Adult Strabismus

Publication Date: February 12, 2024
Last Updated: February 16, 2024


Strabismus in adults can have profound negative effects on quality of life and many aspects of day-to-day function. Patients with diplopia have greatest improvements in quality of life functional domains, and nondiplopic patients have greatest improvements in quality of life psychosocial domains. Instruments such as the ATS20 help measure these changes. (, , )

Recessions of restricted muscles are the mainstay of surgical correction in thyroid eye disease. Resection, or plication, is generally avoided in restrictive disease out of concern for further reducing ductions. These options can be a useful adjunct in select cases, particularly when extremely large recessions have not fully corrected the misalignment. (, , )

A variant of divergence insufficiency esotropia called sagging eye syndrome results from aging and weakening of circumferential supportive bands between the superior and lateral rectus muscles. The superior rectus shifts medially and the lateral rectus shifts inferiorly, resulting in esotropia with diplopia at distance and, occasionally, very modest vertical misalignment. Facial aging with associated blepharoptosis and deep superior lid sulci are commonly present. Sagging eye syndrome, along with other causes of divergence insufficiency esotropia, is a very common cause of acquired binocular diplopia in patients presenting between 60 and 80 years of age, is more frequent in myopes, and, as with other types of divergence insufficiency esotropia, is well managed with prism or strabismus surgery. (, , )

Iatrogenic binocular diplopia after eye surgery is rare but may result from anesthetic toxicity to the extraocular muscles, direct muscle damage during blepharoplasty, local adjacent scarring associated with pterygium excision, or mechanical restriction from implanted hardware (scleral buckles, glaucoma plate reservoirs, plates repairing orbital fracture). Diplopia persisting after several months warrants referral to a strabismus specialist. (, , )

Binocular diplopia may occur after cataract or refractive surgery due to the following:
(1) Unrecognized strabismus (check spectacles for prism correction and perform cycloplegic refraction)
(2) Fusional challenge associated with choice of monovision
(3) Fixation switch diplopia in patients with a history of childhood strabismus and suppression, and cataract or refractive surgery. This has result in better vision in the previously suppressed eye. (, , )

A trial of monovision with contact lenses may determine whether surgically induced monovision will result in new-onset diplopia. Asymmetric vision loss from other common diseases such as macular degeneration, epiretinal membranes, 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.

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Recommendation Grading



Adult Strabismus

Authoring Organization

Publication Month/Year

February 12, 2024

Last Updated Month/Year

February 19, 2024

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 LR, Velez FG, Holmes JM, Archer SM, Strominger MB, Pineles SL, Paysse EA, Pihlblad MS, Atalay HT, Campolattaro BN, Chang YH; American Academy of Ophthalmology Preferred Practice Pattern Adult Strabismus Panel. Adult Strabismus Preferred Practice Pattern®. Ophthalmology. 2024 Feb 12:S0161-6420(24)00013-7. doi: 10.1016/j.ophtha.2023.12.040. Epub ahead of print. PMID: 38349303.

Supplemental Methodology Resources

Methodology Supplement


Number of Source Documents
Literature Search Start Date
January 1, 2023
Literature Search End Date
April 1, 2022