Strabismus and athletic performance with Dr. Brian Lojka

With Olympic gymnast Stephen Nedoroscik taking to the podium earlier this month at the 2024 Olympic Games in Paris, France, strabismus also garnered some airtime. Brian Lojka, OD, division medical officer for optometry at EyeCare Partners, sat down with Optometry Times to chat about the condition and what optometrists should keep in mind regarding care for athletes with eye conditions.

Video transcript

Editor's note: This transcript has been lightly edited for clarity.

Jordana Joy:

Hi everyone. I'm here today with Brian Lojka, optometrist practicing at Clarkson Eyecare and the division medical officer for optometry at EyeCare Partners. He's here to chat about strabismus and how the condition may affect athletic performance. So welcome. It's a pleasure to have you today.

Brian Lojka, OD:

Well, thanks for inviting me. It's an exciting topic these days.

Joy:

Absolutely. So with that, strabismus has been receiving some airtime due to Olympic gymnast Stephen Nedoroscik, because he has the condition. First, would you be able to give an overview of strabismus and how it may affect a patient's daily life?

Lojka:

Yeah, sure. You know, strabismus comes in a lot of different flavors. If you really strip it down, all it is is an imbalance in the muscles that keep our eyes aligned. So there's a delicate balance between muscles that that move our eyes up and down and side to side, they also have to keep our eyes looking straight so we don't have 1 eye looking 1 way and 1 eye looking the other way. When you have a strabismus, you can have a muscle that's either too loose and it lets an eye go out or in, or it can be too tight, and it can move out or in. When you have this condition and the eye moves in, we call that an e or phoria. When it moves out, it's called an exo, and when it moves up or down its hyper or hypo. And you can imagine if our eyes are made to look straight ahead, each eye focusing on the same target, if 1 is looking this way, seeing a target over there, and 1 is looking this way, seeing a target here, we then end up in a situation which causes what we call diplopia, or double vision. Double vision is bad, frustrating, annoying, and if you can imagine being a gymnast, focusing on whatever you need to focus on, and either seeing 2 of it, or seeing an image displaced in 1 direction or another, to say the least, could be offsetting.

Joy:

Absolutely, yeah. So in the case of Nedoroscik, how could the condition affect maybe an athlete's approach to their sport?

Lojka:

You know, it's not necessarily as disturbing in something like he was doing, because it is a gross motor sport where your eyes aren't necessarily guiding what you're doing. If you think of a strabismus in something like baseball, softball, golf, hockey, where you have a small implement going at a really high rate of speed, you need to have both eyes zoomed in, locked into that target at all times, to the point where it would be, you know, prohibitive if you have a version of strabismus, that is constant. Now, what you will see in a lot of cases is the muscles that keep our eyes straight and aligned is the same muscle that makes up the rest of our body that allows us to move – coordinated movements – and in athletes, a lot of times, coordinated movements and dexterity are actually really well developed, because that's what you do. Same thing with the eyes. In the same way that I can train my shoulder to throw a fastball for a strike, I can train my eyes in certain situations to focus in the direction that I want them to focus and you'll oftentimes see that athletes will spend an inordinate amount of time training their eyes, those that don't have strabismus. But in what we call sports therapy, where you can harness the ability to maximize the eyes' ocular motor system to track to the highest level. And if you have a strabismus, a lot of times you can see people will train that to a degree where they can force that eye through a muscular contraction to where, if it was deviated inwards, we can actually deviate them outwards. And you'll see a lot of videos online where these people will then relax, and you'll see that eye go in, and then they'll straighten it, and then they'll allow the other eye to go out.

Joy:

So keeping all of that in mind, as an optometrist, what's important to consider when caring for patients who are athletes, who may have an eye condition like strabismus, and when do you really make a referral for sports therapy?

Lojka:

It's dependent. A lot of people will have a small muscle imbalance, just inherent with the system. A lot of people do, you know, most people do, have very small, or microphorias or microtropias, where the eyes are going to deviate to a small degree. If it becomes cumbersome; if the deviation is, for instance, I look at a computer a lot, if my eye deviation was like this, I look at something up close all day, I have to then overcome the outwards pointing of my eyes, and then I have to make the natural convergence of the eyes to see what I'm seeing, those deviations can be difficult. Now, if I was a carpenter or a truck driver where my viewing is not necessarily up close as much and far away, maybe it's not as disturbing and I can live a lifetime and never address it. If I'm an athlete, if I'm a baseball player, and I'm struggling as I need to converge on a small implement moving at a fast speed, that can be problematic, at which point you can do some training to train as best as you can around that which already exists. If you look at pediatric cases, there are cases that you can use optical corrections and prismatic displacements to take images and put them where the eye wants to go naturally. There are training techniques to develop the dexterities for activities of daily life and daily learning for these kids. And then there's surgical intervention when you when you have deviations over a certain amount of degrees, or what we call prism diopters, which is just the fancy way of saying is how far outwards or inwards or upwards is the eye displaced, you can go in and tighten muscles to bring them in, or bring them out, loosen muscles in the same way, and then hopefully balance that out. Because what you want to avoid is a neuronal development in the back of the brain where we don't have our highest level of binocular vision. To have binocular vision, you have to have both eyes focusing on the image at the same time. And as we go through that critical development period as a child, you have to have that binocular input. So that development takes place at the highest level, and then when that window shuts on that development, we kind of have that in the bank for fine tuning as then we go through life.

Joy:

Absolutely. So, when should a patient who may be concerned with strabismus consult an optometrist or what should someone be looking out for in terms of symptoms?

Lojka:

You know, anytime there [are] problems keeping things in single vision. Every once in a while, people will come in and say, "Yeah, you know, it bothers me that I see double vision when I'm looking at my phone sometimes. And it used to be at the end of the day, and I thought I was just getting tired. Now it's when I pick it up the first thing in the morning." You know, kids are different. We need to watch out just as as an optometrist and in primary care or pediatrics, making sure that you can identify these kids, because a lot of times, they won't tell you. Parents are the ones that tell you, every once in a while, you'll stumble over that in a kid's first exam, and then you just track it back and you have to make a professional decision. Because you want to catch those early to either optically correct it, train it away, or, in the more severe cases, refer for surgery. It's better to do them, I think, when you're younger than it is to sit on this to where it really gets embedded in the system.

Joy:

Absolutely. Was there anything else that you wanted to add that we haven't gotten to yet?

Lojka:

If we think about the continuum of care in a pathology like strabismus and diplopia and muscle imbalance, it's very complicated. When diagnosis is made, when you think that you need to intervene, what's that intervention going to look like, and who's going to do it? I think EyeCare Partners is strategically placed, not everywhere, but we have hubs within certain states that are very well set up to manage not only the primary care component of initial diagnosis in children that would then move over into the specialty care of pediatric optometry. Pediatric optometry is probably the best and most well prepared for initial intervention, long-term therapy, and ongoing therapy of kind of any subspecialty out there. They're outfit with so many tools in that box that can take care of these kids for such a long period of time. They also have the ability to move these kids up into the surgical component of strabismus care as well, which is really comforting. When you have a partner that's able to do a muscle resection surgery on a child and work within the same network as a partnership, as a team, is far better care than having to send somebody down to a large hospital network, which has brilliant and bright people and education network and they're wonderful. But sometimes, when you take people out of the primary care setting and move them into these very large, complicated hospital systems, it's difficult for them. In certain times, it's cumbersome, just because the systems are so large, and a lot of times there's a lot of travel involved, and so you'll see a fair amount of leakage on those referrals and dropouts on those referrals. But when you have somebody that you can pick up the phone and you can within your own team, make sure that these appointments are kept. Make sure that there is communication between primary care, secondary care, and then the tertiary care. And the surgical care is a really nice application the continuum of care that you know we believe that we have within the EyeCare Partners network.

Joy:

Alright, well, I appreciate you taking the time today, Dr. Lojka, it's been a pleasure.

Lojka:

Well, thank you for having me.