Believe it or not, pesticides might be present in fruits and vegetables we eat. They are primarily used during the cultivation of crops and in some cases may remain as residues. Recently many advocacy groups and NGOs conducted random testing on fruits and vegetables and found unacceptably high amounts of pesticide residue in them. According to the Centre for Science and Environment (CSE), "high levels of pesticide residues can be toxic enough to cause long-term cancer, damage to the nervous and reproductive systems, birth defects, and severe disruption of the immune system." (More:Pesticide minimizing measures to be publicized in Delhi: HC)

While steps are being taken by the government to sensitize farmers and vendors about the side effects of using pesticides, health experts suggest consumers explore alternatives like organic food. Even though the mere presence of pesticide residue in food does not imply that they pose a great health risk, you should be extremely careful of what you buy and where you buy it from. You should also take certain measures to minimize any kind of health damage. Here are three simple, do-it-yourself tricks you can adopt at home:

Wash Your Food and Wash it Right

Wash all your fruits and vegetables. According to the CSE, washing them with 2% of salt water will remove most of the contact pesticide residues that normally appear on the surface of the vegetables and fruits. Almost 75 to 80 percent of pesticide residues are removed by cold water washing. Also, be more thorough with these fruits and vegetables in specific: grapes, apples, guava, plums, mangoes, peaches and pears and vegetables like tomatoes, brinjal and okra as they might carry more residue in their crevices.Top of Form

Bottom of FormVinegar Soak

Whip up a solution with 10 percent white vinegar and 90 percent water and soak your veggies and fruits in them. Stir them around and rinse thoroughly. Be careful while washing fruits like berries, and those with a thin peel as the solution might damage their porous outer-skin.

Top of FormBlanch and Peel

Treat your vegetables to warm water for a short while and this should remove any leftover residue. Peeling is another efficient way to remove residue and comes highly recommended especially when there might be some residue in the crevices of the fruit. Also, when cooking with chicken or meat, cut off the excess fat and skin as it could have absorbed unwanted pesticide residue.

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For the latestfood newsandrecipes, like us onFacebookor follow us onTwitter.Tags:Pesticides,Fruits,Toxic,VegetablesDid you know that 65% of produce samples analyzed by the U.S. Department of Agriculture test positive for pesticide residues? Unless youre buying certified organic food, the chances are that youre consuming a significant amount of chemicals with every portion of your healthy greens. The Environmental Working Group (EWG) is trying to inform the public about the level of exposure to often toxic chemicals commonly found in our fresh produce.They publish an annual list of most and least contaminated fruits and vegetables, the so called Dirty Dozen and Clean Fifteen lists. You can find this list for 2014 in myprevious article.Apples, strawberries, grapes, celery, peaches, spinach, sweet bell peppers, imported nectarines, cucumbers, cherry tomatoes, imported snap peas and potatoes are all on the EWGs Dirty list. You should be careful when consuming these produce, as they contain a number of different pesticide residues and have high concentrations of pesticides relative to other produce items. For example, every sample of imported nectarines and 99% of apple samples tested positive for at least one pesticide residue.The cleanest fruits and veggies, which are least likely to hold pesticides, include avocados, sweet corn, pineapples, cabbage, frozen sweet peas, onions, asparagus, mangoes, papayas, kiwis, eggplant, grapefruit, cantaloupe, cauliflower and sweet potatoes. Avocados are the cleanest, with only 1% showing any detectable pesticides (you can findheremore healthy reasons to eat avocado).How to make fruits and veggies safer for consumption?There is a simple and cheap trick that can help you get rid of those nasty chemicals. You can simply wash your fresh produce in distilledwhite vinegarand water solution. Gayle Povis Alleman, a registered dietician, suggests soaking your veggies and fruits in a solution of 10% vinegar to 90% water. Make the mixture, and let the produce sit in for 15 to 20 minutes. When you remove them, youll notice that the water left in the bowl is dirty and may contain some gunk. Rinse fruits and vegetables in fresh water, and then enjoy your cleaner product. This method shouldnt be used on fragile fruits, such as berries, as they have a very porous skin and might get damaged and soak in too much of the vinegar. With other fruits, there should be no lingering vinegar aroma. If you wish, you can also use lemon juice.According to the Center for Science and Environment (CSE), it also helps to wash your fruits and vegetables with 2% of salt water. This should remove most of the contact pesticide residues that normally appear on the surface.Generally speaking, you should be thorough when washing fruits and veggies, as chemicals can linger in crevices that are hard to wash. CSE claims that if done diligently, washing with cold water should be able to remove 70% to 80% of all pesticides. It is important to invest some time in preparing your food, as you dont want to end up consuming a portion of toxins with your snack. American Academy of Pediatrics issued an important report in 2012 that said that children have unique susceptibilities to pesticide residues potential toxicity. By washing your food carefully, you protect the health of your

Bhagaban3 years agosoaking of cut vegetable in turmeric water for some time will also remove some toxins as it is an antioxidantRemoving Pesticides from Fruits and VegetablesWith food prices skyward bound and no reprieve from pesticide residues in fruits and vegetables, fresh fruits and vegetables will soon become a luxury item for those who can afford chemical free and organic products.The source for pesticide residues in our food could be through the application of pesticides on crops, with residues remaining in the fruits and vegetables or through the application of pesticides in homes to disinfect. Pesticide residues, once in our system can be the cause for several acute and chronic diseases. So removing the pesticides, as much as we can, is the first step forward.As consumers we do not have any control on the pesticides that is sprayed on fruits and vegetables in the farms but there are some quick do-it-yourself techniques that can help us get rid of the residues to a large extent.The National Institute of Nutrition (NIN), released the Dietary Guidelines for India recently. The guidelines has introduced some simple steps which should be adopted by every household to remove the pesticide residual contamination. These easy steps should be cast in stone in every household.

Washing

Illustration by :Karno Guhathakurta & Aradhana Gupta The first step in the removal of pesticide residues from the food products is washing. Washing with 2% of salt water will remove most of the contact pesticide residues that normally appear on the surface of the vegetables and fruits. About 75-80% of pesticide reduces are removed by cold water washing. The pesticide residues that are on the surface of fruits like grapes, apples, guava, plums, mangoes, peaches and pears and fruity vegetables like tomatoes, brinjal and okra require two to three washings. The green leafy vegetables must be washed thoroughly. The pesticide residues from green leafy vegetables are removed satisfactorily by normal processing such as washing blanching and cooking.

Blanching

Illustration by :Karno Guhathakurta & Aradhana GuptaA short treatment in hot water or steam applied to most of the vegetables. Certain pesticide residues can effectively be removed by blanching. But before blanching it is very important to thoroughly pre-wash the vegetables and fruits.

Peeling

Illustration by :Karno Guhathakurta & Aradhana Gupta Both systemic and contact pesticides that appear on the surface of the fruits andvegetables can be removed by peeling. Steps such as concentration, dehydration and extraction from the raw product can further reduce pesticide residues in the end product. The net influence of processing almost always results in minimal residues in processed food.

Cooking

Illustration by :Karno Guhathakurta & Aradhana GuptaAnimal Products Animal products are also the major source of contamination for pesticide residues in human diets since the animals feed on fodder, which are sprayed with pesticides. Pressure cooking, frying and baking will remove pesticide residues from the animal fat tissues.Dairy products Boiling of milk at elevated temperatures will destroy the persistent pesticide residues.Vegetable Oils Refined oils will have fewer amounts of pesticide residues. Household heating of oils up to a particular flash point will remove pesticide residues.

What should I do if my child looks cross-eyed or his eyes seem to wander?If your child's eyes look crossed or misaligned, the problem could be strabismus (misaligned eyes) or amblyopia (lazy eye). Talk to his doctor, who will probably refer you to an ophthalmologist. Fortunately, these conditions can be successfully treated if detected early.Note that it's normal for a newborn baby's eyes to wander or cross now and then, up to about 4 months of age. He's just getting the hang of making his eyes work together. If your baby's eyes seem crossed most of the time, though, or if it doesn't get better, talk with the doctor.What is strabismus?Strabismus is a lack of coordination between the eyes. If your child's eyes seem to point in different directions or not focus on the same object, strabismus could be the culprit.Strabismus is a problem with the way the brain is controls the eyes, not with the eye muscles. (That's why experts don't usually recommend eye exercises for strabismus.)If your child has strabismus and it isn't treated, his brain could start ignoring the input from one of his eyes, eventually causing the vision in the ignored eye to deteriorate. This condition is known as amblyopia or "lazy eye" (see below). Depth perception could also be damaged.How will I know if my child has strabismus?If your child has strabismus, his eyes may appear to be "crossed" or one may seem to drift inward, outward, or upward. When the eyes turn inward it's called esotropia, and when they turn out it's called exotropia. Strabismus can be constant (meaning the eyes are always crossed or misaligned) or intermittent (meaning it happens now and then).In some cases a child's eyes appear crossed (especially when he looks to the right or the left) when in fact they're aligned. This is called pseudostrabismus.The most common example of pseudostrabismus is pseudoesotropia, in which a child's eyes appear to cross inward when in fact it's an optical illusion caused by large eyelid folds or a wide nasal bridge. Your child's doctor can perform a simple examination to distinguish pseudostrabismus from true strabismus.What's the treatment for strabismus?Strabismus that's a result of farsightedness can usually be corrected with glasses, especially if caught early. Strabismus that persists even when a child wears glasses may require surgical correction.While the lack of coordination between the eyes centers in the brain, it's not possible to operate on the brain to change the alignment of the eyes. Instead, doctors operate on the eye muscles, which are accessible.The surgery compensates for rather than corrects the problem. "If your car was steered by a computer and the computer kept telling the car to pull to the right, you could at least realign the wheels to the left to compensate," explains pediatric ophthalmologist James Ruben, a member of the AAP section on ophthalmology.What causes strabismus?

Biophoto Associates / Science SourceSometimes strabismus is present at birth. The condition seems to run in families.Strabismus can also show up in children with no family history and when that's the case, it sometimes indicates a more significant vision problem. (Disorders such as cerebral palsy andDown syndromemake strabismus more likely.)Babies bornprematurelyor at low birth weight are at higher risk. Children who are farsighted also seem to be at higher risk.What is amblyopia?Amblyopia (also called lazy eye) develops when the brain shuts off or suppresses vision in one eye. This can happen if your child's eyes are misaligned or if she can't see as well with one eye because of nearsightedness, farsightedness, astigmatism, or something that's blocking clear vision in that eye, like a cataract or a drooping eyelid.About 3 to 6 percent of children under the age of 6 develop amblyopia. Treatment is most successful before age 5 or 6, although recent research shows that even older children may recover their vision. (Recovery is less assured in an older child, though.) If ignored, amblyopia can result in permanent vision loss.How will I know if my child has amblyopia?Identifying the problem isn't easy because children can get along fine using only one eye. The less-used eye may look perfectly normal, even though your child isn't using it to see.Your child's doctor should routinely test for amblyopia (as well as strabismus) by checking the eyes independently and together. But, as pediatric ophthalmologist Ruben says, "Moms are often the best screeners around because they're so connected with their children and often notice something that's not quite right sooner than any doctor."It's also a good idea to occasionally test the vision in your child's eyes at home.How can I test for amblyopia at home?Here's a simple way to get an idea of whether your child's eyes are both pulling their weight:Cover one of your child's eyes (it helps to have a partner for this). Hold an object (such as a teddy bear for a little one or a picture or a letter for an older child) in front of her.See if she follows the object with her uncovered eye as you move it from side to side and up and down. (You can ask an older child to tell you what the letter is, or ask her something about the picture or object.) Then cover the other eye and see if she follows the object just as well and as far.It's a little tricky to test a baby, who may lose interest or become distracted before your informal test is over. But if one eye seems weaker, try testing it again another time maybe starting with the other eye.If your child consistently seems to be able to see better with one eye than the other, schedule an appointment with either your child's doctor for a vision screening test or an ophthalmologist, who can diagnose and treat the problem.What's the treatment for amblyopia?The first step is to address any underlying problem by correcting the astigmatism or nearsightedness with glasses or removing a cataract with surgery, for example. Once that's taken care of, the goal is to encourage your child's brain to connect with the weaker eye, eventually improving its ability to see.If your child has amblyopia due to a need for glasses, the glasses will act like a camera lens and help bring objects into focus on the back of the eye. Wearing them provides the brain will a clearer image, which may improve the eye-brain connection. But if your child's eyes naturally focus light properly, glasses won't help with the amblyopia.Instead, your doctor will probably recommend covering your child's stronger eye with a patch or using eyedrops once a day to blur the vision in that eye. Either of those will force the brain to use the weaker eye. The process could take weeks, months, or even years.Melanie is a healthy one-year-old, but her parents are worried because shes not doing many things that her older brother did at her age, like playing peek-a-boo and mimicking expressions and gestures. Melanies mom and dad try to engage her with toys, songs, and games, but nothing they do gets her interest, let alone a laugh or a smile. In fact, she rarely makes eye contact. And although her hearing has been checked and is normal, she doesnt babble, make other baby noises, or respond when her parents call her name. Melanie needs to be checked out by a child development specialist right away.Early detection of autism is up to parentsAs a parent, youre in the best position to spot the earliest warning signs of autism. You know your child better than anyone and observe behaviors and quirks that a pediatrician, in a quick fifteen-minute visit, might not have the chance to see. Your childs pediatrician can be a valuable partner, but dont discount the importance of your own observations and experience. The key is to educate yourself so you know whats normal and whats not. Monitor your childs development.Autism involves a variety of developmental delays, so keeping a close eye on whenor ifyour child is hitting the key social, emotional, and cognitive milestones is an effective way to spot the problem early on. While developmental delays dont automatically point to autism, they may indicate a heightened risk. Take action if youre concerned.Every child develops at a different paceso you dont need to panic if your child is a little late to talk or walk. When it comes to healthy development, theres a wide range of normal. But if your child is not meeting the milestones for his or her age, or you suspect a problem, share your concerns with your childs doctor immediately. Dont wait. Dont accept a wait-and-see approach.Many concerned parents are told, Dont worry or Wait and see. But waiting is the worst thing you can do. You risk losing valuable time at an age where your child has the best chance for improvement. Furthermore, whether the delay is caused by autism or some other factor, developmentally delayed kids are unlikely to simply grow out of their problems. In order to develop skills in an area of delay, your child needs extra help and targeted treatment. Trust your instincts.Ideally, your childs doctor will take your concerns seriously and perform a thorough evaluation for autism or other developmental delays. But sometimes, even well-meaning doctors miss red flags or underestimate problems. Listen to your gut if its telling you something is wrong and be persistent. Schedule a follow-up appointment with the doctor, seek a second opinion, or ask for a referral to a child development specialist.Regression of any kind is a serious autism warning signSome children with autism spectrum disorders start to develop communication skills and then regress, usually between 12 and 24 months. For example, a child who was communicating with words such as mommy or up may stop using language entirely, or a child may stop playing social games he or she used to enjoy such as peek-a-boo, patty cake, or waving bye-bye.Any loss of speech, babbling, gestures, or social skills should be taken very seriously,as regression is a major red flag for autism.Signs and symptoms of autism in babies and toddlersIf autism is caught in infancy, treatment can take full advantage of the young brains remarkable plasticity. Although autism is hard to diagnose before 24 months, symptoms often surface between 12 and 18 months. If signs are detected by 18 months of age, intensive treatment may help to rewire the brain and reverse the symptoms.The earliest signs of autism involve the absence of normal behaviorsnot the presence of abnormal onesso they can be tough to spot. In some cases, the earliest symptoms of autism are even misinterpreted as signs of a good baby, since the infant may seem quiet, independent, and undemanding. However, you can catch warning signs early if you know what to look for.Some autistic infants don't respond to cuddling, reach out to be picked up, or look at their mothers when being fed.Early signs of autism in babies and toddlers Doesnt make eye contact (e.g. look at you when being fed). Doesn't smile when smiled at. Doesn't respond to his or her name or to the sound of a familiar voice. Doesnt follow objects visually. Doesn't point or wave goodbye or use other gestures to communicate. Doesnt follow the gesture when you point things out. Doesnt make noises to get your attention. Doesnt initiate or respond to cuddling. Doesnt imitate your movements and facial expressions. Doesnt reach out to be picked up. Doesnt play with other people or share interest and enjoyment. Doesnt ask for help or make other basic requests.

The following delays warrant an immediate evaluation by your childs pediatrician. By 6 months:No big smiles or other warm, joyful expressions. By 9 months:No back-and-forth sharing of sounds, smiles, or other facial expressions. By 12 months:Lack of response to name. By 12 months:No babbling or baby talk. By 12 months:No back-and-forth gestures, such as pointing, showing, reaching, or waving. By 16 months:No spoken words. By 24 months:No meaningful two-word phrases that dont involve imitating or repeating.Signs and symptoms of autism in older childrenAs children get older, the red flags for autism become more diverse. There are many warning signs and symptoms, but they typically revolve around impaired social skills, speech and language difficulties, non-verbal communication difficulties, and inflexible behavior.Signs and symptoms of social difficulties in autismBasic social interaction can be difficult for children with autism spectrum disorders. Many kids on the autism spectrum seem to prefer to live in their own world, aloof and detached from others. Appears disinterested or unaware of other people or whats going on around them. Doesnt know how to connect with others, play, or make friends. Prefers not to be touched, held, or cuddled. Doesnt play "pretend" games, engage in group games, imitate others, or use toys in creative ways. Has trouble understanding or talking about feelings. Doesnt seem to hear when others talk to him or her. Doesn't share interests or achievements with others (drawings, toys).Signs and symptoms of speech and language difficulties in autismChildren with autism spectrum disorders have difficulty with speech and language. Often, they start talking late. Speaks in an abnormal tone of voice, or with an odd rhythm or pitch (e.g. ends every sentence as if asking a question). Repeats the same words or phrases over and over. Responds to a question by repeating it, rather than answering it. Refers to themselves in the third person. Uses language incorrectly (grammatical errors, wrong words). Has difficulty communicating needs or desires. Doesnt understand simple directions, statements, or questions. Takes what is said too literally (misses undertones of humor, irony, and sarcasm).Signs and symptoms of nonverbal communication difficulties in autismChildren with autism spectrum disorders have trouble picking up on subtle nonverbal cues and using body language. This makes the "give-and-take" of social interaction very difficult. Avoids eye contact. Uses facial expressions that don't match what he or she is saying. Doesnt pick up on other peoples facial expressions, tone of voice, and gestures. Makes very few gestures (such as pointing). May come across as cold or robot-like. Reacts unusually to sights, smells, textures, and sounds. May be especially sensitive to loud noises. Abnormal posture, clumsiness, or eccentric ways of moving (e.g. walking exclusively on tiptoe).Signs and symptoms of inflexibility in autismChildren with autism spectrum disorders are often restricted, inflexible, and even obsessive in their behaviors, activities, and interests. Follows a rigid routine (e.g. insists on taking a specific route to school). Has difficulty adapting to any changes in schedule or environment (e.g. throws a tantrum if the furniture is rearranged or bedtime is at a different time than usual). Unusual attachments to toys or strange objects such as keys, light switches, or rubber bands. Obsessively lines things up or arranges them in a certain order. Preoccupation with a narrow topic of interest, often involving numbers or symbols (e.g. memorizing and reciting facts about maps, train schedules, or sports statistics). Spends long periods of time arranging toys in specific ways, watching moving objects such as a ceiling fan, or focusing on one specific part of an object such as the wheels of a toy car. Repeats the same actions or movements over and over again, such as flapping hands, rocking, or twirling (known as self-stimulatory behavior, or stimming). Some researchers and clinicians believe that these behaviors may soothe children with autism more than stimulate them.Common self-stimulatory behaviors: Hand flapping Rocking back and forth Spinning in a circle Finger flicking Head banging Staring at lights Moving fingers in front of the eyes Snapping fingers Tapping ears Scratching Lining up toys Spinning objects Wheel spinning Watching moving objects Flicking light switches on and off Repeating words or noises

Causes of autismUntil recently, most scientists believed that autism is caused mostly by genetic factors. But groundbreaking new research indicates that environmental factors may be just as important in the development of autismif not more sothan genes.It appears that certain babies are born with a genetic vulnerability to autism that is then triggered by something in the external environment, either while he or she is still in the womb or sometime after birth.Its important to note that the environment, in this context, means anything outside the body. Its not limited to things like pollution or toxins in the atmosphere. In fact, one of the most important environments appears to be the prenatal environment.Prenatal factors that may contribute to autism Taking antidepressants during pregnancy,especially in the first 3 months Nutritional deficiencies early in pregnancy,particularly not getting enough folic acid The age of the mother(children born to older fathers also have a higher risk of autism) Complications at or shortly after birth,including very low birth weight and neonatal anemia Maternal infections during pregnancy Exposure to chemical pollutants,such as metals and pesticides, while pregnantWhile more research on these prenatal risk factors is needed, if youre pregnant or trying to conceive, it cant hurt to take steps now to reduce your babys risk of autism.Reducing the risk of autism: Tips for expectant mothers Take a multivitamin.Taking 400 micrograms of folic acid daily helps prevent birth defects such as spina bifida. Its not clear whether this will also help reduce risk of autism, but taking the vitamins cant hurt. Ask about SSRIs.Women who are taking an SSRI (or who develop depression during pregnancy) should talk with a clinician about all the risks and benefits of these drugs. Untreated depression in a mother can also affect her childs well-being later on, so this is not a simple decision to make. Practice prenatal care.Eating nutritious food, trying to avoid infections, and seeing a clinician for regular check-ups can increase the chances of giving birth to a healthy child.Source:Harvard Health PublicationsAutism and vaccinesWhile you cant control the genes your child inherits or shield him or her from every environmental danger, there is one very important thing you can do to protect the health of your child: make sure he or she is vaccinated on schedule.Despite a lot of controversy on the topic, scientific research does not support the theory that vaccines or their ingredients cause autism. Five major epidemiologic studies conducted in the U.S., the UK, Sweden, and Denmark found that children who received vaccines did not have higher rates of autism. Additionally, a major safety review by the Institute of Medicine failed to find any evidence supporting the connection. Other organizations that have concluded that vaccines are not associated with autism include the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), the American Academy of Pediatrics, and the World Health Organization.Myths and facts about childhood vaccinationsMyth: Vaccines aren't necessary.Fact:Vaccines protect your child from many serious and potentially deadly diseases, including measles, meningitis, polio, tetanus, diphtheria, and whooping cough. These diseases are uncommon today because vaccines are doing their job. But the bacteria and viruses that cause these diseases still exist and can be passed on to children who arent immunized.Myth: Vaccines cause autism.Fact:Despite extensive research and safety studies, scientists and doctors have not found a link between childhood vaccinations and autism or other developmental problems. Children who are not vaccinated do not have lower rates of autism spectrum disorders.Myth: Vaccines are given too early.Fact:Early vaccination protects your child from serious diseases that are most likely to occurand most dangerousin babies. Waiting to immunize your baby puts him or her at risk. The recommended vaccination schedule is designed to work best with childrens immune systems at specific ages. A different schedule may not offer the same protection.Myth: Too many vaccines are given at once.Fact:You may have heard theories that the recommended vaccine schedule overloads young childrens immune systems and may even cause autism. But research shows that spacing out vaccinations doesnt improve childrens health or lower their risk of autism, and as noted above, actually puts them at risk for potentially fatal diseases.What to do if youre worriedIf your child is developmentally delayed, or if youve observed other red flags for autism, schedule an appointment with your pediatrician right away. In fact, its a good idea to have your child screened by a doctor even if he or she is hitting the developmental milestones on schedule. The American Academy of Pediatrics recommends that all children receive routine developmental screenings, as well as specific screenings for autism at 9, 18, and 30 months of age. Schedule an autism screening.A number of specialized screening tools have been developed to identify children at risk for autism. Most of these screening tools are quick and straightforward, consisting of yes-or-no questions or a checklist of symptoms. Your pediatrician should also get your feedback regarding your childs behavior. See a developmental specialist.If your pediatrician detects possible signs of autism during the screening, your child should be referred to a specialist for a comprehensive diagnostic evaluation. Screening tools cant be used to make a diagnosis, which is why further assessment is needed. A specialist can conduct a number of tests to determine whether or not your child has autism. Although many clinicians will not diagnose a child with autism before 30 months of age, they will be able to use screening techniques to determine when a cluster of symptoms associated with autism is present. Seek early intervention services.The diagnostic process for autism is tricky, and can sometimes take awhile. But you can take advantage of treatment as soon as you suspect your child has developmental delays. Ask your doctor to refer you to early intervention services. Early intervention is a federally funded program for infants and toddlers with disabilities. Children who demonstrate several early warning signs may have developmental delays.They will benefit from early intervention whether or not they meet the full criteria for an autism spectrum disorder.You dont have to wait for a diagnosis to start helping your childWhile autism isnt normally diagnosed and treated before the second year of life, there are thingsparents can doif your child's social and emotional development doesn't seem to be on course. You dont have to wait for an official diagnosis to start targeting developmental delays and working to enhance the bond you share. This is something you can do even when your childs just an infant.The attachment bond is the unique relationship between your baby and yourself as his or her primary caretaker. This instinctual bonding relationship draws the two of you together insuring that the needs of your helpless and vulnerable infant will be met. In the 90s, an explosion of learning uncovered the fact that this unique relationship, the attachment bond, is a key factor in your infants social, emotional, intellectual and physical development.The quality of the attachment bond varies. A secure bond provides your baby with an optimal foundation for life: eagerness to learn, healthy self-awareness, trust and consideration for others. An insecure attachment relationship, one that fails to meet an infants need for safety and understanding, leads to confusion about oneself and difficulties in learning and relating to others.Creating secure attachment with an autistic child(Video) Creating Secure Infant Attachment:Helping Your Baby Get the Best Possible Start in LifeThe quality of an attachment bond between caretakers and their children varies and can be more challenging with an autistic child. Because an autistic child can experience sensory input as unpleasant, a caretaker needs to be especially attentive to their child's nonverbal cues. It is vital to allow an autistic child to lead the way in creating a secure attachment.Bonding securely, even when more difficult, is worth the effort because it encourages optimal development in your child.Helpguide'sfree emotional intelligence toolkitmay aid parents who are challenged by the stress of caring for an autistic child.Nystagmus can be defined as a repetitive, involuntary, to-and-fro oscillation of the eyes.[1]It may be physiological or pathological and may be congenital or acquired. It can be described according to: The direction of movement: this may be horizontal, vertical, torsional or nonspecific. Amplitude - how far the eyes move: this can be fine or coarse. Frequency - how often the eyes oscillate: this is said to be high, moderate or low.Nystagmus is said to be one of three forms: Jerk nystagmus: this is characterised by a slow drifting movement followed by a fast corrective jerking movement. The direction of nystagmus is described according to the fast component. Pendular nystagmus: the drifting and corrective movements occur slowly. Mixed nystagmus: there is a pendular movement in the primary position of gaze (ie looking ahead) but a jerk nystagmus on lateral gaze.Furthermore, nystagmus is said to be symmetrical, asymmetrical, bilateral or unilateral (this is rare and is usually actually asymmetrical but more evident on one side). It may be conjugate (both eyes move together) or disconjugate (the eyes appear to move independently of each other). The exact incidence and prevalence of nystagmus is not known but it is thought to occur in about 1 in 1,000 people.Assessment of the patient with nystagmusThe degree to which these patients can be assessed depends on the patient's age and their ability to co-operate with instructions. A history and some degree of examination should be possible in most patients - even very young babies should look with interest at brightly coloured objects or the light of a pen torch.NEW - log your activity Add notes to any clinical page and create a reflective diary Automatically track and log every page you have viewed Print and export a summary to use in your appraisalClick to find out more History Ask about onset: the age will help determine which type of nystagmus this is and hence point to a possible diagnosis. It is helpful to know when it occurs and when (if at all) it ceases - accommodation and sleep are two occasions to enquire about specifically. Ask about related visual symptoms. Oscillopsia is the term used to describe the symptom of continual movement of the visual environment described by some patients with nystagmus. As a rule of thumb, if a patient is unaware of oscillopsia, the nystagmus is probably congenital.[2]Careful questioning of patients who have had infantile nystagmus may reveal a history ofheadaches, tearing, avoidance of near tasks and blurry vision. Related systemic symptoms - particularly with regards to the nervous system - are highly relevant. Use of prescribed or non-prescribed drugs is important, particularly anticonvulsants. Enquire about a family history.Examination Nystagmus is described as above, with a note made on which position of gaze it occurs in: Primary position- looking straight ahead. Secondary positions- looking straight up/down (also known as the midline positions), straight right or left. Tertiary positions- these are the four oblique positions: up and right, down and right, up and left, down and left. Cardinal positions- these include the right and left (secondary) positions and all the tertiary positions. Examine the patient sitting facing you and observe the nystagmus in the primary position. Using your finger or a small fixation target, observe the nystagmus in all positions of gaze. Ask the patient to comment on any visual symptoms as the eyes move (eg, it has gone blurry towards the left, I can see two fingers looking up and right). Enquire about the 'null' point: this is an angle which some patients find limits their visual impairment - it often results in abnormal head positioning.Oculocephalic reflex (doll's head phenomenon)The oculocephalic reflex develops within the first week of life and represents a vestibulo-ocular reflex normally suppressed in a conscious individual who attempts to turn the head to fixate on an object. This test consists of the rapid rotation of the patient's head in a horizontal or vertical direction. Normally, the eyes move conjugately in the opposite direction of the head turn.Alternatively, the test may be performed by having the patient extend the arm out in front of the body and fixate on the outstretched thumb. Patients should be instructed to rotate their torso such that the thumb remains in front of the body at all times. Patients with the ability to suppress the oculocephalic reflex should be able to maintain fixation on their thumb while rotating. An abnormal test result would show the patient continuously losing fixation of the thumb.Inability to suppress the oculocephalic reflex suggests vestibular imbalance. Other tests of the vestibular system include Romberg's test and caloric testing (see end of the article: vestibular nystagmus). Carry out a full neurological examination. Complement with any other examination depending on findings.Associated problems[3] Patients with nystagmus can tire easily from the extra effort it takes to look at things. They may also complain of balance problems as their depth of perception may be impaired and uneven surfaces or stairs may be difficult to negotiate. This may be perceived as clumsiness by others. There may be associated stress and nervousness at being in unfamiliar surroundings. Confidence may also be a problem in these patients who often have poor vision and have difficulty in making and maintaining eye contact. School children and students may need extra time for reading and sitting exams - there are issues here surrounding the education of carers and teachers. Small print can usually be read with aids but children will find it hard to share books. Patients need to inform the DVLA - many will not be authorised to drive.Management[4]This is difficult and often disappointing. The outcome depends on the visual potential, the presence of visual symptoms such as oscillopsia and the location of a null position, if there is one. It is necessary to refer patients with nystagmus for further investigation. Ophthalmologists are a good first port of call but abnormal neurological findings warrant a referral directly to the neurologists. Subsequent management will depend on the underlying condition but may be conservative, medical (eg, gabapentin, scopolamine and baclofen) or surgical. The latter is unusual and involves altering the insertion of the relevant extraocular muscles. Neurosurgery may also be performed where there is an underlying resectable lesion. There are promising advances made in particular surgical techniques that might make this option more attractive soon.[5] Severe, disabling nystagmus can be treated with retrobulbar injections of botulinum toxin.[6] Many patients will have some degree of decreased visual acuity requiring spectacles; some will be so severely affected as to need registration as sight impaired or severely sight impaired. Associated physical and psychosocial factors need to be explored and addressed where necessary (see 'Associated problems', above).Physiological nystagmus[1]This nystagmus occurs after 6 months of age. It is worth noting that ~5% of the normal population can voluntarily induce a predominantly horizontal, high-frequency, low-amplitude rhythmic oscillation of the eyes - this phenomenon may be associated with behaviouraltics.[7] End-point nystagmus: this is the nystagmus associated with extreme positions of gaze. It is a fine jerk nystagmus with the fast phase being in the direction of the gaze. Optokinetic nystagmus: This describes the nystagmus that occurs when following a moving object (such as looking out of a train window). This is a jerk nystagmus: the slow phase follows the target and the fast phase fixates on to the next target. An optokinetic drum is an instrument consisting of a handle on which is mounted a cylinder which can rotate. The cylinder is printed with thick, regularly spaced vertical black and white stripes and as it rotates, optokinetic nystagmus is induced. It is a helpful instrument in assessing the visual acuity of very young infants and also to detect patients feigning blindness.PatientPlus Dizziness, Giddiness and Feeling Faint Benign Paroxysmal Positional Vertigo Read more articlesEarly-onset nystagmus: 0-6 months of age[7]Nystagmus at this age may be: Idiopathic Neurological in origin As a result of sensory deprivationBabies presenting with nystagmus all need referring (preferably to a paediatric ophthalmologist) for investigation. Congenital idiopathic nystagmus (CIN): Overview- infants with a nystagmus in all positions of gaze but with clinically normal eyes and normal developmental milestones are said to have CIN. This may be X-linked, autosomal recessive or autosomal dominant.[4]This diagnosis is only made when neurological and ocular abnormalities have been excluded. Presentation- these infants present within the first two months of life. The nystagmus is characterised by a horizontal nystagmus in all positions of gaze which may be pendular or jerk, which dampens with convergence/accommodation and which disappears during sleep. The visual acuity is usually fairly good (of the order of 6/9-6/12). The child may eventually adopt an abnormal compensatory head position. Associated diseases- none by definition. Management- the continual movement of the eye may reduce the visual acuity (depending on the speed of movement, whether there are periods of rest from the movement and whether the nystagmus is reduced by accommodation) and visual correction with spectacles may be necessary. There should not be any progression of the severity of the nystagmus beyond that established in the first few months of life. Neurological nystagmus: Overview- neurological disease can present with many forms of nystagmus and this possibility must always be considered in the infant presenting with nystagmus. A history of failure to thrive, developmental abnormalities or any other evidence of neurological abnormalities should prompt investigation for a neurological cause. Presentation- these patients tend to present before 2 months of age. Associated diseases- this form of nystagmus is associated withspace-occupying lesions, metabolic diseases, neurodegenerative disorders and trauma. Management- this depends on the underlying cause, as does the prognosis. Sensory deprivation nystagmus (SDN): Overview- this occurs as a result of an abnormality at some point in the visual pathway, leading to sensory deprivation. It accounts for 80-90% of childhood nystagmus. Presentation- these children often present within the first two to three months of life with a bilateral, conjugate (eyes move together) nystagmus. The movements are horizontal and disappear during sleep. There is often a family history of sensory deprivation and examination reveals poor vision, photophobia, abnormal pupillary reactions and optic neuropathy. More detailed assessments will reveal the presence of a high refractive error and retinopathy. Associated diseases- any abnormalities of the eyes causing abnormal vision including corneal opacities, aniridia (absence of the iris),cataracts,albinism,retinopathy of prematurityand the rod/cone dystrophies. Other culprits include chorioretinal abnormalities, Leber's congenital amaurosis and optic nerve abnormalities. Management- this will depend on the underlying cause of the sensory deficit, as does the prognosis.Late-onset nystagmus: presentation >6 months of age[7]This group of conditions can be usefully subdivided into symmetrical and asymmetrical nystagmus. The symmetrical conditions can be further classified according to the direction of movement of the eyes. The management and outcome depend on the associated diseases/causative factors. Patients - children or adults - presenting with late-onset nystagmus need to be referred for investigation; their management and outcome will depend on the causative factor.Symmetrical vertical nystagmus Upbeat nystagmus: Description- this is a jerk nystagmus with the fast phase going upwards. It is apparent in the primary position of gaze and increases on looking up. Associated diseases- it is most commonly seen as a side-effect of anticonvulsants but it may also occur in cerebellar and pontomedullary abnormalities. It may also be a sign ofWernicke's encephalopathy.[1]Occasionally, it is seen withbenign paroxysmal positional vertigoor it can be a manifestation of an atypical familial CIN. Downbeat nystagmus: Description- this jerk nystagmus has a fast downward phase which is present in the primary position but worse on looking down. Associated diseases- there are a variety of causes including any abnormality at the craniocervical junction (eg,Arnold-Chiari malformation), cerebellar degeneration and drug intoxication (particularly with lithium, phenytoin, carbamazepine and barbituates).[1][8]It also occurs inWernicke's encephalopathy, demyelination, brain stemencephalitis, tumours at the foramen magnum andhydrocephalus.Symmetrical horizontal nystagmus Periodic alternation nystagmus (PAN): Description- this is a horizontal jerk nystagmus, the direction of which usually reverses every 2-3 minutes. There are cyclical phases where the nystagmus amplifies and then decreases. There is a quiet interlude of ~10-20 seconds before the reversal occurs. Associated diseases- cerebellar and brainstem abnormalities, demyelination, Louis-Bar syndrome, drug intoxication (especially phenytoin) and atypical CIN. It is also seen following head trauma, with encephalitis and syphilis. Binocular visual deprivation may produce a PAN.[1]Symmetrical mixed vertical/horizontal nystagmus Gaze paretic nystagmus: Description- this is a jerk nystagmus in the direction of eccentric gaze (eg, when you look right, the nystagmus is to the right). When it is unilateral, its direction is toward the side of the lesion. Associated diseases- this may be associated with vestibular, cerebellar and brain stem disease as well as with drug intoxication. Rebound nystagmus: Description- this is a horizontal jerk nystagmus which changes direction after several seconds of eccentric gaze and then reverts back to its original pattern when the eyes are returned to their primary position. Associated diseases- this occurs in posterior fossa lesions and in cerebellar disease. Acquired pendicular nystagmus: Description- this is a high-frequency, low-amplitude pendular nystagmus in all directions of gaze. Associated diseases- causes include demyelinating disease, oculopalatal myoclonus and drug intoxication.Asymmetrical nystagmus Spasmus mutans: Description- this rare self-limiting condition is characterised by an acquired monocular (or asymmetrical binocular) fine, rapid nystagmus usually occurring within the first year of life (range: 3-18 months). The nystagmus may have vertical and torsional components and is frequently increased in amplitude on abduction.[1]It usually resolves by about the fourth year of life. It is often accompanied by head nodding and torticollis. All these signs disappear during sleep. Associated diseases- usually, this is a benign condition but space-occupying lesions (especially gliomas of the anterior visual pathway) may present in a similar way and therefore these children need investigating to rule this out. Latent nystagmus: Description- this jerk horizontal nystagmus only occurs if one eye is occluded (or has a reduction of light input by using a filter). The nystagmus is bilateral with the fast phase towards the uncovered eye. Associated diseases- infantileesotropia. See-saw nystagmus (of Maddox): Description- this pendular nystagmus is characterised by one eye rising and intorting as the other simultaneously lowers and extorts. Associated diseases- this is classically seen with space-occupying lesions in the suprasellar region (when there will also often be a bitemporal hemianopia) but it is also associated with optic nerve hypoplasia and brain stem disease. It may be seen in patients with visual loss secondary toretinitis pigmentosa. Ataxic nystagmus: Description- this is a rhythmic oscillation of the eye on abduction. Associated diseases- internuclear ophthalmoplegia.Other acquired nystagmusVestibular nystagmus[2] This jerk nystagmus arises from an altered input from the vestibular nuclei to the horizontal gaze centres. It may be elicited by caloric stimulation which is an attempt to discover the degree to which the vestibular system is responsive and also how symmetrical the responses are (ie between left and right): When cold water is poured into the right ear, the patient develops a left jerk nystagmus (fast phase to the left). When warm water is poured into the right ear, the patient develops a right jerk nystagmus (fast phase to the right). When cold water is poured into both ears simultaneously, there is a fast upward phase and warm water produces a fast downward phase. When it is unidirectional, uniplanar and with a torsional element, it is said to be peripheral. In this case, it is associated withvertigo,tinnitusand hearing loss. It may be found in acutelabyrinthitis,Mnire's diseaseand benign positional vertigo. Central vestibular nystagmus is characterised by a chronic jerk which varies with the direction of gaze. There are fewer symptoms of vertigo, tinnitus and deafness. Various brain stem diseases (eg, MS, CVA or tumours) can cause this problem.Convergence-retraction nystagmus[1] Description- this is caused by co-contraction of the extraocular muscles (especially the medial recti), resulting in a jerk nystagmus induced by optokinetic stimulation downwards (see 'Physiological nystagmus', above). Upward re-fixation brings the two eyes towards each other (convergence) and there may be associated globe retraction. Associated diseases- this is typically seen in Parinaud's syndrome (dorsal midbrain syndrome) and is caused by lesions of the pretectal area such as pinealomas and vascular accidents (particularly involving the basilar artery). Other causes of Parinaud's syndrome include: head trauma, multiple sclerosis and arteriovenous malformations.[2]Provide FeedbackTurned eyes (squint)When both eyes are lined up, the brain is able to merge the two pictures into a single, three dimensional picture which allows us to see the position of objects in relation to each other (depth perception). When the eyes look in different directions, the brain has to ignore one eye to be able to see clearly. When a child has a squint, the eyes do not look in the same direction some of the time, or all of the time.Contents What is a turned eye (squint)? Normal development When does it occur? Who is most at risk? What to look for Problems caused by a turned eye Who can help? Treatment References

What is a turned eye (squint)? A turned eye is when one eye does not look in the same direction as the other. One eye may turn in towards the nose (crossed eyes) or outwards towards the ears (wall eyes), or up or down. This is also known as a squint. The medical name for this is strabismus.Normal development In the first few weeks, a baby's eyes often cross, or wander in different directionssomeof the time. By the age of 3 months the eyes should be lined up so that they both look at the same object. If a young baby's eyes are turned in or out most of the time, or if a baby over 3 months old has turned eyes, the baby needs to have his eyes checked. Some babies and young children have turned eyes some of the time (more often when they are tired or unwell). These babies should also have their eyes checked.When does it occur? About 2% to 4% of children will have a turned eye. About half of these children will have a turned eye from birth, and about half develop it at a later age, sometimes because one eye sees more clearly than the other, or because of an injury to the eye or some (fairly rare) illnesses.Who is most at risk? Children are more likely to have a turned eye if there are other people in their family who also have a turned eye (thereare some genetic factors). Children with developmental problems such as cerebral palsy are more likely to have a turned eye. Often the condition will occur without any apparent reason.What to look for One eye may be obviously turned in, or out, or up or down compared to the other. You may be able to see that your baby's eyes do not move together, or that one is not lined up with the other. This may be easier to see in a photograph where a flashhas beenused, because the reflection of the light from the flash will be in a different position on the iris in each eye. The reflection may be closer to the nose on one side than the other, or higher on one side than the other. This difference in position of the light reflection can often also be seen when there is a bright light several metres from the baby (such as a room light).Older children may: close or cover one eye to try to see more clearly tilt or turn their head have difficulty judging distances not be very well coordinated have headaches or tired eyes have difficulty in reading blink a lot have poor concentration.Children who have always had a turned eye may not know that they have an eye problem (after all, it has always been the same for them), but if the squint 'comes and goes', they may be aware of having blurred or double vision some of the time.Treatment started early will produce the best result. If you think your baby or young child may have a vision problem (including a squint), see your doctor soon.Some babies may appear to have a squint when they don't have one. There can be a wide fold of skin near the inner side of the eyes, or a broad, flat nose which can give the appearance of the eyes looking in different directions. The reflection of a light (or a flash in a photo) will show that the eyes are lined up.However, if you think that your child has a squint, get your baby's eyes checked. This 'false strabismus' should disappear as your child gets older.Problems caused by a turned eye The brain normally gets two very similar 'pictures', onefrom each eye, but if a child has a turned eye, the 'pictures' from the eyes will be different. The brain will not be able to merge these different 'pictures' together, so it will 'ignore' one of the pictures. If the 'picture' from one eye is always ignored, vision in that eye will become weaker, and the child may become blind in that eye, even when there is no damage to the eye. This is called a'lazy eye'oramblyopia. Having poor vision in one, or both eyes to start with can also cause a turned eye, as the 'picture' from the weaker eye is 'ignored'. Most people who have a turned eye can manage with very few problems, but: they may havedifficulties with judging distances, and there may be some prejudice about having a turned eye. People usually look at someone with whom they are interacting, and they may find this harder to do if they are not sure whether the other person is looking at them or not. and if the person has good vision in only one eye, there is an increased risk of blindness if the good eye gets injured.Who can help?If you think that your child has a turned eye, see your doctor, as your child may need to be referred to an ophthalmologist (specialist eye doctor)TreatmentA squint does not go away as a child gets older, and it will not get better if it is not treated.Treatment aims to: preserve vision (keep both eyes working well) make the eyes work together straighten the eyes.Treatment may include glasses (this may be enough, so that each eye can see clearly) patching one eye (the good eye is patched so that the brain takes more notice of the image from the other eye) eye exercises (to get the eyes working together better) surgical correction (operating on some of the muscles that control eye movement).Newer techniques usingBotulinum toxin(botox) injections into muscles around the eye can also be effective.If left untreated, a squint may lead to permanent loss of vision in one eye.ReferencesOrthoptic Association ofAustralia Inc. Pamphlet 'Turned eyes in children: understanding strabismus'Raising Children Networkhttp://raisingchildren.net.au/ Recognise and treat squinting in childrenMedline Plus- National Libraries of Medicine USAhttp://www.nlm.nih.gov/medlineplus Strabismushttp://www.nlm.nih.gov/medlineplus/ency/article/001004.htmNemours Foundation - KidsHealth.orghttp://kidshealth.org Strabismushttp://kidshealth.org/parent/general/eyes/strabismus.htmlStrabismusFrom Wikipedia, the free encyclopediaFor the protein Strabismus, seeStrabismus (protein).Strabismus

Strabismus prevents the eyes from aiming at the same point in space

Classification and external resources

ICD-10H49H50

ICD-9378

OMIM185100

DiseasesDB29577

MedlinePlus001004

Patient UKStrabismus

MeSHD013285

Strabismus(/strbzms/, from Greekstrabisms[1]), is a condition that interferes withbinocular visionbecause it prevents a person from directing both eyes simultaneously towards the samefixation point; the eyes do not properly align with each other.Heterotropiais a medical synonym for the condition. Colloquial terms for strabismus includecross-eye,wall-eye, asquintand acast of the eye.[2]Strabismus typically involves a lack of coordination between theextraocular muscles, which prevents directing the gaze of both eyes at once to the same point in space; it thus hampers proper binocular vision, and may affectdepth perceptionadversely. Strabismus is primarily managed byophthalmologists, optometrists, and orthoptists. Strabismus is present in about 4% of children. Treatment should be started as early as possible to ensure the development of the best possiblevisual acuity[3][4]andstereopsis.Contents[hide] 1Diagnosis and classification 1.1Latency 1.2Onset 1.3Laterality 1.4Direction 1.5Naming 1.6Other considerations 2Signs and symptoms 3Pathophysiology 4Psychosocial effects 5Management 6Prognosis 7See also 8References 9Further reading 10External linksDiagnosis and classification[edit]During aneye examination, a test such ascover testingor theHirschberg testis used in the diagnosis and measurement of strabismus and its effect on vision. Several classifications are made when diagnosing strabismus.Latency[edit]Strabismus can be manifest (-tropia) or latent (-phoria). A manifest deviation, or heterotropia (which may beeso-,exo-,hyper-,hypo-,cyclotropiaor a combination of these), is present while the patient views a target binocularly, with no occlusion of either eye. The patient is unable to align the gaze of each eye to achieve fusion. A latent deviation, orheterophoria(eso-,exo-,hyper-,hypo-,cyclophoriaor a combination of these), is only present after binocular vision has been interrupted, typically by covering one eye. This type of patient can typically maintain fusion despite the misalignment that occurs when the positioning system is relaxed. Intermittent strabismus is a combination of both of these types, where the patient can achieve fusion, but occasionally or frequently falters to the point of a manifest deviation.Onset[edit]Strabismus may also be classified based on time of onset, eithercongenital, acquired, or secondary to another pathological process. Many infants are born with their eyes slightly misaligned, and this is typically outgrown by six to 12 months of age.[5]Acquired and secondary strabismus develop later. The onset ofaccommodative esotropia, an overconvergence of the eyes due to the effort ofaccommodation, is mostly in early childhood. Acquired non-accommodative strabismus and secondary strabismus are developed after normal binocular vision has developed. In adults with previously normal alignment, the onset of strabismus usually results indouble vision.Any disease that causes vision loss may also cause strabismus.[6]Sensory strabismus is strabismus due tovision lossorimpairment, leading to horizontal, vertical or torsional misalignment or to a combination thereof, with the eye with poorer vision drifting slightly over time. Most often, the outcome is horizontal misalignment. Its direction depends on the patient age at which the damage occurs: patients whose vision is lost or impaired at birth are more likely to develop esotropia, whereas patients with acquired vision loss or impairment mostly develop exotropia.[7][8][9]In the extreme, completeblindnessin one eye generally leads to the blind eye reverting to an anatomical position of rest.[10]Although many possible causes of strabismus are known, in many cases no specific cause can be identified. This is typically the case when strabismus is present since early childhood[11](see also:Infantile esotropia).Results of a U.S. cohort study indicate that the incidence of adult-onset strabismus increases with age, especially after the sixth decade of life, and peaks in the eighth decade of life, and that the lifetime risk of being diagnosed with adult-onset strabismus is approximately 4%.[12]Laterality[edit]Strabismus may be classified as unilateral if the one eye consistently deviates, or alternating if either of the eyes can be seen to deviate. Alternation of the strabismus may occur spontaneously, with or without subjective awareness of the alternation. Alternation may also be triggered by various tests during an eye exam.[4]Direction[edit]Horizontal deviations are classified into two varieties.Esodescribes inward or convergent deviations towards the midline.Exodescribes outward or divergent misalignment. Vertical deviations are also classified into two varieties.Hyperis the term for an eye whose gaze is directed higher than the fellow eye whilehyporefers to an eye whose gaze is directed lower.Cyclorefers to torsional strabismus, which occurs when the eyes rotate around the anterior-posterior axis to become misaligned and is quite rare.Naming[edit]The directional prefixes are combined with -tropia and -phoria to describe various types of strabismus. For example, a constant left hypertropia exists when a patient's left eye is always aimed higher than the right. A patient with an intermittent right esotropia has a right eye that occasionally drifts toward the patient's nose, but at other times is able to align with the gaze of the left eye. A patient with a mild exophoria can maintain fusion during normal circumstances, but when the system is disrupted, the relaxed posture of the eyes is slightly divergent.Other considerations[edit]Strabismus can be further classified as follows: Paretic strabismus is due to paralysis of one or severalextraocular muscles. Nonparetic strabismus is not due to paralysis of extraocular muscles. Comitant (orconcomitant) strabismus is a deviation that is the same magnitude regardless of gaze position. Noncomitant (orincomitant) strabismus has a magnitude that varies as the patient shifts his or her gaze up, down, or to the sides.Nonparetic strabismus is generally concomitant.[13]Most types of infant and childhood strabismus are comitant.[14]Paretic strabismus can be either comitant or noncomitant. Incomitant strabismus is almost always caused by a limitation of ocular rotations that is due to a restriction of extraocular eye movement (ocular restriction) or due toextraocular muscle paresis.[14]Incomitant strabismus cannot be fully corrected byprismglasses, because the eyes would require different degrees of prismatic correction dependent on the direction of the gaze.[15]Incomitant strabismus of the eso- or exo-type are classified as "alphabet patterns": they are denoted as A- or V- or more rarely-, Y- or X-pattern depending on the extent of convergence or divergence when the gaze moves upward or downward. These letters of the alphabet denote ocular motility pattern that have a similarity to the respective letter: in the A-pattern there is (relatively speaking) more convergence when the gaze is directed upwards and more divergence when it is directed downwards, in the V-pattern it is the contrary, in the -, Y- and X-patterns there is little or no strabismus in the middle position but relatively more divergence in one or both of the upward and downward positions, depending on the "shape" of the letter.[16]Types of incomitant strabismus include:Duane syndrome,horizontal gaze palsy, andcongenital fibrosis of the extraocular muscles.[17]When the misalignment of the eyes is large and obvious, the strabismus is called large-angle, referring to the angle of deviation between the lines of sight of the eyes. Less severe eye turns are called small-angle strabismus. The degree of strabismus can vary based on whether the patient is viewing a distant or near target.Strabismus that sets in after eye alignment had been surgically corrected is calledconsecutive strabismus.Pseudostrabismusis the false appearance of strabismus. It generally occurs in infants and toddlers whose bridge of the nose is wide and flat, causing the appearance of esotropia due to lesssclerabeing visible nasally. With age, the bridge of the child's nose narrows and thefolds in the corner of the eyesbecome less prominent.Signs and symptoms[edit]

Alignedvergence; how one ideally views objects

Esotropia

ExotropiaArrow/dotted line indicates fixation distance: All three patients are fixating with their right eye (assuming an overhead view).When observing a patient with strabismus, the misalignment of the eyes may be quite apparent. A patient with a constant eye turn of significant magnitude is very easy to notice. However, a small magnitude or intermittent strabismus can easily be missed upon casual observation. In any case, aneye care professionalcan conduct various tests, such as cover testing, to determine the full extent of the strabismus.Strabismus can be seen inDown syndrome,cerebral palsy, andEdwards syndrome.Symptoms of strabismus includedouble visionand/oreye strain. To avoid double vision, the brain may adapt byignoring one eye. In this case, often no noticeable symptoms are seen other than a minor loss of depth perception. This deficit may not be noticeable in someone who has had strabismus since birth or early childhood, as they have likely learned to judge depth and distances usingmonocular cues. However, a constant unilateral strabismus causing constant suppression is a risk foramblyopiain children. Small-angle and intermittent strabismus are more likely to cause disruptive visual symptoms. In addition to headaches and eye strain, symptoms may include an inability to read comfortably, fatigue when reading, and unstable or "jittery" vision.Pathophysiology[edit]Theextraocular musclescontrol the position of the eyes. Thus, a problem with the muscles or the nerves controlling them can cause paralytic strabismus. The extraocular muscles are controlled by cranial nervesIII,IV, andVI. Animpairment of cranial nerve IIIcauses the associated eye to deviate down and out and may or may not affect the size of the pupil.Impairment of cranial nerve IV, which can becongenital, causes the eye to drift up and perhaps slightly inward.Sixth nerve palsycauses the eyes to deviate inward and has many causes due to the relatively long path of the nerve.Increased cranial pressurecan compress the nerve as it runs between theclivusandbrain stem.[3]Also, if thedoctoris not careful, twisting of the baby's neck duringforceps deliverycan damage cranial nerve VI.[citation needed]Evidence indicates a cause for strabismus may lie with the input provided to thevisual cortex.[18]This allows for strabismus to occur without the direct impairment of any cranial nerves or extraocular muscles.Strabismus may causeamblyopiadue to the brain ignoring one eye. Amblyopia is the failure of one or both eyes to achieve normal visual acuity despite normal structural health. During the first seven to eight years of life, the brain learns how to interpret the signals that come from an eye through a process called visual development. Development may be interrupted by strabismus if the child always fixates with one eye and rarely or never fixates with the other. To avoid double vision, the signal from the deviated eye issuppressed, and the constant suppression of one eye causes a failure of the visual development in that eye.Also, amblyopia may cause strabismus. If a great difference in clarity occurs between the images from the right and left eyes, input may be insufficient to correctly reposition the eyes. Other causes of a visual difference between right and left eyes, such as asymmetrical cataracts, refractive error, or other eye disease, can also cause or worsen strabismus.[3]Accommodative esotropiais a form of strabismus caused byrefractive errorin one or both eyes. Due to thenear triad, when a patient engagesaccommodationto focus on a near object, an increase in the signal sent by cranial nerve III to the medial rectus muscles results, drawing the eyes inward; this is called theaccommodation reflex. If the accommodation needed is more than the usual amount, such as with people with significant hyperopia, the extra convergence can cause the eyes to cross.See also:Progressive external ophthalmoplegia,KearnsSayre syndrome,Brown's syndrome,Duane syndromeandmonofixation syndromePsychosocial effects[edit]People of all ages may experience psychosocial difficulties if they have noticeable strabismus.[19][20][21]Attention has also been drawn to the potential socioeconomic impact of strabismus. This is also a socioeconomic consideration in the context of decisions on strabismus treatment[19][20][21]including efforts to re-establish binocular vision, possibly withstereopsis recovery.[22]One study showed that behaviour of strabismic children was marked by inhibition, anxiety, and emotional disorders. These disorders, considered to be due to the manner in which others look at the child in view of their altered aesthetic appearance and the symbolic nature of theeyeandgaze, improved afterstrabismus surgery.[23]Notably, strabismus interferes with normaleye contact, often causingembarrassment,anger, and feelings of awkwardness, thereby affecting social communication in a fundamental way, with a possible negative affect onself-esteem.[24]There are indications that children with strabismus, in particular those withexotropia, are more likely to develop a mental health disorder than normal-sighted children. The possible reason why esotropia wasn't found to be linked to the higher likelihood of mental illness was the age of the subjects studied and the follow-up time period; the children with esotropia were monitored to a mean age of 15.8 years, compared with 20.3 years for those with exotropia.[25][26][27]A new study conducted later with patients from the same county has monitored those withcongenital esotropiafor a longer time period than in the first study and the results have shown that, similar to those with constant exotropia, intermittent exotropia orconvergence insufficiency, they were also more likely to develop a mental illness by early adulthood. The likelihood was 2.6 times that of controls. There was no apparent association with premature birth and there was no evidence that psychosocial stressors frequently encountered by those with strabismus were directly linked to the development of mental illness.[28]In one study, mothers of children with strabismus were shown to have higher depression scores, lower tendency to constitute a supportive relation with their children, and lower satisfaction with maternal role, in comparison with the control group; the mothers also had poor role functioning in the family in relation to food, clothing and support needs and poor affective responsiveness.[29]Investigations have highlighted the impact that strabismus may typically have on the quality of life.[30]Studies on the basis of surveys using pictures of strabismic and non-strabismic persons demonstratedpsychosocial effectsandsocioeconomicimplications with regard toemployability.[31][32]Adult and children observers perceive a right heterotropia as more disturbing than a left heterotropia, and children observers perceive an esotropia as worse than an exotropia.[33]Successful surgical correction of strabismus is known to have positive effects on psychological well-being, even when implemented with adult patients.[34][35]A study performed on persons with strabismus found that the psychological effects of strabismus did not depend on the patients angle of deviation, age, sex, presence of diplopia, visual acuity or direction of deviation.[36]A post-operative study found that strabismus surgery performed on adults had the effect, among other results, of reducing subjects' social anxiety levels.[37]A further post-operative study found that the quality of life of the subjects was the higher, the smaller the postoperative angle was.[38]Another study showed that certain psychosocial aspects undergo changes for many months after strabismus surgery.[39]There is very little research intocopingstrategies employed by adults with strabismus. One study categorized coping strategies into three categories: avoidance (not doing an activity), distraction (deflecting attention away from strabismus) and adjustment (doing the activity in a different way). The authors of the study suggested that individuals with strabismus may benefit from psychosocial support such asinterpersonal skillstraining.[40]See also:Prevalence and impact of reduced stereopsis in humansManagement[edit]Surgery to correct strabismus on an eight-month-old infantAs with other binocular vision disorders, the primary therapeutic goal for those with strabismus is comfortable, single, clear, normal binocular vision at all distances and directions of gaze.[41]Whereasamblyopia(lazy eye), if minor and detected early, can often be corrected with use of aneye patchon the dominant eye and/orvision therapy, the use of eye patches is unlikely to change the angle of strabismus. Strabismus is usually treated with a combination ofeyeglasses, vision therapy, andsurgery, depending on the underlying reason for the misalignment. For parents it is important to know that strabismus surgery does not remove the need for a child to wear glasses.In cases ofaccommodative esotropia, the eyes turn inward due to the effort of focussing far-sighted eyes, and the treatment of this type of strabismus necessarily involves refractive correction, which is usually done via corrective glasses or contact lenses, and in these cases surgical alignment is considered only if such correction does not resolve the eye turn.In case of stronganisometropia, contact lenses may be preferable to spectacles because they avoid the problem of visual disparities due to size differences (aniseikonia) which is otherwise caused by spectacles in which the refractive power is very different for the two eyes. In a few cases of strabismic children with anisometropic amblyopia, a balancing of the refractive error eyes viarefractive surgeryhas been performed before strabismus surgery was undertaken.[42]Strabismus surgery attempts to align the eyes by shortening, lengthening, or changing the position of one or more of the extraocular eye muscles. The procedure can typically be performed in about an hour, and requires about one or two weeks for recovery. Adjustable sutures may be used to permit refinement of the eye alignment in the early postoperative period.[43](For details on the surgical intervention,see:Strabismus surgery.)Double vision can rarely result, especially immediately after the surgery,[citation needed]and vision loss is very rare. Glasses affect the position by changing the person's reaction to focusing. Prisms change the way light, and therefore images, strike the eye, simulating a change in the eye position.[44]Early treatment of strabismus in infancy may reduce the chance of developing amblyopia and depth perception problems. Most children eventually recover from amblyopia if they have had the benefit of patches and corrective glasses. Amblyopia has long been considered to remain permanent if not treated within a critical period, namely before the age of about seven years;[5]however, recent discoveries give reason to challenge this view and toadapt the earlier notion of a critical periodto account forstereopsis recoveryin adults.Eyes that remain misaligned can still develop visual problems. Although not a cure for strabismus,prismlenses can also be used to provide some temporary comfort for sufferers and to prevent double vision from occurring.Botulinum toxin therapyis used for treating strabismus in certain circumstances. In 1989, the USFDAapprovedbotulinum toxintype A (BT-A) as a treatment for strabismus in patients over 12 years old.[45][46]Most commonly used in adults, the technique is also used for treating children, in particular children affected by infantile esotropia.[47][48][49]The toxin is injected in the stronger muscle, causing temporary and partial paralysis. The treatment may need to be repeated three to four months later once the paralysis wears off. Common side effects are double vision, droopy eyelid, overcorrection, and no effect. The side effects typically resolve also within three to four months.Prognosis[edit]When strabismus is congenital or develops in infancy, it can cause amblyopia, in which the brain ignores input from the deviated eye. Even with therapy for amblyopia,stereoblindnessmay occur. The appearance of strabismus may also be acosmeticproblem. One study reported 85% of adult strabismus patients "reported that they had problems with work, school, and sports because of their strabismus". The same study also reported 70% said strabismus "had a negative effect on theirself-image".[50]After surgery, the squint can return, so a second operation is sometimes required to straighten the eyes.[3]See also[edit] Pediatric ophthalmology Retinoblastoma Palsyof cranial nerveIII (oculomotor),IV (trochlear),VI (abducens) Orthoptics Bates method Duane syndrome Convergence insufficiency t is not to be used as the absolute diagnostic criteria for labeling children with sensory processing disorder.But rather, as an educational tool and checklist for your own knowledge. Professionals who can diagnose this disorder have their own tools in addition to checklists to observe and test for sensory integration dysfunction. As you go through this list, you may say, "Wow, my child has so many of these characteristics/behaviors, he must have a sensory processing disorder!!" That MAY be true, and I want you to take it very seriously if you find a host of these to be characteristic of your child. But, then use this as a guide to speak with your doctor and an Occupational Therapist so you can clearly explain why you think your child may need help. Or, you may go through the list and say, "No big deal, so my child has some of these behaviors/characteristics, doesn't every child?"

Well, this may be true too and your child's behavior may fluctuate from day to day. What we need to be concerned with iswhichsymptoms your child shows,which categorythey are having difficulty with,how much it interfereswith their or other's livesand what kind of impact it is having on their level of functioning.They may have a lot in one category and none in another or some in all categories. This will help target diagnosis and treatment. Lastly, you may go through the list and say, "Oh my gosh, that is what I have been dealing with my whole life". Then I say, I'm so sorry you never got the help you needed! Perhaps we can start to work on it now. Identifying and understanding this disorder is HUGE! Please understand the "Five Caveats" that Carol Stock Kranowitz points out in her book,"The Out-of-Sync Child"(1995), about using a checklist such as this. She writes:

1. "The child with sensory dysfunction does not necessarily exhibit every characteristic. Thus, the child with vestibular dysfunction may have poor balance but good muscle tone." 2. "Sometimes the child will show characteristics of a dysfunction one day but not the next. For instance, the child with proprioceptive problems may trip over every bump in the pavement on Friday yet score every soccer goal on Saturday.Inconsistency is a hallmark of every neurological dysfunction."

3. "The child may exhibit characteristics of a particular dysfunction yet not have that dysfunction. For example, the child who typically withdraws from being touched may seem to be hypersensitive to tactile stimulation but may, instead, have an emotional problem."

4. "The child may be both hypersensitive and hyposensitive. For instance, the child may be extremely sensitive to light touch, jerking away from a soft pat on the shoulder, while being rather indifferent to the deep pain of an inoculation."

5. "Everyone has some sensory integration problems now and then, because no one is well regulated all the time. All kinds of stimuli can temporarily disrupt normal functioning of the brain, either by overloading it with, or by depriving it of, sensory stimulation." Tactile Sense:input from the skin receptors about touch, pressure, temperature, pain, and movement of the hairs on the skin. Signs Of Tactile Dysfunction: 1. Hypersensitivity To Touch (Tactile Defensiveness) __ becomes fearful, anxious or aggressive with light or unexpected touch

__ as an infant, did/does not like to be held or cuddled; may arch back, cry, and pull away

__ distressed when diaper is being, or needs to be, changed

__ appears fearful of, or avoids standing in close proximity to other people or peers (especially in lines)

__ becomes frightened when touched from behind or by someone/something they can not see (such as under a blanket)

__ complains about having hair brushed; may be very picky about using a particular brush

__ bothered by rough bed sheets (i.e., if old and "bumpy")

__ avoids group situations for fear of the unexpected touch

__ resists friendly or affectionate touch from anyone besides parents or siblings (and sometimes them too!)

__ dislikes kisses, will "wipe off" place where kissed

__ prefers hugs

__ a raindrop, water from the shower, or wind blowing on the skin may feel like torture and produce adverse and avoidance reactions

__ may overreact to minor cuts, scrapes, and or bug bites

__ avoids touching certain textures of material (blankets, rugs, stuffed animals)

__ refuses to wear new or stiff clothes, clothes with rough textures, turtlenecks, jeans, hats, or belts, etc.

__ avoids using hands for play

__ avoids/dislikes/aversive to "messy play", i.e., sand, mud, water, glue, glitter, playdoh, slime, shaving cream/funny foam etc.

__ will be distressed by dirty hands and want to wipe or wash them frequently

__ excessively ticklish

__ distressed by seams in socks and may refuse to wear them

__ distressed by clothes rubbing on skin; may want to wear shorts and short sleeves year round, toddlers may prefer to be naked and pull diapers and clothes off constantly

__ or, may want to wear long sleeve shirts and long pants year round to avoid having skin exposed

__ distressed about having face washed

__ distressed about having hair, toenails, or fingernails cut

__ resists brushing teeth and is extremely fearful of the dentist

__ is a picky eater, only eating certain tastes and textures; mixed textures tend to be avoided as well as hot or cold foods; resists trying new foods

__ may refuse to walk barefoot on grass or sand

__ may walk on toes only

2. Hyposensitivity To Touch (Under-Responsive): __ may crave touch, needs to touch everything and everyone

__ is not aware of being touched/bumped unless done with extreme force or intensity

__ is not bothered by injuries, like cuts and bruises, and shows no distress with shots (may even say they love getting shots!)

__ may not be aware that hands or face are dirty or feel his/her nose running

__ may be self-abusive; pinching, biting, or banging his own head

__ mouths objects excessively

__ frequently hurts other children or pets while playing

__ repeatedly touches surfaces or objects that are soothing (i.e., blanket)

__ seeks out surfaces and textures that provide strong tactile feedback

__ thoroughly enjoys and seeks out messy play

__ craves vibrating or strong sensory input

__ has a preference and craving for excessively spicy, sweet, sour, or salty foods 3. Poor Tactile Perception And Discrimination: __ has difficulty with fine motor tasks such as buttoning, zipping, and fastening clothes

__ may not be able to identify which part of their body was touched if they were not looking

__ may be afraid of the dark

__ may be a messy dresser; looks disheveled, does not notice pants are twisted, shirt is half un tucked, shoes are untied, one pant leg is up and one is down, etc.

__ has difficulty using scissors, crayons, or silverware

__ continues to mouth objects to explore them even after age two

__ has difficulty figuring out physical characteristics of objects; shape, size, texture, temperature, weight, etc.

__ may not be able to identify objects by feel, uses vision to help; such as, reaching into backpack or desk to retrieve an item Vestibular Sense:input from the inner ear about equilibrium, gravitational changes, movement experiences, and position in space. Signs Of Vestibular Dysfunction: 1. Hypersensitivity To Movement (Over-Responsive): __ avoids/dislikes playground equipment; i.e., swings, ladders, slides, or merry-go-rounds

__ prefers sedentary tasks, moves slowly and cautiously, avoids taking risks, and may appear "wimpy"

__ avoids/dislikes elevators and escalators; may prefer sitting while they are on them or, actually get motion sickness from them

__ may physically cling to an adult they trust

__ may appear terrified of falling even when there is no real risk of it

__ afraid of heights, even the height of a curb or step

__ fearful of feet leaving the ground

__ fearful of going up or down stairs or walking on uneven surfaces

__ afraid of being tipped upside down, sideways or backwards; will strongly resist getting hair washed over the sink

__ startles if someone else moves them; i.e., pushing his/her chair closer to the table

__ as an infant, may never have liked baby swings or jumpers

__ may be fearful of, and have difficulty riding a bike, jumping, hopping, or balancing on one foot (especially if eyes are closed)

__ may have disliked being placed on stomach as an infant

__ loses balance easily and may appear clumsy

__ fearful of activities which require good balance

__ avoids rapid or rotating movements 2. Hyposensitivity To Movement (Under-Responsive): __ in constant motion, can't seem to sit still

__ craves fast, spinning, and/or intense movement experiences

__ loves being tossed in the air

__ could spin for hours and never appear to be dizzy

__ loves the fast, intense, and/or scary rides at amusement parks

__ always jumping on furniture, trampolines, spinning in a swivel chair, or getting into upside down positions

__ loves to swing as high as possible and for long periods of time

__ is a "thrill-seeker"; dangerous at times

__ always running, jumping, hopping etc. instead of walking

__ rocks body, shakes leg, or head while sitting