Introduction

Strabismus (misaligned eyes) in adults is often the result of progressive, untreated or unsuccessfully treated strabismus from childhood. There are also many adults who develop strabismus as the result of an injury or disease, which then frequently leads to double vision.

In the past, most eye doctors thought that adults with misaligned eyes could not be treated successfully, or that treatment was "only cosmetic". Advances in the management of misaligned eyes now provide benefits to most adults as well as children. Treating adults with strabismus can improve depth perception, the way the two eyes work together, and the field of vision. Many patients report improved self-esteem, communication skills, job opportunities, reading and driving.

Treatment of strabismus generally requires eye muscle surgery. However, some patients may need glasses, prisms, medications, or may be best left untreated. As with any form of treatment, success can vary and complications may occur. The best way to determine whether straightening of the eyes is possible and appropriate, is to undergo an examination by a strabismus surgeon who is experienced in treating adults.

Definition

Strabismus is a condition in which the eyes point in different directions. It is commonly termed 'misaligned eyes', 'wandering eye', 'eye muscle problem', 'crossed eye', or 'lazy eye'.

Historical Perspective

Over the past several generations it was felt that very little could be done for misaligned eyes in adults. Recently there has been a marked improvement in the outcome of treatment for these patients. Now the majority of misaligned eyes can be significantly improved.  Having straight eyes is a valuable asset that patients deserve.

The Value of Treating Strabismus

Approximately 4% of adults have misaligned eyes. Some cases are related to medical illnesses or accidents. Adult-onset eye misalignment usually results in double vision, which is often hard to tolerate and prompts evaluation and treatment by a strabismus specialist.

A second common type of adult strabismus involves patients with misaligned eyes from childhood. This problem starts at a time when the patient can suppress (that is, 'turn off') one eye and thus avoid double vision. Unfortunately, for decades these patients have been told that nothing could or should be done about their misaligned eyes. As a result, treatment has not been available to them. These patients suffer from a loss of binocular vision and stereopsis, which means that the two eyes do not work together as they should to provide depth perception. Many can have a limitation of their field of vision (peripheral vision or side vision).

In addition to affecting eye function, misaligned eyes can get in the way of normal eye-to-eye contact, communication skills and social interaction. This can lead to reduced self-confidence and many patients will often look down or away from the person to whom they are speaking to avoid eye contact. 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. Such impairment of communication skills can lead to limited job (or job advancement) opportunities.

Straightening the eyes will lead to some binocularity (that is, the two eyes working together) in the majority of cases, even in instances where the onset of the strabismus occurred in early childhood.

Strabismus repair is not a "cosmetic" procedure but should more appropriately be considered reconstructive surgery. Cosmetic surgery (such as in face lifts, etc.) alters a normal appearance, whereas reconstructive surgery changes an abnormal appearance to one that is more normal. Thus, insurance should cover the expense of diagnosis and treatment. However, the issue of insurance coverage is controlled by individual insurance policies. Patients should therefore verify coverage with their insurer.

Following surgery, the eyes may need to adjust to their new position. In a recent study of 424 adults who underwent surgery for long-standing strabismus from childhood, only 9% had temporary double vision, which resolved in 1 to 6 weeks. Less than 1% had persistent double vision, which most patients were able to tolerate or ignore. Patients who have adult onset strabismus with other medical problems and constant double vision before surgery may continue to have some problems with double vision after surgery. Medical treatment (such as prisms, glasses, contact lenses, Botox, patching) may be helpful in selected cases.

Frequently Asked Questions

Q: Is it true that nothing can be done about misaligned eyes in adults after a certain age?

A: No. There have been a number of advances in this field over the past several years that provide an opportunity to most of these patients to correct their misalignment.

Q: Won't straightening my eyes after all these years cause me to see double?

A: Double vision may occur after straightening eyes that have been out of alignment for many years. However, it is generally a transient problem, lasting only a few weeks until the brain adapts to the new eye position.

Q: I've been told that straightening my eyes at my age is strictly cosmetic.

A: That is incorrect. After eye alignment surgery, many adults improve eye function and may gain social and economic benefits.

Q: Does my insurance cover the expense of this surgery?

A: Although eye muscle surgery is reconstructive, not cosmetic, surgery, you may want to check with your insurance carrier to determine their policy on this issue.

Q: Isn't eye surgery at my age risky?

A: Significant complications of strabismus surgery include endophthalmitis (inflammation of the eye ball) and retinal detachment, both as a result of accidental perforation of the globe during surgery. These complications are rare: Perforation of the globe may occur in 0.3% – 2.8% of cases , resulting in endophthalmitis in less than 1:3500, and retinal detachment in even fewer cases. The risk to your health or to your vision may vary with your general health. For patients in poor health, there may be alternatives such as surgery under local anesthesia (instead of general anesthesia).

Q: How successful is eye muscle surgery?

A: Usually most patients are successfully corrected in the straight-ahead position with one surgery. In some patients the surgery may be only partially successful. In some patients the eye alignment will change over time, resulting in the need for additional surgery.

Q: How painful is this type of surgery?

A: Discomfort can vary with the individual. Most of the discomfort after eye muscle surgery is a foreign body sensation in the eye, which lasts for several days. Over-the-counter pain medication is often enough to reduce this discomfort, although your eye doctor may prescribe something stronger. Most patients can be back to full activity in several days.

Q: Am I too old to have my eyes straightened?

A: Eyes can be straightened at any age. If you feel that it will enhance your quality of life, you may want to consider it.

Q: I am embarrassed by my misaligned eyes. I avoid looking people in the eye. They seem to be distracted by my wandering eye. As a result, communicating is difficult, hampering me socially and in getting the job I want. Am I being realistic or paranoid?

A: Recent studies have confirmed these observations. I believe that misaligned eyes hinder social interaction, self-confidence and employment opportunities. I feel that patients deserve straight eyes whenever possible.

Q: Do I have to be hospitalized for eye alignment surgery? How will this affect my normal activities?

A: Eye alignment surgery is usually performed as an outpatient procedure, although the need for hospitalization varies depending upon your general health. Following surgery most patients return to nearly all of their normal activities within a few days.

Treatment Options

Strabismus can be treated in various ways. Depending on the individual case, treatment options include:

• Glasses
• Prisms
• Patch
• Botox injection
• Surgery

Policy Statement of AAPOS

(A Joint Statement of the American Academy of Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology; Approved, March 21, 2001)

Medical Necessity of Adult Strabismus Surgery
Strabismus is a misalignment of the eyes. It is not a normal condition. Strabismus surgery is the only effective treatment in many of these patients. Surgical correction or strabismus in adults is reconstructive in nature and not cosmetic. The indications for strabismus surgery are:

1.       Elimination of double vision (diplopia)

2.      Improvement of three-dimensional vision

3.      Expansion of visual field

4.      Elimination of abnormal head posture

5.      Improvement of psychosocial function

6.      Improvement of vocational status 

Corrective surgery is a medical necessity and its correction should be a covered benefit by insurance companies, health plans and third party payers. However, the issue of insurance coverage is controlled by individual insurance policies. Patients should therefore verify coverage with their insurer.