National Guideline Clearinghouse | Care of the patient with strabismus: esotropia and exotropia.

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Guideline Summary

Guideline Title

Care of the patient with strabismus: esotropia and exotropia.

Bibliographic Source(s)

American Optometric Association. Care of the patient with strabismus: esotropia and exotropia. St. Louis (MO): American Optometric Association; 2010. 74 p. [170 references]

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: 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).

Scope

Methodology

Recommendations

Evidence Supporting the Recommendations

Benefits/Harms of Implementing the Guideline Recommendations

Contraindications

Qualifying Statements

Implementation of the Guideline

Institute of Medicine (IOM) National Healthcare Quality Report Categories

Identifying Information and Availability

Disclaimer

Scope

Disease/Condition(s)

Strabismus:

Esotropia
- Infantile esotropia
- Acquired esotropia
- Secondary esotropia
- Microesotropia
Exotropia
- Infantile exotropia
- Acquired exotropia
- Secondary exotropia
- Microexotropia

Guideline Category

Diagnosis
Evaluation
Management

Clinical Specialty

Optometry
Pediatrics

Intended Users

Health Plans
Optometrists

Guideline Objective(s)

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, as well as teachers, parents, and patients, about the visual complications of strabismus and the availability of treatment and management

Target Population

Children and adults with suspected or diagnosed strabismus

Interventions and Practices Considered

Diagnosis/Evaluation

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/Treatment

Optical correction
Added lens power
Prisms
Active vision therapy
Pharmacological agents
Extraocular muscle surgery
Chemodenervation
Patient education
Follow-up

Major Outcomes Considered

Utility and accuracy of diagnostic tests for strabismus
Effectiveness of interventions for correction of strabismus

Methodology

Methods Used to Collect/Select the Evidence

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

Description of Methods Used to Collect/Select the Evidence

The guideline developer performed literature searches using the following electronic databases:

Ovid: MedLine, EMBASE, PsycINFO, Global Health
Web of Science
Table of contents (electronic): Journal of the American Medical Association, New England Journal of Medicine, Journal of Clinical Epidemiology, British Medical Journal, Health Service Res, Journal of Public Health
Guidelines International Database

The time frame of the literature search was from 1999 (last review period) and forward.

Data and new references were included if the team found groups of published papers to include the same data and/or if the team consensus was to include based on the research results (no ranking criteria were used).

All terms related to causes or treatments of ocular muscle abnormalities, traumatic and congenital muscular problems, and ocular and systemic manifestations were included in the literature search.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The American Optometric Association (AOA) Guidelines Review Committee reviews the list of all AOA guidelines per year for currency and solicits experienced and reputable writers to work on guidelines. Together with the writer, references are searched for new information to include or exclude from the current guideline. This team is diversified to include clinical practice doctors, academicians, researchers, and volunteer members from around the country ranging in age, race, ethnicity, gender, and location.

The Committee reviews all resources/references and searches that produce literature for review. After the guideline is updated, the committee re-convenes to review all literature cited in the draft one more time for accuracy.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

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.

Recommendations

Major Recommendations

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. (Refer to the American Optometric Association [AOA] Optometric Clinical Practice Guidelines on Comprehensive Adult Eye and Vision Examination and 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:

Patient history
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

Management of the strabismic patient is based on the interpretation and analysis of the examination results and overall evaluation (see Appendix 1 in the original guideline document). 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 treatment and management and specific types of treatment and management need to be individualized for each patient.

The treatment and management of strabismus may include any or all of the following procedures.

Optical correction
Added lens power
Prisms
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 based on this dialogue should be developed.

Prognosis and Follow-up

The purpose of the follow-up evaluation is to assess the patient's response to therapy and to adjust treatment as needed. Follow-up evaluation includes monitoring of several aspects of the patient's condition:

Patient history
Visual acuity
Characteristics of strabismus at distance and near
Fusion status
Extraocular muscle function
Refractive error
Tolerance, efficacy, and side effects of therapy

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 by Age*	Management Plan
Accommodative esotropia	1 to 3	Optical correction Added lenses Vision therapy	<6 years: every 4 to 6 months 6 to 10 years: every 6 to 12 months ≥11 years: every 12 months	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 when applicable.
Acute esotropia and exotropia	1 to 3	Prisms Vision therapy Surgery when applicable	Every 3 to 12 months	Use prisms to eliminate diplopia and re-establish binocular vision; prescribe vision therapy when applicable; in stable deviation exceeding 20 prism diopter (PD), consult with strabismus surgeon regarding extraocular muscle surgery.
Consecutive esotropia and exotropia	1 to 3	Optical correction Prisms Vision therapy Surgery when applicable	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 when applicable	<2 years: every 3 months 2 to 5 years: every 4 to 6 months 6 to 10 years: every 12 months ≥11 years: every 12 to 24 months	Provide refractive correction; treat any amblyopia; consult with strabismus surgeon regarding extraocular muscle surgery.
Intermittent exotropia	1 to 3	Optical correction Added lenses Prisms Vision therapy Surgery	<5 years: every 4 to 6 months 5 to 10 years: every 6 to 12 months ≥11 years: every 12 to 24 months	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 strabismus surgeon regarding extraocular muscle surgery.
Mechanical esotropia and exotropia	1 to 3	Prisms Surgery	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 and vision therapy when applicable	Every 3 to 12 months	Provide refractive correction; treat any amblyopia; prescribe vision therapy and/or prism if applicable.
Sensory esotropia and exotropia	1 to 3	Optical correction Prisms Vision therapy Surgery when applicable	Every 3 to 12 months	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 strabismus surgeon regarding extraocular muscle surgery.

*Vision therapy would require additional visits.

Clinical Algorithm(s)

An algorithm is provided in the original guideline document for: Optometric Management of the Patient with Strabismus: A Brief Flowchart.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

The optometrist should emphasize the examination, diagnosis, timely and appropriate treatment and 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 persons with strabismus and their families.

Potential Harms

Pharmacological agents may be associated with local and systemic adverse effects.
Extraocular muscle surgery may be associated with postoperative complications including diplopia, undercorrection, overcorrection, chronic inflammation of the conjunctiva, excessive scar tissue, lost muscle(s), perforation of the globe, endophthalmitis, anterior segment ischemia, retrobulbar hemorrhage, conjunctival pyogenic granulomas, and corneal dellen. Patients with totally accommodative esotropia should not be considered for extraocular muscle surgery, because of the risk of inducing consecutive exotropia.
Chemodenervation may be associated with transient ptosis and vertical strabismus.

Contraindications

Added minus lens power is contraindicated in patients whose exotropia is associated with accommodative insufficiency or who are presbyopic.
The presence of amblyopia, deep suppression, and/or anomalous retinal correspondence generally contraindicates the use of prisms.

Qualifying Statements

Clinicians should not rely on the Clinical Guideline alone for patient care and management. Refer to the listed references and other sources in the original guideline for a more detailed analysis and discussion of research and patient care information.
Professional judgment and individual patient symptoms and findings may have significant impact on the nature, extent, and course of the services provided. Some components of care may be delegated or referred to other practitioners.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Clinical Algorithm
Foreign Language Translations
Patient Resources

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

American Optometric Association. Care of the patient with strabismus: esotropia and exotropia. St. Louis (MO): American Optometric Association; 2010. 74 p. [170 references]

Adaptation

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

Date Released

1996 (revised 2010)

Guideline Developer(s)

American Optometric Association - Professional Association

Source(s) of Funding

American Optometric Association

Guideline Committee

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

Composition of Group That Authored the Guideline

Panel 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.

Edited by: Robert P. Rutstein, O.D., M.S.

American Optometric Association (AOA) Clinical Guidelines Coordinating Committee Members: David A. Heath, O.D., Ed.M. (Chair); Diane T. Adamczyk, O.D.; John F. Amos, O.D., M.S.; Brian E. Mathie, O.D.; Stephen C. Miller, O.D.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Optometric Association Web site External Web Site Policy .

Print copies: Available from the American Optometric Association, 243 N. Lindbergh Blvd., St. Louis, MO 63141-7881

Availability of Companion Documents

None available

Patient Resources

The following are available:

Answers to your questions about strabismus. Brochure. Available to order from the American Optometric Association (AOA) Web site .
Answers to your questions about vision therapy. Brochure. Available to order from the AOA Web site .
Strabismus. Available in English and Spanish from the AOA Web site .
Vision therapy. Available from the AOA Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on December 1, 1999. The information was verified by the guideline developer on January 31, 2000. This summary was updated by ECRI Institute on October 11, 2011. The updated information was verified by the guideline developer on November 9, 2011.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions as follows:

Copyright to the original guideline is owned by the American Optometric Association (AOA). NGC users are free to download a single copy for personal use. Reproduction without permission of the AOA is prohibited. Permissions requests should be directed to Jeffrey L. Weaver, O.D., Director, Clinical Care Group, American Optometric Association, 243 N. Lindbergh Blvd., St. Louis, MO 63141; (314) 991-4100, ext. 244; fax (314) 991-4101; e-mail, JLWeaver@AOA.org.