Psychological implications of a vision disorder.

The paper discusses how the condition of crossed-eyes affects a baby's eye contact with mother and potentially results in the loss of a vital emotional connection with her during the earliest days of life. This loss may contribute to a rupture that arrests emotional development at a deep psychic level. It is suggested that, in the same way as premature separation, the rupture can precipitate a 'fusional complex', a defence that develops to protect the infant against psychotic anxieties. The paper proposes that psychological development atrophies in this place and creates a blind spot. These ideas are explored through analytic theory and developmental literature. The dreams of a patient and his art are used to illustrate a 10-year 'alchemical' process of bringing repressed material into consciousness and transformation. Healing the psychological wounds of deficits in early eye contact may be found to bring sight to a blind spot that was created by the nature of the condition itself.

Nonsurgical treatment of teenagers with high AC/A ratio esotropia.

Nonsurgical treatment options commonly prescribed for teenagers with high AC/A ratios are progressive lens spectacles, single vision lens spectacles, bifocal contact lenses, and monovision. The gold standard treatment for high AC/A ratios in patients with esotropia is bifocal spectacles, but they are not cosmetically acceptable for most teenagers. However, excellent binocularity is often sacrificed with the alternative treatment options. Quality of life surveys acknowledge that poor cosmesis can have a negative psychosocial impact on individuals. Therefore, it is often necessary for practitioners to strike a balance between good psychosocial health and best visual potential with treatment options other than bifocal spectacles.

Surgical treatment of teenagers with high AC/A ratios.

The surgical approach to esotropia with a high AC/A ratio in teenagers should be dichotomized based on whether or not there is satisfactory alignment at distance with the cycloplegic correction in place. If there is not, surgery should target the near angle with glasses on. If there is good alignment at distance, bifocals should be used, and surgery deferred until the patient is approximately 18 years of age. At that time, surgery could be entertained to eliminate the need of a bifocal, by targeting the near angle measured through the distance correction. Surgery for the purpose of eliminating a bifocal in younger teenagers may be unnecessary as 99% of those who maintained satisfactory distance alignment outgrew the need of a bifocal by 18 years of age. However, many still needed a bifocal in their early teenage years.

Binocular inhibition in strabismic patients is associated with diminished quality of life.

PURPOSE: To characterize the relationship between binocular summation (BiS) and binocular inhibition (BI) on the quality of life of adults and children with strabismus. METHODS: Strabismus patients at a single center from 2010 to 2012 were prospectively enrolled. A BiS score was measured using ETDRS and Sloan low-contrast visual acuity (LCA) protocols at 2.5% and 1.25% contrast. Patients were categorized as having BiS (binocular better than better-eye visual acuity by ≥5 letters), BI (binocular worse than better-eye visual acuity by ≥5 letters), or otherwise indeterminate visual acuity (a difference between binocular visual acuity and monocular visual acuity of the better eye of <5 letters). Quality of life was evaluated by the National Eye Institute Visual Functioning Questionnaire 25 (VFQ-25), 20-item Adult Strabismus Questionnaire (AS-20), and the Amblyopia and Strabismus Questionnaire. RESULTS: A total of 108 patients were included. There was no significant BiS or BI for high-contrast ETDRS or 2.5% LCA tests; however, a mean BiS score of -2.14 ± 7.0 letters for 1.25% LCA demonstrated significant binocular inhibition (P = 0.004) for this contrast level. The mean composite VFQ-25 score was significantly lower in subjects with BI on ETDRS (80 ± 19 vs 57 ± 7 for subjects with BiS and BI, resp. [P = 0.03]), 2.5% LCA (81 ± 14 vs 66 ± 16 for subjects with BiS and BI, resp. [P = 0.01]), and 1.25% LCA tests (91 ± 9 vs 72 ± 14 for subjects with BiS and BI, resp. [P = 0.005]). After accounting for potential covariates, significant association persisted for BI, demonstrated by 1.25% LCA (P = 0.01). With BI demonstrable at 2.5%, AS-20 scores were also significantly lower (P = 0.04). CONCLUSIONS: Strabismic patients with BI had significantly lower quality-of -life scores than those who did not, even after accounting for potential covariates and the absence of diplopia.

Functional and psychosocial impact of strabismus on Singaporean children.

PURPOSE: To quantify the effects of strabismus in Singaporean children using the Intermittent Exotropia Questionnaire (IXTQ) and the Adult Strabismus 20 Questionnaire (AS20). METHODS: Consecutive strabismus patients 5-16 years of age were recruited along with an equal number of age-matched controls with eye conditions other than strabismus and amblyopia (group A) and controls with no known eye conditions (group B). All children completed the IXTQ; those 8-16 years of age also completed the AS20 questionnaire. Parents completed the parental proxy IXTQ (pp-IXTQ) and AS20 (pp-AS20) and a parental IXTQ (PIXT). RESULTS: A total of 60 patients and 60 age-matched controls in each group were included. Children with strabismus had lower IXTQ (70.1 ± 19.0) and AS20 (80.0 ± 13.8) scores than those in group B (IXTQ, 90.3 ± 11.8 [P < 0.001]; AS20, 90.0 ± 10.9 [P < 0.001]) and group A (IXTQ, 80.6 ± 14.9 [P = 0.001]; AS20, 81.6 ± 18.3 [P = 0.691]). Among children with strabismus, child IXTQ scores were significantly lower than parental proxy scores (70.1 ± 19.0 vs 76.4 ± 15.8 [P = 0.026]), but there was no difference in control group scores or with AS20 scores. Item-level analysis suggested that children's worry focused on what others thought about them and their ability to make friends, whereas parents were more concerned about eyesight and whether surgery was required. CONCLUSIONS: The IXTQ and AS20 were better at differentiating between children with strabismus and those with no eye condition than between children with strabismus and other eye conditions. Parental proxies were accurate in predicting child scores but parents were more likely to underestimate the psychosocial effects of their children's strabismus.

Amblyopic deficits in the timing and strength of visual cortical responses to faces.

Behavioral research revealed that object vision is impaired in amblyopia. Nevertheless, neurophysiological research in humans has focused on the amblyopic effects at the earliest stage of visual cortical processing, leaving the question of later, object-specific neural processing deficits unexplored. By measuring event-related potentials (ERPs) to foveal face stimuli we characterized the amblyopic effects on the N170 component, reflecting higher-level structural face processing. Single trial analysis revealed that latencies of the ERP components increased and were more variable in the amblyopic eye compared to the fellow eye both in strabismic and anisometropic patent groups. Moreover, there was an additional delay of N170 relative to the early P1 component over the right hemisphere, which was absent in the fellow eye, suggesting a slower evolution of face specific cortical responses in amblyopia. On the other hand, distribution of single trial N170 peak amplitudes differed between the amblyopic and fellow eye only in the strabismic but not in the anisometropic patients. Furthermore, the amblyopic N170 latency increment but not the amplitude reduction correlated with the interocular differences in visual acuity and fixation stability. We found no difference in the anticipatory neural oscillations between stimulation of the amblyopic and the fellow eye implying that impairment of the neural processes underlying generation of stimulus-driven visual cortical responses might be the primary reason behind the observed amblyopic effects. These findings provide evidence that amblyopic disruption of early visual experience leads to deficits in the strength and timing of higher-level, face specific visual cortical responses, reflected in the N170 component.

Psychosocial distress of part-time occlusion in children with intermittent exotropia.

PURPOSE: To evaluate the psychosocial distress of part-time occlusion therapy in intermittent exotropia. METHODS: A total of 25 children (15 males and 10 females, aged 3 to 7 years, mean age 4.7 years) with intermittent exotropia were enrolled. Behavioral and psychosocial problems were assessed by the Korean Child Behavior Checklist (K-CBCL), which consists of eight categories of withdrawal, somatic problems, depression/anxiety, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior, and the Amblyopia Treatment Index (ATI). The ATI was designed to evaluate the three factors of compliance, adverse effect, and social stigma. The Parenting Stress Index (PSI) is a parent self-report designed to identify potentially dysfunctional parent-child systems. The K-CBCL was obtained before and after occlusion therapy, and the ATI and PSI were taken from parents only after occlusion therapy. We evaluated the change on the K-CBCL and the correlation between the K-CBCL and ATI. RESULTS: The attention problem assessed by the K-CBCL significantly decreased after occlusion therapy. On the ATI, the social stigma was relatively lower than compliance and adverse effect factors (Likert scale 2.64, 3.11, and 3.11, respectively). The somatic problem assessed by the K-CBCL and compliance on the ATI were significantly correlated (p = 0.014). There was no significant change in percentile scores of each subscale (parental dominant scale and child dominant scale) of the PSI. Total stress index before and after occlusion therapy was 97.16 ± 8.38 and 97.00 ± 8.16 respectively (p = 0.382). CONCLUSIONS: Occlusion therapy may influence the psychosocial impact on intermittent exotropia patients. Part-time occlusion significantly decreased the attention problem in children with intermittent strabismus. Children with a high somatic problem score on the KCBCL showed poor compliance to the part-time occlusion.

The perception of strabismus by children and adults.

BACKGROUND: Visible strabismus has been shown to have adverse psychosocial consequences. It remains controversial if esotropia or exotropia is perceived more negatively. The aim of this study was to determine if esotropia or exotropia and the eye (side) in which strabismus is present are perceived differently. We also asked our adult participants: (1) if they thought visible strabismus should be corrected by surgery, (2) if they thought that strabismus surgery should only be to improve the cosmesis, and (3) if they thought that the surgery should be paid for by health insurance. METHODS: One hundred adults and 61 children rated four photographs of a digitally altered picture of a boy and four of a girl, showing a large-angle esotropia or exotropia either in the left or on the right eye. The adults were additionally asked if a squint should be operated, if they considered strabismus surgery to be a cosmetic procedure, if in their opinion strabismus surgery should be covered by compulsory health insurance, and if children with strabismus are disadvantaged. Comparisons were performed using ANOVA and regression analysis. RESULTS: Adults perceived a squinting right eye as more disturbing than a squinting left eye p < 0.001). The direction of strabismus, the age, gender, and the number of persons with a squint among family and friends of the respondents did not influence the perception of strabismus by adults (p > 0.1 for each). Children also found that a squinting right eye is more disturbing (p < 0.001) than a left one. Additionally, children ranked esotropia worse than exotropia (p < 0.001). Neither age nor gender had an impact on the perception of strabismus by children. Of the adults, 94% would recommend surgery for all forms of strabismus, 18% thought that surgery is only cosmetic, and 94% found that health insurance should cover strabismus surgery for everybody. Problems of squinting children named by the adults included: being made fun of by other children (53%), problems with eyesight (39%), people looking strangely at them (21%), less acceptance by peers (17%), less self confidence (6%), problems judging distances (4%), and that they are perceived as less intelligent (3%). CONCLUSIONS: Adults and children rated a squinting right eye as worse compared to a left one. Children perceived esotropia as more disturbing than exotropia. Neither age, nor gender, nor the fact that the respondents have friends or family members with a squint, had an impact on this ranking. Almost all adults would correct all forms of strabismus, and think that surgery should be covered by compulsory health insurance.

Comparison of psychosocial and emotional consequences of childhood strabismus on the families from rural and urban India.

PURPOSE: To compare the psychosocial consequences of horizontal comitant strabismus in children between the families of urban and rural India. MATERIALS AND METHODS: In this cohort study, an eight-question quality-of-life instrument was administered by trained staff to the guardians of strabismic children from rural and urban areas by a live interview. RESULTS: This study included 93 strabismic-children aged 4-16 years of which 52 were females. Forty-one had esodeviation and 52 had exodeviation. Seventy per cent parents were extremely distressed due to squint, 65% were extremely distressed due to people's remarks, 65% were extremely worried, 55% children were extremely distressed due to people's remarks, 57% children were severely ostracized, 38% had severe difficulty in communication and 50% had difficulty to cope; 64% parents were not advised a corrective surgery. The difference between families from rural and urban areas, or whether a male child was affected or a female child or for an esodeviation or an exodeviation was statistically not significant. The questionnaire had a good internal consistency (Cronbach's Alpha = 0.71). CONCLUSIONS: There was a significant negative psychosocial and emotional impact of childhood strabismus that was not affected by the rural or urban location of the family or the gender of the strabismic child or type of the deviation. The quality-of-life instrument can be used as part of the clinical examination for strabismic children.

Concordant eye movement and motion parallax asymmetries in esotropia.

The role of eye movements in the perception of depth from motion was investigated in esotropia. Elevated motion parallax thresholds have been shown in strabismus [Thompson, A. M., & Nawrot, M. (1999). Abnormal depth perception from motion parallax in amblyopic observers. Vision Research, 39, 1407-1413] suggesting a global deficit in depth perception involving both stereopsis and motion. However, this motion parallax deficit in strabismus might be better explained by the role that eye movements play in motion parallax [Nawrot, M., & Joyce, L. (2006). The pursuit theory of motion parallax. Vision Research, 46, 4709-4725]. Esotropia is associated with asymmetric pursuit and optokinetic response eye movements [Demer, J. L., & von Noorden, G. K. (1988). Optokinetic asymmetry in esotropia. Journal of Pediatric Ophthalmology and Strabismus, 25, 286-292; Schor, C. M., & Levi, D. M. (1980). Disturbances of small-field horizontal and vertical optokinetic nystagmus in amblyopia. Investigative Ophthalmology and Visual Science, 19, 851-864; Tychsen, L., & Lisberger, S. G. (1986). Maldevelopment of visual motion processing in humans who had strabismus with onset in infancy. The Journal of Neuroscience, 6, 2495-2508; [Westall, C. A., Eizenman, M., Kraft, S. P., Panton, C. M., Chatterjee, S., & Sigesmund, D. (1998). Cortical binocularity and monocular optokinetic asymmetry in early-onset esotropia. Investigative Ophthalmology and Visual Science, 39, 1352-1360.]. The first experiment demonstrates that the motion parallax deficit in esotropia mirrors the pursuit eye movement asymmetry: in the direction of normal pursuit, esotropic observers had normal depth from motion parallax. A second set of experiments, conducted in normal observers, demonstrates that this motion parallax deficit is not a secondary problem due to the retinal slip created by inadequate pursuit. These results underscore the role of pursuit eye movements in the perception of depth from motion parallax.

Effect of adult strabismus on ratings of official U.S. Army photographs.

PURPOSE: To determine if strabismus affects the ratings of official U.S. Army photographs. METHODS: Photographs of seven women and seven men officers (subjects) were digitally altered to give the impression of strabismus. Four photographs of each subject were obtained: two in an orthotropic state; one in a left exotropic state; and one in a left esotropic state. The photographs were presented randomly to a panel of 38 raters. Masked to the study design, the raters rated every photograph on a 1 to 10 Likert scale. The results were grouped according to eye alignment: two orthotropic groups, one exotropic group, and one esotropic group. Comparisons of the mean ratings were made between each eye alignment group and based on the subject's gender. RESULTS: The mean rating for each orthotropic group was 5.4 and 5.5 Likert scale units with a SD of 0.8 and 0.9, respectively (group 1 and group 2). The mean rating for the exotropic group was 5.4 Likert scale units with a SD of 0.7. The mean rating for the esotropic group was 5.1 Likert scale units with a SD of 0.8. Significantly lower ratings were obtained for the esotropic group compared with the orthotropic group (p=0.028). Women received significantly lower ratings regardless of eye alignment (p=0.044). CONCLUSIONS: This study indicates that the presence of esotropia negatively affects the rating of an official U.S. Army photograph; furthermore, female gender negatively affects ratings.

[Acute concomitant esotropia and hysterical amblyopia]. / Endotropía comitante aguda y ambliopía histéricas.

CASE REPORT: The authors present the case of a 26-year-old woman, in her 29th week of pregnancy, who developed intermittent esotropia and diplopia. Six months later, the process was associated with visual loss and an accommodative spasm which did not improve with cycloplegia and refraction. The symptoms remained unchanged two years later. DISCUSSION: Acute concomitant esotropia may have no obvious underlying cause, but it has been associated with disruption of fusion, myopia, neurological problems and decompensation of a pre-existing phoria or monofixation syndrome. A physical or emotional debilitating illness may precede the onset of the problem. In our case, a neurologic origin was excluded and a diagnosis of hysterical neurosis and acute concomitant esotropia with hysterical amblyopia or functional visual loss was established.

Endotropía comitante aguda y ambliopía histéricas / Acute concomitant esotropia and hysterical amblyopia

Caso clínico: Paciente de 26 años embarazada de 29 semanas con endotropía comitante aguda y diplopía intermitentes. Tras seis meses de evolución presenta disminución de agudeza visual relacionada con un espasmo acomodativo, pero que no mejora con cicloplejía y refracción. La clínica permanece invariable 2 años después.Discusión: La causa de endotropía comitante aguda puede no ser obvia, pero con frecuencia se asocia a disrupción de fusión, miopía, procesos neurológicos y descompensación de foria o síndrome de monofijación preexistentes. Cuadros físicos o emocionales debilitantes también pueden preceder al comienzo de la desviación. En este caso, se descartaron procesos neurológicos y se diagnosticó neurosis de renta y endotropía comitante aguda con ambliopía histérica o pérdida de visión funcional

Case report: The authors present the case of a 26-year-old woman, in her 29th week of pregnancy, who developed intermittent esotropia and diplopia. Six months later, the process was associated with visual loss and an accommodative spasm which did not improve with cycloplegia and refraction. The symptoms remained unchanged two years later. Discussion: Acute concomitant esotropia may have no obvious underlying cause, but it has been associated with disruption of fusion, myopia, neurological problems and decompensation of a pre-existing phoria or monofixation syndrome. A physical or emotional debilitating illness may precede the onset of the problem. In our case, a neurologic origin was excluded and a diagnosis of hysterical neurosis and acute concomitant esotropia with hysterical amblyopia or functional visual loss was established

Temporal integration for stereoscopic vision.

With normal binocular vision, maximal stereoacuity requires an extended viewing duration, but the relationship between the critical viewing duration for stereopsis and other variables affecting stereoacuity is unknown. The purposes of the study were to investigate the properties of normal temporal integration for stereoscopic vision with respect to the effects of contrast and spatial frequency of the stimuli and to determine whether the temporal summation of disparity is affected in deficient stereopsis caused by abnormal binocular vision during infancy. Psychophysical methods were used to measure stereothresholds in human and monkey subjects with either normal binocular vision or abnormal binocular vision. The results showed that the critical viewing duration for stereoscopic depth discrimination was independent of variations in basic stimulus parameters and/or the subject's stereoacuity. A critical duration of approximately 100 ms was found for both local (narrowband Gabor and broadband line targets) and global (dynamic random dots) stimuli. Although stereothresholds increased with decreasing stimulus contrast, the properties of temporal integration did not. Stereothresholds were substantially elevated for monkeys and humans with abnormal binocular vision, but the critical durations for these subjects were not significantly different from those of subjects with normal binocular vision. Overall, the results demonstrate that the general properties of temporal integration for stereopsis are similar to other detection and discrimination tasks that do not require binocular processing. In addition, increased integration time does not account for the elevated stereothresholds of subjects with abnormal binocular vision.

Acquired esotropia: subjective and objective outcomes.

PURPOSE: The measurement of outcomes of pediatric therapy will be increasingly important to third-party payers as they allocate health care resources. We undertook this study to assess the effectiveness of treatment of acquired esotropia, as measured subjectively by parents and objectively by examination. METHODS: A chart review was used to gather objective clinical data from all patients presenting between 1994 and 1995 with esotropia after their first birthday. Parents' impressions of the quality and impact of treatment were tabulated by using a telephone questionnaire. RESULTS: Of 48 patients studied (mean age, 3.8 years; 44 months' follow-up), the 26 with amblyopia were effectively treated in 81% of cases. Mean esotropic angles decreased, with glasses and/or surgery, from 33.1 to 4.9 PD at distance and from 40.0 to 11.4 PD at near. The average estimated cost of care was 547 dollars per patient per year. Parents considered treatment "extremely important" to their child's future happiness and success in 90% of cases. CONCLUSION: Our experience has shown that treatment of acquired esotropia in childhood, while relatively inexpensive, is highly effective, both objectively and subjectively.

Impact of large angle horizontal strabismus on ability to obtain employment.

OBJECTIVE: To determine if large angle esotropia and exotropia could impact a person's ability to obtain employment. DESIGN: Laboratory experiment. PARTICIPANTS: Seventy-nine respondents unaware of the purpose of the study. METHODS: Photographs of two men and two women were digitally altered to create photographs of the same individual in an orthotropic, esotropic, and exotropic state. The photographs were then randomly affixed to similarly qualified job resumes. The 79 study respondents, unaware of the purpose of the study, were asked to (1) rate each individual applicant on selected job qualification variables, and (2) rank the applicants against each other in order of hiring preference. MAIN OUTCOME MEASURES: Individual applicant rating and hiring preference scores. RESULTS: Women with normal ocular alignment received greater hiring preference scores than did strabismic women (P = 0.007). No difference in hiring preference scores was noted between strabismic and non-strabismic male applicants (P = 0.47). CONCLUSIONS: Large angle horizontal strabismus appeared to be vocationally significant for female applicants, reducing a strabismic female applicant's ability to obtain employment. The presence of strabismus did not appear to influence hiring decisions of male applicants.

Promoting generalized social interactions using puppets and script training in an integrated preschool. A single-case study using multiple baseline design.

Puppet script training was used to teach the social skills of greeting, responding to conversations, and initiating conversations to a preschool child with visual impairments. Susie and four peers without disabilities were taught social skills utilizing puppets enacting sociodramatic scripts within group training sessions. Training sessions were immediately followed by free-play activities among peers without disabilities to assess skill generalization. A single-case study using a multiple-baseline design demonstrated that the intervention increased performance of social skills during recess with peers. Results demonstrated that Susie learned the target behaviors and generalized their use to free-play activities with her peers.

Visual representation of space in congenital and acquired strabismus.

The aim of the present work was to readdress the problem of altered spatial localization in strabismic subjects and to assess whether and how spatial representation is affected by the degree of plasticity of the brain. We therefore compared targeting performance in adult subjects affected by acquired strabismus versus children affected by congenital strabismus. Our data confirm the correlation between deviation of the eye and targeting errors, but they also show that this correlation is not present when strabismus occurs early in life. We suggest that the neuronal machinery involved in the building of an internal representation of space reaches its full maturity several years after birth and that this might explain the limited differences observed in targeting errors between normal and strabismic children.