There was a day when physical therapy was considered a waste of money by physicians, and surgery deemed the only option for a muscle tear or broken bone. Today, we’re seeing the same dynamic with surgery for strabismus (crossed-eye).
Our colleague, Dr. Dominick M. Maino, is a developmental optometrist who blogs about the efficacy of vision therapy. His recent post about evidence-based medicine in regards to strabismus surgery outcomes was right on the money.
We emphasize that vision therapy should be the first course of action before pursuing a surgical option for strabismus, but many ophthalmologists disagree. Their position is that vision therapy doesn’t work, or that there hasn’t been any research to prove its efficacy.
There is research regarding vision therapy’s efficacy with strabismus, but what about surgery? Dr. Maino’s post looked to answer that question.
Show Us the Research
In his post, Dr. Maino referenced Cochrane Reviews, “an organization trusted to review the quality of research in health care and health policy. They are internationally recognized as providing reviews of the highest standards.”
The Cochrane reviewers tried to find randomized controlled trials (RCT) of any surgical or non-surgical treatment for intermittent exotropia. They reported that the current literature is “mainly retrospective case reviews and are difficult to interpret and analyze.”
The reviewers searched for data on other strabismus surgical procedures, and found either a lack of RCTs or inconclusive ones. That’s hardly a resounding argument in favor of surgery.
Dr. Maino then pointed to a study by Awadein A, et al, that stated that only 45 percent of children had successful outcomes at an eight-year follow-up, and that 20 percent of the children had to undergo repeated surgeries for the strabismus which were ultimately unsuccessful as well.
He also referred to a study by Pineles that noted “62 percent achieved only a fair or poor outcome and that 60 percent of the patients required at least one re-operation.”
Eye Doctors Need to Fast-Forward to the Present
As we’ve noted in previous posts, the entire visual system of a strabismic must be retrained to establish binocular vision, and that won’t happen with surgery.
Dr. Maino is reasoning (and being reasonable in the process) that vision therapy needs to be part of the process. When you consider the lack of conclusive research regarding the efficacy of surgery, his point bears serious consideration by parents and other medical practitioners.
But perhaps the most compelling argument for recognition of vision therapy as a critical part of strabismus treatment comes from this excerpt from the blog of Dr. Len Press: “...for those not young enough to remember… there were serious schisms between orthopedic surgeons and physical therapists. If you went to an M.D. for an opinion about an injury such as a muscle tear or broken bone, you would essentially be told you either needed surgery or you didn’t. Doing physical therapy was a waste of time and money, and there wasn’t sufficient research to support it. If you consulted a physical therapist you would be given advice on a non-surgical approach to rehabilitation, and be cautioned about the invasiveness and lack of predictable outcomes of surgery…”
In one camp, you have a group of eye doctors refusing to accept therapeutic practices, similar to the way doctors used to turn up their noses at physical therapy. How many potentially unnecessary surgeries must occur before the medical community realizes it is making the same mistake all over again?