June 20, 2000 — “Don’t cross your eyes or they’ll stay that way!” It’s even more serious than the threat mothers have used on children who purposely crossed their eyes to get attention. An eye that “stays that way” brings adults a type of attention they don’t want, according to a recent study.

Adults with misaligned eyes — with one eye that either turns out or in — often report difficulties dealing with people and obtaining employment because of their appearance, according to a recent report in the Journal of the American Association for Pediatric Ophthalmology and Strabismus.

Because of the negative effects this condition can have on a person’s quality of life, many doctors now believe that these adults should undergo corrective surgery, even if it doesn’t improve their vision.

Having an eye that does not line up with the other is called strabismus, or more commonly, ‘crossed eyes’ or ‘lazy eye.’ When a child is diagnosed with this condition, doctors are more likely to suggest surgery, along with glasses and patching the eyes as needed, for correction because children are more likely to gain a vision benefit, such as getting the eyes to work together to gain depth perception.

This benefit is not as common in adults, so doctors do not frequently recommend surgery. And corrective surgery has been considered ‘cosmetic,’ so many insurance companies don’t cover it.

“People with strabismus don’t just have a self-esteem problem, they also have problems with the way other people view them,” says Scott E. Olitsky, MD, of the department of ophthalmology of the State University of New York at Buffalo. “Because they don’t look normal and because eye contact and people’s facial features are so important in everyday life, they clearly are at risk of not getting certain jobs and are less likely to advance in the workplace. Discrimination, although it’s a strong word, is a word that comes into play here.

“These people are not looking to be made cosmetically more attractive — they just want to be made to look normal,” Olitsky says.

One adult patient agrees. “He has done a miracle,” he says of his doctor, Arthur L. Rosenbaum, MD, who performed successful corrective surgery. After seven previous unsuccessful surgeries to correct a right ‘lazy eye,’ this patient, in his 30s, reports newly found confidence and an “uplifting of my shoulders. ? I perform better and give my best. It has had a huge effect on my life,” he tells WebMD.

In the recent study to document people’s perceptions, a photograph of a man with normally straight eyes was digitally altered to look like he had either crossed eyes or eyes that drift outward. A group of 212 college students was asked to grade the appearance of the person in the photographs.

The picture of the man with normally oriented eyes was rated more positively than the picture of the same man with his eyes altered on these characteristics:

• attentiveness
• competency
• emotional stability
• intelligence
• leadership ability
• communication skills
• organizational ability

Having crossed eyes was rated more negatively than having eyes that drift outward, say the authors. And students viewing the picture of the cross-eyed man also rated him as being more humorous than the version of him with straight eyes.

“We have documented that people with strabismus have a right to feel that people do view them differently,” Olitsky says. “It has been documented subjectively and objectively that people may benefit from surgery in ways other than purely correction of their visual function.”

Olitsky sees surgery to correct this problem in adults as a reconstructive procedure rather than a cosmetic one. He hopes his study and others should help change the policies of insurance companies and the beliefs of medical professionals who might deny patients this type of corrective surgery.

“You shouldn’t allow physicians to tell you — just because you might not achieve certain things visually that we would ideally like you to achieve — that surgery can’t benefit you,” Olitsky tells WebMD readers. “If your insurance company says no, they should know that there are studies in the literature like this one that indicate this surgery is necessary.”

David K. Coats, chief of ophthalmology at the Texas Children’s Hospital/Baylor College of Medicine in Houston, agrees with Olitsky. “People in the field of ophthalmology who manage strabismus and strabismus surgery for a living have always had the gestalt feeling that strabismus had a pretty profound impact on people’s lives, both socially and vocationally. ? [The] study nicely demonstrates what we believed was the case, in fact is the case: strabismus is a very detrimental thing for anyone to have.” Coats reviewed the study for WebMD.

Coats conducted a study similar to Olitsky’s, in which altered photos were attached to equally qualified resumes for jobs. They found a woman with strabismus had a much lower likelihood of getting the job in question than a woman with straight eye alignment.

Coats has witnessed the psychosocial effects of strabismus surgery. He says that he has frequently encountered patients who, within weeks of surgery, report getting a new job, a promotion, or new boyfriend or girlfriend.

“This is a good article that takes a different approach” to previous studies, says John L. Keltner, MD, chairman of the department of ophthalmology at the University of California, Davis. “It makes one more important contribution to helping us understand the importance of this very overlooked part of ophthalmology. Having crossed eyes, more than eyes that drift out, has tremendous implications. ? I think this is underappreciated by insurance companies.”

Keltner says that his first goal in treating patients with strabismus is to obtain equal vision in both eyes, and the second goal, if possible, is to get the eyes to work together to give perception of depth. “Often we can’t completely achieve either one of those goals, but the one thing we can do realistically is to get the patients to look like the rest of the world,” he says. “That’s tremendous.”

Keltner says his own work is motivated in part by his memories of the psychosocial abuse he encountered in kindergarten as a child with amblyopia, a condition that causes dimness of vision.

The study is an important addition to a growing body of evidence showing that misaligned eyes have a negative social and occupational influence, according to Rosenbaum, who is chief of the division of pediatric ophthalmology at the Doris Stein Eye Research Center at UCLA.

“We now have a lot of evidence to support the idea that this surgery is required to rehabilitate a disability, not to enhance beauty,” he tells WebMD. He says it should be considered in the same category as someone who needs a skin graft or correction of a facial birthmark.

And he says that successful surgery for some patients can still yield visual improvements. “These patients can actually visually benefit from this surgery late in life ? both in terms of quality of vision and the size of the visual field,” Rosenbaum says.

Physicians should view patients with strabismus as having a disability that requires compassion, Rosenbaum says. Early surgical correction will minimize the length of time they will have to deal with the negative effects of the disability.

Vital Information:

• New research studies show that people with strabismus, or misaligned eyes, are judged more negatively in society and that the condition affects their quality of life.
• Corrective surgery for strabismus is often categorized as cosmetic, not reconstructive, and many insurance companies won’t pay for it.
• Some experts argue that the surgery is not cosmetic, because it doesn’t enhance beauty but only makes a person appear normal.