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  • 5 Tips for Managing Patients With Adult Strabismus

    Adult strabismus

    Strabismus can be a life-altering condition. Whether patients have double vision or are bothered by the cosmetic appearance of their misaligned eyes, strabismus can have a significant impact on their day-to-day functioning. Here are some tips to help you take care of this challenging population and make referrals to adult strabismus specialists seamless.

    Image courtesy of Smith Ann Chisholm, MD

    1. Make a basic cover test part of your workup.

    Although it adds a little bit of time, it really is a benefit to your patients and your practice to monitor their alignment over time. Doing a quick cover test (bonus points if you measure the deviation with prism) can help in the following situations:

    • Determining if your patient has underlying eye misalignment prior to refractive or cataract surgery (see warnings below)
    • Uncovering a reason for a patient’s symptoms, such as visual fatigue from convergence insufficiency or blurry vision from binocular diplopia
    • Helping your adult strabismus colleagues better understand the reason for your referral

    2. Prior to sending a patient to an adult strabismus specialist, make sure you have adequately evaluated the patient for monocular diplopia.

    Having strabismus does not protect patients from having monocular double vision. In all patients complaining of double vision, make sure to cover each eye and see if the double vision goes away. I emphasize each eye because monocular double vision from the left eye will go away when the left eye is covered, but not when the right eye is covered and vice versa. To accurately evaluate a patient for monocular diplopia, you need to rule out double vision from the eyes individually.

    If you discover that a patient has monocular double vision, determine and treat the underlying cause before sending the patient to an adult strabismus specialist for management of their alignment. If the monocular diplopia cannot be fixed, mention this in your referral. It does not mean that their alignment cannot be addressed, but it does lead to different expectations for outcomes. 

    3. Give your patients updated glasses before sending them to an adult strabismologist.

    Patients often get sent to adult strabismus clinics with old glasses or no glasses at all. Although the underlying sentiment for this makes sense, as we may end up wanting to prescribe prism, it makes our measurements less accurate. Having a patient’s vision optimized helps us to ensure they will have the best possible control of their deviation. 

    In some patients, the improvement is just as good with an eyeglass prescription that improves their control enough that they do not need any additional treatment. In addition, uncorrected refractive error can lead to monocular shadowing/diplopia, which can muddy the waters when trying to evaluate a patient’s binocular diplopia. 

    4. Send your patients with eye misalignment to an adult strabismus specialist even if you are not sure if we can help.

    We sometimes see patients in our clinics who tell us that they never knew someone could help with their alignment issue. Although we cannot fix all double vision and cannot restore fusion in patients with strabismus since childhood, we can improve things for most patients. Even patients who decide not to pursue treatment often appreciate being able to talk through their options.


    • There are things that we cannot fix, so do not make promises to patients. Let them know that you are sending them to an expert who will be able to discuss their options and set appropriate expectations for outcomes.
    • If patients have acute onset of double vision or other concerning neurologic symptoms, send them to a neuro-ophthlamologist (or an emergency department) for initial workup.

    5. Caution: Be careful with monovision and premium intraocular lenses in patients with strabismus.

    Monovision: Although this can be a useful tool in patients who suppress one eye, it can lead to disruption of fusion in patients with strabismus. Some of my most upset patients are those who paid out of pocket for refractive surgery, got monovision and ended up with double vision due to breakdown of an underlying deviation. Usually these are small deviations that are amenable to treatment with prism, but patients who just had refractive surgery to become glasses independent are not very happy with that option. 

    Premium intraocular lenses (IOLs): Although strabismus is not a contraindication to using premium IOLs, you should make sure to adequately consent your patients if you notice any amount of misalignment of the eyes prior to cataract surgery. Patients with strabismus can have breakdown of their deviation if vision is not optimized at any distance. So they often do better with a monofocal lenses and glasses. They also can have breakdown of their deviation with aging, which may require them to have prism glasses and take away their ability to be glasses independent.

    The Academy’s YO Info Editorial Board is collaborating with YO leaders from our subspecialty society partners and thanks the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) YO Committee Chair Smith Ann Chisholm MD, for contributing this article. AAPOS 2023, the 48th annual meeting, will be held in New York City on March 29-April 2. 

    Smith Ann Chisholm, MD About the author: Smith Ann Chisholm, MD, is an assistant professor of ophthalmology at the Medical College of Wisconsin. Her practice consists of pediatric ophthalmology, oculoplastic surgery and adult strabismus. She is the current chair of the American Association for Pediatric Ophthalmology and Strabismus YO Committee.