infant with crossed and bulged eyes -- update

[crescentstreet]

hello, i wanted to follow up and, as you requested, keep you posted on our visit to the pediatric ophthalmologist yesterday.  she said no strabismus, so i am definitely relieved and reassured about that.  i still am wondering, though, what accounts for the bulged look of my son's eys.  our pediatrician said he's perfectly healthy as well.  so my question is this:  it is the ciliary body that produces aqueous humor, right?  so then is it possible that while my son looked intensely at the mobile, having to converge his eyes, his eyes produced extra aqueous humor that has increased the anterior chamber pressure, thus proutruding the front part of his eyes and possibly bulging forward his cornea?  (i am looking at his old pictures, and i see that the surface of his cornea is more curved now than before.) could this explain the intense look and even smaller appearance of his eyes?  if so, will the anterior chamber pressure correct itself eventually and cornea flatten out itself?  does this make him more myopic that he otherwise would be?  what's the remedy, both for his vision and the changed appearance of his eyes?  thanks so much.

[crescentstreet]

thank you.  i will keep you posted after our follow-up appointment.

[John C Hagan III, MD, FACS, FAAO]

Pseudostrabismus goes away with time as the inner aspect of the eyelids goes into the adult shape which is "pointed", the infant has a semi-circular fold of skin (epicanthal fold) that is stretched as the eye grows. It does not interfer with vision development. Strabismus does not develop due to environmental stimuli  (you cannot not cause it be making the child look at books, your face, toys, etc).

JCH III MD

[crescentstreet]

thank you-- i will really relax. i promise. i am very interested in understanding how things work, in addition to being an anxious mom, so i tend to have lots of questions.  just one question i asked you earlier but didn't get answered:  can the appearance of pseudo strabismus worsen due to environmental condition, such as focusing on objects too close?  also, if he doesn't have strabismus, will his eye muscles develop normally, despite his tendency to converge his eyes?  

thank you for telling me that you and your wife were just as cautious with your first child.  i appreciate that.

[John C Hagan III, MD, FACS, FAAO]

That's okay first mom, my wife and I were that way with our first child also.  The pediatric ophthalmologist has all the training of a regular ophthalmologist (usually 12 years) plus a year or two extra doing mailing eye muscle (strabismus) treatment and surgery. They are highly trained to note "normal" from "abnormal".  The best bet is just to work closely with your Ped Ophthal to watch your child develop. Two months is even better than 6 months. If the PO see's any pathology developting they have all kinds of tools to work with: glasses, surgery, patching, drops.

JCH III MD

[crescentstreet]

thank you for advising me not to seek out acupuncture and chiropractic.  i was very skeptical myself. the first PO told me to bring him back in two months, which i will.   i promise i will relax and this will be the last question i will ask you:  can this be a permanent cosmetic problem?  or will his eye muscles learn to uncross?   thank you so much for your patience with me.  this is my first baby, can you tell?  thank you again.  i'm so grateful to you for allyour questions.

[John C Hagan]

Chiropractic and acupuncture are totally worthless for strabismus and eye problems. I have seen an infant injured while receiving chiropractic treatment for crossed eyes. None of the eye nerves for eye alignment are in the neck or back all in the skull.

If you are unable to relax, and you don't seem to be able to do so, then I would seek a second opinion from another pediatric ophthalmologist if you don't think you can wait for a 6 months recheck.

I've gone about as far as I can go in this forum. You should also feel free to call the first ophthalmologist that checked your child with additional questions.

JCH III MD   Eye Physician & Surgeon

[crescentstreet]

thank you.  i will try to relax.  he looks at things impossibly close to him, severely crossing his eyes, and i have to say his eyes look even more crowded toward his nose than before.  this worries me a great deal.  even if it may not lead to a medical problem, this could potentially be a permanent cosmetic problem?  will his eye muscles know not to stay crossed like this?  i was thinking about acupuncture or chiropractic care for him to correct this appearance of crossed eyes.  do you have any feelings about the efficacy of these treatments for crossed eyes?  thanks so much!!

[John C Hagan]

No you do not need to restrict his using his eyes at all, in fact that would be harmful. Much of the world that interests him/her is "up close and personal".   Main thing relax and have re-check in 6 months or as the pediatric ophthalmologis directed.

JCH III MD

[crescentstreet]

thank you!  so it's okay to let my son keep focusing on close objects then as he tends to do?  no need to discourage him from doing that then? it doesn't make his eyes appear even more crossed?  thanks so much.

[John C Hagan III, MD, FACS, FAAO]

Esophoria or a latent tendency for the eyes to cross but controled by the fusion centers of the brain normally does not need treatment and is considered normal (I'm an eye surgeon and I have wonderful vision and perfect depth perception but I have exotrophia  (out tendency).  It's best NOT to do anything and let the fusions centers work on their own and develop naturally. Glasses are used mainly for esotropia and accommodative esotrophia.

The pediatric eye physician checked on the eye alignment using the light reflex centration on the cornea. Sometimes they even take a picture and look for the location of the "red" reflex.

I would accept the word of the ophthalmologist and stop worrying. Just watch for new problems and have your child rechecked in 6 months. If you do not have strabismus in your family the risk of strabismus is 1-2%.

JCH III MD FACS

[crescentstreet]

thanks so much.  i too am glad and relieved that he doesn't have strabismus.  but is it possible that even though he doesn't have esoTROPIA that he might still have esoPHORIA?  even though he seems to be able to achieve fusion and move his eyes together, there may still be muscle imbalance that makes his natural resting state to converge rather than stay straight? his eyes definitely have the appearance of being crossed.  the pediatric ophthalmologist did not do the cover-the-one-eye test, which is the only way to tell if he has esophoria, isn't it?  what is the remedy for esophoria? glasses? surgery?  it makes sense to me that in his very delicate stage of developing eye muscles that if he crossed his eyes intensely for a couple hours to look at this mobile that his eye muscles might develop and stay that way.  is it possible?  he's also wanting to focus on impossibly close objects, coverging his eyes severely.  should i discourage him from doing this sort of focusing?  or will he outgrow this when he can focus naturally without trying so hard?  i feel like this is the time -- while his eye muscles are still forming and developing -- to correct any problems he may have, so i'd hate to miss any signs of trouble now.  thanks so much again.

[John C Hagan III, MD, FACS, FAAO]

The ciliary body would not respond like that and produce more fluid. It produces aqueous slowly like water seeping slowly out of the ground, it's not like a water faucet that shuts on and off and goes up to large volumes.

If the eys are normal two things can make the eyes look bulgy. One is if the lids are higher than normal that makes the eye look big. Second is that some people have shallow eye sockets and it gives they a big eyed appearance even though the eye may be of normal size.

There is a condition called megalocornea in which the cornea is much larger than normal. The pediatric ophthalmologist should have seen that.

Probably the best thing is to continue to watch for new symptoms or worsening of the things your notice. And consider a follow up exam with the Pediatric ophthalmologist in 6 months in any case.

JCH III MD       PS very glad the exam was normal.