 All right, good morning, everyone. Hopefully you all can hear me okay. Happy New Year. Thank you for being here so early the day, right after New Year's. For those of you who have not had the privilege to meet yet, my name is Sophia Fang, and I'm the first pediatric ophthalmology fellow here at Moran. And today I have the opportunity to share with you some hopefully interesting perspectives on strabismus, more than meets the eye. So every time I walk over the bridge on the fourth floor of Moran over to our pediatric ophthalmology clinic in primaries, I pass by this sign. This little cartoon boy says, sometimes I feel like a really hard math problem the doctors are trying to solve instead of a person. And admittedly, this is not my favorite sign. However, it does serve to remind us that in our brief 10, maybe 15 minute encounter with our patients in our fairly contrived environment of a clinic exam, we're often inundated with all of the measurements we have to make and the boxes we have to click that we often only get the opportunity that we often only get the opportunity to understand our patients and the rather narrow confines of these labels. And we don't always get the opportunity to fully appreciate how strabismus impacts their day to day life. So for the next few minutes, let's take a little pause and a step back from the medical jargon to understand a little different perspective of strabismus. According to the top selling American English Dictionary, the Merriam Webster, strabismus is defined as the inability of one eye to attain binocular vision with the other because of imbalance of the muscles of the eyeball, more commonly known as ocular misalignment. The word strabismus is considered to be late 17th century modern Latin. And as I've been told, Dr. Mamelis ensures all the residents know comes from the Greek word strabismus, which means to squint. Strabismus I think is quite unique amongst eye diseases and that it's a condition that is often readily apparent to people walking around on the street. In other words, it's visible to the naked eye. And as such, strabismus has a long history that not only predates modern medicine, but also carries with it a deeply rooted stigma in society. So let's take a little trip back in time to see where it all began. The earliest documented mentions of strabismus come to us from ancient Egypt around 1550 BC in what is known as the Ebers papyrus. The Ebers papyrus is a document that is currently housed at the library at the University of Leipzig in Eastern Germany and is considered to be the most extensive and best preserved record of ancient Egyptian medicine. In it, strabismus is described as a distortion of the eyes. One of the earliest unequivocal depictions of strabismus also comes to us from Egypt around the 13th century BC, which is the end of their 18th dynasty. And it is a depiction of esotropia on a well-preserved painted sarcophagus lid of Lady Isis, who was a spouse of a famed artist of the time, Quebec Ant. Some of the earliest theories regarding the etiology for strabismus are that it results from a cramp of the muscles that occurs after staring at an oil lamp or another object with one eye for a prolonged period of time, or that it's essentially a curse that's invoked by evil humors and spirits. And so you can imagine that some of the earliest treatments for strabismus were various purges and potions coupled with incantations and attempts to rid the evil spirit from the body. The Ebers Papyrus, for example, contains a page of various treatments for eye diseases, including a remedy consisting of equal parts, turtle brains, and spices used to treat strabismus. It was unclear from the translations whether this was something that was applied topically or ingested orally. In the 600s AD, there was a Greek physician known as Paul of Agina, who developed these metallic masks to help patients straighten out their eyes. This one is for convergent strabismus and this one is for divergent strabismus. The same physician, Paul of Agina, also developed another treatment for esotropia that involved purple or red flocks of wool that were fastened to the lateral canthi or to the temples in order to attract the attention of the interning or esotropic eye to help straighten them. And so certainly we've come a long ways over the centuries in our scientific and medical understanding of strabismus and how to treat it. But what about the psychosocial stigma? In the mid-19th century, one of the major figures in American ophthalmology was Dr. Alfred Post. After setting up his comprehensive surgical practice in New York City, he published a popular book in 1841 called Observations on the Cure of Strabismus. In this brief 67-page book, he basically discussed the state of the art of the medical and surgical treatment of strabismus at the time. And on page 13, he said, the most striking effect of strabismus is the deformity which it occasions, frequently subjecting the patient during childhood to ridicule and insult and being throughout life a source of mortification and mental disquietude. Since this time, there have been literally thousands of studies done to provide evidence that this observation is true, that strabismus does in fact impart significant psychosocial impact on patients who suffer from it. And although we certainly don't have time to discuss all of these studies, I would like to share a few of the ones that I think help illustrate some important ideas. The first idea is that implicit bias towards strabismus is acquired and develops early in life. First, let us define what implicit bias is. Implicit bias is an important concept in the world of social psychology. According to the Kerwan Institute at Ohio State, implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases which encompass both favorable and unfavorable assessments are activated involuntarily and without an individual's awareness or intentional control. In 2001, Dr. Pacey and colleagues at Baylor and Texas Children's set out to determine the age at which children start to perceive strabismus, aka develop implicit bias in dolls and to evaluate their reactions. To do this, they recruited 34 children between the ages of three and seven who were essentially patients of their pediatric ophthalmology clinic or siblings of those patients. And so 47% of them had a diagnosis of strabismus themselves and individually placed these children in a waiting room with a one-way mirror. In this room, there were only three toys with which the children could play which were essentially three versions of the same doll. So this is the original unmodified orthotropic doll that was then modified to create exotropia and isotropia. The reason why they chose this particular doll, which some of you may find looks familiar, this is an action figure of Goku, who's from Dragon Ball Z. It was because this group had done a previous pilot study where they showed various types of dolls to children and found that this was the only doll with which boys and girls equally interacted. This is why they chose this doll. They would observe the children in this room for 10 minutes and then directly ask them about their preferences and attitudes about the dolls. For the observed play portion, they had predefined what they would consider to be positive and negative behaviors. Positive behaviors were things like cradling, caressing, kissing, or verbally complimenting a doll. Negative behaviors were things like throwing, striking, or verbally disparaging a doll. For the expressed response portion, they asked the subjects, what was the first thing you noticed about the action figures? What was your favorite action figure or did you like them all equally? Why was that figure your favorite? Was there an action figure you didn't like or did you like them all equally? Why didn't you like that figure? And what did you think of the action figure's eyes? The results, of course, were quite interesting. They showed that there is a progression of bias that seems to develop in children. That the youngest children did not even notice the strabismus. The slightly older children between the ages of four and a half and five and three quarters years old noticed the strabismus but didn't have a clear preference. And that the older children who were five and three quarters years old and older were 4.4 times more likely to display negative reactions to the strabismic dolls and 73 times more likely to report a dislike of the strabismic dolls. And the results were not affected by the gender of the subject or whether or not they themselves had strabismus. So the takeaways from the study are that negative attitudes towards ocular deviations are acquired responses, which appear to emerge around age five. And that corrective surgery for a strabismus at an early age may help to reduce the psychosocial stigma experienced by these children. The second idea is that even the best among us in one of the most influential roles of early childhood harbor implicit bias. In 2003, a group in Turkey set out to determine whether the presence of noticeable strabismus among children created negative social bias amongst elementary school teachers. To do this, they took headshot photos of four normal orthotropic children. This is for example, as one of the children they had two boys and two girls and essentially Photoshopped them to create obvious 45 prism diopters of esotropia and exotropia. They then showed these photos to 30 elementary school teachers in separate sessions so that in each session, the teacher would only see one alignment state per child. And without knowing the purpose of the study, the teachers were asked to rate their perception of each child on a scale of one to five on 10 personal characteristics the authors felt were important for social functioning and functioning in an educational environment. These were intelligence, health, trustworthiness, capacity for hard work, happiness, cuteness, hesitancy, aggressiveness, activeness, and sentimentality. They then asked the teachers to answer yes, no, or maybe to five questions. Would you assign the student to a duty during cultural activities at school? Would you take special precautions to prevent the student from cheating during a test? Can the student be accepted into a social group of friends? Would the student have any difficulty in learning and can the student fulfill the responsibilities given to him or her? For the results, when it came to the 10 personal characteristics, there was a statistically significant difference in the ratings with orthotropic children being rated higher than the strabizmic children in terms of their perceived health, capacity for hard work, and happiness. The exotropic children also were rated higher than the esotropic children in terms of their capacity for hard work and happiness. When it came to the five questions, there was also a statistically significant difference amongst the children in the teacher's perception that it was harder for strabizmic children to be accepted into a social group of friends and that esotropic children would have more difficulty in learning. The takeaways from this study are that even the best among us elementary school teachers are not immune to having negative implicit bias against children with strabizmus. And that this can obviously inadvertently affect the way teachers treat children with strabizmus and some of their more formative years of development. The third idea is that even in older kids and adults, strabizmus is not just about cosmesis. Of course, we're all familiar with the visual consequences of strabizmus, but even when you are no longer able to chase after serial acuity or improved vision in younger children, there are real and serious physical and psychosocial consequences of strabizmus as well. Dr. Ponellas and colleagues at UCLA, for example, showed that elderly patients with strabizmus had higher odds of sustaining falls and musculoskeletal injuries. And in addition to dealing with a problematic self-image, self-esteem and confidence, patients also suffer from other psychosocial consequences such as being ridiculed and bullied at school or at work, having difficulty with eye contact, being perceived as insincere or less trustworthy, and having decreased prospects for employment, especially among women, which can obviously affect their livelihood. In 1993, Satterfield and colleagues at UC Davis set out to assess the psychosocial implications of growing up with and living with socially noticeable strabizmus. To do this, they identified 77 subjects, age 15 and older, who had uncorrected or incompletely corrected childhood strabizmus past the age of 13. They mailed them two things. One was a questionnaire they created with 25 items that asked about past medical history, ocular strabizmus history, as well as asked them to rate the impact of strabizmus on various aspects of their life during childhood, teenage years and adulthood. They also sent them the Hopkins Symptom Checklist that had 58 items on it. This is a widely used standardized symptom inventory to identify psychological distress and therefore has a large normative database to which they can compare. They were able to get responses from 43 subjects or a little bit more than half, and they reported that strabizmus had a negative impact on many aspects of their lives. Difficulty with self-image, securing employment, interpersonal relationships, school, work and sports. They reported that these problems intensified rather than abated during the teenage and adult years. And the Hopkins Symptom Checklist showed that they had generalized higher levels of distress compared to their age and gender matched counterparts. The takeaways from this study are that psychosocial difficulties with socially noticeable strabizmus are not just a problem for school children, but perhaps even more so for teenagers and adults. Correcting strabizmus is more than just about cosmesis, but rather carries the potential to help improve psychosocial functioning and quality of life. And the last idea is that strabizmus surgery works not only to improve vision and stereopsis in children, but also in restoring a more normal appearance and to improve psychosocial functioning and quality of life for both the young and the young at heart. And these are just a sample of the studies that have proven this. And so in conclusion, I hope that I've been able to intrigue you with some interesting perspectives on strabizmus and how it impacts the lives of our patients and the wonderful opportunity we have to help them. Any questions? So you bring up a very important point and there's no question that I can remember. You don't see as many young kids today anymore who are older, I've done a much better job of getting these corrected at an earlier age, but that was not the case back when I was a kid. And I can remember there were a fair number of friends who had fairly large amounts of deviation, both excellent and so. And I remember that how horribly they were treated. I mean, even I remember as a kid seeing how they were tundid and called wall-eyed. And you can imagine the impact that that would have on people. And then it's interesting, but I watched how we were doing a much better job as you move into the 60s in correcting this. And then I went to Sweden and they weren't for some reason. And I saw a lot of people and you could watch how self-conscious they were about that. How they didn't wanna look straight at people. How they'd look to the side because if you look straight as when it was obvious or you'd watch girls who comb their hair down over one eye trying to cover it. And we often forget about that particular aspect as we're dealing with this. What a huge impact that would have on self-image. Just not only are they being negatively perceived, but people themselves are perceived as that there's an issue of problem because people obviously stare at them and think there's something wrong on her. So I think it's a great issue to bring up. I'm sure too kind of an adult experiences, but my most grateful patients for sure are not often the ones who regains diapsys by surgery, but typically the ones who regain what appears to be orthotrophic. They look straight, they are the ones that are typically in tears and say this is really like changing for them. And I remember seeing a patient in fellowship who was a woman in her 40s or 50s who came to us and she said, I heard this can't be fixed, which I think is a still pretty common feeling in the community and it's conveyed to patients by a number of ophthalmologists even, but my mentor told her, oh no, no, we can certainly straighten your eyes. And she just looked at us with this pause. She says, you mean I could have had this fixed before and she stopped and sobbed for several minutes before we were even able to move on. But she just thought about how much- How much she had gone through. Yes, and how much, how destructive this had been to her social life and to so many, so much of her confidence in her self-image and it was really interesting. She just broke down. Not that she was excited to get fixed because she was so sad that this had been, she'd been told for so long that she couldn't get fixed and she had gone so long with this and it was just a very sobering image. Yeah, we gotta get beyond this concept that this is a cosmetic surgery. Cosmetic insinuates, this is a vanity. This is way beyond that. This isn't worrying about a couple of smile wrinkles that have happened. This is clearly a major social impact. The argument that I think insurance hasn't bought into and now pay for it is that cosmetic is defined as something that typically, and I could be wrong, but as I understand cosmetic is something that you wanna make look better, but it's not inherently abnormal as it is now or it could be abnormal, but it's a part of the knowledging process where this would be more- Rehabilitative or restorative. Because it's abnormal and you just try to get it to normal. Maybe my, I don't know, oculoplastic stills like that was an unfair characterization of a cosmetic surgery. Anyway, excellent job.