From sci.med.vision Tue Oct 10 20:29:41 1995
Path: usenet.ucs.indiana.edu!vixen.cso.uiuc.edu!howland.reston.ans.net!news.sprintlink.net!news.seanet.com!andercoe.seanet.com!andercoe
From: andercoe@andercoe.seanet.com (John M. Anderson)
Newsgroups: sci.med.vision
Subject: Advice needed on strabismus surgery
Date: Sun, 1 Oct 1995 00:02:46 GMT

Our 2 year old daughter has strabismus.  Two pediatric opthamologists have
recommended eye surgery to straighten her eyes.  They have also told us that
if we wait too long to have the problem corrected, her eyes may never fuse.

Does anyone have any information on how often this surgery is 
successful, what problems can occur, and what alternatives there are.  
Are eye exercises or other non-surgical techniques successful?  Is the
surgery likely to help her eyes fuse or is more cosmetic?  Is waiting
longer a waste of time?  Does it reduce the chances that her eyes will
ever fuse? 

In general, I trust the opthamologists, but there are so many surgical
procedures (hysterectomies, heart bypasses, etc.) that are now viewed as
being performed too frequently, that I'm concerned surgery for strabismus
might someday be viewed the same way. 

Some more background on our daughter's case.

Our daughter did not have any obvious eye problems until March of this
year. In March she developed a minor cold.  Shortly after the cold, her
left eye would not turn out past center.  After consulting with a
neurologist and an opthamologist and having an MRI to rule out any more
serious cause, her condition was diagnosed as 6th nerve palsey.  Even
though the palsey effected her left eye, her right eye started wandering
and often crossed in.  She clearly favored her left eye.  Over the course
of two months, the palsey disappeared and she could turn her left eye all
the way out.  Nonetheless, her tendency to cross her right eye continued. 
The opthamologist said she was probably far sighted and the palsey had
caused her to stop fusing.  We tried patching the left eye, but she still
favored the left eye and wouldn't fuse.  She was given glasses, which
helped but she still favored the left eye and rarely fused.  Then they
tried a 15 degree prism on the left lense to blur her vision in her left
eye so she would use the right one.  This helped quite a bit.  With the
prism on, she would frequently use both eyes together.  When they reduced
the prism to 10 degrees, hoping to slowly wean her from the prism, her
eyes stop fusing. 

Now it has been roughly 6 months since the problem began and there hasn't
been any improvement for the last month.  Her opthamologist feels the time
has come for surgery.  We got a second opinion from another pediatric
opthamologist who agreed with the first one. 

We appreciate any advice anyone has.

John Anderson
Judy Coe
andercoe@seanet.com

------------------------------------------------------------------
------------------------------------------------------------------

Run immediately for a second opinion of a behavioral optometrist!  We
have twice to three times the success rates without surgery!!!!

Please E-mail me where you are in the country and I will give you a
name of someone to get a second (sounds like a third actually) opinion.
 Surgery should be the final option after you have exhausted all
others!

Paul Harris O.D., F.C.O.V.D., F.A.C.B.O.
Director, Baltimore Academy for Behavioral Optometry

------------------------------------------------------------------
------------------------------------------------------------------

Paul-

Please post the citations that your success in the 2 year and younger age
group is 2-3 times that of surgery.  Congenital esotropia surgery has
roughly an 80% success rate.  Its hard for me to fathom a 160% to 240%
success rate. 

David Granet, MD

------------------------------------------------------------------
------------------------------------------------------------------

Bottom line here seems to depend totally on the definition of "success"
that you use!  I would highly doubt your 80% success rate unless you
are using a definition of within about 10-15 degrees of straight.  It
cannot be a functional definition.  The 80% you state is the highest I
have ever seen in the ophthalmological literature for cosmesis only,
not for function!  

We in optometry deal much more with assessing functional cures and do
not consider a cosmetic cure only (meaning looks straight but does not
have binocularity) a success.  Help me here understand your criteria.

For the most part what we have seen from your literature is in the
30-35% functional cure rates and 60-65% cosmesis following one surgery.
 Granted, your techniques are better now than when these studies were
done but I don't see how the functional cure rate has gotten up in the
80% range at all!

The articles that I could site off the top of my head are written by
Ludlum and Flax and Etting and appear in the Journal of the American
Optometric Association or the American Academy of Optometry.  I'll look
em up while off line and put up another message later with the
articles.

------------------------------------------------------------------
------------------------------------------------------------------

Paul:
>> Run immediately for a second opinion of a behavioral optometrist!  We
>> have twice to three times the success rates without surgery!!!!

David Granet:
>Please post the citations that your success in the 2 year and younger age
>group is 2-3 times that of surgery.  Congenital esotropia surgery has
>roughly an 80% success rate.  Its hard for me to fathom a 160% to 240%
>success rate. 

David, the original poster was concerned with a case of ACQUIRED, not
congenital esotropia. Nor was Paul talking about congenital esotropia. 
Why do you bring up the success rate for congenital esotropia surgery? 

John M. Anderson :
>Our daughter did not have any obvious eye problems until March of this
>year. In March she developed a minor cold.  Shortly after the cold, her
>left eye would not turn out past center. 

What is the surgical success rate for this kind of esotropia, David? 
Please post citations.

--Alex


------------------------------------------------------------------
------------------------------------------------------------------

> 
> David, the original poster was concerned with a case of ACQUIRED, not
> congenital esotropia. Nor was Paul talking about congenital esotropia. 

Alex you have always wanted to see discussions amongst eye care
specialists on-line yet you insist on jumping in to the discussion to
speak for Paul Harris.  He strikes me as being able to reply for himself. 


I guess its just anothe "Look at me, look at me now !"  call from you.


David Granet, MD
------------------------------------------------------------------
------------------------------------------------------------------

> We in optometry deal much more with assessing functional cures and do
> not consider a cosmetic cure only (meaning looks straight but does not
> have binocularity) a success.  Help me here understand your criteria.


What do you mean by functional ?  Are you using a specific test of
binocularity ?  Grade of fusion, degree of stereo ?  I am not aware of any
level of binocualrity in congenital esotropes using non-surgical methods. 
                         ^^^^^^^^^^^^^^^^^^^^

(I guess one could use 45 prism diopter glasses on a 6 month old but I've
never seen it)


David Granet, MD

[Emphasis on congenital esotropes mine --A.E]
------------------------------------------------------------------
------------------------------------------------------------------


We tend to use Flom's criteria.  Are you familiar with them???

Paul Harris, O.D., F.C.O.V.D., F.A.C.B.O.
Director, Baltimore Academy for Behavioral Optometry

------------------------------------------------------------------
------------------------------------------------------------------


David:
>Alex you have always wanted to see discussions amongst eye care
>specialists on-line yet you insist on jumping in to the discussion to
>speak for Paul Harris. He strikes me as being able to reply for himself. 

I am the Alex. I speak for myself. I caught you making some very sloppy
reasoning, and will not let it slide. Shouldn't I expect high-quality
reasoning from you?

Now then.

Paul was telling John Anderson to take his son[*] to a behavioral
optometrist, because, Paul claims, behavioral optometry's methods are 2-3
times more sucessful than surgery at treating esotropia. You then said
that the success rate for surgery on CONGENITAL esotropia is 80%, as if
that was a contradiction to Paul's statment about the success rate
for esotropia treatment IN GENERAL. You then proceded to ridicule Dr.
Harris, asking for the studies showing a 240% congenital strabismus
success rate. 

But John's son's strabismus was ACQUIRED...

John M. Anderson :
>Our daughter did not have any obvious eye problems until March of this
>year. In March she developed a minor cold.  Shortly after the cold, her
>left eye would not turn out past center. 

For the second time, David, what is the surgical success rate for this
kind of esotropia? And don't forget to give us the references to the
double-blind-cross-eyed studies that support the statistic. 


--Alex

[*] Acutally it was his daughter! (See quote!) I admit I screwed up on 
this post! Funny David didn't catch me on this one!
------------------------------------------------------------------
------------------------------------------------------------------



> I am the Alex. I speak for myself. I caught you making some very sloppy
> reasoning, and will not let it slide.


"I am the Alex".  Is this using the third person ?  Are you that full of
yourself to address yourself in this way ?  This is like saying, "I am the
King".  Earn something, anything, and then take pride.

As to your expertise, in this field, everyone on-line here already knows
it is non-existent.  

David

------------------------------------------------------------------
------------------------------------------------------------------

As an expert in semantics, I felt it is my duty to point out your
misleading conflation of "acquired" and "congenital". 

John Anderson wanted to know if surgery was the best thing for his child, 
  who had acquired esotropia at the age of 2 after having a cold.

Paul said behavioral optometrists' therapy is 2-3 times more successful than 
  surgery for esotropia.

You said, no, that can't be true because surgery for acquired esotropia
  is 80%.

As I have pointed out several times, you simply cannot contradict a
statement about the relative success rate of esotropia treatments with a
statisic on the success rate for ONE TYPE of esotropia. All the more so,
when it is precisely NOT THAT TYPE of estotropia that is in question. If a
man wants to know how much vitamin C apples have, do you quote statistics
on oranges? Of course not. If a man wants to know if surgery will help 
his child with acquired esotropia, do you reassure him with a statistic 
on congenital esotropia?

Well, I guess the laws of logic don't apply when doctors are trying to talk
people into surgery. 

As a citizen with an interest in eyecare issues, I would like to know the 
statistic you are taking such pains to avoid discussing.

What is the success rate for surgery on acquired esotropia?

--Alex

I am the Alex. I speak for myself. I don't need a thneed.
(Apologies to Dr. Seuss)

------------------------------------------------------------------
------------------------------------------------------------------


> What is the success rate for surgery on acquired esotropia?

Alex, you have given advice to many different folks on-line previously.  I
am shocked that you ask the above question without recognizing its
inherent catch-22.

While I am more than willing to discuss eye care issues on-line I have not
and (as you know) will not tutor you on-line.  Your chotzpah in giving
advice in a field you continually demonstrate that you are exceedingly
unfamiliar with is mind boggling.

I advise once again that your *extended and tedious* education take place
at your university.

Best of luck in your education.  Stop back in after it has actually begun.