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  • AAPOS PPP Adult Strabismus Committee and AAO PPP Pediatric Ophthalmology/Strabismus Committee, Hoskins Center for Quality Eye Care
    Pediatric Ophth/Strabismus


    By the American Association of Pediatric Ophthalmology and Strabismus Preferred Practice Pattern Adult Strabismus Committee: Linda R. Dagi, MD,1 Federico G. Velez, MD,2 Jonathan M. Holmes, BM, BCh,3 Steven M. Archer, MD,4 Stacy L. Pineles, MD,5 Mitchell B. Strominger, MD,6 Matthew Simon Pihlblad, MD,7 Evelyn A. Paysse, MD,8 David R. Stager Jr., MD,9 David R. Stager Sr., MD,10 Hatice Tuba Atalay, MD,11 Hilda Capo, MD,12 Natalie C. Kerr, MD,13 Burton J. Kushner, MD,14 Sarah E. Mackinnon, CO, COMT,15 Brian N. Campolattaro, MD,16 Jason H. Peragallo, MD,17 Reecha S. Bahl, MD,18 and by the American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Committee: David K. Wallace, MD, MPH,19 Stephen P. Christiansen, MD,20 Katherine A. Lee, MD, PhD,21 Christie L. Morse, MD,22 Michael X. Repka, MD, MBA,23 Derek T. Sprunger, MD,24 Michele Melia, ScM25

    As of November 2015, the PPPs are initially published online-only in the Ophthalmology journal and may be freely downloaded in their entirety by all visitors. Open the PDF for this entire PPP or click here to access the PPP on the journal's site. Click here to access the journal's PPP collection page.

    1Boston Children’s Hospital, Harvard Medical School, Boston, MA

    2Duke Eye Center, Durham, NC

    3Mayo Clinic, Rochester, MN

    4Kellogg Eye Center, University of Michigan, Ann Arbor, MI

    5UCLA Jules Stein Eye Institute, Los Angeles, CA

    6Renown Medical Center, University of Nevada Reno School of Medicine, Reno, NV

    7University of Pittsburgh, Pittsburgh, PA

    8Baylor College of Medicine, Texas Children’s Hospital, Houston, TX

    9Pediatric Ophthalmology & Adult Strabismus, Plano, TX

    10Pediatric Ophthalmology & Adult Strabismus, Plano, TX

    11Gazi University School of Medicine, Ankara, Turkey

    12Bascom Palmer Eye Institute, University of Miami, Miami, FL

    13Hamilton Eye Institute, Memphis, TN

    14Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI

    15Boston Children’s Hospital, Boston, MA

    16Pediatric Ophthalmology of NY, New York, NY

    17Emory University, Atlanta, GA

    18Kresge, Eye Institute, Wayne State University, Detroit, MI

    19Glick Eye Institue, Indiana University, Indianapolis, IN

    20Boston University School of Medicine, Boston MA

    21St. Luke's Children's Ophthalmology, Boise, ID

    22Concord Eye Center, Concord, NH

    23Wilmer Ophthalmological Institute at Johns Hopkins Hospital, Baltimore, MD

    24Midwest Eye Institute, Indianapolis, IN

    25Jaeb Center for Health Research Foundation, Inc., Tampa, FL

    Highlighted Findings and Recommendations for Care


    Strabismus in adults has profound negative effects on quality of life and many aspects of day-to-day function. Strabismus surgery very often improves quality of life and function, and there are instruments to assess these aspects of evaluation and treatment. Patients with diplopia tend to have greatest improvements in functional domains, and nondiplopic patients tend to have greatest improvements in psychosocial domains.

     Recessions of the restricted muscles are the mainstay of surgical correction in thyroid eye disease. Resection is generally avoided in restrictive disease out of concern for further reducing ductions and operating on a rectus muscle that would be best spared to provid ciliary artery supply to the anterior segment. However, it can be a useful adjunct in select cases, particularly when extremely large recessions have not fully corrected the alignment.


    Screening for a history of childhood amblyopia or strabismus, checking spectacles for prism, and performing a cycloplegic refraction and cover testing are recommended for all patients undergoing refractive or cataract suregery, especially for those patients for whom monovision is planned. Patients with a history of childhood strabismus and suppresion are particularly at risk for developing fixation switch diplopia. This form of diplopia results when the previously nondominant eye becomes the dominant eye as a result of intended or unintended monovision by refractive manipulation or cataract surgery. A trial of monovision with contact lenses is prudent prior to corneal or lenticular refractive surgery to determine whether surgically induced monovision will result in new-onset diplopia. The development of asymmetric vision loss from other common diseases such as macular degeneration, myopia with axial elongation in the previously dominant eye, or diabetic retinopathy when the nondominant eye is left with better acuity may also result in fixation switch diplopia.

    Literature Search

    Adult Strabismus PPP - 2019 - Literature Search