What Is Adult Strabismus?

Most strabismus occurs in children and is treated by pediatric ophthalmologists. But the condition, which is characterized by a misalignment of the eyes, can be present in adults, too.

“Adults can develop strabismus and double vision from a variety of causes that are different from what occurs in children,” explains Prem Subramanian, MD, PhD, professor and Clifford R. and Janice N. Merrill Endowed Chair in Ophthalmology at the University of Colorado School of Medicine. “Those of us who specialize in taking care of adults often have a different perspective and skill set because the needs are a little bit different.”

In the newly developed Unified Adult Strabismus Clinic at the Sue Anschutz-Rodgers Eye Center, Subramanian and Emily McCourt, MD, associate professor and the Ponzio Family Chair for Pediatric Ophthalmology, combined their experience and specialty to enhance patient access and streamline care for various patient populations.

“We wanted to amplify the care and expertise in a way that made sense for our patients, and this clinic does that by addressing the various needs that adult patients and patients who are transitioning into adult care may have,” Subramanian says.

In this interview, Subramanian explains what adult strabismus is, how diagnosing and treating adults differs from pediatric cases, and why specialized care remains so important:

What are the major ways in which adult strabismus differs from pediatric cases?

Most pediatric strabismus is either something a child is born with or is a consequence of something with the eye, such as being very far sighted. This means there's a smaller group of diagnoses that children typically have. They present at a typical age with a typical syndrome of moderately crossed eyes that can be more obvious when they look at close objects. The approach to taking care of those patients is well established, and there are lots of guidelines around how to do that.

With adults, it’s a much broader range of problems that may lead to the development of strabismus and double vision, which is a symptom adults experience more than children. Children often develop something called suppression, where the brain ignores one of the images, and so they don't see double. But in adults, the big issue is double vision.

Adult strabismus can happen because of a recurrence or an unmasking of the childhood type problems. But then there are other things that can cause strabismus in adults, which include systemic diseases like thyroid eye disease (TED) or myasthenia gravis, a neuromuscular junction disease that weakens the action of the extraocular muscles. They can develop it because of cranial nerve problems, such as tumors or other diseases that compress or infiltrate the cranial nerves.

People with diabetes or hypertension can get ischemia of the cranial nerves, and that can cause an eye movement problem. People who have multiple sclerosis can also develop strabismus and double vision that is different from that people in who have strokes.

Are there risk factors that are common among that broad range of conditions that may lead to adult strabismus and double vision?

Cranial nerve palsies tend to occur in patients over the age of 50, but there aren’t many risk factor connections that overlap among patients who have diabetes, high blood pressure, TED, myasthenia gravis, and other conditions.

In treating adult strabismus, we have to look at what might be an underlying cause, so there is an added layer of investigation into what might need additional care or treatment.

In addition to double vision, are there are common symptoms for adult strabismus?

Patients may noticed that their eyes are not aligned. They may look in the mirror and realize that their eyes aren’t where they should be.

Depending on the underlying condition, there certainly may be other symptoms as well. It’s not unusual that we see patients who only report double vision, but then we recognize that there are other things going on like eyelid drooping or weakness, and it helps lead to a more specific and correct diagnosis.

What does treatment look like for patients in your clinic?

Our goal in treatment is to help patients function more normally and not see double. Depending on the cause of the strabismus, treatment may vary.

Sometimes we utilize prism glasses when a patient doesn’t want surgery or doesn’t qualify for it.

Surgery and medications are often needed for underlying conditions and that can alleviate the double vision. I often tell patients, there's a diagnosis phase and a management phase, and that diagnosis phase is really important to ensure that we uncover the correct reason for why they have their strabismus before we go and do something surgically.

Beyond ocular health, are there other ways this condition can impact the patient?

Yes. Studies show that when strabismus alters a person’s appearance, they may experience a negative effect on their mental health and it interferes with social interactions. People often look at people who have strabismus as being different and that also has an effect.

This is another reason it’s important to get to the root of the condition and treat each individual patient according to their needs. As physicians we must recognize mental health as a part of care and the impact it has on the patient.