The Sandwich Approach to Vision Therapy and Strabismus


Our good friend and colleague, Dr. Nancy Torgerson, who has established a model synergistic relationship with the surgeon Dr. Thomas Lenart, reports that the term “sandwich approach” seems to be gaining traction in the Pacific Northwest for the combination of vision therapy and strabismus surgery to boost clinical outcomes in certain cases.  This might consist of vision therapy prior to strabismus surgery to optimize sensory readiness for motor fusion, and/or post-surgical therapy to stabilize or safeguard binocular vision.

As I’ve blogged before, the implications of providing enhanced patient outcomes through  this individualized and synergistic approach are enormous.  There are signs that more practices may be leaning in this direction.  As an example, Northwest Eye Surgeons posts on its website: “The goal of strabismus treatment is to improve eye alignment so that the eyes work together (binocular vision). Treatment addresses the underlying cause and may include eye glasses, eye exercises, prism therapy, vision therapy and/or eye muscle surgery … Strabismus, like many other conditions, requires an individualized treatment plan. Your doctor will assess your eye condition, develop a treatment plan with you and keep you informed as your treatment progresses.”

To date there have been isolated case reports in the literature about combination or sandwich approaches of optometric vision therapy providing a more optimized outcome of strabismus surgery, such as this one on cyclic esotropia.  A compendium from the Royal College of Ophthalmologists notes the role of non-surgical exercises for convergence insufficiency, distance esotropia and symptomatic phorias.  You would think that the sandwich approach might be a natural subject for a group like PEDIG to study, and as collaboration in clinical practice grows this may occur one day.


In building the sandwich approach I’m reminded of the need for “entente cordiale” in the early treatment of squint (the British term for strabismus), as related in this classic 1977 article in which Pigassou wrote: “Orthoptic treatment has its place in the current therapy of all functional and developmental troubles. The principles are the same as those on which the treatment of the other functions is based, and in particular the troubles of general motricity. It is virtually possible to transpose the directives of Bobath on the early treatment of cerebral palsy to the early treatment of squint, keeping in mind that in cerebral palsy there are organic lesions and that in squint in normal children the perturbation has a functional origin.”

Perhaps the greater impetus for entente cordiale these days actually stems from the drive toward strabismus treatment in adulthood.  Consider this perspective on adult strabismus published by the American Academy of Ophthalmology:  “In the management of adult strabismus, the detailed sensory assessment provided by an orthoptist is crucial in determining the prognosis for achieving or maintaining single vision. The orthoptist can also assist in determining prism power when treatment with prisms is indicated, can offer eye exercises to build fusional amplitudes when appropriate, and can provide accurate strabismus measurements for surgical planning when muscle surgery is indicated.”

A landmark paper authored by McBain and colleagues makes it clear that much remains to be learned about bridging the gap between clinical criteria for success in strabismus and how patients feel about their outcomes.  We believe that the sandwich approach may hold the key in that regard.

One thought on “The Sandwich Approach to Vision Therapy and Strabismus

  1. Great post, Dr. Press. Vision therapy and strabismus surgery are both possible tools to be used in the treatment of strabismus. For practitioners arbitrarily to exclude either tool, however heartfelt that practitioner’s biases, is unfortunate. The arguments between proponents of surgery and therapy date back to the time of Javel in the 19th century. Since then, both surgical techniques and therapy procedures have changed dramatically. Instruments such as VTS4 and the virtual reality Vivid Vision are revolutionizing therapy. And personally I have seen profound changes in cosmesis and performance after a combined surgical and therapy approach. We can look forward to a future in which practitioners work together to enhance how patients both look and see.

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