aeon magazine has a fascinating article that provides more insight into the concepts we introduced in Part 1. Here is an excerpt illustrating a few of the points we made regarding early psychosocial deprivation and the subsequent behavioral and visual sequelae:
“A boy in a red T-shirt and sweats skipped up to me, grabbed my hand, and wouldn’t let go. His head didn’t reach my shoulders, so I figured he was eight or nine years old. He was 13, Ţibu said. The boy kept looking up at me with an open, sweet face, but I found it difficult to return his gaze. Like most of the other kids, he had crossed eyes — strabismus, the professor would explain later, a common symptom of children raised in institutions, possibly because as infants they had nothing to focus their eyes on.”
In a pilot study published by Koslowe and colleagues, the prevalence of strabismus in a population of institutionalized children with cognitive limitations was significantly higher than in the general population. In an article published by Johnson in Pediatric Annals, the author’s personal observations in one Romanian orphanage was that 25% of the population had strabismus. Considering that this was done by gross observation, the actual percentage of strabismus including intermittent and small angle strabismus is likely to be higher. Dr. Johnson advises that all previously institutionalized international adoptees should be examined by a pediatric ophthalmologist within the first few months of arrival.
Despite the posturing of some pediatric ophthalmologists that they be considered the clinical authorities in vision development (see here for example), it should be clear that the strabismus seen in these populations has to be managed in a broader developmental context than a decision to patch or otherwise penalize the child with atropine, or to realign the eyes through surgery or botulinum toxin. Parents who have come to our practice have been told repeatedly that there is no indication to consider vision therapy for any condition other than convergence insufficiency. Thus the child is further deprived of meaningful interventions that could actually lessen the burden of deprivation.
Let me give you a case in point about developmental expertise that’s fresh on my mind. A friend and colleague e-mailed to ask if an acquaintance of hers could contact me about a premature infant with developmental delays for which physical therapy had been implemented. His mother became concerned about the onset of nystagmus with anomalous head posture. The pediatric ophthalmologist who evaluated him described a 45 degree right face turn alternating with a left face turn, with preference for the right face turn. There was a rotary nystagmus with low amplitude and high frequency with null points in side gaze. The frequency of the nystagmus was higher in the left eye than in the right eye. Motility testing revealed a variable exotropia at all fixation distances with full extraocular rotations. A diagnosis of spasmus nutans was given and the parents were advised, per a copy of the doctor’s letter that the shared with me, that this is a benign and self limiting type of nystagmus that may resolve without treatment over the next few years. However, in light of the asymmetric nature of his nystagmus, an MRI of the brain was ordered to rule out a chiasmal glioma. Thankfully when the infant’s mother sought my advice two months later the results of the MRI were negative for chiasmal glioma and non-contributory to the nystagmus or variable exotropia.
Now consider this observation related in passing in the pediatric ophthalmology report: the 10 month old infant was described as “visually inattentive at times”. Why is that? Most developmental optometrists will tell you that 10-month old infants are a dream to examine compared to toddlers at the “terrible two” stage. They play peek-a-boo with you and are typically spellbound by the variety of targets we present.
Perhaps this is a clue: The cycloplegic refraction revealed OD: +4.00-3.00×130, OS: +3.50-2.75×60 (no “dry” refraction was conducted). I would daresay that any developmental optometrist would trial frame lenses to observe changes in the infant’s looking behavior, visual attention, head posture, and exotropia. In this instance the letter to the pediatrician concludes: “Moderate hyperopia with astigmatism. In light of his young age, eyeglasses may be deferred.” There is no evidence based medicine supporting the notion that asymmetric oblique compound hyperopic astigmatism of this magnitude resolves by itself. As confirmed by the infant’s mother, the doctor did not assess the influence of a lens prescription on head posture, looking behavior, visual attention, or strabismus. There was no attempt to conduct preferential looking nor any mention of the potential utility of the VEP. My contention is that by withholding these assessments, the doctor is potentially compounding the infant’s developmental challenges. (See in particular slide 33 in this insightful Webinar by our colleague, Dr. Glen Steele.) For that reason I was pleased to be able to refer her to a developmental optometrist in her area who has significant expertise in infantile strabismus and visual development.