Stars' Eyes: Abraham Lincoln

Widely regarded as perhaps the greatest of the Presidents of the United States of America, Abraham Lincoln held office during the Civil War, from 1861 until his assassination in 1865. Many aspects of Lincoln's life -- from his humble beginnings in Kentucky and Indiana, to his practicing law before becoming a leader in the nascent Republican party -- are well known. But did you know that he also had strabismus?

Look carefully at this image. Notice how his left eye appears to be looking higher than his right. This is suggestive of a vertical strabismus (eye misalignment), as are the reports that Lincoln suffered from double vision and that his left eye would "roll upward when he was excited or tired."

The intermittent nature of this symptom is consistent with either an intermittent left hypertropia or a dissociated vertical deviation. Both of these conditions are easily diagnosed by a pediatric ophthalmologist, and treatment options may include prisms glasses or corrective surgery.

Because of his very tall, thin stature, many historians have suggested that Lincoln had a condition called Marfan syndrome, a genetic disease which affects the connective tissues in the body. People with Marfan syndrome are typically very tall, thin, and "loose jointed." They are more likely to have strabismus, and may also develop early cataracts, glaucoma, corneal problems, or retinal detachments.

Note: Special credit to my partner, Dr. Jeffrey Colburn MD, of the Spokane Eye Clinic, for making me aware of President Lincoln's strabismus.

PEDIG Meeting -- Tampa, Florida

This week, I've had the opportunity to attend the annual meeting of the Pediatric Eye Disease Investigator Group (PEDIG) in Tampa, Florida. PEDIG, founded in 1997 and funded by the National Eye Institute/National Institutes of Health, is a collaborative network dedicated to supporting research in amblyopia, strabismus, and other childhood eye disorders.

As part of my practice at the Spokane Eye Clinic, my partner Dr. Colburn and I are honored to participate in several PEDIG research studies. This research allows us to help define and develop new and cutting-edge treatments for children with eye problems.

Prior PEDIG research has helped us learn these important findings, among many others:

• Infantile esotropia: Constant, large esotropia (eye crossing) in infants is exceedingly unlikely to go away on its own, and very likely to require corrective surgery.
• Treatment of amblyopia: For moderate amblyopia, with vision in the 20/40 to 20/100 range, part time patching and atropine eye drops are equally effective treatments.
• Nasolacrimal duct obstruction: For infants between 6 and 10 months old who have tear duct obstruction, there is a 66% chance the symptoms resolve without surgery over the next 6 months.

To see the complete list of over 100 PEDIG research articles published in peer-reviewed scientific journals, click here.

Although I can't discuss the actual research data I've seen at this meeting -- stay tuned, as it will be published in scientific journals in the near future! -- I can say that there are a number of exciting potential advances in treatment of retinopathy of prematurity, amblyopia ("lazy eye"), and strabismus (eye misalignment).

One wonderful thing about PEDIG is that it allows eye doctors in private practice, like myself, to participate in nationwide research studies along with physicians in university settings. I am grateful for the chance to help both current patients and future generations by learning more about childhood eye disease and how best to treat it. I've enjoyed the chance to reconnect with old colleagues and make friends with a lot of highly intelligent, motivated people, all of whom want the same thing I do: to figure out how best to take care of our little patients and their eyes.

Isn't strabismus just a cosmetic problem?

Strabismus is more than just an aesthetic issue, as it can interfere with visual development in childhood.

This is a common question. The short answer is "No!" Want the the longer answer? Here are five reasons why:

1. Strabismus, or eye misalignment, in children can cause amblyopia, or poor visual development, in the eye that isn't straight. This can be so severe as to cause permanent, severe vision loss. Fortunately, if detected, it can be treated effectively and reversed.
2. Strabismus in children can prevent the natural development of something called "binocular fusion," a process in which the eyes learn to work together, so to speak. In the first year or two of life, the neural connections between the eyes and the brain are rapidly developing, and the brain learns to put the images produced by both eyes -- images which are similar, but not identical -- into one single image. This process allows us to develop depth perception. Strabismus very commonly inhibits this.
3. Strabismus in adults typically causes diplopia, or double vision. It's easy to understand why: if the eyes are looking in different directions, they will produce different images, which the adult brain will see as double images. Want to know what that's like? Cross your eyes and walk around for a few minutes. It's decidedly unpleasant!
4. Strabismus surgery, because it is not cosmetic, is covered by medical insurance.
5. Strabismus in our society is unfairly associated with things like reduced intelligence and diminished potential for success in the workplace. Below is a review of the scientific literature on the negative societal implications of strabismus:

• A 2001 study published in the Journal of the American Association for Pediatric Ophthalmology and strabismus allowed children to play with "normal" dolls and dolls that had been made to have strabismus. They were questioned after 10 minutes of play. Grade-school children were 73 times more likely to express a negative bias toward the dolls with strabismus. PubMed link
• A 2003 study published in Acta Ophthalmologica Scandinavica showed photographs of the same children with and without strabismus to 30 elementary school teachers. Kids with strabismus were considered by teachers to be more unhealthy, less hard-working, and less happy. They were also felt to be less likely to be accepted by their peers and more likely to have difficulty learning. PubMed link
• A 2000 study published in Ophthalmology showed photos of the same job applicants, both with and without strabismus, to potential employers. Women with strabismus were less likely to be considered for the job compared to women without strabismus. Strangely, this unfair bias was not seen toward men with strabismus. PubMed link
• A 2008 study published in the British Journal of Ophthalmology interviewed 40 dating service agents, and 92.5% of them felt that a client having strabismus would make it more difficult to find a partner. Among facial disfigurements, only very prominent acne or a missing tooth had a greater negative impact. PubMed link
• A 1993 study published in the Archives of Ophthalmology interviewed 43 teens and adults that had strabismus in childhood which was not corrected. Over 1/3 of them reported that their friendships had been moderately to severely affected, particularly friendships with the opposite sex. 84% reported that their strabismus interfered with school, work, and/or sports. Sadly, 50% said they had experienced ridicule or abuse because of their eye misalignment. The majority said it had a negative impact on their self image, and 1/3 made some attempt to hide their strabismus, with their hair, head position, or sunglasses. PubMed link

In sum, strabismus is much more than just a cosmetic problem. It has a significant impact on people's vision and quality of life. And it can be fixed! Helping patients fix their strabismus is one of the most gratifying parts of my job.

What do you think? Have you had strabismus and realized it's much more than a cosmetic issue? Have you treated patients who had been told previously that this was the case?

Special thanks to Dr. Scott Larson, MD, for compiling these scientific papers. Dr. Larson, a mentor and friend, is a pediatric ophthalmologist at the University of Iowa. His excellent website can be found here.