• American Optometric Association. Care of the patient with strabismus: esotropia and exotropia. 2nd ed. St. Louis (MO): American Optometric Association; 1996. 69 p. (Optometric clinical practice guideline; no. 16). [115 references]

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed on a biannual basis and is considered to be current as of 2004. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.

Strabismus:

• Esotropia
  • Infantile Esotropia
  • Acquired Esotropia
  • Secondary Esotropia
  • Microesotropia
• Exotropia
  • Infantile Exotropia
  • Acquired Exotropia
  • Secondary Exotropia
  • Microexotropia

Diagnosis
Evaluation
Management

Optometry

Health Plans
Optometrists

• To identify patients at risk of developing strabismus
• To accurately diagnose strabismus
• To improve the quality of care rendered to patients with strabismus
• To minimize the adverse effects of strabismus and enhance the patient's quality of life
• To preserve the gains obtained through treatment
• To inform and educate other health care practitioners including primary care physicians, teachers, parents, and patients about the visual complications of strabismus and the availability of treatment.

Children and adults with suspected or diagnosed strabismus.

1. Diagnosis
   1. Patient History
   2. Ocular Examination
      • Visual Acuity
      • Ocular Motor Deviation
      • Monocular Fixation
      • Extraocular Muscle Function
      • Sensorimotor Fusion
      • Accommodation
      • Refraction
      • Ocular Health Assessment and Systemic Health Screening
2. Treatment
   1. Optical Correction
   2. Added Lens Power
   3. Prisms
   4. Active Vision Therapy
   5. Pharmacological Agents
   6. Extraocular Muscle Surgery
   7. Chemodenervation
3. Patient Education

Not stated

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not applicable

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and approved by the AOA Board of Trustees.

Diagnosis of Strabismus

The examination of strabismic patients generally includes all areas of the evaluation of a comprehensive adult or pediatric eye and vision examination. The evaluation of sensory, motor, refractive, and accommodative functions requires further, in-depth examination. Additional office visits may be required to complete the examination process, especially with younger children.

The evaluation of a patient with strabismus may include, but is not limited to, the following components. Professional judgment and individual patient symptoms and findings may have significant impact on the nature, extent, and course of the services provided.

1. Patient History
2. Ocular Examination
   1. Visual Acuity
   2. Ocular Motor Deviation
   3. Monocular Fixation
   4. Extraocular Muscle Function
   5. Sensorimotor Fusion
   6. Accommodation
   7. Refraction
   8. Ocular Health Assessment and Systemic Health Screening

Management of Strabismus

The extent to which an optometrist can provide treatment for strabismus may vary depending on the state's scope of practice laws and regulations and the individual optometrist's certification. Management of the patient with strabismus may require consultation with or referral to an ophthalmologist for those services outside the optometrist's scope of practice.

The management of the strabismic patient is based on the interpretation and analysis of the examination results and overall evaluation. The goals of treatment may include (1) obtaining normal visual acuity in each eye, (2) obtaining and/or improving fusion, (3) eliminating any associated sensory adaptations, and (4) obtaining a favorable functional appearance of the alignment of the eyes. The significance of normal ocular alignment for the development of a positive self-image and interpersonal eye contact cannot be overemphasized.

The indications for and specific types of treatment need to be individualized for each patient.

The treatment of strabismus may include any or all of the following procedures:

1. Optical Correction
2. Added Lens Power
3. Prisms
4. Active Vision Therapy
5. Pharmacological Agents
6. Extraocular Muscle Surgery
7. Chemodenervation

Patient Education

The prognosis, advantages, and disadvantages of the various modes of treatment should be discussed with the patient and/or the patient's parents and a plan developed based on this dialogue.

Prognosis and Follow-up

The purpose of the follow-up evaluation is to assess the patient's response to therapy and to alter or adjust treatment as needed.

The frequency and composition of evaluation and management visits for esotropia and exotropia are summarized in the following table:

* Vision therapy would require additional visits.

An algorithm is provided for Optometric Management of the Patient with Strabismus.

The type of supporting evidence is not specifically stated for each recommendation.

The optometrist should emphasize the diagnosis, timely and appropriate management, and careful follow-up of patients with strabismus. Proper care can result in reduction of personal suffering for those involved as well as a substantial cost savings for the involved individuals and their families.

• Pharmacological agents may be associated with local and systemic adverse effects.
• Extraocular muscle surgery may be associated with postoperative complications including diplopia, under-corrections, overcorrections, chronic inflammation of the conjunctiva, excessive scar tissue, lost muscle(s), perforation of the globe, endophthalmitis, anterior segment ischemia, and corneal dellen.
• Chemodenervation may be associated with transient ptosis and vertical strabismus.

Clinicians should not rely on this Clinical Guideline alone for patient care and management. Please refer to the references and other sources listed in the original guideline for a more detailed analysis and discussion of research and patient care information.

An implementation strategy was not provided.

Getting Better

Effectiveness
Patient-centeredness

• American Optometric Association. Care of the patient with strabismus: esotropia and exotropia. 2nd ed. St. Louis (MO): American Optometric Association; 1996. 69 p. (Optometric clinical practice guideline; no. 16). [115 references]

Not applicable: The guideline was not adapted from another source.

1995 (revised 1999; reviewed 2004)

American Optometric Association - Professional Association

Funding was provided by the Vision Service Plan (Rancho Cordova, California) and its subsidiary Altair Eyewear (Rancho Cordova, California)

American Optometric Association Consensus Panel on the Care of the Patient with Strabismus

Members: Robert P. Rutstein, O.D. (Principal Author); Martin S. Cogen, M.D.; Susan A. Cotter, O.D.; Kent M. Daum, O.D., Ph.D.; Rochelle L. Mozlin, O.D.; Julie M. Ryan, O.D.

AOA Clinical Guidelines Coordinating Committee Members: John F. Amos, O.D., M.S. (Chair); Barry Barresi, O.D., Ph.D.; Kerry L. Beebe, O.D.; Jerry Cavallerano, O.D., Ph.D.; John Lahr, O.D.; David Mills, O.D.

Not stated

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed on a biannual basis and is considered to be current as of 2004. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.

None available

This summary was completed by ECRI on December 1, 1999. The information was verified by the guideline developer on January 31, 2000.