Friday, November 15, 2013

FAQ: "I have a cross-eyed infant/child so what the hell am I supposed to do?!" - A guide based upon what I would have wanted my parents to know twenty years ago

NOTICE: I am not an optometrist or vision care professional. However, I have a lot of experience in dealing with strabismus and am well-read on the subject. As an independent patient who has no stake in your choice of practitioner I feel it is my moral duty to warn parents about possible pitfalls in the vision care system. Moreover I feel like I can lend special insight into a strabismic child's situation and visual development for two reasons. I used to be a strabismic child myself and after much trial and error in dealing with the medical system am only now undergoing healthy visual development as a conscious young adult. I don't want to imply I know thé truth about strabismus because it is a highly complex condition and every brain is different. Still I feel like my thoughts can be of great value to parents or fellow strabismics.

When babies are born with crossed eyes people often think the child is 'born with strabismus'. That's only half of the truth. Some sort of primitive vision already develops to some extent during pregnancy but more than anything else children are born with a 'clean visual slate' even if the eyes physically look crossed at birth. Vision develops as the infant's brain develops. I won't say genes don't play a role in the development of a person and the brain because they do, but very few diseases are truly 100% genetic. At least as important, if not more important, in the building of the brain and visual system are experience and environment. The great thing about that fact is that you as a parent can take action to improve your child's experience and in doing so improve the development of the visual system.
"A child is not born into the world with all of their vision skills in full operation. Rather, a child is born with the proper tools allowing their vision to interact with their environment in a meaningful way. It is the quality of this interaction that will ultimately determine the extent and ability of the child’s vision development. 

Vision is our dominant sense. There is more central nervous system area representing vision and related movement behaviors than with any of our other senses. Our vision system, although extremely complex, has the potential to operate effortlessly. Other areas of a child’s development, including language, curiosity, imagination, social skills, emotional development, fine and gross motor skills, and cognition depend upon how vision develops. It is as if vision is the rudder guiding the entire ship of a child’s development. 
When the child later enters this world fully prepared with well developed vision skills, then the process of learning is supported. When vision skills are not well developed, then learning is encumbered. Children not succeeding in school have been studied closely and were found to have a higher incidence of poorly developed vision skills compared to children succeeding in school.
From 'Fundamental vision development in infants
In short, vision problems are functional problems and not merely cosmetic ones! 

THE VISUAL SYSTEM: My own simplified and intuitive schematic
The visual system is a system. The organism, your child, already has the tools to develop good vision. It is your job to create the conditions under which this system can thrive by using the limited amount of energy your child has for vision development at any given time as optimally as possible. It's not surprising then that developmental optometrists often use words that resemble engineering lingo like degrees of freedom, stress, strain, load, plasticity, ... There are things you can do that are constructive and there are things that can be destructive such as, in extreme cases, child abuse. The fact that you are reading this blog entry clearly indicates that you are of the constructive kind.

There are far more detailed and accurate representations of the visual system out there but my simplified version is more accessible and just as effective in telling you what you need to know.

Based on my experience I would, for our purpose, divide the visual system into three parts.
1. Mechanics of the eye: flexibility of the eye lens and just general eye health.
2. The eye movements: alignment, ability to track, to execute saccades, ...
3. Processing of the visual input by the brain which in turn will determine many aspects of life and behavior.

Enlarge to learn about important pitfalls in the vision care system

One of the keys to building a better visual system is to avoid bottle necks and (visual) overloads. One visual skill supports the other and if you try too much at once the whole structure collapses.

Looking at my schematic, it is important to realize that only number 1. can be aided by optical correction (glasses). So in order to avoid a bottle neck in the system this is to be your first priority. Save the organism's energy by giving the child the best refractive correction. This way, energy that would be wasted by not having glasses can be relocated to number 2. and 3. Often getting the right kind of glasses already gets you half way through solving the problem.

Once you checked that box and your child still seems to be having inconsistent eye movements you will have to make sure the brain gets better at executing those movements. Basically the movements will have to be done more efficiently and get less energy consuming in order for your child to advance visually (and in life). This can be accomplished through Vision Therapy. There are many aspects of vision that are learned. With the proper environment and adequate vision stimulation, vision can be guided to assume its proper role as the dominant sense.
"By three months of age infants have begun to incorporate a time for exploring and a time for playing. Optometric vision therapy will best be included during this time. It is important that the activities be carried out while the baby is happy and free of the desire to satisfy a particular need. Optometric vision therapy, while the infant is hungry, sleepy, or unhappy is of little benefit. An ideal time usually occurs just after the baby’s bath.
The true change in vision behavior will come about by doing the activities on a regular basis as opposed to doing them for long stretches only intermittently.
The optimal situation in optometric vision therapy occurs when a parent recognizes the underlying visual skill that is being emphasized in the activity. Next the parent can see the potential to develop the same skill with other similar but distinct activities that their baby engages in naturally."
These excerpts are taken from a valuable paper called: Infant Vision Guidance: Fundamental Vision Development in Infancy. The best thing about this paper is that it outlines a number of procedures one can do at home to encourage visual development in infants so don't fail to read it. Also take a look at this great piece on the 'Three Keys to Effective Strabismus Treatment'. Vision is a sensory motor process so do not only focus on the eyes, overall motor development is crucial. Some parents whom I've talked to also seem to be getting great results with physical or chiropractic therapy as a supplement to Vision Therapy. Do consult with a developmental optometrist to know whether this might be appropriate. This article is no replacement for professional guidance but the more parents know and understand about what they are doing, the better!

The American Optometric Association recommends a comprehensive vision exam for ALL children at the following ages:
- 6 months
- At 3 years of age
- Every 2 years thereafter
Children who are found to be at risk for visual problems may be examined annually.

It is important to also emphasize that Vision Therapy is NOT age restricted but naturally takes a different form for older children and adults than for infants. If you want to know more about possible Vision Therapy procedures for older children or adults, learn about red green anaglyph glasses, prism flippers, accommodative flippers, the brock string, eccentric circles monocular fixation in a binocular field exercises, simple visual attention exercises, light therapy, stereograms, ... Once you understand the principle of red green anaglyph glasses the possibilities are endless as exemplified by anti-suppression tetris and 3D gaming. Especially when dealing with children I would nonetheless recommend involving a professional to oversee and measure progress.

My final piece of advise would be: think like a scientist. After reading this you already know a whole lot but it's important to realize this is a process you need to monitor. Make observations, learn, give up on flawed ideas, readjust, improve, persevere without pushing your child too much and use common sense. The developmental optometrist is there to help and advise you and measure progress but you are in a much better position to see how your kid's vision is evolving on a day to day basis. Speaking of scientists, reading or listening to the book 'Fixing My Gaze' by neuroscientist Susan Barry will go a long way towards understanding strabismus and what your child is experiencing.

If you have enjoyed or benefited from this and other blog entries, consider donating an amount as small as 5$ through the Paypal donate button. It's just the best feeling in the world to know your work is being appreciated. In addition, I can use some encouragement and financial support to do an even better job and get through my own visual rehabilitation. In a sense this article adds more value to people's lives than the overwhelming majority of eye care professionals who are misinforming and mistreating patients while being paid for it.  Even though I learned about these pitfalls in the strab-business the very hard way, I love working on vision related subjects and a little help would go a long way toward advancing my work of proliferating Vision Therapy as a vital treatment option for strabismus and amblyopia.

Last but not least, share this article on your favorite social network and give it a +1 on Google if you think other parents should be warned about these life altering pitfalls in the vision care system.

Thank you for reading and good luck in solving vision problems!

1 comment:

  1. Your observations are absolutely on point, Michael! If you are inclined, you would make an outstanding behavioral/developmental optometrist!

    Thanks for the work you do to help others with similar challenges!

    Samantha Slotnick, O.D., F.A.A.O., F.C.O.V.D.