Strabismus - Fundamentals of Clinical Ophthalmology.pdf

7 Therapy of strabismus
Non-surgical therapy
The team approach to strabismus
In the unravelling of strabismus and eye
movement disorders, the ophthalmologist and
the eye health professional team form the nucleus
for the investigation of the ocular motor system.
However, it is essential that they see themselves
also as a part of a larger team where the child is
the centre of focus. In children, eye movement
disorders may rarely be part of systemic or
neurologic system disorders and at times they
may require the expert advice of geneticists,
radiologists, neurologists, dysmorphologists and
good paediatricians both specialist and general,
with team members all working closely with the
family and the family doctor. This is particularly
important in a children’s hospital where so often
the consultation is about a child or infant in the
care of another colleague. By contrast, outside of
the hospital setting, ophthalmologists, family
doctors, and community eye care workers may be
the first point of contact and it is important that
they understand child and visual development
and recognise what may appear to be “a simple
squint” but is in fact a clinical sign of underlying
disease requiring further investigation.
Eye health professionals can and do play a
valuable role in the recognition and care of the
strabismic child and in working closely with the
ophthalmologist. However, potentially the most
valuable members of this team are the parents.
Other trusted adults in the child’s life including
teachers can also play an important role.
The parents as part of the team
Time should be spent with the parents to
explain in simple terms the natural history of the
particular form of strabismus the child has.
Time should be spent explaining the concept of
amblyopia and how each eye “competes for
visual space in the brain” and how the constantly
squinting eye may not gain equal visual space
and as a result lose sight and become amblyopic.
It must be made clear that surgical alignment
does not improve vision; indeed it increases the
need for vigilance and continued intermittent
occlusion. Occlusion treatment should be
explained and the risk of occlusion amblyopia.
Time should be spent explaining the
importance of visual tasks during occlusion; for
example in a young uncooperative child the
mother can be advised to supervise occlusion
while the meal is prepared. The other children
are excluded from the room and the child is
given the opportunity to colour in pictures or do
simple tasks with toy blocks, puzzles or hand
held electronic games. It should be explained
that the younger the infant, the more rapidly
vision is lost from amblyopia, the more rapidly it
can be recovered and that occlusion amblyopia
can occur more quickly in the infant and young
child than in the older child.
Total occlusion is easier to control in younger
children. Arm splints prevent the child from
removing the occlusion but leave the hands free
for the child to play (Figure 7.1). If the child is
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