even with kiddos who seem to have, like, one good eye and one bad eye, as some people call it, the good eye is not great.

What we also do is we work on making sure that the good eye or better is doing as well as it possibly can to. And then we want to look at the eye tuning key. So let's develop appropriate depth perception. Let's fill out those neurological pathways that are focused on having those two eyes work together, taking in all the information appropriately without blur, without double vision and with accuracy.

And then on top of that, we build up the processing scale. So now the information is going in properly, making sure that the kiddo is able to process all that information appropriately and act on it as they should. So that's kind of the process that we take with vision therapy. And the reason why we don't do patching is because Like we said, when you're patching, you're often teaching the brain to only use the lesser seeing eye when the better seeing eye is getting absolutely no information at all.

And in real life, when the child is walking around, that's not the case. We don't want it to be what somebody had likened it to was if you're right handed and you end up breaking your right hand, and then you kind of have to. work with your left hand for a little bit. As soon as your right hand is available again, as soon as it's healed, you're not going to be like ambidextrous.

Like your left hand is going to go right back to not being your dominant hand anymore. You're going to go right back to using your right hand. And that's kind of the same thing that happens with patching. So what we do in vision therapy is we actually work with both hands together and have the two hands or eyes support themselves appropriately.

So now they can work as a team. And that's really what, what we're doing there. When you kind of skip all those steps and go straight to surgery, what you're doing is you're aligning those eyes cosmetically and that's about it. And so this eye has weaker tracking, it has weaker focusing power, and there's not really those neurological pathways for you to have binocular vision so that eye teaming. So then what happens is eventually the brain turns that eye again, and that's why it's so common to need subsequent surgeries after that first surgery. So usually if you've had an eye turn in, you need to have two more surgeries in order to get that eye to be cosmetically aligned, but then depth perception still isn't going to usually be attained.

Jessica Liedke: If you could make a positive change in your child's reading ability and confidence with reading in just 20 minutes a day, you would jump at the opportunity, right? Of course you would.
The 4D Built to Read program trains you, the parent, to become a junior vision therapist and provides you with tools, activities, and support you need to give your child a strong visual foundation so they can read, play, and take on whatever challenges they face. 
If your child is too bright to be struggling and getting low grades, or you've been told that in-office vision therapy would help, but you just can't find the time to commit, the 4D Built to read program may be just what you're looking for at a fraction of the cost.Visit 4D built to read.com or check out the show notes for a link to learn more. 

Essentially what you're saying is that the goal of surgery is a cosmetic alignment. But it doesn't do anything about the neurology of the brain as, as the child has been developing and they've learned how to use their eyes with an eye turn. You fix the eye turn, but you don't fix the brain. All you're doing is just kind of making the muscles look straight.

Dr. Juanita Collier: And that's the thing that I feel like isn't explained to parents as clearly as it could be. And so I think that parents feel like, okay, well, if the two eyes are pointed in the same direction, now my child can use the two eyes together. And that makes sense because theoretically, that feels like how it should be.

And I think that for the most part, Doctors know that that's not actually the case, but the kind of hope is that if the two eyes are pointing in the same direction at the same time, then maybe the brain might decide to use those two eyes together. Research shows that that's not what tends to happen.

However, it's still kind of what's. It's either directly or indirectly, um, presented to parents as what will be the outcome at the end. And it's also the case that many kiddos are not able to report whether or not they have binocular depth perception, especially if they've never had binocular depth perception.

And so the parent is thinking that their child is seeing out of both eyes at the same time and using the information from both eyes together until they start to notice the turn happen again. And the child has nothing to report because they've never seen appropriately in the first place. 

Jessica Liedke: So if parents are considering surgery for their child, how do they avoid these sorts of, of issues? Or let's say, you know, they have varying opinions from different providers. Say they went to a behavioral optometrist like you, and you're saying that vision therapy is going to help. And then they went to their family ophthalmologist who said, no, we need to, we need to operate. And chances are, they're saying we need to do it now, um, before they get too old and what kinds of questions should a parent be asking to determine whether surgery is the right choice for them and their family?

Dr. Juanita Collier: I think that one, you want to go to a surgeon who has done it a lot and you know is competent and you really want to ask them what their success rate is. That is something that surgeons tend to know and it's often something that you might need to ask. But I also think that doing the research, there's a ton of research out there that shows the success rate of different types of surgery.

So you want to know what kind of surgery are they doing? Are they doing surgery in both eyes or just one eye and why are they choosing to do it on whichever way they're choosing to do it. Then we also want to know the rate of recurrence because the research shows that if you have an eye turn in, you often need surgery more than once after, and then a lot of times what can happen is you can have what's called a consecutive exotropia.

And so that when they're doing the surgery, they cut too much of the tissue. So the eye actually ends up pointing out now instead of in. And that causes a lot of difficulty for kids because their brains were already wired for the eye pointing in and now their eyes pointing out. So they have absolutely no idea where they are in space and you kind of created a whole nother problem there.

So we want to talk about what the risk factor is for that consecutive exotropia and you know what they're doing to. ensure that that's not going to happen. I would personally, if my child needed a surgery, I would work with somebody who works with behavioral optometry because studies also show that if you are going to have surgery, having vision therapy both before and after actually improves the results of the surgery, but also makes it significantly less likely for you to need a second surgery.

And so I think that really kind of seeing how open minded that doctor is too is very important because if, you know, everything What did they say? Like to a hammer, everything looks like a nail. So I think that, you know, if you want the doctor that's, that has the whole toolkit, not just the hammer, because we want to make sure that, you know, like we're looking at everything going on.

How's your child doing academically? How's your child doing in sports? What's your child's competence looking like as far as for a parent? How much time do you have to commit to, you know, doing vision therapy or something like that? If you are unable to actually like follow through with vision therapy, vision therapy won't work.

We can only do what we can do. And a lot of it, you know, relies on you getting to the office or you doing the exercises at home and you being able to motivate your kiddo. And if If that's not able to happen and that's unable to happen consistently, then maybe surgery is a better option for you with some enhancement before and after for, with vision therapy.

Or, you know, really kind of having a group approach, a group treat approach to see, okay, so this is my surgeon, this is my behavioral optometrist. What can we do to all work together to provide the best outcome for my child? And. I don't know the behavioral optometrist that wouldn't have that conversation, but you know, you want to make sure that you find a strabismus surgeon that is also willing to have that conversation.

Jessica Liedke: That's a very good point. You know, I know that we will talk all day, all night about it, but you want to find the good surgeons that want what's best for your child too. And, and are really, you know, I don't think that there's any surgeons out there that are like gunning for that surgery in such a way that, you know, they're thinking they're going to harm the child.

I don't believe that that's a thing. I also know that there are many out there who just have their point of view and are very kind of in that point of view and, and have a hard time accepting diversity or, or looking at the actual research behind the success of what vision therapy can do for strabismus, and so that can be a difficult conversation.

Dr. Juanita Collier: With that, also asking about their continuing education because, you know, you want to make sure that they're having well rounded continuing education with what Jessica was just saying. If all of your continuing education is just on different surgical approaches, then there might be a whole other aspect of holistic vision care that you might be missing out on.

And so I think that it's a good idea to make sure that That doctor is also committed to having a holistic approach because your child is not just two or you as an adult, you're not just two eyeballs like you're connected to a whole body and what are the requirements of that body? What are the daily activities of that body and how does your vision connect with what needs to happen there? Because sometimes it's It's easy for some doctors to forget that everything kind of needs to be, be working together. 

Jessica Liedke: If a parent is looking into different options for their child, what steps should they take in being able to access some of this research or some of the bigger holistic view of what's happening? Where can they find this information and what should they do? 

Dr. Juanita Collier: Well, we have a lot of references in our show notes today, so they can look there. But also there are a lot of websites that have research articles, you can go to Google Scholar and type in, you know, surgical treatment for esotropia, and they'll find a million articles.

So I think that really just. I'm looking at scientific data, not really more. We want something that has like actual research as opposed to just people's opinions published in something. So we want actual scientific data that shows what's happening. What are the risk rates as far as your kiddos concerned, because you don't really want to have your child undergo surgery and then have a mistake happen.

And what are, what are the chances of that happening? Whereas with something like less invasive, like vision therapy, that's not going to happen, you know? So, um, we only want to put our kiddos under surgery if we have to, and we definitely want to know what all of the other options are prior to. And then when you're looking for a behavioral optometrist, some people say that they enjoy doing, you know, binocular vision or things like that.

But it's really a, a field where you have to really, really specialize. And that's the way that you can be up on all the most recent research and everything like that. So if it's somebody who like does some vision therapy on the side, that's not a person that I would. trust my child to have vision therapy with our office at 4D Vision Gym, all we do is vision therapy. We don't do anything else. So all conferences that we go to, you know, that's vision therapy except for, you know, the other ones required for my license and everything like that. But you know, that's kind of what our, what we do. So we've seen every type of strabismus.

We corrected every type of strabismus. We work with strabismus surgeons when necessary. We'll work with your occupational therapist. We'll work with your, your physical therapist, your speech therapist, your teachers, your school counselors. We'll do all of that because this is what we do. Whereas that's a little bit more difficult for a doctor who practices, you know, general optometry and has an interest in this.

And there are definitely diagnoses that can be corrected in those situations, but the amount of time that your doctor can put in to really making sure that. Your child is getting the best outcome possible is really what we want to look at, especially when you're treating something like strabismus. 

Jessica Liedke: So, this has been a very enlightening talk.

I'm really excited to hear from folks who listen in. Don't be afraid to reach out even if you're not local to us. If you're looking for resources in your area, you can reach out to us and we can, we can help you out. And, um, you know, we just, we just want to get the word out there that there are options and that all we want is, is these kids to, to have the best possible. you know, outcomes for them. So we're excited to hear from you and talk to you all and we will see you next time at our show. 

Dr. Juanita Collier: Have a great day. 

Jessica Liedke: Thank you for tuning in to this episode of the It Could Be Your Eyes Podcast.To schedule an appointment with Dr. Collier, visit us@4dvisiongym.com. To train your vision at home, visit us at 4D vision therapy@home.com. Rate and review our podcast and email a screenshot to receive 10% off a new evaluation or any of our digital programs. Subscribe to join us for more eye-opening episodes as we dive deep into all the ways that it could be your eyes.