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.
- Patient History
- Ocular Examination
- Visual Acuity
- Ocular Motor Deviation
- Monocular Fixation
- Extraocular Muscle Function
- Sensorimotor Fusion
- Accommodation
- Refraction
- 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:
- Optical Correction
- Added Lens Power
- Prisms
- Active Vision Therapy
- Pharmacological Agents
- Extraocular Muscle Surgery
- 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:
Frequency and Composition of Evaluation and Management Visits for Esotropia and
Exotropia
|
| Type of Patient |
Number of Evaluation Visits |
Treatment Options |
Frequency of Follow-Up Visits* |
Management Plan |
|
| Accommodative esotropia |
1 to 3 |
- Optical correction
- Vision therapy
|
- <6 years: every 4 to 6 mos
- 6 to 10 years: every 6 to 12 mos
- >11 years: every 12 mos
|
Provide refractive correction; treat any amblyopia; use added
plus at near if needed to facilitate fusion; prescribe vision therapy to develop/enhance
normal sensory and motor fusion. |
| Acute esotropia and exotropia |
1 to 3 |
- Prisms
- Vision therapy
- Surgery
|
|
Use prisms to eliminate diplopia and re-establish binocular
vision; prescribe vision therapy; in stable deviations over 20 to 25 prism diopter (PD),
consult with ophthalmologist regarding extraocular muscle surgery. |
| Consecutive esotropia and exotropia |
1 to 3 |
- Optical correction
- Prisms
- Vision therapy
- Surgery
|
- Variable, depending on etiology
|
Provide refractive correction; prescribe prism and/or vision
therapy to prevent amblyopia, eliminate diplopia, and establish normal sensory fusion, if
applicable. |
| Infantile or early-acquired esotropia and exotropia |
1 to 3 |
- Optical correction
- Prisms
- Vision therapy
- Surgery
|
- <2 years: every 3 mos
- 2 to 5 years: every 4 to 6 mos
- 6 to 10 years: every 12 mos
- >11 years: every 12 to 24 mos
|
Provide refractive correction; treat any amblyopia; use prism
to establish normal sensory fusion, if applicable; consult with ophthalmologist regarding
extraocular muscle surgery. |
| Intermittent exotropia |
1 to 3 |
- Optical correction
- Prisms
- Vision therapy
- Surgery
|
- <5 years: every 4 to 6 mos
- 5 to 10 years: every 6 to 12 mos
- >11 years: every 12 to 24 mos
|
Provide refractive correction; use added minus lens power or
base-in prism if needed to facilitate fusion; prescribe vision therapy; if deviation
persists or increases, consult with ophthalmologist regarding extraocular muscle surgery. |
| Mechanical esotropia and exotropia |
1 to 3 |
|
- Variable, depending on etiology
|
No therapy if strabismus is not present in the primary
position of gaze and no diplopia. Consider prisms and/or surgery to treat head turn. |
| Microtropia |
1 to 3 |
- Optical correction
- Prisms
- Vision therapy
|
|
Provide refractive correction; treat any amblyopia; prescribe
vision therapy and/or prism to establish bifoveal fusion, if applicable. |
| Sensory esotropia and exotropia |
1 to 3 |
- Optical correction
- Prisms
- Vision therapy
- Surgery
|
|
Consult with ophthalmologist regarding treatment of any
underlying ophthalmic disease; provide refractive correction; treat any amblyopia;
prescribe vision therapy and/or prism, if applicable; if deviation persists or increases,
consult with ophthalmologist regarding extraocular muscle surgery. |
|
* Vision therapy would require additional visits.
