Overcorrection for 9 year old with accommodative esotropia

Dr.Hagan,  my daughter's diagnosis is accomodative esotropia and she has an astigmatism in her right eye.  I am worried about her worsening vision without glasses.  She sees a peidiatric opthomolgist. Her prescription in October 2011 was quickly outdated as by January 2012 she could not see the chalk board at school with her glasses on however, she could see it with them off.  

The ped opto's nurse initially refused to test her eyes with her glasses off but eventually gave in because she could not even identiify the big letters on the eye chart with them on.  She received a new weaker prescription that was filled in February 2012.    The doctor commented that it was odd that she grew out (lower presription strenght) of those glasses so fast.

In December 2012 she told me that she again could not see the chalk board but this time with or WITHOUT the glasses. We went to the eye appt this week (February 2013) and they again refused to take the eye test with the glasses off. They said that did not matter.  I insisted and they did.  The nurse said her vision is great with the glasses off in each eye for distance 20/20.  I told them this is not the case as she cannot even read a large street sign or notes on our refrigerator!  Theyjust kind of ignored my concern.  They asked if she had a growth spurt because they had no explanation as to why the prescription needed to be lowered 2 diaptors (SP) except maybe a growth spurt. She has barely grown a half inch over the last year.

Later that day, I realized that they tested her vision without the glasses while covering  one eye and then the other. When i asked my child to cover one eye her sight was fine but not with both open at the same time at all.  

This did not used to be the case.

I called back to express my concern about the worsening vision  without  glasses and explained about her not seeing with both eyes open.  The tech told me that the doctor is more concerned with keeping the eye from turning and her seeing WITH the glasses than without.  She had nothing to say about the fact that the vision is worse now without glasses at all.  Before they had said she would probably not need glasses at all once she hit the teen years and now they say she probably will always need them to keep the eye from turning. The tech did say that the last prescription appears  to have been an over correction. I have been voicing concern all along about over correction as i have the same dianosis and have had glasses since age 4 myself.

We are awating the new glasses but i am still concerned about the fact that her vision with out the glasses is not good at all.  I am not sure what the old prescription was but the current one is R = +3.50 +0.50 100  L = +4.50
Thanks for any info you can offer.

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

I love to talk and explain things to my patients. But in the US there is a huge shortage of physicians, pediatric ophthalmologists being one of the most critical shortages, and a massive number of new people that must be seen under the ACA act.  Physicians my age (60's) are retiring early and medical students are graduating with debts of about $100,000 and cardiac and neurosurgeons almost a quarter of a million dollars of debt. Plus Medicare and Medicaid reimbursement to physicians decreases every year.

The bottom line is that all physicians are under huge time pressure to see more patients and spend less time with them. I find this terrible both as a physician and as a patient. My fear is that Medicine will become so unattractive to our best and brightest young women and men that doctoring will be 'dumbed down'

Best of luck and be sure, as I said that all blood relatives have their childred checked at young age say no later than age 3.

JCH MD

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

You do not have a level of unerstanding of accommodative esotrophia that a parent should have. I suggest you read the sections on wikipedia and emedicine.

The child with accommodative ET is hyperopic and can see without the glasses. The problem is when the child focuses to see clearly it pull one eye out of line. The brain then sees double and the brain suppresses the vision in one eye (central vision not peripheral vision) and the eye become amblyopic. This may be permanent if not corrected early with glasses, patching, often bifocals and sometimes with surgery which DOES NOT eliminate the need for glasses.

Vision is always tested each eye separately. With accommodative ET is is the vision with glasses that is the most important and on follow up visits the vision may not be tested without glasses.

The eye can become less hyperopic as it grows especially in adolescence.  Often a child will have blurred vision when they first get the glasses because the focus muscle cannot relax completely. Often it will take several weeks for the eye to let the glasses do the work. For that reason going without the glasses is generally a very bad idea and makes adjustment to the glasses, crossing and vision in one eye worse.

You should understand this by now.  Since you seem to have lost confidence in your peds ophthal consider getting a second opinion from another peds ophthalmologist.

Also realize this condition has a STRONG tendency to run in families have other children checked ad all blood related nieces, nephews and eventually grandchildren. the most common age of onset is age 2 to 4.

JCH MD

[janny47]

Dr. Hagan, thank you for your response. I want to clarify something please. I do understand completely what your have said about the ET and focusing.  As i said, i have lived (almost  50 years) with the same vision. Many in may family have as well.

I may not have been clear that my daughter does NOT routinely go without her glasses. I do know better than to allow that and she does as well. She puts them on first thing in the mornng all the way til bedtime and  has always embraced them.  

She went without only to see in school when she could no longer seethe chalk board writing with with them on when that pair became problematic within a few months (NOT WEEKS) of getting them. That was unusual for her and she knows what to expect in getting used to a new pair after 7 years.  While awaiting her appt that time, she wore them for general use but took them off to read the chalk board in class since she had no alternative until the visit and new prescription was issued.That was for about a week.

This time,  those glasses lasted about 8 months before she again said she can no longer see the chalk board writing. This time she ALSO now cannot see to read without them  - which was NOT the case last time.

What concerns me is that her vision without is worse and that in 8 months her prescription has needed to be reduced so much...2 diaptors. Also, the way her Ped OP reacted to the extent of the decrease in her new prescription as he kept saying how odd this is this soon and he seemed puzzled by it.

When she first saw him he predicted that when she entered teen years she may not even need glasses. She is  nine. Now he says she will most likely need them as an adult.

I also failed to mention that now her former dominant eye it is the eye that is turning in not the eye that was weak.  I have wondered it that is why she cannot see without them now. She has no "dominant eye" and they are both weak?

Several folks in my family have had this vision and I know that with me, my brain has always allowed my dominant eye (which was 20/20 until i reched 40)  to make up for the weak eye since I cannot read anything smaller than that big E on the chart with it.
  Until i reached 40 I had 20/20 with my "good eye" and never had problems seeing in general even with the lack of depth perception caused by it as it compensated for the weak one.

My eye does not cross because i did wear my glasses but i cannot read with it.  I do not want to find out in a few years that my daughter has great looking eyes that do not cross but she is hard pressed to see if she finds herself in a situation without the glasses.  I did not expect her to be that dependent on them based on my family history in dealing with this.

Right now, that seems where we are headed.  My daughter seems to have lost that ablity.  Should that be the case?

Thanks you for reviewing my clarification. I hope this sheds addtional light on my queston. Thanks again Dr.
  

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

With strabismus the first goal is to have good vision in each eye with whatever glasses RX that are necessary.

The second goal is to have cosmetically straight eyes with or without glasses as need be.

The third goal and the most difficult and often unachievable is to have good vision in each eye, to have them perfectly straight (both of these with glasses if needed) and to work perfectly together to give 100'% depth perception (which we call stereopsis)

My suggestion is to find the best pediatric ophthalmologist you can get to reasonably easy for a second opinion.  Your pediatrician may be able to refer you or you can go to www.geteyesmart.org to find one that, if you like better, you might continue care with.

JCH MD

[janny47]

Thank you so much for your additional response.

It really helps to have a  more clear understanding of the goals are for ET vision. I wish her Ped OP  had said this to us at the onset of treatment. This also helps me to understand how my vision ended up poor in that eye but my eye strait.  I will seek a second opinion.  Thanks so much Dr, Hagan!

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

I love to talk and explain things to my patients. But in the US there is a huge shortage of physicians, pediatric ophthalmologists being one of the most critical shortages, and a massive number of new people that must be seen under the ACA act.  Physicians my age (60's) are retiring early and medical students are graduating with debts of about $100,000 and cardiac and neurosurgeons almost a quarter of a million dollars of debt. Plus Medicare and Medicaid reimbursement to physicians decreases every year.

The bottom line is that all physicians are under huge time pressure to see more patients and spend less time with them. I find this terrible both as a physician and as a patient. My fear is that Medicine will become so unattractive to our best and brightest young women and men that doctoring will be 'dumbed down'

Best of luck and be sure, as I said that all blood relatives have their childred checked at young age say no later than age 3.

JCH MD