Isn't strabismus just a cosmetic problem?

Strabismus is more than just an aesthetic issue, as it can interfere with visual development in childhood.

This is a common question. The short answer is "No!" Want the the longer answer? Here are five reasons why:

1. Strabismus, or eye misalignment, in children can cause amblyopia, or poor visual development, in the eye that isn't straight. This can be so severe as to cause permanent, severe vision loss. Fortunately, if detected, it can be treated effectively and reversed.
2. Strabismus in children can prevent the natural development of something called "binocular fusion," a process in which the eyes learn to work together, so to speak. In the first year or two of life, the neural connections between the eyes and the brain are rapidly developing, and the brain learns to put the images produced by both eyes -- images which are similar, but not identical -- into one single image. This process allows us to develop depth perception. Strabismus very commonly inhibits this.
3. Strabismus in adults typically causes diplopia, or double vision. It's easy to understand why: if the eyes are looking in different directions, they will produce different images, which the adult brain will see as double images. Want to know what that's like? Cross your eyes and walk around for a few minutes. It's decidedly unpleasant!
4. Strabismus surgery, because it is not cosmetic, is covered by medical insurance.
5. Strabismus in our society is unfairly associated with things like reduced intelligence and diminished potential for success in the workplace. Below is a review of the scientific literature on the negative societal implications of strabismus:

• A 2001 study published in the Journal of the American Association for Pediatric Ophthalmology and strabismus allowed children to play with "normal" dolls and dolls that had been made to have strabismus. They were questioned after 10 minutes of play. Grade-school children were 73 times more likely to express a negative bias toward the dolls with strabismus. PubMed link
• A 2003 study published in Acta Ophthalmologica Scandinavica showed photographs of the same children with and without strabismus to 30 elementary school teachers. Kids with strabismus were considered by teachers to be more unhealthy, less hard-working, and less happy. They were also felt to be less likely to be accepted by their peers and more likely to have difficulty learning. PubMed link
• A 2000 study published in Ophthalmology showed photos of the same job applicants, both with and without strabismus, to potential employers. Women with strabismus were less likely to be considered for the job compared to women without strabismus. Strangely, this unfair bias was not seen toward men with strabismus. PubMed link
• A 2008 study published in the British Journal of Ophthalmology interviewed 40 dating service agents, and 92.5% of them felt that a client having strabismus would make it more difficult to find a partner. Among facial disfigurements, only very prominent acne or a missing tooth had a greater negative impact. PubMed link
• A 1993 study published in the Archives of Ophthalmology interviewed 43 teens and adults that had strabismus in childhood which was not corrected. Over 1/3 of them reported that their friendships had been moderately to severely affected, particularly friendships with the opposite sex. 84% reported that their strabismus interfered with school, work, and/or sports. Sadly, 50% said they had experienced ridicule or abuse because of their eye misalignment. The majority said it had a negative impact on their self image, and 1/3 made some attempt to hide their strabismus, with their hair, head position, or sunglasses. PubMed link

In sum, strabismus is much more than just a cosmetic problem. It has a significant impact on people's vision and quality of life. And it can be fixed! Helping patients fix their strabismus is one of the most gratifying parts of my job.

What do you think? Have you had strabismus and realized it's much more than a cosmetic issue? Have you treated patients who had been told previously that this was the case?

Special thanks to Dr. Scott Larson, MD, for compiling these scientific papers. Dr. Larson, a mentor and friend, is a pediatric ophthalmologist at the University of Iowa. His excellent website can be found here.