DRIFTING AWAY:  IT REALLY ISN’T YOUR IMAGINATION!

A story by Cindy Avilla, C.O.

It is so adorable when your little girl closes one eye in the sunlight and gazes lovingly at you—a coy gesture due to her tender age, a real Kodak moment.  But then, you notice that she has one eye closed in every photograph taken outside, and even some shot inside.  Is this really just a cute reaction for the camera, or does it mean something more?

Your mother-in-law notices the abnormal eye position first.  “Her right eye was just sitting off to the side when she was looking out of the window!   But now it’s normal!”  You call to your daughter, and are relieved to notice nothing unusual when she turns in your direction.  Your mother-in-law was mistaken.  Still, that is the eye that she always closes in bright light.  No further incidents occur during your mother-in-law’s visit, but you vow to keep a closer watch.

And then your little one runs a fever.  Suddenly, that right eye is no longer sharing the same direction with its companion on the left, and even worse, your daughter talks of seeing “two mommies”!  This is obviously not the standard childhood illness with which you are familiar, so you frantically call the pediatrician, who is busy, attending to the daily crowd, and unable to speak with you at that moment.  The nurse promises to have the pediatrician call at the first available break in the regular office activity.

It is late in the afternoon before the pediatrician calls.  Your daughter’s fever isn’t unusually high, but the presence of the outward-drifted eye and double vision has created fear in an otherwise rational mother.  The pediatrician thinks that the fever is probably caused by a common childhood virus.  And the drifting eye may be caused by the fact that she is under-the-weather.  Just to be on the safe side, he recommends that you make an appointment to have her eyes examined by a local pediatric ophthalmologist, an eye doctor who specializes in children’s eye care.  You call the telephone number that the pediatrician has given you, but the office has closed for the day.  First thing in the morning…

The appointment scheduler for the pediatric ophthalmologist gives you the next available date, which is a month away!  Your daughter’s temperature has returned to normal:  she no longer sees “two mommies”, yet her right eye still turns out towards her ear. There are times that you are certain that her eyes are straight, so you watch her discreetly as she plays throughout the day.  The straightness of the eyes is definitely related to her sense of well-being, for the eyes drift more as nap time approaches.  And after an hour of sleep, the eyes are straight again.  But she continues to close her right eye in the sunlight.

The day of the appointment with the pediatric ophthalmologist finally arrives.  By then, you have determined that the eyes are straight at times, drifting outward at others, usually when she is sleepy.  And it is not just the right eye that wanders, for if she looks with her right eye, then the left will drift to the side.  The eyes always seem to focus well when the two of you are face-to-face, but as she gazes off into the distance, the drifting is apparent.

A certified orthoptist is an eye muscle specialist who is not a doctor but has received advanced education in eye problems that affect the way the eyes work together.  The orthoptist is an important team member who assists the pediatric ophthalmologist to examine children with “strabismus”, which describes any type of eye muscle imbalance, “like car is a vehicle that we drive, and Toyota Camry is the type of car”.  From the information that you have provided, Cindy, the orthoptist, says it sounds as if your daughter has “intermittent exotropia”, a condition where one, or either eye, may turn out some of the time and remain straight at others.  She tells you that the drifting becomes more obvious when the child is sleepy or not feeling well, situations that you have observed firsthand.

Cindy shows your daughter a pair of what look like inexpensive sunglasses, and asks her to wear them.  They are “magic sunglasses” and will make the several pictures in the book that she is holding “jump off the page”.  Your little one is a little nervous, so you put on the glasses first and are surprised by the three dimensional effect you see that is not present when the glasses are removed.  Your daughter is now eager to play the game, pointing enthusiastically at the pictures that appear to float over the page of the book.  The orthoptist explains that this is a test for depth perception, or stereopsis, and that the eyes must work together for the effect to occur.  She also tells you that the measurement of your daughter’s depth perception is completely normal.

After testing depth perception, the orthoptist measures the amount of the intermittent exotropia, the outward drift of either eye.  A children’s movie is playing on a television monitor at the end of the examination room, and she asks your daughter to tell her what is happening in the movie.  The DVD is one that you and your child have watched together often, and she excitedly describes the action on the screen.  At the same time, the orthoptist covers first one eye, and then the other, with a large spoon-like paddle called an occluder.  She explains that by alternating the occluder back and forth, without letting your daughter use her eyes together, she is able to bring out a larger amount of deviation than is present to casual observation.  From a box in a drawer, she picks a piece of triangular plastic and holds it over your daughter’s right eye, while continuing to cover the left eye with the occluder.  “This is called a prism, and it bends light that passes through it and places it on the place at the back of the eye where the vision is sharpest.  The fatter the prism, the larger the amount of eye muscle problem is present.”  You are stunned to see that it takes the fattest prism, the last one in the box, before the orthoptist finally places the tools of her trade back in the drawer.  Lastly, the orthoptist takes several pretty adhesive patches from a box sitting on the top of her desk.  She asks your little one to choose one, and explains that she will then cover one eye at a time to check the vision of each eye.  Four letters—H, O, T and V will be displayed on the video monitor, and your daughter will match the letter that she sees on the screen with one of the four letters printed on a card that she is holding.  The patch is placed over the left eye first, and as she matches the letters correctly, they are decreased in size, until they are so tiny you have trouble seeing them!  Then the patch is switched to the right eye and the game is repeated.  Again, she sees the very smallest size.  The orthoptist praises your daughter’s cooperation with the first part of the examination, and leaves the room to find the doctor.

The pediatric ophthalmologist enters the room, introduces himself and then immediately charms your little one by asking her about her favorite color and whether she likes puppies or kittens better.  He asks several questions that you have already answered, and then repeats a few of the same tests that the orthoptist and your daughter had done just minutes earlier.  He agrees with the measurements of the deviation that the orthoptist has obtained with the prisms, is pleased that your daughter’s vision and depth perception are normal but doesn’t appear happy that her eyes drift constantly as she gazes into the distance.   He then explains that he needs to look at the back of your daughter’s eyes and check her need for glasses, both of which require that the pupils of each eye be dilated with eye drops so that the most precise information is obtained.  The pediatric ophthalmologist takes two bottles from the cupboard above the desk.  The examination chair that your daughter has been sitting in is tilted backwards.  She grips the arms of the chairs tightly and starts to cry, but the pediatric ophthalmologist is very quick with the drops, and is already raising the chair back to its full, upright and locked position before the tears flow in earnest.  It’s time now to have a seat in the waiting room, for it will take about 30 minutes for the drops to work.

Thirty minutes later, you think of the Little Red Riding Hood fairy tale and the little girl’s remark when she mistook the wolf for her grandmother:  “Grandmother, what big eyes you have!”  The wolf must have been using dilating eye drops, because your daughter’s eyes are now as big and dark as the creature’s probably appeared to Red Riding Hood.  At that moment, the orthoptist calls you both to the examination room so that the pediatric ophthalmologist may finish the exam.

The pediatric ophthalmologist starts by dimming the room lights, then taking an instrument from a stand next to your daughter’s chair.  He opens a drawer in his desk that has a tray filled with lenses.  He explains that the instrument, which is the size of a standard ruler, is called a “retinoscope” and that he will use it to perform a “refraction”, a test that will determine if your child needs glasses.  He will shine the bright light from the retinoscope back and forth before each dilated pupil and adjust any movement that he sees with the lenses.  He first tests the right eye, and then repeats the test on the left eye.  He remarks that your little one doesn’t need glasses, that her refraction is “entirely normal for her age.”  He then removes an instrument from the wall that he places on his head, adjusting it to fit by turning a large screw at the back.  He turns on the instrument, which has a very bright light and grabs a large lens from the top of his desk.  The brightness of the light and the doctor’s strange appearance frightened the little girl and the large lens that he held just inches from her eye only caused her to become more upset.  However, he said that the lens allowed him to see inside her eye, that it made everything so big and clear that he could tell that everything was alright.

The room lights were turned on; the pediatric ophthalmologist adjusted his chair to face the little girl’s mother.  He explained that her daughter had an eye muscle condition called intermittent exotropia.  He said that the brain has the ability to recognize when the visual picture is not quite right and corrects it by making the eyes work together again.  This is called “fusion”.  One eye would drift out towards the ear, but fusion would cause the eye to re-adjust to the straight ahead position, in synch with the other eye.  Depth perception would disappear when the eyes drifted, but would recover to normal once the eyes were working together.  But when the fellow eye drifted out, the little girl’s ability to use the eyes together would once again be disrupted.  Squinting or closing of one eye in bright sunlight commonly occurred, and was often the first thing that parents noticed.

He admitted that no one knew why this condition developed, but that treatment usually began with patching each eye, one eye one day and the other eye the next day, for several hours each day.  Alternate occlusion could be performed indefinitely and, in young children, was preferable to surgical correction.  He said surgery for intermittent exotropia was usually performed on the outer eye muscles and usually with general anesthesia.  However, surgery would become necessary if alternate patching did not improve the child’s ability to use the eyes together when patching was stopped, or in the rare situations where alternate patching actually caused a breakdown in fusion.  He told you to patch each eye for four consecutive hours each day, and in 6 weeks he would examine your daughter again.

You are horrified about your beautiful little girl wearing an ugly black pirate patch—for 2 months!  But the pediatric ophthalmologist quickly explains that a black pirate patch is not for this type of treatment, and especially not for children.  Then he takes one of the pretty patches from the box on the shelf, exactly like the one that your little one wore when the orthoptist tested her vision.  He instructs you on how place it properly over the eye so that it adheres to the skin well, covering the eye completely, and assures you that each box of patches contains enough designs to match her school day outfit each day!

Relieved that surgery is not an option for the present, you are also uncertain about how your little girl will tolerate the patch for 6 weeks.  But for now, some questions have been answered, some fears placed on a back burner…and those patches are really cute!

Copyright © 2010 by Eye Care and Cure, 4646 S. Overland Drive, Tucson, AZ 85714. No part of this story may be reproduced without written permission from Eye Care and Cure.