The pirates of preschool: amblyopia and the curse of the lazy eye

Tom French grew up on Wellesley Island and is a graduate of St. Lawrence University and SUNY Potsdam. He teaches seventh-grade English at J.W. Leary Junior High School in Massena and lives in Potsdam with his family.

My family is a "pirate family." You see, our son has amblyopia (lazy eye) and had to wear a patch on his good eye in order to strengthen the lazy one for almost four years.

Daniel is not alone — 2 percent to 3 percent of all children are afflicted with this medical condition, which if left unchecked can lead to blindness in one eye, lack of depth perception and, potentially, a wandering eye.

He was diagnosed when he was 4 after he failed an eye exam in the pediatrician's office for the second year in a row. The nurse lined him up on a piece of masking tape, and he tried to identify the pictures (a house, a sailboat, a duck) on a chart at the other end of the hall while I struggled to keep one of his eyes covered.

The first year, when Daniel wasn't able to see much with his left eye, no one thought anything of it. It was chalked up to 3-year-old fidgetiness and lack of attention span. But the following year he failed with the same eye again.

This time, we were referred to a pediatric ophthalmologist, Dr. Monica Nuyens of North Country Eye Associates in Ogdensburg.

It was the beginning of my education not only of this largely misunderstood condition, but also in the resilience of a little boy and the degree to which children are able to tolerate unpleasant conditions.

Amblyopia occurs when the brain essentially turns off the information coming from one eye. There is usually some underlying vision problem that leads to this, but once corrected, with eyeglasses or surgery, the patient will still exhibit poor vision in the affected eye because of the amblyopia. The brain needs to be rewired to use the "lazy eye."

Daniel was extremely farsighted in one eye. At an early age, his brain realized that one eye could see much better than the other, and it began to rely on that information and it shut off the weak eye.

In order to correct the amblyopia, Daniel had to be forced to use the weak eye. The two most common therapies are patching and eyedrops. Because of the degree of our son's lazy eye, the doctor recommended patching. An eye patch is worn over the strong eye, forcing the child to use the weak eye, thereby rewiring the brain to start using that eye. Eyedrops also force the child to use the weak eye by paralyzing the focusing muscle of the strong eye.

Dr. Nuyens, our pediatric ophthalmologist, gave us some sample patches to get us started. Colored to look like camouflage, a Holstein cow, or decorated with rockets and stars or soccer and basketballs, these designer patches attempt to make the therapy "fun," though I tried wearing one for a little while just to see what I was asking Daniel to do, and it wasn't pleasant.

Despite the fact that more than a million children under the age of 10 are afflicted with amblyopia, my wife and I had a hard time finding additional patches in the local drugstores. What we finally found looked like Band-Aids. They weren't nearly as cool as the patches from the doctor's office. Even our 4-year-old son recognized that. They were also much stickier, and when it came time to remove them — well, it was like ripping off a Band-Aid.

So you can imagine, Daniel fought against wearing the patch — literally. On the first few occasions, I had to pin him down while my wife put it on. Once it was in place, though, he calmed down and wore the patch for the required time (two to four hours a day) without any fuss. Perhaps it was the knowledge that taking it off would hurt.

We solved that problem by dabbing a little lotion around his eye prior to putting the patch on. It helped, though it also made the patch less adhesive.

Patching became a ritual of sorts. My wife bought a slew of stickers that our son would pick out and apply to the patch before putting it on. He was still dubious of the process at best.

In the meantime, I redoubled my efforts to find a source for the patches from the doctor's office. As we didn't have a box, I searched the wrappers and peels to find the name of the company that produced them. A quick Internet search led me to Ortopad USA (www.ortopadusa.com).

Within a couple of weeks, Daniel, though still reluctant, at least stopped fighting us. He seemed to accept our resolve and the patch as a reality, though he still played games to avoid it. Some days were easier than others. He often required privacy to put it on. He'd run off into another room and return a few minutes later with the patch on. We'd find the wrappers behind the couch or under his bed. Over time, he no longer needed lotion prior to applying the patch. He ripped it right off when we told him his patch time was up.

People often asked Daniel what happened to his eye. "Did you hurt it?" they queried.

He eagerly pointed to the unpatched eye and explained. "I'm making this eye stronger."

His neighborhood friends never questioned it, though, and on one occasion I almost had to break up a brawl in the backyard when some kids visiting the neighborhood started teasing him. All the neighborhood regulars came to his rescue.

Within a couple of months, Daniel's sight in the weak eye improved from worse than 20/80 to 20/60 — with his glasses on. (Remember, the glasses should correct his vision to 20/20, but the condition of amblyopia is preventing that). By his next visit to the ophthalmologist, he was seeing 20/50. But then the progress slowed considerably.

When we first started patching, we hoped it would be for only a few months. After more than a year, we realized it was going to be a longer trial. Four years later, we're still a pirate family, though recently the doctor switched our son to atropine eyedrops as we make the final push to the end of therapy. At a recent visit to the ophthalmologist's office, he was pushing 20/25. Soon, the doctor will wean him off, though we will still make regular visits to her office to ensure that he doesn't lose ground.

There are several reasons the brain might ignore signals coming from an eye. The most common cause is strabismus (misaligned eyes), or in other words, cross-eyes. The "crossed eye" is turned off by the brain to avoid double vision. Families with a history of crossed eyes should have their children's eyes checked by an ophthalmologist early in life.

Sometimes there is an obstruction partially blocking the vision in one eye. This could be caused by a cataract (a clouding of the eye's natural lens), a tumor, or any impediment that prevents a clear image from focusing in the eye. This type of amblyopia is considered the most severe form and might require surgery.

Daniel's condition was "unequal focus," or refractive error. One eye is out of focus because it is more nearsighted, farsighted or astigmatic (not perfectly round) than the other. This is the most difficult type of amblyopia to diagnosis since the eyes appear normal to the untrained observer. It requires careful measurements and testing to pinpoint not only the amblyopia but also the underlying cause.

Many insurance plans do not cover routine optical care, but amblyopia's distinction as a medical condition means that it should be covered under many insurance plans. Don't give up if at first coverage is denied.

In our case, it took convincing, cajoling and a series of letters and appeals to our insurance provider from both the ophthalmologist and ourselves. I believe one difficulty was simply that our insurance company rubber-stamped denial on any invoice coming from an ophthalmologist. Eventually we were successful in our efforts to have complete insurance coverage.

As much as I hate putting Daniel through this torment, I know it's in his best interest. I occasionally see a child at T-ball or Biddy Basketball with crossed or wandering eyes, and I know, that at age 7, it's too late to correct. The brain just isn't that malleable any more. It saddens me to see a child with this uncorrected condition. With kindergarten screening and portable autorefractors for less than $500, there really is no excuse. Some gains might be made with late diagnosis and treatment, but early detection is the key to success.