Mark Silverberg, MD, FAAP, FAAO
If you look at these 3 pictures, can you tell which child has a lazy eye? Frequently patients and physicians will be concerned about a child with a “lazy eye”. This is a common catch-all term, yet it can mean various things with different treatment implications. It can refer to a droopy lid (ptosis), an eye that is misaligned (strabismus), or an eye that appears normal with poor vision (amblyopia).
First, among the more obvious causes of a “lazy eye” is ptosis. Congenital ptosis is frequently due to poor development of the levator palpebrae muscle in the upper lid. Why is ptosis important in childhood? Primarily, an eye with a droopy lid is at risk for vision loss due to blockage of the upper visual field. Most notably if the lid is obscuring the pupil, the risk of vision loss is increased. However, even without pupil blockage there can be a threat to vision. Namely, an eye with ptosis is more prone to astigmatism as the upper lid induces warping of the cornea. Children with ptosis may require glasses to correct astigmatism and/or surgical correction to elevate the lid. When surgery is required, a “sling” procedure links the dysfunctional upper lid to the properly functioning frontalis. Frequently, children will require a second surgery later in childhood as the linkage ultimately wanes over time. However, the key is to clear the visual axis early in life so that proper vision can develop.
Second, children may have strabismus. Esotropia (eye going in) and exotropia (eye going out) are among the more common deviations. Some children with esotropia will have high underlying hyperopia (far-sightedness) and require glasses to improve their alignment (accommodative esotropia), while others are more than likely to require surgical correction (infantile esotropia). Patching the “good” eye can also be used in some cases. Children with exotropia may be managed initially with exercises and/or patching, although strabismus surgery is often required as well. Similar to ptosis, children may need more than one surgery.
Third, and less obvious, is amblyopia. This is the most common cause of vision impairment in childhood. While an eye might appear to be perfectly normal, it can still have profound vision loss! How is this possible? If one eye has a significantly different refractive error, the brain will start to favor the “good” eye, and ignore the “bad” eye. Over time, the eye with the higher refractive error will silently lose vision. The child will not complain or display signs of poor vision because they are able to rely on their “good” eye for daily activities.
Screening for amblyopia in the primary care office is vital, as detection is the key first step. Once an amblyopic eye is identified, it can usually be treated with glasses, patching, or atropine eye drops. After the age of 7 or 8 years, a child with amblyopia is more difficult to treat, so early detection and treatment are essential.
In summary, all three of these children in the photos could have a “lazy eye”. While the term “lazy eye” may have various meanings, thankfully we have successful treatment options available at Sansum Eye Center to treat common causes of vision impairment.
Dr. Mark Silverberg was nominated by his peers and selected as a Castle Connolly Top Doctor. He sees children at our Pediatric Ocular and Motility Center, a separate eye clinic for children where they are examined in a comfortable, relaxed atmosphere. Dr. Silverberg received his medical degree from the University of California, San Francisco and has been with SansumClinic since 2001.For more information or to schedule an appointment call (805) 681-8950.