SURGERY TREATMENT FOR STRABISMUS
Is strabismus surgery the only treatment option?
No. Strabismus treatment options and outcomes vary considerably based on types of strabismus (direction of eye turns, angle of deviations, etc.) and other factors, such the presence of convergence insufficiency, double vision, or amblyopia (lazy eye). Non-surgical treatment is available and more likely to lead to improved vision. See all Treatment Options.
Will eye muscle surgery help me or my child?
Your brain directs and controls your eyes and eye muscle surgery is not brain surgery. Cutting and moving the eye muscles will not automatically change the brain or the signals it sends to the eye muscles. This is why patients' eyes often "go back" or deviate again after surgery. Frequently, then, the surgeon recommends a repeat surgery. It is important to understand that while eye muscle surgery can improve cosmetic appearance, it does not necessarily improve eyesight or vision.
Numerous peer-reviewed scientific studies report success rates for eye muscle surgeries ranging from 30% to 80%. In those studies, the success is sometimes defined as cosmetic improvement only. "Cosmetic improvement only" means that, following the eye muscle surgery, the patient's eyes maintained a straight and aligned appearance, but improved vision was not achieved.
For example, one scientific research study (Flax and Duckman, Orthoptic Treatment of Strabismus, Journal of AOA, 49th edition (12) p. 1353, 1978) reported a 50% success rate as a result of surgical treatment only for strabismus. In that study, success was defined as ANY long-lasting positive benefit, including cosmetic improvement only [to repeat, as explained above, cosmetic improvement only means outside appearance improved, the patient's vision did not].
In the American Journal of Ophthalmology, von Noorden, a well-known strabismus surgeon and researcher reviewed the records of 408 patients who had eye turns shortly after birth, and divided their surgical outcomes based on age at the time of surgery. The results of that study can be found on strabismus and lazy eye surgery as part of an interview with Dr. Leonard Press. Based on the statistics in that study, Dr. Press points out that a parent should feel no need to rush into surgery. Parents are advised to take time to explore all treatment options.
Clearly, it is important to determine whether surgery is being recommended for the purposes of cosmetic improvement only. Ask the surgeon to be explicit regarding the goals and risks associated with any surgery. Parents are encouraged to ask many questions. Ask about expected outcomes. For example, ask whether the surgeon expects the eyes to work better as a binocular (two-eyed) team as a result of surgery. You should know the possibilities regarding better appearance (cosmetic cure) and/or better vision (a binocular cure). Also, do not forget to discuss the likelihood that multiple surgeries will be recommended. See below.
When looking for help for you or your child, it is best to consider all your Treatment Options.
How many surgeries?
If your surgeon has recommended initial eye muscle surgery, ask how many surgeries! The surgeon should be very clear as to the possibility that repeat surgeries will be recommended down the road.
Normal Appearance vs. Normal Vision
(Cosmetic Cure vs. Binocular Cure)
In regards to a cosmetic cure, the parent or adult patient needs to be informed in advance that good cosmetic alignment is often not achieved until two or three surgical procedures are performed. Regarding the gaining or recovery of normal vision (binocular cure), the parent or patient needs to know that if -- following surgery -- the two eyes are almost straight but not perfectly straight, then they still can not work together. This is important to keep in mind when the surgeon says a child needs strabismus surgery. Ask him/her if she/he is going to make the eyes look better or work better together. You should know the chances of cosmetic cure (normal appearance) vs. a binocular cure (normal vision).
Pre- and post-surgical treatment
Surgery which does not achieve perfect alignment yields cosmetic improvement only. Effective surgical intervention to gain the use of both eyes requires not only perfect alignment but also an eye doctor who knows how to stimulate the two eyes to work together with lenses, prism, and Vision Therapy. This is why we recommend pre- and post-surgical consultation with a developmental optometrist.
Surgery, if necessary, should be coordinated with the developmental optometrist who is knowledgable in visual development if the goal is for improved vision or binocular vision. During the critical period, if therapy is not initiated immediately following surgery, the chances of success diminish. Pre-surgical consultation and stimulation by the optometrist are also helpful.
Does the age of the patient matter?
Age has an impact on whether surgery is appropriate. For example, early occurring CONSTANT strabismus is the one type of strabismus which might need early surgery to eliminate the eye turn.
For other types of strabismus (especially, intermittent), by all means, don't allow a surgeon to rush you into surgery based on statements about age. In all cases, we recommend that you seek a second opinion (preferably from an optometrist who offers Vision Therapy). Surgeons are experts in surgery and may often fail to fully explain all treatment options.
It is best to have a behavioral optometrist [developmental optometrist] be the captain of the ship. Often, surgeons are concerned only with the cosmetic appearance and do not provide all treatment options, such as Vision Therapy. Optometrists are more likely to be concerned with obtaining functional binocularity that requires the use of Vision Therapy.
Contrary to the statement of some strabismus surgeons, you/or your child will never go blind without strabismus or lazy eye surgery. This is the ultimate scare tactic!
A surgeon might have told you that surgery is the only option. However, in the First Quarter, 2002 issue of the Binocular Vision and Strabismus Quarterly, the Journal editor, Paul E. Romano, M.D. stated,
I simply do not believe the current organized ophthalmology -- pediatric ophthalmology mantra that virtually nothing with regard to binocular [two-eyed] vision (except maybe convergence insufficiency) can be affected, altered or improved by anything other than surgery. There are too many other areas in medicine where change is achieved without drugs and surgery.
Why Vision Therapy?
Vision Therapy deals with two parts of the visual system, i.e. motor (which makes the two eyes aim accurately) and sensory (the ability to unify the two images into one 3D image in the brain). You must have motor control and alignment in order to make the eyes see properly. Often eye turns that develop before the age of two may have good motor alignment without the ability to have stereopsis.
The parent must realize that if surgery is used as early intervention in order to improve vision, then the goal must be perfect alignment! If the eyes are close to alignment after surgery, but not perfectly aligned, then the two eyes will not work together. Binocular vision [two-eyed vision] will not be attained.
In order to have functional success [two-eyed vision], alignment must be perfect and suppression must no longer present. These results are best accomplished with Vision Therapy.
If the eyes do not suppress (ignore input from one eye) and they are not perfectly aligned, then the patient will see double. Surgery which results in suppression or double vision on the part of the patient could be described as cosmetically successful but claims re: functional improvement [better vision] are questionable.