Strabismus 1
Running Head: STRABISMUS AND COMPLICATING VISUAL IMPAIRMENTS
Child with Strabismusand Complicating Visual Impairments:
A Case Study
Audra Bishop
Elisabeth Cohen, PhD
Beth Moline
Stephen F. Austin University
Case Study: Strabismus
General Information
Name:“MC”
Birthday:11/24/2002
Age at first visit:3 years, 11 months
General Health Status: good
Chief Complaint:Parents noticed that MC sat close to the TV, and held books close. His eyes began to cross, and at times did not seem to focus. Mother noticed a vertical deviation of the left eye as well.
Initial diagnosis: Accommodative Esotropia (Strabismus), amblyopia OS
Background:
“MC” was born in Saratov, Russia and immediately hospitalized for a rare infection, MorganaMorganella, in his intestinal tract. Information on his birth mother and any prenatal care is incomplete. Following two months of hospitalization he was moved to an orphanage and placed for adoption. At that time MC, who was extremely small, was given diagnoses of microcephaly and failure to thrive. At 6 months of age he was adopted and brought to the United States where he was immediately hospitalized for infection, which had moved to his urinary tract, an ulcer, and chronic reflux. At that time he weighed only 10 lbs. MC’s health improved over time, although he remained small for his age and slightly behind his same-age peers in developmental milestones.
The first indication that vision would be a problem was during preschool when, at the age of three, slow development of letter and number recognition and writing skills led to a referral to an occupational therapist. MC was diagnosed with a sensory integration issue. Shortly thereafter, both parents noticed changes in MC’s eyes, and problems such as standing directly in front of the television, or leaning close to books and art paper. Shortly before his 4th birthday, he went for his first eye visit. He was given a possible diagnosis of accommodative esotropia and amblyopia OS. His initial visual acuity was tested with HOTV at OD 20/50 and OS 20/100. Treatment was patching of right eye 5 hours per day, and glasses. His parents were advised at this time that surgery would be necessary in the future.
MC was seen every 2-3 months following his initial exam. In the late spring of 2007, using a Fundus exam, the doctor noted that while his right optic nerve was normal, his left was dysmorphic by comparison, was oval with a large pigmented lesion on the left side of the disc. MC was scheduled for an MRI to check the optic nerve. The MRI showed no intracranial abnormality and no orbital abnormality.
MC was seen at the end of his first preschool year to schedule his first surgery. At that time he had a firm diagnosis of accommodative esotropia, amblyopia OS, and dysmorphic nerve OS. His corrected visual acuity, tested with HOTV, was OD 20/25 and OS 20/60. He was patching 5 hours daily. Educational implications at this time included: full-time private OT services for sensory integration issues and handwriting, use of Atropine drops for chemical patching at school, use of prescription sunglasses when out-of-doors, working with teachers to explain visual issues. MC was approximately 1 year behind peers in writing and learning letters and numbers. While he enjoyed being read to, he was not able to pick out simple words.
MC’s first surgery was performed in August, 2007 by Dr. Stager, Sr. He had recessed medial rectus preformed on both eyes, and tenotomy preformed on his right superior oblique. Although MC had moderate tissue reaction to the surgery, it was successful. At his post-operative check-up, his visual acuity corrected tested OD 20/25, OS 20/50, patching was reduced to 4 hours per day, atropine was discontinued, and weaker glasses with a prism were ordered.
MC’s second surgery was performed in December to recess his right inferior oblique. At his post-operative check his corrected visual acuity tested OD 20/20, OS 20/50. The doctor again lessened the strength of glasses, included a prism, and reduced number of hours per day of patching.
In March, 2007 MC’s corrected visual acuity tested with HOTV OD 20/25, OS 20/30. His eyes were holding in a straight position. The Fundus exam, however, indicated that his left optic nerve continued to be tilted, with some distortion. His glasses were again weakened. Educational issues at the end of his second year of preschool were: continued work with OT on sensory integration and handwriting, patching at school as necessary (parents attempted to patch at home as much as possible), prescription sunglasses and prescription goggles for swim lessons. MC continued to perform behind peers in academics.
MC continued with eye check-ups every 3-4 months, and part-time patching (hours gradually reduced to 2 per day.) His third and final surgery was in October, 2008, when his left eye again began to drift. His left lateral rectus was recessed 8.5 mm with supraplacement 1/2 tendon width. Following surgery MC’s corrected acuity was OD 20/25, OS 20/50. He again began patching.
Following this final surgery MC’s eyes held steady in a forward position. His visual acuity showed some small fluctuations, but also remained somewhat constant at OD 20/20, OS 20/40. He has monocular vision. His depth perception, which has been virtually nonexistent, has shown some improvement over the last year. he continues to patch his left eye 2 hours per day, and will continue to do so until he is 9 years of age. At that time, the doctor has predicted that he will not retain the visual acuity he now has in his left eye; however, should his right eye ever be damaged, his left eye should improve up to its best visual acuity achieved.
Final Diagnosis: Accommodative Esotropia OS (with some nonaccommodative aspects, esotropia OD), amblyopia, dysmorphic nerve OS
Outcome: good
Educational implications: All patching is done at home so this no longer affects school work. MC remains approximately 1 year behind his peers and will be repeating 1st grade. He favors his right eye, a problem that can usually be addressed by letting his teacher know and seating him with his right side toward the chalk board. Because he has monocular vision and relies on his right eye, his parents need to be aware of eye strain. However, in all other respects MC’s vision no longer affects his school performance.
References
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Moss, M. (2005). Amblyopia. Pediatrics for Parents, 22(3), 10-11. Retrieved from Health Source - Consumer Edition database.
Stein, H. A., Slatt, B. J., & Stein, R. M. (1994). The ophthalmic assistant (6th ed.). Saint Louis: Mosby.
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