posted 09-15-2003 06:12 PM            

Just out of curiousity does your son have any sinus problems? Has he been screened for them? A couple of the "intermittent esotropia" cases I have read about were actually traced to sinus problems. When the sinus problem got bad the eyes would cross, when it was better, they would return to normal.

Another thing that came to mind was a decompensating phoria. Has your son been diagnosed with a phoria? Sometimes when children get older and more demands are made on there visual system for close work like reading and writing, a phoria that was previously controled will begin to decompensate. It doesn't happen overnight and at first it is intermittent.

The other thing that came to mind was "Cyclic Esotropia" Although cyclic esotropia usually has a 24 hr cycle, that is 24 hours straight, 24 hours crossed, there have been documented cases of cycles that are much different i.e.1 week, 3 months and variable. Cyclic esotropia is EXTREMELY rare, and most POs will go their entire careers and never see one single case. Of the two articles I found regarding this, one PO has passed away and the other retired a few years back. I did manage to pull up a couple of "personal stories", so I encourage you to read up on cyclic esotropia because some of them sound similar to your son.

Prognosis? Well, all intermittent tropias, exo or eso, tend to become more constant over the years. For some people it happens by the time the are in grade school, some as teens, and some later in life. Treatment? Since there is very little information out there on cyclic esotropia (if that is what it is) there is also a lot of contraversy about what should be done and when. Some POs believe that you should operate sooner rather than later when proper fusion is present during "straight" periods because over time the patient will begin to surpress the deviated eye to avoid double vision when the eye turns. Some POs think that press on prisms should be used during "turned" periods to avoid double vision and taken off during straight periods. Some say do nothing until the deviation becomes constant so that you will know what deviation to correct for.

I encourage you to contact Dr. David Guyton at John Hopkins in Baltimore, MD. He is THE authority on strabismus. He works exclusively with difficult and unusual cases. He may be willing to review your sons medical records and give his opinion as regards what to do. If I had such an unique case, Dr. Guyton is the person I would trust.

posted 09-16-2003 12:14 PM            

As far as this being cyclic, we have not found any patterns. Some episodes last a few hours, some a few days. Between episodes can be a few days, or several months. His most recent crossing was a few days ago, and the time before that was 7 months ago. As of now the episodes are happening farther apart. I know that can (and probably will) change.
Acquired eso was one almost diagnosis, but was dismissed because they can't find any cause. ie: any syndrome, damage, etc. He did in fact aquire eso, but why, and why it comes and goes is the problem. It is intermittent, but not cyclic. Sudden, but not acute. Hurry up and wait
So far, no PO has wanted to do surgery, and I agree (at this time). I've tried to contact several PO's out of our area, to see if they have ever seen this, or anything similar. So far, the only response I've recieved is that they would have to examine him to form an opinion. Very frustrating as I am not able to travel thousands of miles for an office visit and exam....If I could find someone who has seen this, or even heard of this I would be willing to go anywhere. We are trying to exhaust all of our resources in our immediate area (a few hundred miles). I will contact John Hopkins, and Dr. Guyton. Hopefully they will be willing to help, or at least point us in the right direction.
Mentioning sinus problems did set off a light for me, as my son does have allergies, and is very nasaly, and "drippy" most of the time. I have told all POs this but none have said that this could be related. This I will pursue also.
My son has not been diagnosed with any phoria ( has not been diagnosed with ANYTHING, that's the problem!!!! ) All Dr.'s have had ideas, but with further testing become dumbfounded. His vision is near perfect in each eye (whether crossed or not) MRI was normal, no pattern or common circumstance. He doesn't fit for Duanes syn. any nerve palsy, Arnold Chiari I, nothing I or the PO's can find. It's like he's a little of this, some of that, a pinch of something else, but not enough to be this, or too much to be that.
We will be going to Childrens Mercy next week, and will push for retesting of everything, including MRI. I believe a lot can change over a few years, and will put my mind at ease as far as any neuro. problems that may exist. (After many late nights doing internet research, you read so many terrible things that MAY be the cause, your mind can get carried away!)
Thank you again for your reply. Any information could be helpful.

posted 09-16-2003 04:19 PM            

Although you don't think his case sounds like cyclic esotropia, your story sounds a whole lot like the stories told by other parents who ended up with that diagnosis to me. At first, cyclic esotropia has no pattern and eventually degenerates in to the "cycle". What sets these kids apart from "normal" acquired esotropia is that 1)they do not have high hyperopia i.e. their is little to no "accomadative" portion to the eso; little to no rx as opposed to rx of +6 or more you see in most acquired eso 2) They have no sensory defect, that is the have excellent fusion/binocularity on their straight days; "normal" acquired esos have binocular disfunction due to their sensory problems

Here's a short excerpt from a story I found:

My 7 year old developed strabismus...and soon thereafther noticed his right eye turning in occasionaly, and then more frequently. It is now in a pattern where his right eye will turn every other day, and both eyes are straight the other days. Our optometrist...found the following:
- low hyperopia - .5 diopter dry, 1.25 wet
- comitant intermittent alternating non-accomodative esotropia
- stereoscopic perception to 70 seconds of arc

Sound at all familiar? They did turn out finding a sinus component to the problem which they treated, and the strabismus went away. It did return and they started looking for other answers. Started a HUGE debate as to correct diagnosis i.e. continuing sinus problem, decompensated phoria or cyclic esotropia.

I hope Dr. Biglan is able to offer you some guidance regarding the need for further testing. Good luck.

posted 09-16-2003 09:34 PM            

Torre

posted 09-16-2003 09:53 PM            

As far as the cyclic is concerned, wouldn't the episodes become more frequent as time goes on? My sons are becoming less frequent (as of the past 3-4 times). Not to say they won't continue this way, as we've learned not to try to predict anything at this time. Also this has been going on for a few years now. How long does it typically take for the cycles to become regular? I've read about infants that begin intermittently, then become cyclic, but none that begin after 1yr or so. Cyclic seems to be very rare, and very specific.

We will be asking more about the sinus-relationship. He is seeing his family pract. Dr. for his yearly physical and possible specified allergie testing 2 days after his appt. at Childrens Mercy. Kinda wish it was the other way around, but you take the appt.'s as you get them.

Thanks for the info on Dr. Guyton. I will be trying to contact him.

Where did you come across the story you quoted? I'd like to read it in its entirety.

posted 09-16-2003 10:17 PM            

All I can say is you need to research "Cyclic Esotropia" and you should find what there is to read about it. It is not a medical journal type source so I can not quote it as it is against TOS.

BTW, Torre is correct that Dr. Guyton is often willing to review cases via e-mail. That is a good thing because the current wait for a "face to face" with him is 9 months to a year!