Strabismus - After Botox / Surgery

[MrsHManchester]

Hello,

My 10 month old has strabismus and also nystigma.  It was diagnosed at 6 months and treated in France with eye patches firstly, then a Botox treatment at 9 months, we are now waiting to see what the result is of the botox after 3-4 months, at the same time continuing the use of patches, with a visit to the Optomologist every 1-2 weeks.

So far his previously outturned eyes now focus centrally when the opposite eye is covered, however when both eyes are uncovered he only uses one eye, the other one drifiting aside. I wondered how the eyes would work together and when I asked the surgeon who carried out the Botox treatment yesterday, I was a little confused about what he told me.  He said that using the two eyes together is something the brain learns to do within the first 3 months of life and that if not developed during this time then they would never learn to work together.  Even though his eyes could be corrected (with botox or surgery) so that they looked straight ahead, they would never work together. But this seems to conflict with most of what I have read online  Also this leaves me with lots of questions:

- Will this affect his vision long term?
- Even with straight eyes, will it be obvious he is looking with one eye at a time only?
- Is he likely to compensate by closing an eye or dropping an eye lid to use one eye only?
- Will it be obvious cosmetically that his eyes are not working together?
- Will it restrict him from doing anything? sports, occupations etc?

I am going to go back to the doctor again but wondered if anyone could make sense of this for me?

[Michael J Kutryb, MD]

The one problem here is the issue of nystagmus.  Nystagmus could pose a problem - because it cannot usually be corrected with treatment or surgery.  Now exotropia may respond well to surgery and sometimes children can develop different levels of fusion (both eyes working together.)  Even if eyes don't get 100% fusion, if they are very close, people can develop monofixation syndrome where eyes still work fairly well together but don't have perfect 3D depth perception.

Usually with successful treatment for strabismus - the child would look mostly to have straight eyes or very close to straight.  Could take more than one surgery.  I don't normally see successfully treated children closing one eye.  Remember, however that years of strong glasses and patching or dilating drops (instead of patching) could be in order.  As far as occupation - there's is a possibility that child could  not be fighter pilot, brain surgeon, eye surgeon, professional baseball player - or other things that require perfect vision - but you never want to put limits on people - especially with all the inspirational stories I see all the time.

MJK MD

[Michael J Kutryb, MD]

Regarding your child's nytagmus - I can't make too much comment - I don't know type and degree of nystagmus so don't want to make assumptions.  I hope you have an excellent pediatric ophthalmologist because you really need one.

MJK MD

[signe778]

A related discussion, Botox eye surgery gone bad? was started.

[pankajsarkar]

A related discussion, strabisums botox was started.

[Michael J Kutryb, MD]

Awesome story - I just love hearing things like that!  Thank you so much for sharing.  

MJK MD

[NorthernLight]

Here's something that might make you feel better, and have a good outlook for your child's future.  
I'm 46 years old and have had nystagmus since sometime in my early infancy.  I also have had surgery to basically "straighten" out my eyes.  However, there will always be the constant movement.  I am also a successful Operating Room Technician which requires fine motor skills, and depth perception. Funny though...I don't have depth perception. lol  Somehow, by the grace of God, I manage to cut the suture..not the docs fingers!   Our brains are miraculous...I manage to compensate for so much.   I have learned to memorize where all of my instruments are, and distances between things, so I can "see"  without even looking back at what I'm grabbing.    Now here's the clincher....I am even able to have lasik to correct my vision which has always required contact lenses.  Pretty amazing what can be done!   No one says anything to me about my eyes.   When I was young my parents never even mentioned to me that I had limitations with my vision.   I might not be a brain surgeon..but..hey, I'm still in the operating room assisting!  
  

[MrsHManchester]

Thank you so much for your answer and speed!  It was very useful and reassuring.  Just one more thing, regards the nystagmus, you mention that this could be a problem.  Can you explain a bit more about this. The effects I think are related to this (flickering eye, my baby lifting his head to focus his eyes) have stopped since the botox but the doctor explained that this may or may not be a permanent thing... just have to wait for the botox to expire, would like your advice though.

[mooduk]

Our daughter has alternating, variable esotropia has part of her cerebral vision impairment.  She uses one eye alternately sometimes (she's 9 now).  Bifocals have helped her use both eyes together so she has developed nearly normal depth perception.  However, without her glasses, her eyes are all over the place.  A parent on swim team came up and asked me if someone couldn't please fix her eyes!  Unfortunately, we've been told surgery won't help because the strabismus is variable.  Even with her glasses, her eyes drift occasionally - its very fast so often we catch it only in family photos.

Is your son a preemie?  Mooduk