Is virtual reality or physiotherapy (physical therapy) more effective for treating strabismus in children?

Treatment of Strabismus in Children: Virtual Reality vs Physiotherapy

For children with strabismus, traditional orthoptic exercises (physiotherapy/vision therapy) remain the established first-line non-surgical treatment, while virtual reality-based binocular therapy shows promise but currently lacks sufficient evidence to recommend it over conventional approaches.

Primary Treatment Approach

Office-based orthoptic training is more effective than home-based exercises in children with strabismus, particularly for convergence insufficiency. 1 The evidence demonstrates that:

• Convergence orthoptic exercises are often helpful for treating strabismus-related symptoms 1
• Office-based training appears to be more effective than home-based exercises specifically in the pediatric population 1
• Results of convergence training are more consistent in children compared to adults 1

Virtual Reality (VR) Technology: Current Evidence

The evidence for VR-based treatment in pediatric strabismus is limited and shows mixed results:

Promising but Inconsistent Findings

• One randomized trial using VR headsets for dichoptic treatment showed improvement of 1.8 lines in visual acuity at 12 weeks compared to 0.8 lines with glasses alone (P = 0.0011) 1
• However, this study focused on amblyopia treatment rather than strabismus correction specifically 1

Significant Limitations

• Three randomized trials failed to demonstrate that VR-based game play (1 hour daily) was as effective as traditional patching (2 hours daily) or better than placebo 1
• A trial in children aged 7-12 years found no benefit when comparing binocular VR therapy with continued glasses alone 1
• A parallel trial in children aged 4-6 years showed clinically important improvement at 4 weeks, but the benefit was not sustained at 8 weeks 1

Current Guideline Position

The American Academy of Ophthalmology states that "the evidence remains limited to recommend binocular therapy for treatment of amblyopia," and by extension, strabismus 1

Clinical Algorithm for Treatment Selection

Step 1: Initial Assessment

• Comprehensive sensorimotor evaluation 1
• Assessment of refractive status with appropriate optical correction 1
• Quantification of strabismus angle and type 1

Step 2: First-Line Treatment

• Prescribe office-based orthoptic exercises as the primary non-surgical intervention 1
• Ensure appropriate refractive correction with eyeglasses 1
• Consider prism reading glasses for specific cases 1

Step 3: Treatment Monitoring

• Regular follow-up to assess response to orthoptic training 1
• Monitor for development or worsening of amblyopia 2
• Evaluate binocular function and symptom improvement 1

Step 4: Surgical Consideration

• If non-surgical treatment fails and symptoms are consistent, strabismus surgery should be considered 1
• Surgery is particularly indicated when manifest deviation is present and conservative measures are unsatisfactory 1

Important Caveats and Pitfalls

Age-Related Considerations

• Treatment should be started early, as the longer the duration of strabismus, the more complex the problem and the less probability of functional cure 3
• Children under 8 years are at risk for developing amblyopia, which requires concurrent treatment 2

VR Technology Limitations

• VR therapy is primarily studied for amblyopia in children with no strabismus or small-angle strabismus with some binocularity 1
• The technology is rapidly expanding, but research remains ongoing without definitive recommendations 1
• VR may not be appropriate for children with large-angle strabismus or those lacking binocular potential 1

Treatment Compliance

• Office-based training requires regular visits and professional supervision 1
• Home-based exercises, while less effective, may be necessary when office visits are not feasible 1
• Educating parents about the importance of treatment improves compliance 2

When to Avoid Relying on VR Alone

• Do not use VR as primary treatment for moderate to large-angle strabismus 1
• Avoid VR in children with poor binocular potential or suppression 1
• Do not delay proven treatments (orthoptic exercises, surgery) in favor of experimental VR therapy 1

Concurrent Amblyopia Management

If amblyopia is present alongside strabismus:

• Correct refractive error first, allowing 8-18 weeks for adaptation 2
• Implement patching therapy (2-6 hours daily depending on severity) or atropine penalization 2
• Monitor for strabismus changes during amblyopia treatment, as it may worsen or improve 2