Can Pre-Surgical Vision Therapy Enhance the Outcome of Strabismus Surgery?

Here is Cassandra. At age 32, after having three failed eye muscle surgeries, one at 18 months of age, the second at 17 years of age, and the third when she was 21 years old, she decided to try for a fourth time. She was growing weary of people making snide remarks about her misalignment, but by this time was insightful enough to realize that she had to do something differently than she had in past. Otherwise, the outcome wasn’t likely to be any better than her current state of a 35 prism diopter right exotropia.

Sure enough, the fourth time was a charm. Here she is with her before (R) and after (L) photo, the after being her status six months post-surgery. As you can see, her ortho position has held steady.

I don’t know Cassandra. I only know of her, through her post on the “Adult Amblyopia, Lazy Eye and Strabismus Information Forum” on Facebook, which has nearly 5,000 members. So what did she do differently the fourth time around that enabled her to have such a good outcome? She believes that it was the six months of optometric vision therapy she did prior to surgery. She describes that she was panoramically viewing at the outset and that prism helped jump start her therapy.

So is there any basis for Cassandra’s claim? Actually, there is. Way back in 1951, the ophthalmologist Richard Scobee authored a manual for use by physicians on Disturbances of Ocular Motility, which was published by the American Academy of Ophthalmology and Otolaryngology. Regarding strabismus surgery he wrote (page 60) that some form of fusion is attainable in approximately 50% of patients, but that the addition of formal orthoptics to the therapeutic regimen improves the success rate to 80%.

It’s fair to say that over time surgeons gravitated away from this approach. Patients like Cassandra were left to fend for themselves. Discovering the potential for optometric vision therapy (orthoptics on steroids) to better pave the way in the brain for sensory processing that would support the new motor alignment would mostly occur serendipitously. That is something that Sue Barry addressed in Fixing My Gaze.

In 1993, in a chapter on strabismus co-management that I co-authored with a surgeon, Dr. Brian Altman in Clinical Pediatric Optometry, we wrote: “If extensive vision therapy had been done prior to surgery, particularly if a centration range had been established in esotropia or a compensated exotropic angle had been sensorially massaged through lenses, prism, or instrumentation, a good postsurgical result is anticipated.”

In Applied Concepts in Vision Therapy 2.0 (page 118) I cited an article written by Dr. Frederick Brock (of Brock String fame) stating that the orthoptist (the term he used for any practitioner administering vision therapy) should exhaust all available means, including strabismus surgery, to reestablish binocularity. Brock went so far as to state that patients with strabismus whose only form of seeing was anomalous correspondence rarely respond to means other than lenses, surgery, or both. I acknowledged in that chapter that finding a surgeon with whom to co-manage strabismus cases is not an easy task,

As a model of that collaboration I cited the co-management relationship between our VisionHelp colleague Dr. Nancy Torgerson and Dr. Thomas Lenart. Several years ago I reproduced an interview between these two doctors conducted through Elsevier’s Practice Update Eyecare. In a subsequent VisionHelp blog entry I wrote the following:

“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.”


The optometrist with whom Cassandra did her six months of vision therapy prior to the surgery that finally gave her a stable outcome was Dr. Jenna McDermed. Robert Nurisio, a masterful COVT, interviewed Dr. McDermed for his Sit Down blog in 2014, which resulted in the following exchange:

Switching gears a bit, the treatment of strabismus tends to be a polarized topic between Ophthalmology and Developmental Optometry, and one that seems to perpetually be in the forefront. Some Developmental Optometrists seem to view strabismus surgery as a valuable tool when done in conjunction with Vision Therapy, and others feel differently. Where are your thoughts on the matter?

I truly feel that every patient that walks through my door has a unique story, and so I approach each case and treatment recommendation in this way.  As Developmental Optometrists, we are in a unique position that we have many tools that we can access when addressing the needs of our patients.  For most of us treating strabismus (eye turns or misalignments), these tools include lenses, patching, surgery, & vision therapy.  Not only that, but within the vision therapy room we can take different approaches to the treatment, including vestibular & motor based therapy, ocular-motor & orthoptic based training, and sensory-based training.


With all of these tools at our disposal, why would we want to limit ourselves to just one or two treatment strategies?  However, it is extremely important for parents to understand that surgery is no magic bullet.  In fact, it can come with complications that can sometimes inhibit the visual learning process in the therapy room, and it’s not unusual for patients to require multiple surgeries.  Even when the child’s eyes look straight after surgery, if the underlying developmental dysfunction is not addressed, the child may still have significant visual difficulties that remain, sometimes undetected.  However, I believe that it has its place in cases when the patient’s or doctor’s goals aren’t met with vision therapy alone.”

That sums it up nicely.

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