Adult Strabismus

Publication Date: September 23, 2019
Last Updated: March 14, 2022


Strabismus in adults has profound negative effects on quality of life and many aspects of day-to-day function. Strabismus surgery very often improves quality of life and function, and there are instruments to assess these aspects of evaluation and treatment. Patients with diplopia tend to have greatest improvements in functional domains, and nondiplopic patients tend to have greatest improvements in psychosocial domains.

Recessions of the restricted muscles are the mainstay of surgical correction in thyroid eye disease. Resection is generally avoided in restrictive disease out of concern for further reducing ductions and operating on a rectus muscle that would best be spared to provided ciliary artery supply to the anterior segment. However, it can be a useful adjunct in select cases, particularly when extremely large recessions have not fully corrected the alignment.

Screening for a history of childhood amblyopia or strabismus, checking spectacles for prism, and performing a cycloplegic refraction and cover testing are recommended for all patients undergoing refractive or cataract surgery, especially for those patients for whom monovision is planned. Patients with a history of childhood strabismus and suppression are particularly at risk for developing fixation switch diplopia. This form of diplopia results when the previously nondominant eye becomes the dominant eye as a result of intended or unintended monovision by refractive manipulation or cataract surgery. A trial of monovision with contact lenses is prudent prior to corneal or lenticular refractive surgery to determine whether surgically induced monovision will result in new-onset diplopia. The development of asymmetric vision loss from other common diseases such as macular degeneration, myopia with axial elongation in the previously dominant eye, or diabetic retinopathy when the nondominant eye is left with better acuity may also result in fixation switch diplopia.

Recommendation Grading




Adult Strabismus

Authoring Organization

Publication Month/Year

September 23, 2019

Last Updated Month/Year

July 28, 2023

Document Type


External Publication Status


Country of Publication


Document Objectives

Perform a clinical examination and ancillary testing as indicated to diagnose the cause of strabismus. Counsel the patient on the diagnosis and treatment options. Consult other medical providers if the diagnosis indicates the need for multidisciplinary management. Establish priorities in the goal-directed management of strabismus (improved eye contact and appearance of alignment, enhancing binocular potential, or reduction or resolution of diplopia and/or compensatory head posture. Inform the patient's primary care and other health care providers of the diagnosis and treatment plan. 

Inclusion Criteria

Female, Male, Adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Optometrist, nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D005128 - Eye Diseases, D013285 - Strabismus


Strabismus, cross-eyed, eye misalignment

Source Citation

Dagi, L. R., Velez, F. G., Holmes, J. M., Pineles, S. L., Archer, S. M., Strominger, M. B., … Kerr, N. C. (2019). Adult Strabismus Preferred Practice Pattern®. Ophthalmology. doi:10.1016/j.ophtha.2019.09.023

Supplemental Methodology Resources

Methodology Supplement


Number of Source Documents
Literature Search Start Date
February 1, 2017
Literature Search End Date
June 1, 2019