What are the treatment options for strabismus?

Treatment Options for Strabismus

The primary treatment options for strabismus include optical correction with glasses or prisms, orthoptic exercises, botulinum toxin injections, and surgical correction, with the specific approach determined by the type and severity of strabismus. 1

Types of Strabismus and Their Management

Divergence Insufficiency/Sagging Eye Syndrome

This condition typically presents in adults over 50 years with esotropia (inward eye deviation) that is worse at distance than near.

Treatment options:

1. Monitoring/Observation

   • For mild, occasional symptoms or if patient declines treatment

2. Non-surgical Options

   • Prism correction: Fresnel or ground-in prisms can provide temporary or long-term relief
   • Note: Fusional exercises have not proven beneficial for divergence insufficiency 1

3. Surgical Options

   • Bilateral lateral rectus muscle resection
   • Bilateral medial rectus muscle recessions
   • Unilateral medial rectus recession with lateral rectus resection
   • Typically requires greater surgical dose than standard for childhood strabismus 1

Convergence Insufficiency

Presents with eyestrain, headaches, blurred vision, or diplopia during near activities, with exophoria or exotropia greater at near than distance.

Treatment options:

1. Orthoptic Exercises

   • Office-based training may be more effective than home-based exercises
   • Results are less consistent in adults than children 1

2. Optical Correction

   • Prism reading glasses

3. Botulinum Toxin Injection

   • May help in some cases

4. Surgical Options

   • Lateral rectus recession (based on distance deviation)
   • Medial rectus resection (based on near deviation)
   • Consider risk of inducing postoperative distance diplopia 1

Strabismus Fixus (Heavy Eye Syndrome)

Severe form associated with high myopia, presenting as large-angle esotropia with or without hypotropia and limited ocular rotations.

Treatment options:

1. Surgical Options

   • Marginal insertional tenotomies
   • Recessions, resections, and plications
   • Superior and lateral rectus muscle myopexy 1

2. Prism Correction

   • May be useful postoperatively for residual deviation, but typically not adequate for the primary large-angle deviation 1

Sensory Strabismus

Occurs when vision loss in one eye leads to misalignment.

Treatment options:

1. Monitoring/Observation

   • For mild symptoms or if patient declines treatment

2. Botulinum Toxin Injection

   • Can yield long-term improvement in some cases 1

3. Surgical Correction

   • Various strabismus surgical techniques
   • Adjustable sutures may be preferred by some surgeons
   • Large extraocular muscle recessions/resections can also improve associated ptosis, enophthalmos, or proptosis 1

Post-Traumatic Strabismus

Strabismus following orbital trauma is common and may be multifactorial.

Treatment options:

1. Initial Management

   • Address life-threatening and vision-threatening conditions first
   • Detailed assessment to determine cause (muscle damage, nerve injury, orbital fracture)

2. Observation Period

   • Diplopia may resolve spontaneously within 6 months 1

3. Surgical Correction

   • Indicated if diplopia persists beyond 6 months
   • Approach depends on specific cause (muscle repair, orbital reconstruction) 1

Factors Influencing Treatment Selection

1. Type and angle of deviation

   • Small-angle deviations may respond to non-surgical approaches
   • Large-angle deviations often require surgery

2. Patient age

   • Children have better potential for developing binocular vision after correction
   • Early intervention is preferred when possible 2

3. Duration of strabismus

   • Longstanding strabismus may be more complex to treat
   • May have developed complications like suppression and amblyopia 2

4. Visual acuity in each eye

   • Significant vision loss in one eye affects treatment goals and approach

5. Presence of diplopia

   • Symptomatic diplopia often requires more aggressive intervention

Clinical Pearls and Pitfalls

• Timing matters: The longer the duration of strabismus, the more complex the problem and the less probability of functional cure 2

• Comprehensive evaluation: Preoperative evaluation should include assessment of fusion potential, variations in alignment at different distances, and sensory evaluation 3

• Surgical planning: When surgery is indicated, it should be performed after achieving the best possible results with conservative measures 2

• Post-surgical expectations: Patients should understand that surgery may improve alignment but not necessarily restore normal binocular vision in all cases

• Multiple origins: Strabismus can result from genetic and/or acquired factors, anatomical and/or functional abnormalities in both sensory and motor systems 4

• Prism adaptation: The magnitude of prism correction needed may increase over time, particularly in progressive conditions like divergence insufficiency 1