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Dr. Dan B.
Dr. Dan B., Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 3135
Experience:  Eye surgeon experienced in cataracts, glaucoma, retina & neuro-ophthalmology
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Hi,Our son is 4 years old and is being treated for amblyopia

Resolved Question:

Hi, Our son is 4 years old and is being treated for amblyopia and esotropia. He was diagnosed about a year ago, when his pediatrician noted his right eye turning in during a routine exam. The ophthalmologist we were referred to (who is board certified by the ABO) asked us to patch the eye for two hours each day (more on the weekends ) to first resolve the amblyopia. After 3 months, his vision had improved from 20/90 to 20/40 but the esotropia did not resolve itself and his right eye was still turning in. At this time, he indicated that glasses would not help since his hyperopia was only +2 diopters and suggested surgery. We were informed that the success rate was about 75%, and decided to move forward. The procedure took place the following month (he operated on both eyes) and was unfortunately not successful in resolving the esotropia. His right eye still turned in, and now there was also now a very slight inward turn of the left eye, probably not noticeable to someone who is not looking that closely but noticeable to us. At the follow-up a few days after the surgery, we were told that the goal was to improve binocular vision without over-correcting. He advised us to continue patching for an hour a day and scheduled a follow-up in 3 months. In the interim, we sought out a second opinion. Our son was not that cooperative during the acuity test, unfortunately, so his visual acuity could not be determined at that visit, but the second ophthalmologist told us that the outcome of the surgery was an under-correction. Without being able to determine the level of hyperopia as a disclaimer, his initial suggestion was for a second surgery. 3 months after the surgery, we had the follow-up with the doctor that performed the surgery. At that visit, he informed us that our son’s hyperopia has increased from +2 to +4 diopters. The diagnosis was changed to accommodative esotropia and glasses we prescribed (bi-focals); he stated that there was a 50/50 chance of success. The glasses appeared to work, and the next follow up with the doctor who performed the surgery confirmed that the deviation had been significantly reduced, and the glasses should continue to worn during all waking hours. He also told us to continue patching the left eye for an hour a day, since he felt that the left eye was still being favored. He also mentioned that chances for a postive outcome have improved with the success of the glasses, though future surgeries could not be ruled out. Although I am relieved that the glasses are working, I’m beginning to wonder if we may have rushed into the surgery. We realize that we can’t “put the genie back in the bottle” so to speak, but I have some questions I would like answered (that I would feel uncomfortable discussing with him directly) to help us decide whether to continue with this doctor or seek out another. My primary interest is whether some of my concerns below are warranted, since there are relatively few pediatric ophthalmologists where we live and our son is now comfortable with ophthalmologist (no small task). So, my questions are: 1. Is it possible for hyperopia to go from 2 diopters to 4 diopters in 6 month time period in the normal course of events for a 3 year old? 2. If not, could the surgery have caused the change in far-sightedness? 3. As a general rule (understanding that every individual case is different), can glasses be prescribed when the hyperopia is measured at 2 diopters for a 3 year old child? 4. Are there any potential negative ramifications to having had strabismus surgery first, followed by glasses? (My understanding is that the usual treatment plan is reversed – glasses followed by surgery if necessary.) Do the potential odds for future surgeries increase, even though the glasses are working, after having had a surgery? Thanks so much.

Submitted: 8 months ago.
Category: Eye
Expert:  Dr. Dan B. replied 8 months ago.

Dr. Dan B. : Hello and thanks for your question. Are you available to chat?
Customer:

yes, thanks for the quick response

Dr. Dan B. : Let me address these questions. Number one, it is possible to have a change from 2 to 4 diopters in six months. Changes in the refractive error usually follow growth cycles and children at this age are growing rapidly. So this is not surprising. Number two...
Dr. Dan B. : The surgery is very unlikely to have caused the increase in farsightedness. It is possible that after the surgery, there was more binocular fixation, and the increase in successful focusing may have spurred the farsightedness along, but if it wasn't in his genes to get that farsightedness, he wouldn't have gotten it.
Customer:

yes, i suspected that number one was more likely, but wanted to be sure. thanks

Dr. Dan B. : Yes, glasses can be prescribed for hyperopia of 2 dpt, but, depending on the case, many times after the doctor just will not prescribe that low level, because it usually does not improve the esotropia if there's only 2 dpt. Some ophthalmologist will prescribe the glasses just in case, but many will not.
Dr. Dan B. : Number four, For the most part, no, I don't see any significant ramifications of having surgery first and then having glasses. The important thing is the glasses are helping now as long as his eyes are straight in the glasses this is the best hoped-for outcome.
Customer:

that is very helpful, I'm just a little curious why, since it's not surprising for the diopters to change from 2 to 4

Customer:

why is wasn't suggested to wait a little while

Customer:

I understand in the end, the parent are responsible for the decision

Customer:

but your answers have been very helpful and reassuring

Customer:

thanks again

Dr. Dan B. : Number five, no, I do not think the chances for surgery are higher because he had surgery for esotropia prior to glasses, I think this is all dependent on how his eyes are going to grow, what his refractive error is going to be, and how his esotropia responds to the glasses. I would not be surprised if you need another surgery, but since the esotropia is controlled by the glasses now, I would not be surprised if he didn't require another surgery.
Dr. Dan B. : He likely was not recommended to wait, because no one can predict the refractive error and how it will change, but the longer he goes without binocular fixation, the more likely the amblyopia is to continue or worsen, and the less likely he is to develop a binocular fixation and have a good outcome. Does this make sense?
Customer:

yes, it does, thanks

Customer:

but can one still have binocular improvement after a surgery and not have the esotropia resolved?

Customer:

i assumed that one outcome is related to the other..

Dr. Dan B. : Oh yes, you can especially if his eyes are straight while wearing the glasses. Even if the esotropia is still present, as long as the eyes are straight while he's wearing the glasses and the glasses are worn all day long, yes it can definitely improve.
Customer:

but the surgery by itself probably did not improve binocularity if the esotropia was still present

Customer:

after the under-correction, and before the glasses

Dr. Dan B. : The eyes being straight and focused on the same object at the same time is what dictates the ability to have binocular fixation. No matter how this is achieved, either with the surgery alone, glasses alone, or surgery glasses. What matters is whether the eyes are straight the large majority of the time.
Dr. Dan B. : That is likely correct, I just can't say for sure, not having examined him.
Customer:

and they are now, so I guess that is what I should be focusing on.

Customer:

so to speak..

Dr. Dan B. : Absolutely--that's the desired goal so that's a very good thing.
Customer:

thanks so much

Dr. Dan B. : My pleasure. Do you have any other questions about this?
Customer:

no, no more questions

Customer:

you have been very helpful

Customer:

thanks so much

Dr. Dan B. : Okay. Good luck. My pleasure. Your feedback is important to me and will help me improve my encounter with future customers. Please rate your encounter with me by providing positive feedback (by pressing the smiley face); any bonus you may feel prompted to provide would be welcomed and is appreciated. If you feel like your concerns are not resolved or you have a problem or issue with anything I have said or haven’t said, please don’t issue a negative feedback rating—My goal is your satisfaction and I would rather work together to solve your concerns, until you are satisfied, than have you leave our encounter unhappy and unsatisfied. My opinion is solely informative and does not constitute a formal medical opinion or recommendation. For a formal medical opinion and/or recommendation you must see an eye doctor. Thanks for your inquiry!
Customer:

thansks again!

Dr. Dan B. : Happy to help.
Dr. Dan B., Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 3135
Experience: Eye surgeon experienced in cataracts, glaucoma, retina & neuro-ophthalmology
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