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 Table of Contents  
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 17-20

Adults with strabismus seek surgery for pyschosocial benefits

1 Department of Ophthalmology, Royal Children's Hospital, Brisbane, Queensland, Australia
2 Sydney Ophthalmic Specialists, Sydney, Australia
3 Sydney Ophthalmic Specialists; Department of Ophthalmology, Westmead Childrens Hospital, Westmead; Sydney Eye Hospital, Sydney, Australia

Date of Web Publication4-Mar-2014

Correspondence Address:
Trent M Sandercoe
Department of Ophthalmology, Royal Children's Hospital, PO Box 373, Royal Brisbane Hospital Post Office, Herston, Brisbane, Queensland 4029
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Source of Support: None, Conflict of Interest: None

DOI: 10.1016/j.tjo.2013.10.004

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Background/Purpose: The goal of strabismus surgery is to align the eyes, help eliminate diplopia, and restore and/or expand binocular visual function. Adults with strabismus are subjected to psychosocial prejudices, and many patients seek strabismus correction for these reasons.
Methods: A surgical audit was performed on 91 adult patients, by a singular surgeon. The type of strabismus, preoperative measurements, and indications for surgery were obtained from the patient notes, as were all final outcomes. Final measurements, on average, were taken at 16 weeks postoperatively, and patients were asked to comment subjectively on their outcome.
Results: The majority of patients were seeking surgery for combined psychosocial and cosmetic reasons (78.4%), or combined psychosocial and functional indications (9.6%), whereas the remainder were seeking surgery for functional indications only. Eighty-three percent of patients reached the desired surgical outcome of <10 prism dioptres; 97.6% were satisfied or very satisfied with their surgery, with the remaining patients having a neutral standpoint, and none were dissatisfied.
Conclusion: Adult strabismus surgery is highly successful and provides patients with a good level of satisfaction. Many patients seek surgical correction for cosmesis and psychosocial benefits.

Keywords: adult, indications, psychosocial, strabismus

How to cite this article:
Sandercoe TM, Beukes S, Martin F. Adults with strabismus seek surgery for pyschosocial benefits. Taiwan J Ophthalmol 2014;4:17-20

How to cite this URL:
Sandercoe TM, Beukes S, Martin F. Adults with strabismus seek surgery for pyschosocial benefits. Taiwan J Ophthalmol [serial online] 2014 [cited 2022 Jan 26];4:17-20. Available from: https://www.e-tjo.org/text.asp?2014/4/1/17/203972

  1. Introduction Top

The major aims of adult corrective strabismus surgery are satisfactory cosmetic alignment of the eyes, elimination of diplopia, and restoration or expansion of binocular visual function. In addition to cosmetic appearance, several studies have demonstrated significant benefits to patients’ psychosocial function, that is, improvement in interpersonal relations, employment, sport, and self-image.[1] Restoration of ocular alignment in those who acquire strabismus after and prior to visual maturation (AVM and BVM, respectively) may re-establish sensory fusion as well as eliminate diplopia.[2]

Establishment of various levels of binocular function after adult strabismus surgery is dependent upon several factors, and more likely to be achieved in patients who acquired their strabismus AVM than in those acquiring strabismus BVM. This also applies to acquired versus congenital strabismus, and horizontal versus vertical strabismus. A higher success rate has been reported in those whose surgery is performed prior to the age of 50 years.[3] Some level of binocularity can be attained with primary strabismus (86–92%) and consecutive strabismus (79–87%), and lesser success rate with vertical misalignments (58–64%).[3] Achieving some level of binocularity with adult strabismus surgery decreases with age, from 85-88% in those under 50 years to 73% in adults older than 50 years. Maintaining binocularity is dependent on having good vision in both eyes (90% at 1 year, 85% at 3 years, and 82% at 10 years postoperatively).[3] Restoration of binocularity and sensory fusion improves stability of postsurgical alignment.[3]

Some level of stereopsis (50–3000 seconds of arc) can be achieved following adult strabismus surgery. Greater success is seen in patients who have acquired strabismus AVM (81%) than in those who have acquired strabismus BVM (44%) and in those with congenital strabismus.[2] Some level of binocularity and stereopsis can be achieved in patients who have acquired their strabismus BVM and have delayed primary strabismus surgery.[4] Sensory fusion can be achieved in those with infantile esotropia, even after many years of having esotropia and amblyopia.[5] Expansion of binocular visual fields can be achieved in up to 92% of patients, varying between 0° and 34° horizontally in esotropes.[3],[6] This can also be achieved in the case of vertical binocular visual fields with vertical recti operations.[7]

Benefits of regaining ocular alignment extend beyond functional benefits and pure cosmesis. Jackson et al[1] demonstrated that adults with strabismus have higher levels of social anxiety, social avoidance, and general anxiety compared with those of the nonstrabismic population, but the same level of depression. Postoperatively these patients have a significant reduction of these levels, improving their psychosocial function. Strabismus has a negative impact on many aspects of a person’s life: self-image, securing employment, interpersonal relations, school, work, and sport. The negative impact of strabismus increases from 63% in childhood to 84% in teenage years and to 85% by adulthood.[8] Evidence suggests that many people with strabismus believe that they have been subjected to ridicule and abuse secondary to their strabismus, and this continues into their adult lives, affecting their ability to obtain employment or have a successful career in jobs that require face-to-face contact.[8]

Adults with strabismus are subjected to prejudices that their orthotropic counterparts are not. A study comparing perceived personality traits, as judged from photos, of orthotropic patient’s and those with large-angle esotropia or exotropia demonstrated this.[9] The traits judged were attentiveness, communication skills, competency, dependability, emotional stability, honesty, humor, intelligence, leadership, organization, and sincerity. The total score (the summative of the personality traits average scores) of strabismic patients were significantly lower than the orthotropic persons. The strabismus patients were judged to be poor communicators, have poor humor, and be of lower intelligence than their orthotropic counterparts. The effect of perceived judgment of personality was worse for esotropia than for exotropia patients.[9]

In regard to employability, women with strabismus have been shown to receive lower hiring preference scores than those with normal ocular alignment. This prejudice was not demonstrated between strabismic and nonstrabismic male applicants.[10] A study of Swiss head-hunters judged that persons with strabismus are perceived as being less attractive and less intelligent by potential employers.[11] Although this study showed that exotropia had greater negative impact on employability than esotropia, early studies have found the reverse.[10],[12] Goff et al[13] demonstrated that esotropia had a significant effect on a person’s ability to gain promotion, whereas no difference was noted in exotropes.

Patients with strabismus have significantly less chance of finding a partner through dating agencies. A study of Swiss dating agencies suggested that potential partners would judge clients with strabismus as being less attractive, erotic, likeable, interesting, successful, intelligent, and/or sporty than orthotropic individuals. In this study, exotropia was perceived as having a more negative impact than esotropia.[12]

Psychosocial impact of adult strabismus is complex, and its impact varies between the type of strabismus, sex, age, and psychosocial circumstances (obtaining employment, promotion, and dating). There is growing evidence of negative perception/prejudgment of others toward patients having strabismus, which supports that there is some basis for the anxiety and perceived negative impact that strabismus has on the lives of individuals.

This study adds to the body of literature in regard to indications for adult strabismus surgery, its surgical outcomes, and patient’s perception of outcomes.

  2. Methods Top

A retrospective chart review of all adult patients who had undergone strabismus surgery by a single surgeon between January 2009 and July 2011 was performed.

Patient selection criteria were as follows: 91 adult strabismu patients from a surgical audit, operated on by a singular surgeon between 2009 and 2011. Final measurements were, on average taken at 16 weeks postoperatively. These patients were consented to be included in the study, in accordance to the Helsinki Conven tion. Patients were asked to comment subjectively on their surgica outcome as very satisfied, satisfied, neutral, unsatisfied, or very dissatisfied. Reasons for surgery were obtained from the patient’ notes, as were all final outcomes.

  3. Results Top

Of the 91 patients who were audited, eight were excluded due to inadequate follow-up or insufficient data, leaving 83 patients. Th average age of patients when surgery was performed was 37 years and 60% (50 patients) were female. The indications for surgery, typ of strabismus, and size of deviation are detailed in [Table 1],[Table 2],[Table 3] respectively. Of these patients, 56.6% had some form of amblyopia whereas 60.2% had undergone previous strabismus surgery. O those undergoing surgery previously, 70% had undergone only one 20% two, and 10% three or more operations.
Table 1: Indication for adult strabismus surgery.

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Table 2: Type of strabismus.

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Table 3: Pre- and postoperative measurements.

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3.1. Surgical outcomes

The majority of patients (83.1 %) had a desired surgical outcom of less than 10 prism dioptres (PD) and 10.9% had an acceptabl result of between 10 PD and 20 PD [Table 4]. Only 2.4% had 20–30 PD, a further 2.4% had 30–40 PD, and 1.2% (1 patient) had ove 40 PD postoperatively. It should be noted that the patient having over 40 PD postoperatively had a preoperative angle size measuring in excess of 95 PD. Of the cohort, 23 patients (27.7%) had preop erative diplopia and five (6%) had residual postoperative diplopia of whom one (1.2%) was diplopia free with prisms. The remaining three patients required further surgery. No incidents of othe complications of strabismus surgery were noted. Patient subjectiv satisfaction matched objective satisfaction closely [Table 4], with less than 5% of patients having a neutral or dissatisfactory stand point on the surgical outcome.
Table 4: Comparison of surgical outcome with patient subjective satisfaction.

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  4. Discussion Top

Adults with strabismus are often perceived as having lowe communication skills and intelligence when compared to ortho tropic persons.[9] They are viewed as less attractive and les employable,[11] and females have a decreased likelihood of gaining employment.[10] Socially, patients with strabismus have significantl less chance of finding a partner through dating agencies.[12] Ir addition to the prejudices that adults with strabismus face, stra bismus also has a direct psychological effect on the patients. Psy chologically, strabismus surgery has been demonstrated to exhibi the following benefits: to decrease levels of anxiety and depression social anxiety, and avoidance postoperatively[1] and to improve psychosocial and functional scores.[14] Beauchamp et al[15] reported that 60% of adult strabismus patients would trade part of their life expectancy to be free of strabismus.

There is an overlap between psychosocial, cosmetic, and functional indications for strabismus surgery in adults. The over-riding indication for surgery in this study was for cosmesis and psychosocial reasons (78.4%). Only 12% were for functional indications, and the remaining (9.6%) were for combined psychosocial, cosmetic, and functional indications. Our study fits well with the findings of Scot et al,[2] who reported that the majority of patients who had acquired strabismus BVM were seeking restoration of ocular alignment, although the exact percentage was not reported. The incidence of preoperative diplopia is reported between 40% and 100%.[1],[2],[5] In this study, the lower incidence of patients with preoperative diplopia (20.4%) may reflect the difference in the ratio of strabismus acquired BVM and AVM.

In this study, 97.6% of the patients were satisfied or very satisfied after surgery, which was greater than the objective measurement (95.2%; see [Table 4]). A good functional outcome and cosmesis are not mutually exclusive. Successful surgical outcomes have been demonstrated to improve quantitative quality of life and functional scores.[14] A recent work by Hatt et al[14] demonstrated that the patients who were regarded as postoperative partial success still had improvement in their psychosocial and functional scores. Of the patients in this case series, 97.6% were satisfied or very satisfied with the results of their surgery, 2.4% had a neutral stance, and none were dissatisfied. This fits well with previous observations that the majority of patients gain and perceive some level of benefit, even with partial successful adult strabismus surgery.[1],[8],[14] A more recent smaller series of 20 patients, however, found no change in mean scores of quality of life questionnaires, with unsatisfactory surgical outcomes.[16] The fact that our study did not use quantitative measures may explain the difference between our findings and those of the previously mentioned study. Our level of satisfaction is higher than the satisfaction rate (87%) reported by Kushner 2011 (review article).[17] A lower level of satisfaction may be reflected in patients who had insufficient follow-up and were hence excluded from our study, although this is speculative. Patients’ expectation level leading to their subjective satisfaction may often be less than that of the objective satisfaction of the doctor.

The final ocular alignment less than 10 PD for this case series was 83.1%, which sits within the same range cited for other studies (76.9–100%).[2],[5],[18] In the present case series, 6% of our patients had residual postoperative diplopia compared to other studies (ranging from 0.8% to 28%).[2],[3],[5] Mills et al[5] reported that of those who had preoperative diplopia, 28% had residual diplopia after surgery. In this cohort of patients, 17% (4 out of 23) required further surgery for their diplopia.

Establishment of binocularity and sensory fusion helps maintain postoperative stability, the ability to maintain a level of binocularity falls from 90% at 1 year postoperative to 82% at 10 years.[3] Reoperation (at 6 weeks to 10 years postop) rates are reported to be between 6% and 21%. With the more complex forms of strabismus such as thyroid eye disease and incomitant strabismus, reoperation rates can be as high as 50%.[5] In this study 60.2% had undergone previous surgery, which sits within the range reported previously by other studies (58.7–63%).[1],[8] Although adult strabismus surgery has good outcomes and high satisfaction, some patients will require further surgery later in life.

With the exception of postoperative diplopia we did not have any other complications, such as globe perforation and slipped muscle, the incidence of which has been reported to be 0.8–1.8% and 0.3–0.5%, respectively. Nor did we have any serious complications such as anterior segment ischemia or endophthalmitis, which is exceptionally rare. The absence of these complications may be secondary to the small number of patients involved in this study and long-term experience of the surgeon. Other possible complications such oculocardiac reflex, where the intraoperative incidence is 13–20%, and postoperative nausea and vomiting (incidence 21–31%)[5] were not examined in this study.

In conclusion, the goals of adult strabismus surgery are satisfactory alignment of the eyes, elimination of diplopia, and restoration or expansion of binocular visual function. Adults with strabismus are subjected to prejudices that their orthotropic counterparts are not. Successful surgery provides a good cosmetic outcome and psychosocial benefit. In this series of adult patients who underwent strabismus surgery, the majority were seeking surgery for psychosocial/cosmetic or combined psychosocial/ cosmetic and functional indications. The vast majority were satisfied or very satisfied with their surgical outcome, despite only 83% acquiring the desired surgical outcome. Strabismus surgery is safe, has a low incidence of complications, and provides a high level of patient satisfaction. The psychosocial benefit of adult strabismus surgery should not be underestimated, as it is often the primary reason why patients seek surgery.

Conflicts of interest: The authors declare that they have no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in the manuscript.

  References Top

Jackson S, Harrad RA, Morris M, Rumsey N. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol. 2006;90:883–888.  Back to cited text no. 1
Scott WE, Kutschke PJ, Lee WR. 20th Annual Frank Costenbader Lecture–adult strabismus. J Pediatr Ophthalmol Strabismus. 1995;32:348–352.  Back to cited text no. 2
Kushner BJ, Morton GV. Postoperative binocularity in adults with longstanding strabismus. Ophthalmology. 1992;99:316–319.  Back to cited text no. 3
Gharabaghi DAM. Binocular vision and stereopsis following delayed strabismus surgery. Iran J Ophthalmol. 2006;19:46–50.  Back to cited text no. 4
Mills MD, Coats DK, Donahue SP, Wheeler DT. American Academy of Ophthalmology. Strabismus surgery for adults: a report by the American Academy of Ophthalmology. Ophthalmology. 2004;111:1255–1262.  Back to cited text no. 5
Wortham ET, Greenwald MJ. Expanded binocular peripheral visual fields following surgery for esotropia. J Pediatr Ophthalmol Strabismus. 1989;26:109112 [Erratum appears in J Pediatr Ophthalmol Strabismus 1989;26:208.].  Back to cited text no. 6
Kouri AS, Bessant DA, Adams GG, Sloper JJ, Lee JP. Quantitative changes in the field of binocular single vision following a fadenoperation to a vertical rectus muscle. J AAPOS Am Assoc Pediatr Ophthalmol Strabismus. 2002;6:294–299.  Back to cited text no. 7
Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol. 1993;111:1100–1105.  Back to cited text no. 8
Olitsky SE, Sudesh S, Graziano A, Hamblen J, Brooks SE, Shaha SH. The negative psychosocial impact of strabismus in adults. J AAPOS Am Assoc Pediatr Ophthalmol Strabismus. 1999;3:209–211.  Back to cited text no. 9
Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large angle horizontal strabismus on ability to obtain employment. Ophthalmology. 2000;107:402405.  Back to cited text no. 10
Mojon-Azzi SM, Mojon DS. Strabismus and employment: the opinion of headhunters. Acta Ophthalmol. 2009;87:784–788.  Back to cited text no. 11
Mojon-Azzi SM, Potnik W, Mojon DS. Opinions of dating agents about strabismic subjects’ ability to find a partner. Br J Ophthalmol. 2008;92:765–769.  Back to cited text no. 12
Goff MJ, Suhr AW, Ward JA, Croley JK, O’Hara MA. Effect of adult strabismus on ratings of official U.S. Army photographs. J AAPOS Am Assoc Pediatr Ophthalmol Strabismus. 2006;10:400–403.  Back to cited text no. 13
Hatt SR, Leske DA, Liebermann L, Holmes JM. Changes in health-related quality of life 1 year following strabismus surgery. Am J Ophthalmol. 2012;153:614619.  Back to cited text no. 14
Beauchamp GR, Felius J, Stager DR, Beauchamp CL. The utility of strabismus in adults. Trans Am Ophthalmol Soc. 2005;103:164–171. discussion 71–2.  Back to cited text no. 15
Dickmann A, Aliberti S, Rebecchi MT, et al. Improved sensory status and qualityof-life measures in adult patients after strabismus surgery. J AAPOS Am Assoc Pediatr Ophthalmol Strabismus. 2013;17:25–28.  Back to cited text no. 16
Kushner BJ. The efficacy of strabismus surgery in adults: a review for primary care physicians. Postgrad Med J. 2011;87:269–273.  Back to cited text no. 17
Carruthers JD, Kennedy RA, Bagaric D. Botulinum vs adjustable suture surgery in the treatment of horizontal misalignment in adult patients lacking fusion. Arch Ophthalmol. 1990;108:1432–1435.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4]

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