Is anyone else sick of the overly biased opinions of optometrists and ophthalmologists claiming that only their methods can truly fix a lazy eye (strabismus)? It can leave those of us with strabismus confused, frustrated and defeated, but it doesn’t have to. I have been in the strabismus world long enough that I have discovered that the truth lies somewhere in the middle, let me help you find it too!
So should you choose strabismus surgery or vision therapy to fix strabismus? Surgery is generally necessary for children born with constant strabismus, those seeking cosmetic alignment alone, and for eye turns over 15pd. Vision Therapy is required to gain binocular vision (both eyes working together) and generally can work without surgical intervention for intermittent strabismus and constant strabismus that is less than 15pd.
For straight eyes that work seamlessly, many children and adults with strabismus will need vision therapy, surgery and more vision therapy to truly fix the problem.
Because strabismus varies extensively from person to person, it is important to look everything from eye function at birth to the desired end result.
Download and take this fun quiz that may help you make the decision! I am not a doctor, it is just a great way to look at the possibilities! It is super simple, just press play and click the buttons that describe you.
If you want the explanation version, read on…but prepare yourself, I’m about to drop a bomb…
Strabismic Eyes Do Not Work Together Effectively…or at All
Strabismus means that the eyes are not pointing in the same direction. There are several causes, but the point that I want to drive home is that if your eyes look like this, they aren’t working properly.
Most people with strabismus have no 3D vision and live in a flat world. I have experienced both 2D and 3D vision and I am here to say that they are NOT the same. I had no idea that I only had 2D vision. The thought had never occurred to me.
Understanding this deficiency is so important as you decide whether to pursue vision therapy or surgery.
Many strabismic adults have adjusted to the 2D world and feel like they aren’t missing anything. Their brain most likely suppresses one eye and they just want their eyes to be cosmetically straight. Surgery is a great option for these people. The success rate is around 70% for cosmetic alignment with strabismus surgery.
Surgery alone, is mostly cosmetic, although having the eyes more aligned will improve peripheral vision in most cases and can restore binocular function in rare cases. My surgeon told me that surgery resulted in this only 2% of the time, definitely not something to plan on.
The surgery will not magically make your eyes work together, especially if they never have before. The brain must be taught to use the images from both eyes to create a 3D world.
This isn’t just a fun, cherry on top. Binocularity effects reading, writing, balance, coordination, and pretty much every aspect of life. It also is the glue that keeps the eyes straight so that they don’t keep wandering over time, as is common with strabismus.
“I was monocular. I had been in two-dimensional ignorance all these year and had no idea what I was missing.
Was my ignorance bliss?”
Susanna Zarayksky – One Eyed Princess
When I discovered that I was only seeing in 2D, I was shocked, embarrassed, and appalled. Why had no ophthalmologist or optometrist ever bothered to mention this to me before? I felt betrayed.
I also felt determined to teach my eyes to work together. I realized that the reason my eye kept drifting further and further out was that I wasn’t using it. My monocular (one eye) vision explained the eye turn, the difficulties with driving at night and depth perception issues.
Seeing with both eyes has become my obsession and quest as you can tell by this website. I have even designed some of my own activities and exercises to help along the way. Vision therapy is my new favorite thing.
I understand that not everyone feels this way. Some people are perfectly fine in the 2D world.
What Result Are You Seeking?
Before you decide whether to pursue surgery or vision therapy, you have to decide what result you are going for or what result you want for your child.
Are you working towards 3D vision? Do you want your eyes to work together? This is a decision that only you can make.
There is no right or wrong answer, but it is something that you should research and fully understand before deciding.
Cosmetically Straight Eyes
If you are just going for cosmetically straight eyes, surgery (sometimes multiple) will be the easiest path to take. Not that surgery is a walk in the park, but it definitely is faster if you aren’t worried about the eyes working together.
3D Vision
For those who want binocularity for yourself or your child, extensive vision therapy will be part of the process. Sometimes that process will also require surgery. Many times it involves vision therapy, then surgery, and then more vision therapy for a full treatment.
It definitely requires the care of both an expert Developmental Optometrist and an Ophthalmologist who specializes in Strabismus Surgery. Finding two that don’t fight like cats and dogs might be more challenging than fixing the strabismus. But do your research and find professionals that you trust that can guide you on the journey.
The rest of this article is geared towards those who are seeking binocular vision.
Early Childhood Considerations
It is important to look at your early life, or the life of your child to understand how to approach teaching the brain to effectively use the eyes together.
Were Eyes Misaligned From Birth?
When did the eyes start to turn? Was it from the time you were an infant or was it later in life? If the eyes were severely misaligned from birth, surgery is almost always required to align the eyes and for vision therapy to be effective. Having surgery early on can help keep both eyes at least working together peripherally until the child is old enough for vision therapy.
Many times, though, the eye turn comes on later. In these cases, it is likely that the brain has used both eyes and can relearn to use them both through vision therapy without the help of surgery.
Have you or Your Child Ever Passed a Stereo Acuity Test?
These stereo acuity tests are able to see if the eyes are working together. I took my first one at age 3 and got a big fat 0. This means that I’ve never had stereopsis (using both eyes). It also means that we had to start from ground zero and completely build the binocular function in my brain. No stereo definitely promises a longer road in vision therapy.
If there was a time that you or your child had stereo acuity and then lost it, that is great news! It means that the brain has the ability to see in 3D, it just needs some training. Relearning is always much easier than learning for the first time.
Vision Therapy will be extremely effective in cases where stereopsis was present at some point in life, if this is you, consider yourself lucky, the chances of needing surgery decrease significantly.
Looking at your history with strabismus can definitely give you an idea of what to expect in the future.
There are other things to take into consideration about what you are experiencing right now. Let’s consider a few.
Is the Eye Turn Constant or Intermittent?
For constant exotropia (eye turns out) or constant esotropia (eye turns in) that is greater than 15 diopters, surgery is more commonly needed for vision therapy to be effective. That’s not to say that there haven’t been hundreds of success stories for strabismics with turns over 15.
But I can tell you that doing vision therapy with a 35 degree turn required me to always think about straightening my eye. It hurt and exhausted me and took concentration. I thought that that was normal. Now that my eyes are closer to being aligned, I don’t have to think about straightening them to have success with my exercises. I can focus on relaxing and opening my peripheral instead of thinking about making my eyes straight.
Before Surgery Relaxed 
Before Surgery Focused 
After Surgery Relaxed
Intermittent strabismus is different because sometimes the brain uses both eyes and then many times when the person is tired or stressed the eye goes in or out. These cases are much more straightforward and many times just require exercise and training to keep the eyes straight all the time.
This is especially common when one eye has much worse vision, amblyopia.
If you or your child has intermittent strabismus, I would not, personally, consider surgery until after at least 6 months of vision therapy. Every case is so different and many times, vision therapy is enough to get the eyes working together consistently.
After time in vision therapy, you will have a better feel for how well it is working. Surgery might still be necessary, but hopefully not!
Are You or Your Child Experiencing Double Vision (Diplopia)?
Double vision, diplopia, can be caused by a wide range of ailments. Stroke, head injuries or tumors can all lead to diplopia that is caused later in life. These cases generally take help from multiple medical disciplines working together like vision therapy, physical therapy, occupational therapy and sometimes surgical interventions.
Other times, diplopia is a result of misaligned eyes. In order for the brain to fuse the images from both eyes, they need to be pointing straight. When the eyes aren’t aligned, strabismus, the brain sometimes suppresses, or ignores one of the eyes. Other times the person just sees two different images.
Ophthalmologist, David Sami, explained, “In order to achieve perfect cosmetic alignment, your child will need to undergo two or three eye surgeries. When considering binocular cure, the patient or parent needs to understand that if after the surgery, the eyes are not perfectly straight, then the eyes cannot function as one organ. At the end of the day, the main objective of the surgery should be to make the eyes work more effectively together and then look better.” Read full article here.
Unless the surgeon gets the eyes exactly straight, the diplopia is not likely to go away. The surgeon can get the eyes closer to being straight, but in-office vision therapy will definitely be required to get those images to fuse. And it is absolutely possible.
Are You Willing to Do the Work?
This is an extremely important to ask yourself.
Strabismus is not a quick fix. There is no easy answer, unfortunately.
If you choose to go with surgery alone, plan on it taking multiple surgeries (usually 2-3) up front with maintenance surgeries every 10-20 years to keep the eyes looking cosmetically aligned. Also plan on struggling with depth perception, night driving, and disorientation.
Gah, strabismus is such a pain!
If you choose to go the vision therapy route be prepared for 1-2 years of in-office visits and daily home exercises. You will be on the most wild rollercoaster of your life. The magical euphoria of seeing in 3D the first time is unforgettable and makes the nausea, headaches, dizziness and self doubt worth it.
Each time you regress, fail at an exercise or trip over your own feet, you’ll wonder what in the world you’ve gotten yourself into.
Each time you discover intricacies like the texture of a flower or expanse of snow fall, the determination that started the journey will be renewed.
After a year of vision therapy, you may find yourself on the operating table like I did. While there were moments that I felt like I had failed, I also felt this strong realization that choosing to combine vision therapy and surgery was the perfect option for me.
Decide in advance that you are in for all of it. You were made for this.
So What?
Strabismus is a complicated, neurological disease. Each case is unique and every person responds differently to surgery and vision therapy.
My advice is to find yourself an amazing, developmental optometrist who is open to surgery and try vision therapy first. Go to www.covd.org to find a specialized optometrist near you.
Also, find an ophthalmologist who specializes in strabismus surgery. Shop around for one that wants to help you achieve binocular vision with vision therapy, they do exist. The surgeon looks at strabismus from a completely different angle and their opinion is an important one to consider, but be aware that they almost always suggest surgery.
After you have your doctors, go all in. Push yourself to the the limits with your vision therapy home exercises and give it your all. Then buckle up for the most incredible experience of your life, 3D vision.
If the time comes when surgery is necessary, you will know and your optometrist will know. You are not a failure, your journey just happens to include surgery.
You will be amazed at the difference it will make to have your eyes aligned when you go back to vision therapy after surgery, well after the initial 2 months of adjustment and healing.
If you still don’t know what to do, you can take the Quiz that I made to help you decide! I go through so many different options like previous surgeries, angle of deviation, age and end goals and help narrow down your options. All you have to do is click the buttons that describe where you’re at and I’ve done the rest.
No matter what you decide to do, own your choice and embrace it. Don’t look back, don’t second guess yourself, it will only slow you down!