Sudden crossed eye at 6 years old

[mary815]

My daughter was diagnosed with amblyopia and strabismus at the end of her 5th year by the nurse at her school conducting the kindergarden eye exams and began wearing glasses as soon as she turned six.  Her eyes never crossed.  After having the glasses for 12 weeks I noticed her eye would cross inward after we returned from a vacation in Mexico where she didn't wear her glasses alot due to playing in the ocean, pool, etc.  Her eye crosses even when she has her glasses on.  It doesn't occur all the time, just intermittently.  I took her to see our doctor who said that it is common with amblyopia (especially since she was very tired and was also ill from our trip) and for me not to be alarmed.  He checked her vision with the glasses on, and it was no worse than the last time we had them checked at her 8 week appointment.   He said the glasses are helping, but I'm so confused since her eyes never crossed before this.

Is the crossed-eye something that could correct itself with glasses or will she always have it?  When is surgery presented as an option?  Since my daughters symptoms didn't present themselves until she was six, is that too late for a good prognosis?  

Please help.  

[Joan M Pernoud, MD]

Dear Mary,

If your doctor is a pediatric ophthalmologist, it could be that waiting is just to see if your daughter's vision will come up on it's own after a few visits. Since the vision is pretty good, it may not take too long to bring it up with patching and maybe that is why your doctor is waiting. You might wish to bring your questions to your doctor so that you feel satisfied that they are all answered.

The orthoptist is a secondary referral ordinarily from your doctor. Sometimes this does not need to be done because the doctor does not need the information for the best possible treatment.

I would still like to see some pretty quick improvement in the vision sooner rather than later. Do not hesitate to keep me posted in the future on a new question as I don't follow-up more than a day or two. All the best.

[mary815]

Thank you again for the response.  Just so you know, the doctor she has been seeing is a well respected pediatric opthalmologist.  

I'm curious as to when a patient is seen by orthoptists.  I live in the Bay Area and Stanford is not too far away.  Should I investigate having her evaluated?  Or is that just for AFTER she has reached her "maximum vision" and before possible surgery to correct the crossed eye?  Would it only happen at the recommendation of her pediatric opthalmologist?

Thanks again.  I appreciate your insight into "microstrabismus" and for suggesting a second opinion.  You are so kind.

[Joan M Pernoud, MD]

Classically if the best vision is not obtained by age seven, it may never happen. However, cases have been reported that still improve after age seven. So, if she were my daughter, I would patch her until she got to a vision which did not improve after patching of at least 3 months. Even 20/20 in a lazy eye may not be the same quality and may drop back although in theory once it achieves the best vision level it could always get there again. Sio I would go for a really good 20/20 or even 20/15 if possible.

The relationship of the two eyes have probably already been established and it is doubtful that her eyes will work together perfectly because her brain has just not adjusted to complete binocular vision over the years which is not to say that she has no depth perception because there are degrees of depth perception. There is probably not much to do about this relationship at this point.

There are specially trained individuals at university medical centers who are trained to evaluate the sensory relationship of the two eyes. They are known as orthoptists and they give ophthalmologists important information in their testing as to how welll the two eyes work together which is especially important in preparation for any possible surgery to estimate how well the eyes work together after the surgery.

Your daughter probably had "microstrabismus" which finally broke down into regular visible strabismus. This is not rare. Be thankful that her lazy eye is as good as it is as many are 20/200 when discovered.

I would consider getting a second opinion about the patching. You may wish to see a pediatric ophthalmologist.

[mary815]

Thank you for your response.  Regarding her vision, her "good eye" is at 20/20 and her amblyopic eye is at 20/40 with glasses.  She does have amblyopia, however, her doctor said patching was NOT necessary at this point because the vision in the weaker eye had not gotten any worse.  Should I get a second opinion?  I was surprised because I was ready to hear she needed patching.  However, I'm interested in how you said the crossing could be due to resistance of the eyes working together.  How do you determine if that's the case?  

My husband and I are just blown away at how she NEVER showed one sign of strabismus until the Friday after Thanksgiving.  I understand the fatigue issue, etc., but it seems like all of this has just hit us at once and she was six in August!  

At what age do they determine that the lazy eye vision is as good as possible?  I would think that if she still had major issues with a crossed eye, then surgery could be performed?

Thank you again.  

[Joan M Pernoud, MD]

You did not state what your daughter's vision is. I would be most concerned with this as it is true that if the vision is not cranked up to equal to the other eye before age seven or so, it will be destined to be subnormal of various degree. If she has amblyopia (lazy eye) she should be getting some sort of treatment to stimulate vision in the lazy eye such as occlusion or eyedrop therapy.

The second issue is the straightness of her eyes. Strabismus is a condition where the eyes are not perfectly straight...this may be hardly noticeable or very noticeable but testing by the doctor can detect this. This often worsens with fatique or sickness as the eye muscles do not work as hard to keep the eyes straight when they are tired, like every other muscle in the body.

The more noticeable crossed eyes could be some resistance of the eyes to work perfectly together as they were almost surely not working perfectly well together before.

Make sure you are seeing an eye MD ophthalmologist for your daughter's care. Surgery should not be considered until the lazy eye vision is as good as possible and then only if needed for best possible straightness.