Our colleague Dr. Dominick Maino posed an interesting question on his blog:  If 33% of patients are strabismus surgery failures, are they suffering a decrease in their quality of life as well?

Dr. Maino was responding to this recent study regarding “Changes in health-related quality of life 1 year following strabismus surgery.”  Strabismus is the technical term for an eye turn, and is commonly referred to as “crossed eye.”

According to the results section of the abstract, “For patients successfully aligned at both 6 weeks and 1 year (n=51), further improvement in median scores was seen from 6 weeks to 1 year for both the psychosocial scale (83.8 vs 93.8; P<.0001) and the function scale (72.5 vs 77.5; P=.007). Also, a greater proportion exceeded limits of agreement at 1 year than at 6 weeks (psychosocial: 48% vs 30%; P=.007, function: 67% vs 51%; P=.01).”

In other words, in a successful surgery, the patient’s quality of life improved.  But what happens if the surgery is not a success? (i.e. more surgeries are needed)

“For patients who became partial success (n=18) or failure (n=4) at 1 year there was a numerical decrease in scores at 1 year,” was reported in the abstract.

The quality of life “took a nose dive” for patients with failed strabismus surgery, according to Dr. Maino.  He notes that what is particularly troubling is that “a review of the literature (or search his blog) indicated that about 1/3 of those who have strabismus surgery fail (or need another surgery).”

Why does quality of life suffer?  It’s relatively simple:  When your visual function doesn’t improve after a major surgery, you’re going to get frustrated, right?  This happens, even after “successful” surgeries. While there may be cosmetic changes, a person’s visual function won’t experience significant improvement.  

How to Improve Your “Functional Vision”

The natural inclination with strabismus is to address the cosmetic appearance of a crossed eye, or an eye turn.  Parents will meet with an ophthalmologist, who will recommend operating on the eye muscles.

However, even if the cosmetic surgery works (which, as Dr. Maino points out, is far from a certainty), nothing is being done to deal with the underlying functional vision problem:  The patient still has a problem with space perception.

We gave a detailed explanation of functional vision and how it affects space perception in a previous post on performance lenses.  “Having good vision is more than just seeing 20/20.  Visual skills such as eye teaming, tracking and focusing are part of your functional vision, and should also be addressed.”

With a strabismic patient, improving functional vision is based on a single premise: The strabismus exists because the patient is not utilizing their vision optimally: We must get the eyes to both look at the same place in space. Here are some key components of how this improvement can be achieved, as was detailed in a previous post on strabismus treatment with vision therapy:

1. Approach each eye individually.  In strabismus, visual skills are often very different between the two eyes. Working to equalize visual skills in the two eyes leads to improved function and can set the stage for improved eye teaming.
2. Improve visual processing in the strabismic eye.  The brain typically stops using information in the strabismic eye, which is called suppression.  Vision therapy can improve the brain’s use of information from the strabismic eye so that it will eventually become easier to use the two eyes together.
3. Emphasize peripheral vision. Two major pathways exist between the brain and the eyes for processing.  Central vision picks out details, and peripheral vision is used for background and spatial information.  Vision therapy works towards efficient use of central and peripheral vision to make it easier to use both eyes together.

With this approach, we can improve the functional vision, and in many cases, improve the eye turn without invasive surgery.  This brings us to one of the most important reasons for this post:  The reason why you should consider vision therapy first.

What’s the Rush to Surgery?

Considering Dr. Maino’s reflections of the recent study, parents may want to consider the order in which they approach treatment for strabismus.  

We’re not suggesting that you abandon any surgical procedures to correct strabismus.  That’s an individual decision, and should be made on a case-by-case basis. 

We are, however, recommending that in each and every case, vision therapy be the first course of action.  For any parent, here are the appealing reasons:

• Vision therapy is non-invasive.  With no serious side effects or complications to consider, vision therapy makes the most sense as the first line of treatment.
• More than one surgery may be required.  In many cases, the solution for an unsuccessful strabismus surgery is to cut again.  Sue Barry, a neuroscientist who benefited from vision therapy, had repeated unsuccessful operations as a child.
• Vision therapy corrects the underlying problem.  Even if the surgery manages to correct the eye turn, that doesn’t mean the patient’s vision is corrected.  Without improved functional vision, it’s possible for the strabismus to return – thus the need for repeated surgery.

With vision therapy, you address the underlying issue:  Improved utilization of vision.  If visual function is improved, the eye turn may improve without surgery and, if it doesn’t, will most likely make any medical procedure more effective.

Really, shouldn’t that be our goal – to find the most effective medical procedure for people suffering from vision problems?  If we’re going to conduct studies on quality of life improvements after surgery, then we need to give proper weight to all the data – and for the good of the patients, act accordingly on it.