When you or your child has an eye turn all too often the first recommendation for intervention is surgery. You should know the outcomes, risks and complications associated with this surgical procedure and alternative ways to manage these problems.

1. Strabismus Surgery
Outcomes
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor of Pediatrics/Binocular Vision
Illinois Eye Institute/Illinois College of Optometry
Optometrist, Lyons Family Eye Care

2. 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)

3. 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….

4. 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)

5. 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.

6. 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.

7. How Do You Treat Strabismus?
Optometric vision therapy
Vision 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.

8. How Do You Treat Strabismus?
Surgery
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.

9. How Do You Treat Strabismus?
Surgery
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.

10. 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.

11. 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.

12. Strabismus Surgery Outcomes
An article I published ….
Maino D.
The number of placebo controlled, double blind, prospective, and random
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.

13. What the research notes about
Adjustable versus non-adjustable sutures for the eye muscle
….. 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…..

14. 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. ….

15. 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.™

16. Different treatments for a squint (deviation of the eye
….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 nonsurgical interventions and the optimal timing of either type of intervention…..

17. Other research notes that:
Outcome of strabismus surgery in congenital esotro
: 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 rec
: Both groups had a high fail rate at 3 years: 59% in
the infantile XT group and 49% in the intermittent XT
group…

18. 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 a
.

19. 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

20. Strabismus Therapy FAQs
If needed, surgical intervention may be recommended between monocular
and biocular or biocular and binocular phases.
Glasses
Monocular
This was
previously
described
• Hand-eye
• Focusing
• Eye
movement
Biocular
• Same as
noted in
monocular
phase and
antisuppression
Binocular
• Same as
noted
previously
plus
convergence
and
divergence
therapy
Integration
&
Stabilization
• Hand-eye, eye
movement,
focusing,
convergence
and divergence
therapy done
simultaneously

21. Vision Therapy FAQs
Tell 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.

22. 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.

23. Vision Therapy FAQs
What 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.

24. Strabismus Surgery FAQs
What 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.

25. Vision Therapy FAQs
Does 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.

26. Vision Therapy FAQs
Where do I learn more about treatment, especially
from a parent’s or patient’s point of view?
Go to:
Parents Active in Vision Education
Vision Therapy Parents Unite!
Vision Therapy Changed My Life
Convergence Deficiency/Insufficiency
Living with Diplopia

27. Vision Therapy FAQs
Where can I get additional information on pediatrics,
binocular vision, vision therapy, children wearing
glasses and more?
MainosMemos
Vision Therapy at Lyons Family Eye Care
VisionHelp blog
COVD blog
Discovering Vision Therapy blog
Wow Vision Therapy blog
SOVOTO
Little Four Eyes

28. FAQs
Where can I get additional help?
Call or email us at Lyons Family Eye Care.
Lyons Family Eye Care
3250 N. Lincoln Ave.
Chicago, IL 60657
Click here to view a map of our location
Phone Number: 773-935-2020
Email: info@lyonsfamilyeyecare.com
“LIKE” us at Vision Therapy at Lyons Family Eye Care
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29. CI FAQs
Where can I get additional help?
More information about Lyons Family Eye Care
Wild Chicago
Harlem Shake
Artists LFEC Jingle
“LIKE” us at Vision Therapy at Lyons Family Eye Care
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30. About Dr. Stephanie Lyons

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

32. About Megan Westergren, OD