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Strabismus--How to Cope?


DoctorH

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Hi!

This is my first post, and I'm starting with a tricky question that's driving me crazy. I've had strabismus since childhood, but it wasn't diagnosed as a child when there would have been (or at least there would be today) treatment options short of surgery. That is, I'm cross-eyed--not in the sense of cross-eye dominance, but in the sense of my eyes wanting to cross lines of sight. That also makes it so that my dominant eye changes depending on distance. In everyday life, I can compensate for this and actually keep my eyes aligned, but as soon as anything removes clear visual guidance how to keep them aligned, they'll drop into a strongly cross-eyed position, north of ten prism diopters offset.

Now for shooting this obviously is a problem. With iron sights I hit fine, but unless I close one eye things really fall apart, in some cases with my picking up the sight with one eye and the target with the other, which throws me totally off. So for any chance at shooting with both eyes open and some speed, I prefer red dots, and in USPSA I shoot Carry Optics. I use prism lenses that partially (about halfway) correct the problem for driving to relief eye strain, but not for reading (since the chromatic aberration creates more stress than the prism resolves) nor for shooting (since I haven't found any safe shooting glasses that'd accommodate prism and they don't make prism correction to correct me all the way anyhow).

With red dots of various kinds, it turns out that with a 1x scope that sort of acts like a red dot on my AR when the magnification is at 1, on a lucky day I can achieve stereoscopic vision and fusion, i.e., seeing the same thing with both eyes and having the red dot superimposed. Although it's said that being able to correct this by training as an adult is very hard or impossible, since it sometimes works and I have some conscious control over it, I hope to be able to get a bit of reproducibility into that with enough training.

With a slide-mounted red-dot, I don't get so lucky, though. It's probably because the gun itself is in my field of vision and the frame of the red dot is visually large, too, but the best thing I can achieve with a mini-red dot is that even though I keep both eyes open I'm using only my dominant eye for target acquisition. Typically I don't get double vision, but if several identical targets are close together I can happen that I need to think about which one I'm on. At any rate I'm looking through a tiny tunnel. My results are as one would expect from this, nice hits but way too slow, typically in the 25% range.

For obvious reasons, this is extremely frustrating. And it's getting even more frustrating, because shooting makes me more conscious of when I fail in the same way at everyday visual tasks. (I could never really catch a ball, and when I was a kid I had the additional frustration of not knowing the medical reason why, so I was just told I'm clumsy and lack and talent.)

Does anyone here have any suggestions about techniques or people that might help? I haven't gotten much out of a strabismus specialist who has a very good reputation, but is, like almost everyone in the field, almost exclusively working with children. That combined with living in a rather gun-unfriendly area where it might be that some of the staff think of shooting problems as a psychiatric, not a vision problem made this rather unproductive. So I'd be really grateful if I could find someone with similar issues who's found a way to make things work, at least kind of, sort of, or even a pointer to some expert for strabismus with experience with adults and athletics.

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Wow, that sounds like a hard issue to live with. No idea about fixing it, as I thankfully don't have to deal with it.

But, have you tried putting translucent tape over the non-aiming eye's lens? I know several people with eye dominance issue that dramatically improved with just tape over the lens.

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What's your age? Is your refractive error fully corrected? Do you know exactly how much of an esotrope you are? What exactly are you trying to accomplish....shooting with both eyes open all the time with a red dot on a pistol?

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But, have you tried putting translucent tape over the non-aiming eye's lens? I know several people with eye dominance issue that dramatically improved with just tape over the lens.

this is what I was going to suggest. I don't know if it would help in this situation, but it really helped me with double-vision issues and the visual clutter and confusion that results from not having a strongly dominant eye. It is way more comfortable than closing 1 eye and i can still use my left eye for peripheral vision and movement.

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Wow, that was a lot of thoughtful responses for an exotic question! I'll try some dryfire with a translucent tape and/or these Fresnel prisms over my nondominant eye and see how that feels.

What's your age? Is your refractive error fully corrected? Do you know exactly how much of an esotrope you are? What exactly are you trying to accomplish....shooting with both eyes open all the time with a red dot on a pistol?

I'm 38. My exact amount of esotropia is a bit tricky to measure, since I am normally able to correct for it with something clear to look at. So one thing the doc did was to have me sit in a dark room for half an hour and then to measure quickly, but even there as he was measuring my eyes started to converge, so each time he got to a different result. That being said, my glasses with 5 prism diopters on each side (the maximum that's commonly available and doesn't create horrible distortions), so 10 total, seem to be about a bit less than half the total needed correction, both by doc's measurement and by my experimentation with reflex sights. So let's make it 23 prism diopters total, or about 13 degrees.

What I'm trying to accomplish is twofold: On the one hand, I'd like to find a way to do better in the speed disciplines. Ideally, that'd presumably be using both eyes, which I can do in some visual situations, and with a bit of luck even with an AR optic. On the other hand, I've got to say that I also simply get a huge kick when (say with the AR) the red dot does work as intended--it's almost like magic; imagine how you'd feel if you could only see colors when you work really hard on concentrating on them what a kick it'd be to see a course of fire in glorious color. (For the same reason, I'm also a bit of a sucker for totally overdone 3D effects in movies; if it's horrendously overdone, even I can see a world in stereoscopic three dimensions.) So if one way or another I could get to the point where I could get my pistol red dot superimposed onto a picture of the target (one picture of the target, not two offset ones!) that should not only benefit my time quite a bit but also produce a very big grin in my face.

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You never said your refractive error. It sounds as if you have been thoroughly evaluated so I assume you have probably had a cycloplegic refraction at some point and if you are hyperopic, that has been COMPLETELY corrected. As I am sure you are aware, as you accommodate, your eyes turn in so the more plus (if you are hyperopic) or less minus (if you are myopic) in your prescription you can handle, the smaller the esotropia will be. Without knowing the specifics, have you ever tried using a small over-the-counter (0.75 D) reading glass and looking far away through them. It depends on your refractive error and ACA ratio, but they may help with the esotropia although it probably will blur you at distance (again, it depends on your refractive error). Translucent tape and Fresnel Prisms (which are already somewhat translucent to begin with) are a good choices because they will still allow you to have peripheral vision but avoid the double vision. Another option would be clear safety goggles over your prism glasses. Whichever method you chose (assuming that can't fix your refractive error), I would bet if you spend some time aligning the sights while not being at the range (just consciously trying to maintain fusion), you could see some improvement since you do have some stereopsis and the ability to align the eyes at times. Vision training can't fix all of your problems and is definitely much less effective at 38 compared to a child, but training your brain/eyes to do a specific task (such as shooting with a red dot and maintaining fusion) may be possible if you work at it. That is why I would try not to even worry about shooting at first so that you can concentrate on one thing.....seeing what you need to see. If you can consistently get the correct sight picture, then introduce dry fire and shooting.

One other thing to keep in mind.....Adam Brown passed all of Seal Team 6 requirements (including CQC) AFTER losing his dominant eye and much of the function of his dominant hand so quick shooting can be done with just one eye.

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Not exactly an "exotic question" either ...

The question of shooting with one vs two eyes comes up once in a while -

esp with people right handed and left eye dominant.

If you read some of the old postings here you'll find similar discussions :)

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But, have you tried putting translucent tape over the non-aiming eye's lens? I know several people with eye dominance issue that dramatically improved with just tape over the lens.

this is what I was going to suggest. I don't know if it would help in this situation, but it really helped me with double-vision issues and the visual clutter and confusion that results from not having a strongly dominant eye. It is way more comfortable than closing 1 eye and i can still use my left eye for peripheral vision and movement.

A third for this technique. I actually use either sunscreen or chapstick smeared on the lens for the same effect as scotch tape, but it isn't quite as opaque.

My eyes are VERY nearly 50/50 on dominance, and my shooting took a quantum leap after I gave up on both eyes being fully open and unobstructed, and blurred one lens slightly, and I've shot that way ever since. Works great for me with irons. Give it a try.

You still get peripheral vision and enough of a view to aid in acquiring targets and to give yourself depth perception (the primary benefits to keeping both eyes open) but for anything requiring precision the brain pretty much ignores the blurry eye's input. Or so it seems.

Edited by MemphisMechanic
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You never said your refractive error. It sounds as if you have been thoroughly evaluated so I assume you have probably had a cycloplegic refraction at some point and if you are hyperopic, that has been COMPLETELY corrected. As I am sure you are aware, as you accommodate, your eyes turn in so the more plus (if you are hyperopic) or less minus (if you are myopic) in your prescription you can handle, the smaller the esotropia will be.

My refractive error is -0.75 left and +1.25 right spherical, with some minor cylindrical as well. In my shooting glasses, I have that corrected, but no prism. That also makes things interesting in that my eye dominance changes depending on distance and whether I'm wearing glasses, though with glasses it's strongly left eye at all distances.

The connection between esotropia and refractive error is interesting. In terms of optics it makes complete sense, but none of a number of ophthalmologists I've seen over my adult life ever brought it up. There is something a little weird in that my prescription, even though regularly verified, sometimes cycloplegically, somehow doesn't seem to be quite right at times.

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Cycloplegic retractions tend to over-plus or under-minus which will leave you to some degree blurry at distance if you are prescribed more plus/less minus than you can handle (key is handle). Many people can't completely relax their accommodation all the way which is what the cyclo drops do (well relax most of ithe accommodation) depending on which drop is used.. The 2 diopters of difference in your Rx complicates things too...with glasses, 2 different images (due to difference in prescription) sizes are going to your brain and that makes it more difficult to fuse them into one. Contact lenses eliminates most of the difference in image size but they can't correct the esotropia. Have you ever tried contacts? If so, we're you able fuse (no double vision or suppression)?

Your true eye dominance never changes, but the eye you prefer to use will based on which eye gives you the clearest vision with the least accommodation and diplopia. Based on your refractive error without glasses, it makes perfect sense that your "dominant" eye changes depending on the distance you are looking... If you accommodate, you're right eye will see better than your left eye at distance up to 0.75 D but the right will have to do a lot of accommodating to make things clear which will tire your eyes quicker as well as make the esotropia worse (actually you can't accommodate in only one so both eyes will always accommodating the same amount at any given time) so when you look at things close enough, the left eye will take over. Hopefully understanding that will help you solve your problem.

Are you shooting with any refractive correction (even if it is without prism)? If not, are you aligning the dot to the right eye?

Edited by B585
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Are you shooting with any refractive correction (even if it is without prism)? If not, are you aligning the dot to the right eye?

I shoot with protective glasses that have refractive correction built in. Always (except for carbine support hand practice and the like) with the left hand and left eye, and right eye feels seriously unnatural.

I never had contact lenses.

Edited by DoctorH
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DoctorH, while I might not have all the answers, I can at least empathize fully with your situation. At age 18, I developed a significant case of 4th nerve palsy in my left eye. The only way I could keep from seeing double was to have a substantial head tilt to the right. Considering that I only started regularly shooting at age 21, I was in a terrible position to start up something that requires solid visual abilities. The only way I could do anything was to close or patch my left eye or tilt the crap out of my head... playing pool, shooting pistols, reading books. I tried prism glasses... I found them straining and all it lead to was a perpetual headache along with dizziness. Plus my condition wasn't really conducive to prisms since the extent of my diplopia varied depending on the position of my head relative to my head tilt and the pull of gravity.

Basically, I ONLY shot with my left eye closed for about a decade and a half. I found all kinds of work arounds in daily life... picking a side of the bed to sleep on or the orientation of the TV to the couch, etc. I got to the point where everything was second nature, but I continued to shoot with my left eye closed.

About 7 or 8 years ago, I was getting my routine eye exam (near-sighted on top of the other issue) with an different doctor. He asked me why I never explored strabismus surgery. I told me that it was never presented as an option to me back when I was first diagnosed. So I was referred to a surgeon -- who, as you pointed out, was primarily a pediatric surgeon. I elected to get the surgery... it was going to be more art than science considering the variability of my condition. Factor in that apparently the extent of my condition was severe enough that he felt it was necessary to split the difference and operate on both eyes instead of trying to do the full correction in just the left eye.

I can give you the gory details of the surgery, but the short version was that it was incredibly unpleasant. He also over-corrected and I had to have a second corrective surgery performed 7 days later. The second surgery didn't require the fun part of the first surgery, which was that the final steps of the surgery were actually performed when I was awake in order for me be able to tell him how tightly or loosely he should finish adjusting the muscle and then suturing my eye closed. My wife was in the room with me during this time and was putting on a brave face, but afterward she admitted that it was horrific for her to watch. We are both clearly not medical professionals and have weak constitutions. ;-) I did ask him if he puts little kids through that process, and he said no way. He also mentioned that kids seem to heal incredibly quickly and with much less discomfort than adults. (He probably should have left that part out until after I had already finished the healing.)

Now that it has been a long while since I had it done, I'm very glad I did. It's not 100% gone, plus I know that there is a good possibility my condition will start to come back to a certain degree over time. However, it's made life a lot easier. And after about 20 years of shooting, I started to try shooting with both eyes open for the first time. It was surprisingly easy since the brain does all the work. I still have to close one eye when distances get farther out than about 10 yards, and I'm trying to get accurate hits.

Personally, I think you might be in a position to have little choice but to try to block the vision in one eye -- either with a patch or glasses or closing an eye. I found little way around it. As a side note, I now can actually attend 3D movies without getting a headache 5 minutes into the film. People with normal binocular vision have no idea the seemingly inconsequential ways it affects daily life... not to mention constantly feeling self-conscious about the cosmetic appearance of the condition.

Good luck, sir.

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  • 3 years later...

I figured it's time for an update to this. I did a lot of research, and it seemed surgery for this has come a long way. So I took the chance two years ago. 

 

Worst part: The final alignment is a couple of days after the main surgery. You need to be conscious while someone is adjusting threads in your fregging eyes. Local anesthesia never does much for me (and not, I should add, due to a history of abuse--it just doesn't). I told the surgeon that every horse would get ketamine for this. He responded that he grew up with horses and I was right, but unfortunately I wasn't a horse.

 

Best part: It worked perfectly. I can now look into a red dot sight with a front cover on, aim with both eyes, take the front cover off, and the red dot is where it's supposed to be.

 

Middling part: The window for brain development supporting binocular vision closes at age three or so. So while I can now use both eyes open without getting thrown off far enough to get into DQ territory, catching a ball coming in at some speed likely isn't going to happen.

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6 hours ago, DoctorH said:

I figured it's time for an update to this. I did a lot of research, and it seemed surgery for this has come a long way. So I took the chance two years ago. 

 

Worst part: The final alignment is a couple of days after the main surgery. You need to be conscious while someone is adjusting threads in your fregging eyes. Local anesthesia never does much for me (and not, I should add, due to a history of abuse--it just doesn't). I told the surgeon that every horse would get ketamine for this. He responded that he grew up with horses and I was right, but unfortunately I wasn't a horse.

 

Best part: It worked perfectly. I can now look into a red dot sight with a front cover on, aim with both eyes, take the front cover off, and the red dot is where it's supposed to be.

 

Middling part: The window for brain development supporting binocular vision closes at age three or so. So while I can now use both eyes open without getting thrown off far enough to get into DQ territory, catching a ball coming in at some speed likely isn't going to happen.

I also have double vision. I've just learned to live with it. Interesting enough in my case is that visual acuity in my non-dominant eye - the one that does not properly localize an object - is better than my dominant.

 

The surgery you describe was developed at Univ. of Iowa but long after my childhood. I didn't know it was a viable tx for older adults. I've already had 3 surgeries during my childhood so they may not like all the scar tissue they would have to work through.

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41 minutes ago, lgh said:

I didn't know it was a viable tx for older adults.

 

I was lucky enough to find someone nearby who's supposed to be one of the world's best (and has a bit of an attitude that reflects that reputation, but one probably wants that in a surgeon). Even so, the front desk ladies repeatedly asked me where the patient was...

 

Looking back, though, I find it amazing that with a PE teacher for a mom, a large number of government-paid and strongly recommended routine exams growing up in Europe, and PE in school, of course, nobody every asked any questions about my binocular vision. If diagnosed before I was two or so, one quite possibly could have alleviated much of it even without surgery. I even remember distinctly that this routine test with polarized glasses and a three-dimensional fly to grasp for and buttons appearing to jump out of a page was given to me as a kid (older than two, of course), but no diagnosis or explanation or followup of any kind happened. Instead, the principal of my elementary school, I kid you not, wrote a poem making fun of my lack of athletic ability. I eventually learned what was going on with the mandatory and somewhat detailed vision exam for a driver's license over there.

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18 hours ago, DoctorH said:

I eventually learned what was going on with the mandatory and somewhat detailed vision exam for a driver's license over there.

I know what you mean. Having been through all the stuff you describe as a kid - eye therapy sessions with 3D images, etc. - I can usually get through the eye exam at the motor vehicle dept. knowing what I'm SUPPOSED to see. I get a letter from my ophthalmologist if needed.

 

I've been around academic medicine my whole career and whenever the eye doc sees me he/she calls in the medical students. "You may never see this again." I should send them a bill for my services.

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Surgery is an option but has anyone mentioned Bupivacaine injections? My patients have had a great deal of success with this. The injection helps realign the muscles. It wears off after about 3 months but by then you usually don't need a second injection. It all depends on amount of eye turn. This paper was about a surgeon that I co-manage surgery with , Dr Stephen Mathias. https://www.healio.com/news/ophthalmology/20170404/bupivacaine-seen-as-alternative-to-strabismus-surgery

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11 hours ago, Youngeyes said:

Surgery is an option but has anyone mentioned Bupivacaine injections? 

Sounds promising although it was all in peds. It sounds like it's (relatively) risk free. The std surgical procedure really turned things around for strabismus. Do you do the procedures?

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11 hours ago, lgh said:

Sounds promising although it was all in peds. It sounds like it's (relatively) risk free. The std surgical procedure really turned things around for strabismus. Do you do the procedures?

I do not do the procedure. The majority of my patients who have had it done are adults. As we get older the extra ocular muscles can atrophy and cause a double vision. Initially prism glasses work. As time goes on, the amount of prism needed can be too much. I always refer out to someone like Dr Mathias for a consult. 

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  • 1 month later...

I'm glad I stumbled on this resurrected thread.  I'm in my 70's and had surgery at age 10 to correct what was then called exotropia (I believe). While the surgery gave me good function I don't have binocular vision and couldn't, for example, pass the binocular vision test required in the 60's for pilot training.  I can converge images in binocular helmet mounted displays and I suspect that's a product of the symbology focused at 300 ft. minimum.  I've had cataract surgery in my dominant eye with resulting excellent acuity and use 2.25d lens with a tiny bit of cylinder in my right/dominant eye and distance prescription in my left eye for shooting SC with iron sights.  Something in this thread has me rethinking the distance vision in my left eye.   Shooting primarily steel challenge I find myself squinting when shooting "distance" targets and this decreases contrast.  Obviously, the image is much sharper in my left eye and I now wonder if the squint has something to do with overcoming my brain's natural preference to use the left eye; I can use the sunscreen on the left lens trick to test this, but anyone with an opinion feel free to chime in.

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  • 2 years later...

I have strabismus (crossed eye) fortunately I was diagnosed young and have had prisms in my glasses since 2nd grade. Shooting with iron sights I close one eye. This weekend my husband was introducing me to red dot. I have struggled and couldn't hit the target with both eyes open. It took me so long to align the sights on the target. I tried using the red dot without my glasses to see if that would help and it made it worse. I saw double targets and couldn't shoot where I was aiming. I went back to closing my non dominant eye and used the red dot with and without my glasses and hit my target. After my experience this weekend, I think I like my iron sights better but would like to see if I can adapt to red dot. I am glad that there are others that have the struggle like I have had. Thanks for sharing this suggestion. 

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