Dominick M. Maino, OD, MEd, FAAO, FCOVD-AProfessor of Pediatrics/Binocular Vision

Illinois Eye Institute/Illinois College of Optometry

Optometrist, Lyons Family Eye Care

Strabismus Surgery Outcomes

What is Strabismus?…Strabismus is the condition in which a person is unable to align both eyes simultaneously under normal visual conditions. When both eyes do not point at an object at the same time, it results in the appearance of one eye "turning" in relation to the other. This turning may be in, out, up, down. This eye turning may be constant, in which an eye turns all the time, or it may be intermittent. It may also alternate so that either eye turns at any given time…. (1)

What Symptoms are Associated with Strabismus?

…Strabismus… is often associated with a variety of symptoms, including seeing double (diplopia), difficulty judging distances, eyestrain, headaches, blurred vision, sleepiness, difficulty concentrating, movement of print while reading, and loss of comprehension after short periods of reading or performing close activities. … A person with a constant eye turn may only notice a few of these symptoms or none at all….

What is the Prevalence of Strabismus?

…The estimated prevalence of strabismus in the general population is from 2 to 5% …5 to 15 million individuals in the United States may have this condition…Strabismus is more prevalent in persons with multiple handicaps…The prevalence of strabismus is also higher in families in which a parent or sibling has strabismus, ranging from 23 to 70 % of family members (2)

At What Age Can You Treat Strabismus?

Despite what you may hear from those who have not kept up with the latest research, strabismus can be treated AT ANY AGE! (3)

Children, Adults and Seniors may all benefit from treatment.

How Do You Treat Strabismus?

Treatment always starts with the best prescription glasses possible. This prescription may change over time as the functional vision problems improve.

How Do You Treat Strabismus?

Optometric vision therapyVision therapy is a doctor-supervised, non-surgical, customized program of therapeutic procedures designed to prevent, remediate, and/or enhance vision problems and/or improve visual skills.

Vision therapy can include the use of lenses, prisms, filters, computerized procedures and non-computerized instrumentation. The goal of vision therapy is to treat vision problems that cannot usually be treated successfully with eyeglasses, contact lenses and/or surgery alone, and help individuals of all ages achieve single, clear, comfortable binocular (two-eyed) vision using the scientific principles of neuroplasticity.

How Do You Treat Strabismus?

Unfortunately, many doctors recommend surgical intervention before trying other forms of treatment such as glasses and vision therapy. Surgery is always an option, but should usually be the last thing suggested and not the first.

Surgery

How Do You Treat Strabismus?

Probably the best approach is what is typically used in other specialties. If your doctor was recommending a knee replacement, he/she would usually suggest physical therapy and other pre-surgical activities first, then the surgery and finally more physical therapy. Unfortunately, this seldom happens when you have strabismus surgery.

Surgery

Strabismus Surgery Outcomes

Strabismus surgery is as much an art as it is a science. The outcomes of strabismus sugery can vary depending upon a whole host of pre-surgical conditions.

Strabismus Surgery Outcomes

In general 20-30% of those who have strabismus surgery, may require a second surgery. Twenty to 30% of those individuals who have had a second surgery may need a third surgery.

Strabismus Surgery OutcomesAn article I published ….Maino D. The number of placebo controlled, double blind, prospective, and randomized strabismus surgery outcome clinical trials: none!. Optom Vis Dev 2011;42(3):134-136.

… reviews what Cochrane Summaries note about the research in the area of strabismus surgery outcomes. This PowerPoint review will indicate what the Cochrane Summaries say about the various studies in italics. I will change the language from success rates to failure rates to help make you better aware of the limitations seldom discussed.

What the research notes about Adjustable versus non-adjustable sutures for the eye muscles in strabismus surgery

….. A variety of surgical techniques are available, including the use of adjustable or non-adjustable sutures for the muscles surrounding the eye. There is uncertainty as to which of these suture techniques results in a more accurate alignment of the eye, and whether there are specific situations in which it is of benefit to use a particular technique. This review could not find enough evidence to answer these questions and suggests that more research is needed…..

What the research notes about Treatment for a type of childhood strabismus where one or both eyes intermittently turn outwards….. The one study included in this review was conducted by a single surgeon in the USA and compared surgery on one eye to surgery on both eyes in 36 children with the basic type of X(T). Success was defined as no exotropia (or other strabismus) one year following surgery. The study found that surgery on one eye was … ineffective 18% of the time while surgery on both eyes had a 48% fail rate. There are many studies of X(T) in the current literature but the methods used make it difficult to reliably interpret the results. Furthermore, there is a worrying lack of evidence regarding the natural history of X(T) and poor validation of measures of severity. There is a clear need for further randomized studies to provide more reliable evidence for the management of this condition. ….

Botulinum Toxin for the Treatment of Strabismus My paper noted that: Rowe and Noonan found four RCTs that were eligible for inclusion. Two of these found no difference between the use of botulinum toxin and surgery for patients requiring retreatment for acquired esotropia or infantile esotropia. There was no evidence for a prophylactic effect in an article discussing an acute onset sixth nerve palsy, and that botulinum toxin had a poorer positive outcome than surgery in patients without binocularity with horizontal strabismus. Unfortunately there was a fairly high rate of complications that included ptosis and induced vertical deviations that ranged from 24% of the population in a trial using Dysport™ to 52.17% and 55.54% in trials using Botox.™

Different treatments for a squint (deviation of the eye) that occurs within the first six months of life

….Infantile esotropia can affect the vision in the eye, the ability to use the two eyes together (binocularity) and also be a cosmetic issue to the child/parents. Treatment includes surgical and non-surgical interventions to reduce the squint and to enhance/aid binocularity in children. …. This review did not find any randomised trials that compared treatment to another treatment or to no treatment. A large, multi-centre, non-randomised trial found that children operated on earlier had better binocularity at age six compared to the late surgery group. This group had been operated on more frequently however and there was no significant difference in the angle of the squint after surgery in either group. This review does not resolve the controversy regarding the best type of surgery, the value of non-surgical interventions and the optimal timing of either type of intervention…..

Outcome of strabismus surgery in congenital esotropia: The results of squint surgery in 40 children with congenital esotropia were analyzed. A unfavorable outcome was achieved in 43.5% of the children.Long-term ocular alignment after bilateral lateral rectus recession in children with infantile and intermittent exotropia: Both groups had a high fail rate at 3 years: 59% in the infantile XT group and 49% in the intermittent XT group…

Other research notes that:

Complications Associated with Strabismus Surgery

Although complications are rare, they do occur. These complications include: Death, Surgery on the wrong eye or wrong patient, Blindness and accidental damage to parts of the eye, Infections, inflammations and more surgery to fix, Slipped or lost eye muscles, Scars and wound problems - large cysts and more surgery and as noted previously Repeated Surgeries and poor success rates. Repeated surgeries could result in ADHD and learning problems as well.

Vision Therapy + Strabismus Surgery

Although I have emphasized the negatives of strabismus surgery, it does not mean I do not recommend such surgery from time to time. Just like your doctor may recommend physical therapy before and after knee surgery, I have recommended strabismus surgery as a tool to make vision therapy and surgery more successful. Clinically I and other optometrists who specialize in this area have noted that:Vision therapy+Surgery+Vision therapy=more opportunity for success

Strabismus Therapy FAQs

This was previously described

• Hand-eye• Focusing• Eye

movement

• Same as noted in monocular phase and anti-suppression

• Same as noted previously plus convergence and divergence therapy

• Hand-eye, eye movement, focusing, convergence and divergence therapy done simultaneously

MonocularGlasses

Biocular BinocularIntegration &Stabilization

If needed, surgical intervention may be recommended between monocular and biocular or biocular and binocular phases.

Vision Therapy FAQsTell me about home vision therapy

Home vision therapy can vary from doctor to doctor. I recommend a minimum of 20 to 30 minutes per day, 5 days per week. Some doctors do not prescribe home vision therapy, but I find that the in office therapy program progresses at a faster rate of speed if home therapy is conducted.

Vision Therapy FAQs

Tell me about in-office vision therapy

In-office vision therapy can vary from doctor to doctor. I recommend one therapy session per week for 45 minutes with home therapy.

Vision Therapy FAQsWhat does vision therapy cost?

This will vary from office to office but is comparable in cost to occupational, physical, and/or speech/language therapy. Some offices charge for each individual visit while others have a “program” similar to that of having braces applied by your dentist.

Strabismus Surgery FAQsWhat does strabismus surgery cost?

This will vary from doctor to doctor but strabismus surgery ranges from $3000 to $6000. This may not included the cost of the hospital room, surgical room, x-rays, other pre-surgical testing and post-surgical care that is often required.

Vision Therapy FAQsDoes insurance cover the cost of vision therapy?Yes. No. Maybe. Some time ago most insurance would have picked up about 80% of the cost. Then my impression was that the insurance companies just seemed to stop reimbursement for therapy. Now they are once again picking up some of the cost. Know your insurance policy. Do not take “NO” for an answer. Your doctor’s office will usually assist you when it comes to insurance, but it is ultimately your responsibility.

Vision Therapy FAQsWhere do I learn more about treatment, especially from a parent’s or patient’s point of view?

Go to:

Parents Active in Vision EducationVision Therapy Parents Unite!

Vision Therapy Changed My LifeConvergence Deficiency/Insufficiency

Living with Diplopia

Vision Therapy FAQsWhere can I get additional information on pediatrics, binocular vision, vision therapy, children wearing glasses and more?

MainosMemosVision Therapy at Lyons Family Eye Care

VisionHelp blogCOVD blog

Discovering Vision Therapy blog

Wow Vision Therapy blog

SOVOTO

Little Four Eyes

FAQsWhere can I get additional help?

Call or email us at Lyons Family Eye Care.

Lyons Family Eye Care3250 N. Lincoln Ave.Chicago, IL 60657Click here to view a map of our location

Phone Number: 773-935-2020Email: info@lyonsfamilyeyecare.com

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CI FAQsWhere can I get additional help?

More information about Lyons Family Eye Care

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“LIKE” us at Vision Therapy at Lyons Family Eye Care

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About Dr. Stephanie Lyons

About Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

About Megan Westergren, OD