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  • AAPOS PPP Adult Strabismus Committee, Hoskins Center for Quality Eye Care
    By the American Association of Pediatric Ophthalmology and Strabismus Preferred Practice Pattern Adult Strabismus Committee: Linda R. Dagi, MD, Chair,1 Federico G. Velez, MD, Vice-Chair,2 Jonathan M. Holmes, MD,3 Steven M. Archer, MD,4 Mitchell B. Strominger, MD,5 Stacy L. Pineles, MD,2 Evelyn A. Paysse, MD,6 Matthew Simon Pihlblad, MD,7 Hatice Tuba Atalay, MD,8 Brian N. Campolattaro, MD,9 Yoon-Hee Chang, MD, PhD1

    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.

    Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
    2Jules Stein Eye Institute, Doheny Eye Institute, UCLA, Los Angeles, California
    3Department of Ophthalmology and Vision Science, University of Arizona-Tucson, Tucson, Arizona
    4Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
    5Department of Ophthalmology, Renown Health, University of Nevada Reno, Reno, Nevada
    6Department of Ophthalmology and Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
    7University of Pittsburgh, Pittsburgh, Pennsylvania 
    8Gazi University School of Medicine, Ankara, Turkey
    9Pediatric Ophthalmology of NY, New York, New York

    Highlighted Findings and Recommendations for Care

    Strabismus in adults can have profound negative effects on quality of life and many aspects of day-to-day function. Patients with diplopia have greatest improvements in quality of life functional domains, and nondiplopic patients have greatest improvements in quality of life psychosocial domains. Instruments such as the ATS20 help measure these changes.

    Recessions of restricted muscles are the mainstay of surgical correction in thyroid eye disease. Resection, or plication, is generally avoided in restrictive disease out of concern for further reducing ductions. These options can be a useful adjunct in select cases, particularly when extremely large recessions have not fully corrected the misalignment.

    A variant of divergence insufficiency esotropia called sagging eye syndrome results from aging and weakening of circumferential supportive bands between the superior and lateral rectus muscles. The superior rectus shifts medially and the lateral rectus shifts inferiorly, resulting in esotropia with diplopia at distance and, occasionally, very modest vertical misalignment. Facial aging with associated blepharoptosis and deep superior lid sulci are commonly present. Sagging eye syndrome, along with other causes of divergence insufficiency esotropia, is a very common cause of acquired binocular diplopia in patients presenting between 60 and 80 years of age, is more frequent in myopes, and, as with other types of divergence insufficiency esotropia, is well managed with prism or strabismus surgery.

    Iatrogenic binocular diplopia after eye surgery is rare but may result from anesthetic toxicity to the extraocular muscles, direct muscle damage during blepharoplasty, local adjacent scarring associated with pterygium excision, or mechanical restriction from implanted hardware (scleral buckles, glaucoma plate reservoirs, plates repairing orbital fracture). Diplopia persisting after several months warrants referral to a strabismus specialist.

    Binocular diplopia may occur after cataract or refractive surgery due to the following:
    (1) Unrecognized strabismus (check spectacles for prism correction and perform cycloplegic refraction)
    (2) Fusional challenge associated with choice of monovision
    (3) Fixation switch diplopia in patients with a history of childhood strabismus and suppression, and cataract or refractive surgery. This has result in better vision in the previously suppressed eye.

    A trial of monovision with contact lenses may determine whether surgically induced monovision will result in new-onset diplopia. Asymmetric vision loss from other common diseases such as macular degeneration, epiretinal membranes, 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 - 2023 - Literature Search