What are the recommended eye exercises to strengthen and correct strabismus (crossed eyes)?

Eye Exercises for Strabismus

Eye exercises alone cannot "strengthen" or correct most forms of strabismus, as the condition is typically caused by muscle imbalance, neurological factors, or structural abnormalities rather than muscle weakness—surgical intervention or other treatments are the primary management options for most adult strabismus cases. 1

When Eye Exercises May Be Beneficial

Eye exercises have a limited but specific role in strabismus management, primarily for convergence insufficiency, which is a distinct binocular disorder rather than typical strabismus:

Convergence Insufficiency

• Office-based orthoptic training is the most effective form of eye exercises for convergence insufficiency, showing better outcomes than home-based exercises 1, 2
• These exercises specifically target patients with exophoria or intermittent exotropia that is greater at near than distance, with insufficient positive fusional vergence at near (<20 PD) and distant near point convergence (>6cm) 1
• Results are less consistent in adults compared to children, with office-based training more effective at improving positive fusional vergence but not necessarily improving symptoms in adults 1, 2
• The American Academy of Ophthalmology guidelines indicate that convergence orthoptic exercises are "often helpful" but emphasize that office supervision improves compliance and outcomes 1

Why Exercises Don't Work for Most Strabismus

The underlying pathophysiology of most strabismus types makes exercise ineffective:

Structural and Mechanical Causes

• Sensory strabismus results from vision loss causing ocular misalignment—no amount of exercise can restore alignment when the fundamental problem is visual deprivation 1
• Restrictive strabismus (from thyroid eye disease, trauma, or myopia) involves mechanical restriction of eye movement due to fibrosis, edema, or anatomical changes that exercises cannot address 1
• Paralytic strabismus involves nerve damage where the muscle literally cannot receive signals to contract 1

Neurological Causes

• Strabismus from central nervous system pathology, cranial nerve palsies, or congenital abnormalities requires treatment of the underlying condition, not muscle strengthening 3

Evidence-Based Treatment Algorithm

First-Line Management

1. Correct refractive error with appropriate glasses—this is foundational and may improve alignment in accommodative esotropia 1, 2
2. Prism glasses for small vertical deviations or horizontal deviations, though lateral incomitance often limits success 1
3. Observation if symptoms are mild, occasional, and well-tolerated 1

When Convergence Exercises Are Appropriate

• Documented convergence insufficiency with exophoria greater at near than distance 1
• Insufficient positive fusional vergence at near 1
• Symptoms of eyestrain, headaches, or diplopia specifically with near work 1
• Refer for office-based orthoptic training rather than prescribing home exercises 1, 2

Definitive Treatment Options

• Botulinum toxin injection can yield long-term improvement in select cases, particularly for small-angle deviations or as a temporizing measure 1, 4
• Surgical correction is the primary treatment for most strabismus, with approximately 80% of adults achieving satisfactory alignment with one procedure 5
• Surgery is not merely cosmetic—most adults experience improvement in binocular function, expansion of visual fields, and some may regain stereopsis even with longstanding strabismus 5

Critical Pitfalls to Avoid

• Do not delay definitive treatment (surgery or botulinum toxin) in favor of unproven exercise regimens for non-convergence insufficiency strabismus 1
• Do not assume strabismus is untreatable in adults—this is a common misconception among patients and even some healthcare providers 5
• Do not prescribe home-based exercises without proper diagnosis of convergence insufficiency, as they are ineffective for other strabismus types and less effective than office-based training even for convergence insufficiency 1, 2
• Fusional exercises have not proven beneficial for divergence insufficiency or other forms of adult strabismus 1
• Virtual reality therapy remains experimental with limited evidence and is not recommended as primary treatment for strabismus 2

Psychosocial Impact Justifies Treatment

The 2024 American Academy of Ophthalmology guidelines emphasize that strabismus surgery provides significant benefits beyond cosmesis, including enhanced emotional health, self-esteem, employment opportunities, and social interactions 1. Adults with strabismus report they would trade a portion of their life expectancy to be rid of their ocular misalignment, underscoring the profound quality-of-life impact 5.