Double take: The special approach that corrected one child’s vision overnight

Dr. David Hunter, pictured here, corrected Eliza's crossed eye at Boston Children's Hospital
Dr. David Hunter is a pioneer in detecting and treating children’s eye conditions with a range of new and tried-and-true technologies and techniques.

“At school I was seeing double today, Mom,” said 9-year-old Eliza in May of 2015. Catherine hadn’t noticed her daughter’s eyes crossing and suspected that her fourth grader was simply tired.

A few weeks later, however, Catherine and her husband were sitting in the front row at Eliza’s chorus concert, when suddenly they both noticed their daughter’s eye was crossed. It was Eliza’s 10th birthday.

“She was fine one day, and then the next her eyes weren’t working together,” says Catherine. “It was terrifying.”

Losing sight of answers

As Eliza struggled to read in school, see where she was going while riding her bike, and watch her steps in dance class, Catherine and her husband struggled with their growing concern over their daughter’s crossed eye.

“Is there a neurological issue?” they wondered to each other. “Is it a tumor — cancer, even?”

With Eliza’s 4-year-old brother in tow, the Pennsylvania-based family began traveling to different hospitals all over the east coast, seeking answers about what was happening to their daughter’s eye.

“I am a researcher by nature,” says Catherine. “I began reading everything I could about crossed eyes.” She read online that Eliza’s type of strabismus (crossed eye) was called esotropia, meaning that the eye was turning inward.

“But nobody knew exactly what had caused her eye to cross, or how best to fix it,” Catherine says. “The doctors we saw kept saying, ‘Wow, this happened very suddenly.’”

A clear need for quick action

Catherine had also read online about a promising, minimally-invasive procedure for treating a crossed eye with Botox injection. But among all the doctors they saw, the consensus was that Eliza needed traditional strabismus surgery, which involves cutting back the eye’s medial rectus muscle. Her eye alignment was too deviated for Botox to be effective, they insisted.

They also said Eliza would have to wait for her crossed eye to stabilize. “Come back for surgery in six months,” the family was told.

But Eliza’s eye was crossing more and more as time went by. Her parents helped fashion an eye patch so that she could block out her double vision. Every day, Eliza asked them, “Can’t I just have the surgery now?”

Looking to Boston for hope

By late July that summer, they only had one more doctor appointment on their calendar. It was with Dr. David Hunter, ophthalmologist-in-chief at Boston Children’s Hospital. “We talked about whether we should even keep the appointment, given the fact we had all heard the same thing from four doctors at other hospitals,” says Catherine.

Eliza's crossed eye pictured before Botox injection
Eliza’s crossed eye led her family to seek the help of Dr. Hunter at Boston Children’s.

Ultimately, with no expectations, Catherine and her husband decided to get one last opinion. They held onto hope that Hunter might be able to perform the surgery sooner than the other doctors had prescribed.

Arriving in Boston on a Thursday afternoon, Catherine, her husband, Eliza and her little brother were weary from their “summer of doctor visits.” The entire family was pleasantly surprised when, right away, Hunter recognized Eliza’s specific condition as “acute comitant esotropia.”

“When the measurement of the eye’s misalignment is the same in all directions, we call that comitant esotropia,” says Hunter. “And when the condition doesn’t respond to glasses and isn’t associated with other systemic or structural disease, that’s a hallmark of a rare condition called acute comitant esotropia.”

Correcting Eliza’s crossed eye

“It’s as if the brain and the eyes just suddenly become uncoordinated, like a glitch in which the brain loses track of the eye’s alignment just long enough for the eye to get stuck turning inward,” he says. “Parents should certainly know about the possibility of using Botox to correct it.”

“Dr. Hunter told us he would rather correct Eliza’s eye sooner rather than later,” says Catherine. “He asked us to stay in town overnight, so that he could administer an injection of Botox to Eliza’s eye muscle the next morning.”

Eliza's corrected eye (formerly crossed eye) shown after Botox injection
Eliza’s eye alignment was corrected after Dr. Hunter used a Botox injection to weaken the offending eye muscle.

Almost in disbelief that a doctor was finally confident in a diagnosis and taking action, the family checked into a nearby hotel. Bright and early the next morning, Eliza entered the operating room. A mere five minutes later, she was brought out to the recovery area.

“With Botox injection, you’ll spend the longest amount of time in the waiting room before going into the OR,” Hunter says with a smile. “The procedure is done in five minutes and then there’s about 40 minutes of recovery.”

Seeing results from Botox

Hunter knows from experience that fast corrective action helps prevent long-term effects including reduced stereopsis (depth perception) and amblyopia (lazy eye). Whereas traditional strabismus surgery permanently changes the relative position of the medial rectus muscle with respect to the eye, Botox does not disturb the anatomy of the eye muscle, but instead, weakens the muscle for about three months.

During that three-month period, the Botox relaxes and stretches the medial rectus muscle. In turn, that causes the lateral rectus muscle (outward pulling muscle) to get stronger from more use.

At the same time, the brain regains proper vision and gets a chance to recover control of eye alignment. As a result, the effects of one Botox treatment can remain indefinitely.

A bright future in focus

“The day after her Botox procedure, we were having breakfast at our hotel, and abruptly Eliza became emotional because she was looking at us from across the table and no longer seeing double,” says Catherine. “Just as suddenly as this issue had come into our lives – it was gone.”

“I didn’t know it would happen so quickly,” Eliza says. “It was so cool.” In the last two years since her Botox procedure, Eliza’s eyes have remained perfectly aligned.

“Dr. Hunter is certainly special; he’s got a rare combination of brilliance, confidence and a humble approach that allows him to connect with children very easily,” says Catherine. “Going through all those initial medical visits was scary for Eliza, but once we got to Dr. Hunter, she was just fine.”

The names in this story have been changed to protect the family’s privacy.

Learn more about ophthalmology at Boston Children’s.