Explore strabismus surgery benefits for adults

Issue: April 2007

ByLeonid Skorin Jr., OD, DO, MS, FAAO, FAOCO

Leonid Skorin Jr., OD, DO, FAAO, FAOCO
Leonid Skorin Jr.

A 6-month-old child comes in with a large angle esodeviation. The child’s parents provide a history of the ocular deviation occurring shortly after birth. The child is otherwise healthy.

A cycloplegic refraction reveals only 1 D of hyperopia. This child has congenital or infantile nonaccommodative esotropia. Most clinicians would agree that the child will need surgery to obtain some form of sensory binocular fusion, decrease the risk of developing amblyopia and maintain reasonably straight alignment.

But what would you recommend to the same patient if he or she were 30-something or 40-something and had a lifetime of strabismus? Many clinicians may feel that very little can be done for misaligned eyes in adults. Some may be concerned that the patient will develop intractable diplopia after strabismus surgery or that the realignment will only last temporarily. Others may think that adult strabismus surgery is only cosmetic, thus undervaluing its worth to the patient. The clinician may not even breach the subject of strabismus surgery, dismissing the topic under the belief that the surgery cost is not covered by health insurance. Some doctors and many patients believe that strabismus surgery is only available for children and cannot be performed on adults. All these assumptions are false.

Surgical options

A variety of surgical and nonsurgical treatment options are available to adults for their strabismus. Nonsurgical options include glasses, prisms, occlusion or patching and vision therapy. Botulinum toxin, a potent neurotoxin that selectively binds to cholinergic synapses, blocking the conduction of the nerve impulse, has been used both diagnostically and therapeutically in strabismus. The injected muscle – medial rectus in esotropia and the lateral rectus in exotropia – is weakened and lengthened following the injection.

Surgical options include the standard nonadjustable and adjustable suture techniques. Weakening procedures include myotomy, myectomy and recession. Strengthening procedures include resection, tucking and advancement.

Strabismus surgery should always be considered in adult patients with a long-lasting deviation and diplopia. Correction of the misalignment usually eliminates the diplopia and increases the patient’s safety when driving or ambulating. It also helps restore any impaired coordination caused by the diplopia.

Surgery results encouraging

Adult with exotropia: Surgery corrected this patient’s strabismus.

Image: Skorin L

Will the nondiplopic adult patient with long-standing strabismus develop intractable diplopia after strabismus surgery? In a study by Kushner (2002), it was found that the incidence of temporary diplopia in these patients was only 9% (all clearing within 6 months), and only 0.7% had persistent diplopia. No postoperative diplopia occurred in any patient who had no diplopia on preoperative prism testing.

Strabismus surgery can improve peripheral fusion. In another study of adult patients, 86% achieved satisfactory alignment and developed simultaneous perception when tested with Bagolini lenses regardless of the type of deviation present preoperatively, the duration of strabismus or depth of amblyopia in the patient’s eye (Kushner and Morton).

Stereopsis may also improve after strabismus surgery. It has long been thought that visually mature individuals will not recover fine stereoacuity if their misalignment exists beyond a critical duration of time. It has recently been shown that up to 67% of adult patients with chronic acquired strabismus and no preoperative fusion can regain measurable stereoacuity, and 44% can regain fine stereoacuity of at least 60 arc seconds after successful strabismus surgery (Lal and Holmes). Such recovery of stereoacuity may take several months to occur, and misalignment for up to 4 years did not preclude the development of postoperative stereoacuity.

Psychosocial benefits

Beyond the functional benefits that strabismus surgery can bring to adults, a significant psychosocial benefit also occurs. Adults with strabismus will often look down or away from the person to whom they are talking, thus avoiding eye contact. This can signal to others a lack of self-confidence. The person being spoken to may be uncertain which eye the patient is using and may be distracted from what the patient is trying to communicate (AAPOS).

Adults with strabismus have reported difficulty with self-image, securing employment and job advancement, interpersonal relationships, school, work and sports (Satterfield and colleagues). Several studies have confirmed that strabismus creates significant negative social prejudice (Olitsky and colleagues, Coats and colleagues). These biases can have a detrimental impact on socialization and employability. These studies showed that patients with esotropia fared worse in the applicant’s ability to obtain a job than those with exotropia or those with no strabismus, and that female applicants with large angle horizontal strabismus fared the worse.

The negative effect on these individuals can be so great that these adult patients would be willing to trade 10% of their remaining life expectancy to be rid of their strabismus (Beauchamp and colleagues). After surgery, many patients will report improved self-esteem, communication and socialization skills, job opportunities, reading and driving (Olitsky and colleagues, Beauchamp and colleagues).

Finally, in a joint policy statement from the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus, these professional organizations regard the surgical correction for strabismus in adults to be reconstructive in nature and not cosmetic surgery. They encourage that this corrective surgery be a covered benefit by insurance companies, health plans and third-party payers.

For more information:

Leonid Skorin Jr., OD, DO, FAAO, FAOCO, practices in Albert Lea, Minn., and writes and lectures on ocular disease and neuro-ophthalmic disorders. He underwent fellowship training in neuro-ophthalmology. He may be contacted at the Albert Lea Eye Clinic, Mayo Health System, 1206 W. Front St., Albert Lea, MN 56007; (507) 373-8214; fax: (507) 373-2819; e-mail: skorin.leonid@mayo.edu.

References:

American Association for Pediatric Ophthalmology and Strabismus Web site: www.aapos.org. Accessed January 1, 2007.

Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults. 1. Clinical characteristics and treatment. J Am Assoc Ped Ophthalmol Strab. 2003;7:233-240.

Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large angle horizontal strabismus on ability to obtain employment. Ophthalmology. 2000;107:367-369.

Kushner BJ. Intractable diplopia after strabismus surgery.Arch Ophthalmol. 2002;120:1498-1504.

Kushner BJ, Morton GV. Postoperative binocularity in adults with long-standing strabismus. Ophthalmology. 1992;99:316-319.

Lal G, Holmes JM. Postoperative stereoacuity following realignment for chronic acquired strabismus in adults. J Am Assoc Ped Ophthalmol Strab. 2002;6:233-237.

Olitsky SE, Sudesh S, Grazano A, et al. The negative psychosocial impact of strabismus in adults. J Am Assoc Ped Ophthalmol Strab. 1999;3:209-211.

Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol. 1993;111:1100-1105.