What New Grads Need to Know About Strabismus


As a new grad, you should feel like you have a well-rounded education and are prepared for anything that walks through your door.

However, there are always going to be a few things that make you a bit uncomfortable. I often hear from my colleagues that don’t deal with binocular vision issues on a daily basis that “strabismic patients make them nervous.”

This review will help remind you of the most important aspects to identify in your patients with strabismus so that you can discuss appropriate treatment options with your patient, even if you don’t provide them.

What makes a good doctor is not being able to treat everything; rather, being able to identify, work-up, educate and then provide the best treatment options to your patients, even if that means referring them out!

1.  Case History

This is by far the most important aspect of learning about the patient and the potential etiology of the strabismus.

You want to ask the following questions:

  • Onset – this is a really important question; if it is new onset in an adult, you will want to rule out a systemic etiology.
  • Presence of diplopia, ‘tired eyes’ or other symptoms that might tip you off that they have an issue.
  • Systemic health (hypertension, diabetes, etc…)
  • Family history
  • Any prior treatment

2. Visual Acuity

Test this at distance and near.

If amblyopia is also present, remember to test both single letter acuity vs. whole line.

3. Cover Test

This determines the type, magnitude and constancy of the deviation.

Start with unilateral cover test then move to alternating. If you have the equipment you can measure it with a prism bar… if not, make an estimation.

4. Level of Stereopsis

If you have the proper equipment, test for level of stereopsis as this will give you a good indication of how your patient is functioning.

This includes Worth 4 Dot for presence of flat fusion, Wirt Circles (local stereo) and RDS (global stereo).

5. Complete your regular “eye doctor stuff”

This includes a refraction to achieve the best corrected visual acuity. Additionally, a slit lamp exam and dilation should be completed to rule out any pathological etiology.

It should go without saying that this workup doesn’t include everything, but it will give a good picture of how your patient is functioning with their strabismus in a very short amount of time.

With this information you’ll be able to discuss with your patients what the treatment options are and which is best suited for them.

Treatment Options Can Include:

1) Compensatory prism

For example: patients with divergence insufficiency or vertical deviations often find a lot of relief with a little bit of prism in their glasses.  Determining the amount of prism is a matter of the size of the deviation, the patient’s fusional ranges as well as their sensitivity.

I recommend trial framing the prescription and having the patient wear it and walk around the office to ensure success with your prism prescriptions.

2) Referral for vision therapy or surgery (if warranted)

Make sure you know which of your colleagues perform vision therapy so you can make the appropriate referral!

3) Monitoring

Sometimes if the patient is happy and is functioning just fine, you can choose to just monitor them.

You can also attend their annual meeting this year April 25-29 in Jacksonville, Florida!

Check out these COVD Resources:

  • Learn what COVD has to offer students and residents!
  • Sign up for your FREE COVD membership here!
  • Already a member of COVD? Access programs and benefits here.
  • Come experience the ‘COVD Family’ in person this April–Travel Grants available!

About Miki Lyn DAngelo

Miki Lyn DAngelo
Miki Lyn D’Angelo, O.D. graduated with honors from the SUNY College of Optometry in New York, receiving the VSP Excellence in Primary Care and Excellence in Vision Therapy awards. She then continued her education by completing a residency in vision therapy and rehabilitation with Dr. Barry Tannen, OD. She has extensive experience in family eye care with a specialty and passion for pediatrics, vision training and neuro-rehabilitation with traumatic brain injury patients. She recently just opened a private practice cold with a partner on the Eastern End of Long Island. In her spare time she loves cooking and working on the farm with her fiancé.

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