Strabismus "It is often asked at what age should treatment no longer be attempted.

The answer is, everyone deserves a chance! Age should not be a deterrent..." What is it?
Strabismus, more commonly known as cross-eyed or wall-eyed, is a vision condition in which a person can not align both eyes simultaneously under normal conditions. One or both of the eyes may turn in, out, up or down. An eye turn may be constant (when the eye turns all of the time) or intermittent (turning only some of the time, such as, under stressful conditions or when ill). Whether constant or intermittent, strabismus always requires appropriate evaluation and treatment. Children do not outgrow strabismus! Learn all about Strabismus at this comprehensive advertising-free site. See: All About Strabismus

All About Strabismus

by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006

Development, Causes, Diagnosis, Types, and Treatments. Table of Contents

Evolution of Two-eyed Vision: Two Eyes to the Side Two Eyes in Front Benefits of Two Eyes in Front What is Stereopsis (3D Vision)? Benefits of Stereopsis

What is Strabismus? When two-eyed vision breaks down. by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006

What is Strabismus?
Strabismus or tropia are the medical terms for eye conditions commonly called by various names: eye turns, crossed eyes, cross-eyed, wall-eyes, wandering eyes, deviating eye, etc. Strabismus is not the same condition as "lazy eye" (amblyopia). A strabismus is defined as a condition in which the eyes deviate (turn) when looking at the object of regard. The object of regard would be the target that you, the patient, regards (aims eyes toward, looks at!). Eye doctors generally look for the presence of a strabismus when looking at distance (20 feet or more); at near (16 inches for an adult and 13 inches for a child); and the lateral and vertical directions (up, down, left, or right). When the eye turn occurs all of the time, it is called constant strabismus. When the eye turn

occurs only some of the time, it is called intermittent strabismus. With intermittent strabismus, the eye turn might be observed only occasionally, such as during stressful situations or when the person is ill.

Constant or Intermittent Strabismus?

This is one of the most important findings the eye doctor makes! This distinction has a great impact on decisions regarding timing and types of treatment. It is important for you, as a parent, or patient to understand the difference. See Constant or Intermittent?

Different Types of Strabismus

Strabismus is classified into many different types. Each type has its own causes, characteristics, and appropriate treatment plan. Dr. Cooper's article, All About Strabismus, discusses all the types of strabismus and their treatments. You can also refer to the pull-lists in the yellow box on every page. Is It Lazy Eye? Is strabismus a lazy eye condition? by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006 What is Amblyopia (lazy eye)? Lazy Eye and Strabismus are not the same condition. Causes of Amblyopia Diagnosis of Amblyopia Treatment of Amblyopia

What is Amblyopia (lazy eye)?

Amblyopia, commonly known as lazy eye, is the eye condition noted by reduced vision not correctable by glasses or contact lenses and is not due to any eye disease. The brain, for some reason, does not fully acknowledge the images seen by the amblyopic eye. This almost always affects only one eye but may manifest with reduction of vision in both eyes. It is estimated that three percent of children under six have some form of amblyopia. Learn more and read the latest research at All About Amblyopia (Lazy Eye).

Lazy Eye and Strabismus are not the same condition.

Many people make the mistake of saying that a person who has a crossed or turned eye (strabismus) has a "lazy eye," but lazy eye (amblyopia) and strabismus are not the same condition. Some of the confusion may be due to the fact that strabismus can cause amblyopia. Amblyopia can result from a constant unilateral strabismus (i.e., either the right or left eye turns all of the time). Alternating or intermittent strabismus (an eye turn which occurs only some of the time) rarely causes amblyopia. While a deviating eye (strabismus) may be easily spotted by the layman, amblyopia without strabismus or associated with a small deviation usually can be not noticed by either you or your pediatrician. Only an eye doctor comfortable in examining young children and infants can detect this type of amblyopia. This is why early infant and pre-school eye examinations are so

necessary. Due to misunderstanding or misuse of the terms for different visual conditions (i.e., crossed eyes vs. lazy eye), many people are inaccurately labelled as having a "lazy eye." If you think you or someone you know has lazy eye, it is recommended that you learn more about Lazy Eye and the different types of Strabismus. For example, see What is Strabismus?, Exotropia or Esotropia. In addition, learn about a much more common visual condition which affects binocular (twoeyed) vision and is also not easily discernable to the outside viewer. This condition is also not detected by the standard 20/20 eye test. See What is Convergence Insufficiency? To complete the picture, find out about the treatment options for amblyopia and strabismus.

Causes of Amblyopia
Both eyes must receive clear images during the critical period. Anything that interferes with clear vision in either eye during the critical period (birth to 6 years of age) can result in amblyopia (a reduction in vision not corrected by glasses or elimination of an eye turn). The most common causes of amblyopia are constant strabismus (constant turn of one eye), anisometropia (different vision/prescriptions in each eye), and/or blockage of an eye due to trauma, lid droop, etc. If one eye sees clearly and the other sees a blur, the good eye and brain will inhibit (block, suppress, ignore) the eye with the blur. Thus, amblyopia is a neurologically active process. The inhibition process (suppression) can result in a permanent decrease in the vision in that eye that can not be corrected with glasses, lenses, or lasik surgery.

Diagnosis of Amblyopia
Since amblyopia usually occurs in one eye only, many parents and children may be unaware of the condition. Far too many parents fail to take their infants and toddlers in for an early comprehensive vision examination and many children go undiagnosed until they have their eyes examined at the eye doctor's office at a later age. The most important diagnostic tools are the special visual acuity tests other than the standard 20/20 letter charts currently used by schools, pediatricians and eye doctors. Examination with cycloplegic drops can be necessary to detect this condition in the young.

Treatment of Amblyopia
Amblyopia can be successfully treated up to the age of 17. See a report on the latest research at National Institutes of Health -- National Eye Institute. Early treatment is usually simple, employing glasses, drops, vision therapy and/or patching. Detection and correction before the age of two offers the best chance for a cure. According to current research, amblyopia can not be cured -- normal 20/20 stereo vision -without early detection and treatment. However, treatment for older children and adults is usually successful in improving vision and should be attempted. Treatment of amblyopia after the age of 17 is not dependent upon age but requires more effort including vision therapy. Every amblyopic patient deserves an attempt at treatment. Strabismus is responsive to treatments at all ages. Therefore, as explained earlier, it is important to make careful distinction between amblyopia and strabismus. While no recent scientific studies have been done on treatment of amblyopia after the age of 17, the optometrists in our network collectively report decades of clinical success with adult

amblyopia. [This editor hopes for an NEI study on adult amblyopia and neuroplasticity ]. To quote one of our members, Dr. Leonard J. Press, FAAO, FCOVD: " It's been proven that a motivated adult with strabismus and/or amblyopia who works diligently at vision therapy can obtain meaningful improvement in visual function. As my patients are fond of saying: "I'm not looking for perfection; I'm looking for you to help me make it better". It's important that eye doctors don't make sweeping value judgments for patients. Rather than saying "nothing can be done", the proper advice would be: "You won't have as much improvement as you would have had at a younger age; but I'll refer you to a vision specialist who can help you if you're motivated." In conclusion, improvements are possible at any age, but early detection and treatment offer the best outcome. If not detected and treated early in life, amblyopia can cause a permanent loss of vision with associated loss of stereopsis (two eyed depth perception). Better vision screenings are needed for young children. The 20/20 eye chart screening is not adequate. Amblyopia causes more visual loss in the under 40 group than all the injuries, and diseases combined in this age group. What Causes Strabismus? Eye muscles or the brain? by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006

What Causes Strabismus?

Many things and/or events can cause a strabismus. They include genetics, inappropriate development of the "fusion center" of the brain, problems with the controlled center of the brain, injuries to muscles or nerves or other problems involving the muscles or nerves. Surprisingly, most cases of strabismus are not a result of a muscle problem, but are due to the control system -- the brain. Treatment should be directed at the source of the problem. The eye doctor must determine if the strabismus is due to an eyeglass problem or brain problem. Sometimes, bifocals are needed to eliminate the eye turn.

Different Types Have Different Causes

Strabismus is classified into many different types. Each type has its own causes, characteristics, and appropriate treatment plan. See Types and Treatment of Strabismus. You will also find pull-down lists at the bottom of each page.

What Does Strabismus Cause? "What does my child see"?

If a person's two eyes are not aligned (strabismic) three different things can happen: 1. the patient will see double because the two eyes are not aimed at the same point; 2. one of the eyes can suppress or turn off (in the brain) to avoid double vision (technically called diplopia). This condition is called suppression.; 3. the brain can develop a new match with each eye so that fusion occurs even though the eyes are not aimed at the same spot. This last phenomenon is known as anomalous retinal correspondence. It occurs early in life and will almost never occur if

the strabismus develops after four years of age. If the eye turn develops after the age of 6 then suppression, confusion, and/or anomalous retinal correspondence will not occur. If any of these three sensory conditions occur, then the eyes are not working together and can not have normal stereopsis. The only way to eliminate these obstacles to fusion and stereopsis is with vision therapy (orthoptics). The longer suppression has been in effect, the more difficult it will be for the patient to eliminate and re-establish normal binocular vision. Early detection and treatment is very important in all cases of strabismus! What Does Strabismus Cause? What does my child with strabismus see? by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006

What Causes Strabismus?

Many things and/or events can cause a strabismus. They include genetics, inappropriate development of the "fusion center" of the brain, problems with the controlled center of the brain, injuries to muscles or nerves or other problems involving the muscles or nerves. Surprisingly, most cases of strabismus are not a result of a muscle problem, but are due to the control system -- the brain. Treatment should be directed at the source of the problem. The eye doctor must determine if the strabismus is due to an eyeglass problem or brain problem. Sometimes, bifocals are needed to eliminate the eye turn.

Different Types Have Different Causes

Strabismus is classified into many different types. Each type has its own causes, characteristics, and appropriate treatment plan. See Types and Treatment of Strabismus. You will also find pull-down lists at the bottom of each page.

What Does Strabismus Cause? "What does my child see"?

If a person's two eyes are not aligned (strabismic) three different things can happen: 1. the patient will see double because the two eyes are not aimed at the same point; 2. one of the eyes can suppress or turn off (in the brain) to avoid double vision (technically called diplopia). This condition is called suppression.; 3. the brain can develop a new match with each eye so that fusion occurs even though the eyes are not aimed at the same spot. This last phenomenon is known as anomalous retinal correspondence. It occurs early in life and will almost never occur if the strabismus develops after four years of age. If the eye turn develops after the age of 6 then suppression, confusion, and/or anomalous retinal correspondence will not occur. If any of these three sensory conditions occur, then the eyes are not working together and can not have normal stereopsis. The only way to eliminate these obstacles to fusion and stereopsis

is with vision therapy (orthoptics). The longer suppression has been in effect, the more difficult it will be for the patient to eliminate and re-establish normal binocular vision. Early detection and treatment is very important in all cases of strabismus! Early Detection and Treatment. When should my child have the first eye exam? by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006

Early Detection and Treatment When should my child have the first eye exam?
This is an important health issue. According to both the American Optometric Association and American Ophthalmological Association, all children should have their first examination around 9 months of age. However, if an extreme or constant eye turn is noticed, the baby should be examined before 9 months. If a constant eye turn or significant refractive error is found, the eyes need to be fully evaluated and corrected as early as possible. Read on to find out why.

Why So Young?
The development of keen binocular vision with resultant stereopsis is a result of genetics and appropriate development of the binocular system during the early formative years. The ability to see 20/20, focusing ability (accommodation), eye muscle coordination (aiming or alignment) and stereopsis are all developed by 6 months of age in humans. By 9 months of age, the system is in place. In general, research suggests that the maximum "critical period" in humans is from just after birth to 2 years of age. Any disruption of binocular vision from 6 months to approximately 4 years will result in strabismus and/or amblyopia. Problems with binocular vision are often not detected by the untrained observer. Thus, every infant without an apparent problem should have their first examination between 9 months to one year of age. By all means, do not hesitate to have children with extreme or constant eye turns examined before 6 months. Young babies are also easy to exam. Age 2 is neurologically late and a difficult time to examine the young toddler. If everything is normal at that 9 months examination, the next examination should be in kindergarten.

How Would the Eye Doctor Examine an Eye Turn?

The most important diagnostic tool is the history as this allows the doctor to know the age of onset, duration of turning, family history of strabismus, and a medical history. The eye doctor will then attempt to rule out amblyopia, uncorrected refractive error, and amount of deviation. The doctor should dilate the eyes to make sure that there is no hidden eye disease causing the strabismus.

Early Treatment
Children with strabismus and amblyopia (lazy eye) must be identified and treated at a young age to obtain the best chances of restoring normal visual acuity in the presence of amblyopia and/or constant strabismus. Thus, the first examination should be performed just after the

visual system has completed maturation, so treatment can be initiated immediately, if necessary. This is the period of time in which the visual system is most easily modified.

Will my child outgrow strabismus?

Children do not grow out of eye turns. Proper diagnosis and treatment is necessary. Treatment will depend on the condition and individual. Although, intermittent eye turns do not require aggressive treatment, professional evaluation and monitoring is still recommended. Eyeglasses may be prescribed to eliminate the eye turn and/or eliminate any optical difference between the eyes. The eye doctor might institute patching to stimulate the "lazy" eye, which was suppressed or turned off (when the two eyes are not aligned, the brain is forced to ignore one of the images to prevent double vision). Infants or young children should be encouraged to do things which involve hand and eye coordination. Movement and hand eye tasks speed the improvement in treatment of amblyopia and strabismus. When is it too late for treatment? What is the "critical period? Why does my eye doctor say it is "too late?" What are basic treatment options? Types of Strabismus and their Recommended Treatments by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006

Types of Strabismus and Their Recommended Treatments

Constant or Intermittent? by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2006

Does the Person Have Constant or Intermittent Strabismus?

This is one of the most important findings the eye doctor makes! It is important for you as a parent or patient to understand the difference between constant and intermittent strabismus. This distinction has great bearing on timing and types of treatment. When the eye turn occurs all of the time, it is called constant strabismus. When the eye turn occurs only some of the time, it is called intermittent strabismus or alternating strabismus. With intermittent strabismus, the eye turn might be observed only occasionally, such as during stressful situations or when the person is ill. Up to the first 6 months of age, intermittent strabismus is a normal developmental milestone. After 6 months, it needs to be evaluated.

A Common Cause of Intermittent Strabismus

Convergence Insufficiency, if untreated, can cause an outward eye turn that comes and goes (intermittent exotropia). Convergence Insufficiency (CI) is also the leading cause of

eyestrain, blurry vision, double vision (diplopia), and/or headaches. Nevertheless, most people have never heard of this visual condition. The National Institutes of Health/National Eye Institute is currently funding a large study on this visual condition. Learn more at What is Convergence Insufficiency? Treatment of Constant Strabismus Constant turns must be dealt with immediately if one wants to re-establish proper use of the eyes. Treatment for this condition needs to be early and aggressive. If the eye turn is constant and simple things like patching, glasses (bifocal, prismatic, etc) do not eliminate the eye turn, either vision therapy or surgery needs to be considered. Keep in mind that surgeons like to perform surgery and often do not consider other treatment options. The best way to treat each infant/or child must be determined and discussed with the parent.

Treatment of Intermittent Strabismus

With intermittent strabismus, the eye does not turn in all the time, so the brain is probably receiving appropriate stimulation for the development of binocular vision. After 6 months of age, this condition does need attention, but neither the eye doctor nor parent needs to panic. As long as the eyes are straight some of the time, the brain will develop normal functioning of the eyes (stereoscopic depth perception). Children with intermittent eye turns should be handled with judicious patching, special glasses, and/or vision therapy. Surgery, if considered at all, should be a last resort.

A Parent's Choice re: Treatment for Intermittent Exotropia

Read what several parents have written regarding making the choice between surgery or vision therapy for intermittent exotropia. Esotropia Infantile Esotropia Congenital Esotropia Accommodative Esotropia Exotropia Hypertropia Duane's Syndrome

Associated Conditions:
Amblyopia Anisometropia Brown's Syndrome

Cataracts Convergence Insufficiency Double Vision Esophoria Exophoria Grave's Disease Lazy Eye Myasthenia Gravis Orbital Fracture Retinal Detachment References

References
Birnbaum MH, Koslowe K, Sanet R. Success in amblyopia therapy as a function of age: a literature review. Am J Optom Phys Opt. 1977; 54:269-275. Cooper J, Ciuffreda K, Kruger P. Stimulus and Response AC/A Ratios in Intermittent Exotropia of the Divergence Excess Type. British Journal of Ophthalmology, 66(6): 398-904, 1982. Cooper J, Feldman JM, Selenow A, Fair R, Bucciero F, MacDonald D, Levy M. Reduction of Asthenopia Following Accommodative Facility Training. Am J Optom Physiol Opt. 64, 30-436, 1987. Cooper J, Burns C, Cotter S, Daum KM, Griffin JR, Scheiman M. Optometric Clinical Guideline: Care of the patient with accommodative or vergence dysfunction. Am. Optom. Ass. 1998. Cooper J, Ciuffreda KJ, Carniglia PE, Zinn KM, Tannen B. Orthoptic Treatment and Eye Movement Recordings in Guillain-Barre Syndrome. A case report. Neuro-ophthalmology 15(5):249-256, 1995. Cooper J, Duckman R. Convergence Insufficiency: Diagnosis and Treatment. Journal of the American Optometric Association, 49(6):, 1978. Cooper J, Feldman J. Operant Conditioning of Fusional Convergence Ranges Using Random Dot Stereograms. American Journal of Optometry & Physiological Optics, 57(4): 205-213, 1980. Cooper J, Feldman J. Panoramic Viewing, Visual Acuity of the Deviating Eye and Anomalous Retinal Correspondence in the Intermittent Exotropia of the Divergence Excess Type.

American Journal of Optometry & Psychological Optics, 56(7): 422-429, 1979. Cooper J, Medow N, Dibble C. Mortality Rates in Strabismic Surgery. Journal of the American Optometric Association, 53(5): 391-395, 1982. Cooper J, Medow N. Intermittent Exotropia of the Divergence Excess Type: Basic and Divergence Excess Type (Major Review). Bin Vis Eye Mus Surg Qtly 8:187-222, 1993. Cooper J, Selenow A, Ciuffreda J, Feldman J, Faverty J, Hokoda S. Reduction of Asthenopia in Patients with Convergence Insufficiency Following Fusional Vergence Training. Am J Opt Physl Opt, 60: 982-989,1983. Cooper J. "Diagnosis and Remediation of Accommodative Anomalies", Chapter in Clinical Diagnosis of Optometric Problem Ed: John Amos Butterworth Publications, 1987. Cooper J. A Case Report: Treatment of a Decompensating Esotropia Who Had Diplopia and Vertex Headaches. Journal of American Optometric Association, 48(12): 1557-1558, 1977. Cooper J. Intermittent Exotropia of the Divergence Excess Type. Journal of the American Optometric Association, 48(10): 1251-1273, 1977. Cooper J. Orthoptic Treatment of Vertical Deviations. J Amer Optom Ass. 59 (6): 463-468, 1988. Cooper J. Review of Computerized Orthoptics with Specific Regard to Convergence Insufficiency. Am. J. of Optom. and Phys. Optics. 65(6): 455-463, 1988. Cooper, J. Clinical Implications of Vergence Adaptation. Opt Vis Sci, 69 (4): 300-307, 1992. Cotter S. Conventional therapy for amblyopia. Probl Optom. 1991; 3:312-330. Feldman J, Cooper J, Reinstein F, Swiatoca J. Asthenopia Induced by Computer-Generated Fusional Vergence Targets. Opt Vis Sci, 69: 710-716, 1992. Flax N, Duckman RH. Orthoptic treatment of strabismus. J Am Optom Ass 1978; 49:13531361. Flom NC. The prognosis in strabismus. Am J Optom Arch Am Acad Optom. 1958; 35:509-514. Garcia RP. Efficacy of vision therapy in amblyopia: a literature review. Am J Optom Phys Opt 1987; 64:393-404. Ludlam WM. Orthoptic treatment of strabismus. Am J Optome Arch Am Acad of Optom. 1961; 38:369-388 Ludlam W, Kleinman B. The long range results of orthoptic treatment in strabismus. Am J Optom Phy Opt. 1965; 42(11); 647-684. North RV, Henson BD. Effects of orthoptics upon the ability of patients to adapt to prism

induced heterophoria. Am J Optom Phys Opt. 1982; 59: 983-986. Scheiman M, Ciner e. Surgical success rates in acquired, comitant, partially accommodative and non-accommodative esotropia. J Am Optom Ass 1987; 58:556-561. Wick B. Vision therapy of small angle esotropia. Am J Optom Physiolk Opt. 1974; 51(7); 490496. Wick B, Cook D. management of anomalous correspondence: efficacy of therapy. Am J Optom Physiol Opt. 1987; 64:405-410. Ziegler D, Huff D. Rouse MW. Success in strabismus therapy: a literature review. J Am Opt Ass. 1982; 53:979-983.

Evolution of Two-eyed Vision Two Eyes to the Side

Nature has given animals the physical attributes necessary for survival. Lateral placement of the eyes is essential to the survival of hunted animals or herbivorous animals (e.g., horse, rabbit, cow) as it allows them to increase side or peripheral vision. Side vision (increased by lateral placement) is a sensitive detector for motion or movement. Peripheral vision allows creatures to effectively scan for danger. The rabbit must be constantly aware of its natural enemies while it eats your garden greens. At the first sign of danger, peripheral vision, the motion detector system, alerts the rabbit that there is danger. The immediate reflexive response is for the rabbit to run.

Two Eyes in Front

Faster moving carnivorous hunters do not need as much peripheral vision as the hunted. It is more important for hunters to locate their prey and accurately determine the distance from

themselves to that prey. Therefore, animals that hunt (carnivorous or meat eating animals, e.g. lion, cat) as well as humans have frontal placement of the two eyes in order to determine the exact location of their prey. The hunters sacrifice the large peripheral motion detection system afforded by side placement of the eyes in favor of the incredibly accurate depth perception system created by frontal placement of the eyes. To make up for the loss of peripheral vision, most carnivorous animals have also developed a sophisticated, pivoting system which extends the range of side vision...that is, the neck.

The Benefits of Two Eyes in Front

Frontal placement of the eyes allows for a remarkable visual phenomenon called stereopsis. Stereopsis is the 3D perception that occurs as a result of both eyes working together to create relative depth perception. Many of you have experienced exaggerated demonstrations of stereoscopic depth by viewing I-Max 3D movies or old stereoscopes. Or, perhaps, you have seen photos of theatergoers in the 1950's wearing special Polaroid glasses in order to view 3D movies.

What is Stereopsis?
Stereopsis results from the combination of the two images received by the brain from each eye. Each eye views the world from a slightly different vantage point (See Fig 1). The fusion of these two slightly different pictures from our two "cameras" (the eyes) gives us the sensation of strong threedimensionality or relative depth.

Figure 1
At near, there is a greater difference in what the two eyes view as compared to far. Thus, stereopsis is strongest and most important at near distances. At near is where man uses accurate hand-eye coordination to make tools and other items!

The Benefits of Stereopsis

Stereopsis has been very important in human development. Keen and accurate two-eyed depth perception has allowed man to develop tools and the manufacture of goods, a central aspect of modern civilization. Stereopsis plays a role in many other human activites, such as, catching a ball, parking a car, threading a needle, performing surgery, or any other activity that requires accurate depth perception at close distances.

Animals that have lateral position of the eyes and individuals who have constant strabismus (eye turn) lack stereopsis. This does not mean that they have absolutely no depth perception. There are many oneeyed (monocular) depth perception cues that allow us to make reasonably accurate depth judgements. These monocular depth perception cues may be familiar to you and include: perspective, overlay, shadowing, aerial perspective (color of the sky), relative motion, relative size, etc. Binocular vision cues (from two eyes), such as stereopsis and parallax, are dependent on accurate alignment of the eyes and appropriate unification of the two images by the brain. People with only monocular or one-eye depth perception skills can do fine in many situations. However, they are not allowed to fly a rocket ship, drive the trains in New York city subways, and they definitely should not be surgeons. They may have trouble catching a fly ball or becoming a NBA point guard. However, many jobs do not require stereopsis and thus the lack of stereopsis does not preclude a successful life. Stereopsis does enhance quality of life and life choices, however! Some eye doctors might tell you that it is a luxury, but it is part and parcel of our evolution and human potential. 3D vision is a human skill we all want and deserve. Every attempt should be made to develop this visual-motor skill in a child [and it's not too late for many adults!]

What is the "critical period?"

In the early 1960's, two Nobel Prize winners from Harvard , Hubel and Weisel, did research on the development of vision. They studied monkeys and cats who have stereoscopic vision similar to humans. This led to conclusions regarding a "critical period" of development for stereopsis. What is the "critical period" and what does it mean in regards to you or your child and your treatment options. Explore this controversial topic by reading the following two articles by Dr. Jeffrey Cooper and Dr. Paul Harris, two different experts on strabismus. Dr. Harris refers to the famous 1960s Hubel and Weisel study as well as later studies by Hubel and Weisel and others. Many of the more recent studies call into question the idea of a finite "critical period." Dr. Cooper explains the Hubel and Weisel study and its implications in detail. The Myth of the Critical Period by Dr. Paul Harris Development of Vision (Critical Periods) by Dr. Jeffrey Cooper

Why does my eye doctor say it is "too late?"

Whenever an eye doctor tells you that it is "too late" to treat your child's loss of binocular vision (or eye turn or "lazy eye"), he or she is probably referring to his or her earlier education regarding the "critical period." He or she might even be directly or indirectly referring to the aforementioned research dating from the 1960s. Remember, a great deal has been learned about the human brain since the 1960s! For example, a new ground-breaking study on the brain's plasticity (its ability to change and grow) was released to broad media fanfare in the year 2000. We recommend that you find a doctor who is more up-to-date on the latest in developmental vision and the brain (neuronal plasticity).

When is it too late to treat strabismus or lazy eye?

It is often asked at what age should treatment no longer be attempted. The answer is, everyone deserves a chance! Age should not be a deterrent, though treatment under age 6 (especially before 2) is ideal and allows better results than later treatment. After age 6, age is not important. The best chance of success in eliminating the effects of the most difficult conditions, amblyopia or constant strabismus, occurs before the age of two. However, this does not preclude excellent success in many older patients and at least partial success in most patients older than 6 years of age. There are numerous studies that demonstrate that treatment after the age of 6 is very successful. One study compared treatment before age 6 to treatment after age 6. They found no statistical difference between the two groups. As a matter of fact, loss of an eye in patients over the age of 65 who were never treated for their amblyopia experienced a spontaneous improvement in vision in over one-third of the cases.

"... every attempt should be made to improve strabismus and lazy eye."

Thus, every attempt should be made to improve strabismus and lazy eye, though treatment might not be as effective after the age of six, and definitely requires more work. Also, remember that if an eye turn occurs only some of the time (intermittent), the cells of the brains do not develop the changes associated with the more challenging cases of constant eye turns. An analogy to understanding the relationship of age in regards to the treatment of eye muscle anomalies would be to consider the relationship of one's age in learning to speak a second language. During the period of neurological development, around the first year of life, language development is natural and spontaneous. Children raised in families "It is never too late that speak two languages from birth automatically learn both to try!!" languages. However, if the second language is introduced in later school years, language development takes a longer time and is more arduous. Yet, remember, people learn languages well into their sixties and seventies. The very same is true of visual development. It is easier to develop normal vision during the critical period, but with work, many people can develop normal binocular vision in later years. See the following relevant sections: "What is the "critical period?" About eye muscle surgery for strabismus. What are basic treatment options? Types of Strabismus and their Recommended Treatments References

; All Types of Strabismus; All Treatment Options; Constant or Intermittent?; What is Double Vision?; What is Lazy Eye?; and more!