The cost utility of strabismus surgery in adults

Strabismus Surgery for Psychosocial Reasons-A Literature Review

Introduction

Strabismus surgery may be undertaken for visual benefit, to improve or eliminate diplopia symptoms, or to restore or improve binocular single vision (BSV). In patients without visual symptoms or expected visual benefit, strabismus surgery may still be undertaken if the presence of strabismus causes the patient psychosocial symptoms. To evaluate strabismus surgery undertaken for psychosocial reasons, evidence of postoperative outcomes in this specific cohort is needed.

Methods

A systematic search of the literature was conducted (1946-2023) to identify evidence where postoperative outcomes were reported for adult patients (age 18 years and above) who had undergone strabismus surgery for psychosocial reasons.

Results

Sixty-nine papers were included in the literature review. Most sources of evidence included patients within heterogeneous cohorts of strabismus surgery outcomes, with a range of symptoms and differing surgical aims.

Discussion

In adults who underwent strabismus surgery for psychosocial reasons, improved postoperative ocular alignment and/or improved health related quality of life (HRQoL) were common. Strabismus surgery outcomes appeared to be measured satisfactorily at three months postoperatively. Additional surgical outcomes, including an expanded field of vision, unexpected BSV, improved binocular summation, improved task performance and improved eye movements have been reported, but not fully investigated. There was a lack of consensus on how postoperative success should be defined and measured. A core outcome set for strabismus has been suggested and there is potential to add to the available evidence by investigating which outcome measures are most relevant to those with strabismus and psychosocial symptoms. There is a growing need for robust evidence in this specific subgroup of patients due to a lack of evidence specifically reporting postoperative outcomes in adults with strabismus and psychosocial symptoms.

Medical expenditure for strabismus: a hospital-based retrospective survey

Background and aims

The misconception of the purpose of strabismus treatment has, on the one hand, affected the motivation of strabismus patients to seek care and, on the other hand, has resulted in strabismus not being covered by health insurance, both of which interact to limit the motivation of strabismus patients and also impose a financial burden on strabismus patients. Previous studies on the cost of strabismus had only addressed the cost utility and functional and psychosocial benefits of strabismus surgery. The aim of this study was to estimate the direct medical expenditure incurred for strabismus surgery and analyze the trend for the period 2014–2019 using the data collected by local eye hospitals in northeast China.

Methods

This study was based on 6-year strabismus medical expenditure data collected from the eye hospital of the first affiliated hospital of Harbin medical university, covering 3596 strabismus patients who had strabismus surgery. All medical expenditure data were adjusted to 2014 using China’s annual consumer price index to remove the effects of inflation.

Results

The average direct medical expenditure for strabismus cares (in 2014) was 5309.6 CNY (US$870.4), and the annual growth rates from 2015 to 2019 (compared with the previous year) were 9.3, 7.7, 21.7, 14.5, and 4.3%, respectively. Surgical expenses accounted for the highest proportion (33.1%) of the total medical expenses followed by examinations expenses (19.7%) and medical consumables expenses (18.7%). The regression coefficient for general anaesthesia was 1804.5 and age was less than 0.

Conclusion

The average direct medical expenditure for strabismus increases year by year, and the growth rate is rapid. Anesthesia was the most important factor increasing medical cost, and age was negatively correlated with cost.

Economizing strabismus surgery: Using half the double-armed suture for horizontal muscles

In a developing country like India, both availability and affordability of medical care are obstacles, leading to delay in seeking timely treatment. To reduce the cost incurred to the patients for strabismus surgery, we used half of a 6-0 polyglactin suture for performing common muscle weakening and strengthening procedures: a fixed and hang back recessions with plication and resection. We cut the 45-cm-long double-armed 6-0 polyglactin sutures in two halves, and with a modified approach, used one-half in each of two patients planned for monocular two horizontal muscles surgeries: fixed recession-plication and hang back recession-resection. By devising an intuitive manner of threading a single armed 22.5 cm suture we successfully carried out horizontal extraocular muscle surgeries on each of two patients of exotropia. We believe in the long run, this will reduce the cost to individual patients and sponsoring groups, and suggest that strabismus surgeons consider adopting this option.

Psychosocial impacts of adult strabismus and strabismus surgery: a review of the literature

BACKGROUND

Patients with strabismus may suffer from both reduced visual functioning and the psychosocial effects of ocular misalignment. For adults with strabismus, there is a strong body of evidence supporting the advantages of surgical restoration of binocular visual function. However, even in the absence of binocular visual potential, patients may benefit from reconstructive surgery to restore an aesthetically acceptable ocular alignment.

OBJECTIVE

To review the psychosocial implications of strabismus in the adult population and to summarize the psychosocial impact of surgical correction.

METHODS

A Medline search (1946-2013) was conducted to identify the psychosocial implications of strabismus, its effects on employment, and the impact of surgical correction on strabismic adults using the following keywords: strabismus, surgery, quality of life, life style, employment/employability effects, job satisfaction, social support/social isolation/social marginalization, adaptation, stress, depression, family relations, interpersonal relations, friends, and peer group. The search was limited to patients older than 18 years and studies published in English. Of the initial 87 articles for which abstracts were reviewed, 20 studies were of sufficient relevance to be included in the review.

RESULTS

Eight studies examined the psychosocial impact of strabismus, 2 of which explored the effect of strabismus on finding partners, and 4 studies examined the effect of strabismus on employment. These studies examined perceptions of both patients with strabismus and the general population. Eight studies evaluated the impact of strabismus surgery. Strabismus was shown to have negative psychosocial functioning and employability in both patients' and the public's perceptions. Surgical correction was associated with long-lasting improvement in psychological and social functioning.

CONCLUSIONS

There is a fairly strong body of evidence in the literature to suggest that adult strabismus patients suffer significant social, psychological, and economic effects because of their condition. Surgery can be effective in improving these disadvantages. Clinicians should be aware of the importance of offering surgery to patients with significant strabismus, even in patients for whom it is not expected to improve visual function.

One-Month Postoperative Horizontal Strabismus Surgery Outcomes Using Adjustable and Nonadjustable Sutures

INTRODUCTION

Previous series suggest adjustable sutures (AS) in adult strabismus surgery yield improved ocular alignment and better success rates compared to nonadjustable sutures (NAS). We questioned whether these differences are clinically significant and whether they justify the added time and discomfort required for AS.

METHODS

We reviewed all available records of adults undergoing horizontal strabismus surgery by the last two authors between 2000 and 2014. Independently, the two surgeons developed a preference for NAS midway through the study period, permitting comparisons between two treatment groups. Results were assessed at one to two months postoperatively. The primary outcome was alignment in primary position at one to two months postoperatively. The secondary outcome was success rate, defined as <10PD residual or consecutive deviation.

RESULTS

We included 184 patients, 68 with AS and 116 with NAS. No significant difference in primary position alignment at 1-2 months was noted between AS and NAS for esotropia (P = .26) or for exotropia (P = .10). Success rates were similar (P = .58 for esotropia and P = .34 for exotropia).

DISCUSSION

Although we acknowledge limitations in this retrospective study, our results suggest that AS overall was not associated with improved alignment or success rates, compared to NAS, at 1- to 2- months postoperatively.

CONCLUSIONS

Although adjustable sutures represent a valuable surgical option at the discretion of individual surgeons and their patients, we no longer routinely use AS in all adult cases. A prospective study to evaluate long-term outcomes would be helpful.

The Impact of Strabismus Surgery on Irish Adults

Aims:

Our primary objective was to evaluate our adult strabismus service and the impact strabismus surgery has on quality of life (QOL) in patients from an Irish cohort. Our secondary objective was to compare QOL outcomes across different subgroups.

Methods:

A service evaluation was prospectively performed over an 18-month period. We prospectively audited the preoperative and postoperative QOL scores from 35 adult strabismus procedures using the adult strabismus score (AS-20) (0–100).

Results:

Postoperative patients achieved an average 14.22 score increase in QOL (p = 0.0018). Females showed lower preoperative scores (46.78 vs. 60.89; p = 0.047) and a trend towards larger increases compared to males (21.05 vs. 51.12; p = 0.1). No significant difference was detected between primary and recurrent strabismus repairs (18.10 vs. 16.55; p = 0.4). Lower preoperative scores (0–33) were associated with higher increases compared with moderate (34–66) and high (67–100) preoperative scores (33.47, 12.03, –4.57 respectively). Patients reporting QOL score decreases after surgery were more likely to come from the high preoperative score group than the moderate or low groups (50%, 19% and 22% respectively).

Conclusion:

We demonstrate that strabismus surgery has a significant positive impact on QOL scores in Irish adults. We show that patients with high preoperative QOL scores may have a greater chance of QOL score decreases postoperatively, despite good clinical alignment. We believe greater preoperative discussion around patient expectations in these cases, may improve subjective postoperative results.

The Functional Benefits of Strabismus Surgery

When performed prior to visual maturity, strabismus surgery can result in the development or recovery of binocularity. When strabismus surgery is performed after visual maturity, the functional benefits of the surgery should be dichotomized according to whether the onset of the strabismus was before or after visual maturity. If the onset was after visual maturity, patients typically are diplopic. Specific success rates for eliminating diplopia vary according to the nature of the strabismus; however, overall the success rate is quite high. There is a common misperception that surgery in adults for strabismus that began prior to visual maturity is merely cosmetic. Numerous studies contradict this misconception. Even if the strabismus has been longstanding, most adults will experience some improvement in binocular function after strabismus surgery. In esotropic patients, this improvement typically takes the form of an expansion of binocular visual fields; however, some patients may also regain stereopsis. There are many psychosocial benefits to adult strabismus surgery. This is reflected in the finding that the majority of adults surveyed with strabismus would trade a portion of their life expectancy to be rid of their strabismus.

Clinical profiles and surgical outcomes of adult esotropia

OBJECTIVE

The aim of this study was to describe the clinical features and surgical outcomes of teenage and adult patients with esotropia undergoing strabismus surgery with adjustable sutures.

METHODS

Seventy-three patients were included in this retrospective, cohort study. Patients were stratified into group 1 (35 with childhood-onset esotropia [CET]) and group 2 (38 with adult-onset esophoria-tropia [EPT]). Preoperative immediate, 2-week, and 4-6-month postoperative measurements of ocular alignment, as well as fusional testing, were performed. Postoperative success was defined as distant (6 m) and near (33 cm) alignment within 12 prism diopters (PDs) of orthotropia in the primary position at 2 weeks and at 4-6 months with a single surgery.

RESULTS

Patients with CET more frequently had hyperopia and amblyopia and were more likely to present for surgery because of psychosocial strabismus-related problems. Patients with EPT predominantly had myopia and were more likely to experience diplopia and asthenopia. In group 1, the mean preoperative distance deviation improved from 30 PDs to 4 PDs at 2 weeks and to 4 PDs at 4-6 months (p < 0.001). In group 2, mean preoperative distance alignment improved from 22 to 3 PDs at 2 weeks and to 3 PDs at 4-6 months (p < 0.001). The mean objective, single-surgery success rate at 2 weeks was 88% and 97% in groups 1 and 2, respectively. At 4-6 months, postoperative success was 71% in group 1 and 80% in group 2. The majority of patients reported subjective improvement.

CONCLUSIONS

There are distinct preoperative differences between CET and EPT patients. Adjustable, strabismus surgery in this cohort is safe and effective in achieving subjective and objective success.

Health-Related Quality of Life (HRQoL) in Young Adults with Strabismus in India

INTRODUCTION

Strabismus has negative psycho-social and functional effects in adults. The impact can be minimised with surgery. However, in a low-income setting, it is important to evaluate the level of impact and prioritise the target population for intervention. The Adult Strabismus (AS-20) questionnaire is a reliable tool for assessment of Health-Related Quality of Life (HRQoL) in strabismic adults.

AIM

To assess the HRQoL in young adults with manifest strabismus through psychosocial and functional scores according to gender and direction of deviation using the AS-20 questionnaire.

MATERIALS AND METHODS

In this cross-sectional cohort study, 132 young adults who manifest horizontal strabismus were recruited and the AS-20 questionnaire was administered. Patient's demographic profile and type of strabismus were noted and compared with the overall mean scores of psycho-social and functional subscales. Data was analyzed using SPSS 21 and p-value less than 0.05 was considered statistically significant.

RESULTS

The participants comprised of 70 (53.03%) males and 62 (46.97%) females with a mean age of 24.5±3.57 years (range 18 to 38 years). The overall mean AS-20 score of young adults with strabismus was 61.62±12.61. The overall mean score for male and female were 65.54±13.53 and 57.68±13.46, respectively. Similarly, the mean scores for esotropes was 57.03±11.66 and 66.19±15.30 for exotropes. The overall mean scores were statistically significantly reduced (decreased QoL) in females as compared to males (CI 95%; p=0.002) and in esotropes as compared to exotropes (CI 95%; p=0.001). However, there was no significant difference between the psychosocial and functional score for all types of strabismus and genders (for all, p>0.05).

CONCLUSION

The Quality of Life (QoL) is affected through psychosocial and functional factors in adults with strabismus. Females and adults with esotropia faced greater difficulties in the QoL. We recommend clinicians to consider the impact on QoL while managing adult with strabismus.

Long-Term Quality of Life in Adult Patients with Strabismus after Corrective Surgery Compared to the General Population

PURPOSE

To evaluate the status of and factors associated with long-term health-related quality of life (HRQOL) in adult patients with strabismus following corrective surgery.

METHODS

Prospective cross-sectional study. A total of 122 adults who underwent corrective surgery and were followed up for at least 1 year were recruited. Pre- and post-operative HRQOL were evaluated using the Chinese version of the Adult Strabismus 20 (AS-20). Demographics and clinical characteristics were recorded. Eighty-nine age-matched, normal individuals without a history of strabismus were recruited as a control group.

RESULTS

AS-20 scores improved significantly in the psychosocial subscale and total scale after surgery for all122 patients, but not in the function subscale. HRQOL was better in the successful cases than in the non-successful cases (p<0.005). Subjects who recovered stereo function had better HRQOL than those who did not (p<0.01). Compared to the control population, the patients had poorer HRQOL post-operatively, with only approximately 30% of the subjects having scores within the normal threshold scores. The self-sense of a lack of ocular deviation and a successful surgical outcome were significant factors associated with post-operative HRQOL status.

CONCLUSIONS

HRQOL, as evaluated by AS-20 scores, improved in the patients after surgery but was worse than that in the general population. Successful surgical outcomes and a sense of good alignment were the main factors that correlated with increased post-operative HRQOL. Positive assessments of surgical results by patients may benefit post-operative HRQOL.

Gain beyond cosmesis: demonstration of psychosocial and functional gains following successful strabismus surgery using the adult strabismus questionnaire adult strabismus 20

Background:

Strabismus adversely affects psychosocial and functional aspects; while its correction impacts positively.

Aim:

The aim was to evaluate the gains in scores: Overall scores (OASs), psychosocial subscale scores (PSSs) and functional subscale scores (FSSs) following successful surgical alignment.

Settings and Design:

We evaluated changed scores in the adult strabismus 20 (AS-20) questionnaire, administered before and after successful surgery.

Materials and Methods:

Thirty adults horizontal strabismics, were administered the AS-20, at baseline, and at 6-week and 3-month. Group-wise analysis was carried out based on gender, strabismus type (esotropia [ET] or exotropia [XT]), back-ground and amblyopia.

Statistical Analysis:

We used Wilcoxon, and Mann-Whitney U-tests. Significance was set at P ≤ 0.05.

Results:

At baseline, there were no significant differences within the groups, except that those with amblyopia significantly scored less than nonamblyopes in OAS (median scores: 53.8 vs. 71.3; P = 0.009) and FSS (56.3 vs. 85.3; P = 0.009). OAS, PSS and FSS showed significant gains at 6-week and 3-month (all Wilcoxon P < 0.001). Compared with males, females showed significantly more gain at 3-month (OAS: 37.9 vs. 28.7; P = 0.02), on account of PSS gain (49.6 vs. 37.5; P = 0.01). The ET performed better than XT only on the FSS at 6-week (28.7 vs. 15.0; P = 0.02). Vis-à-vis the nonamblyopes, the amblyopes showed significantly more benefit at 6-week alone (OAS: 18.7 vs. 28.7; P = 0.04), largely due to gains in PSS.

Conclusions:

Successful strabismus surgery has demonstrated significant gains in psychosocial, functional and overall functions. There is some evidence that gains may be more in females; with a trend to better outcomes in ET and amblyopes up to 6-week.

Bifocals Fail to Improve Stereopsis Outcomes in High AC/A Accommodative Esotropia

PURPOSE

To assess whether stereopsis outcomes of patients with accommodative esotropia with high accommodative convergence/accommodation relationship (AC/A) were improved after treatment with bifocal glasses compared with single-vision lenses.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with high AC/A accommodative esotropia; evidence of stereopsis, binocularity (on Worth 4-dot testing), or improvement in near angle with +3.00 D lenses; and at least 4 years of records available for review, who were seen in the Department of Ophthalmology at Boston Children's Hospital between 2006 and 2014.

METHODS

Use of bifocal or single-vision glasses. Charts were reviewed retrospectively. Stereopsis was log transformed for statistical analysis. Linear (for stereopsis) or logistic (for surgery) regression was used to control for confounders.

MAIN OUTCOME MEASURES

Stereopsis at final follow-up, difference in stereopsis between final and initial visits, and progression to strabismus surgery. Secondary outcomes included final near and distance deviations.

RESULTS

Of the 180 patients who met inclusion criteria, 77 used bifocals and 103 used single-vision lenses. Bifocals did not improve stereopsis outcomes compared with single-vision lenses. In both groups, stereopsis was similar at the initial and final visits, with similar improvement in both groups. Children in the bifocal group had a 3.6-fold higher rate of strabismus surgery than children in the single-lens group (P = 0.04.) Additionally, children in the bifocal group had near deviations 4 PD larger than those with single lenses at final follow-up, even after controlling for age and initial deviation (P = 0.02). These results did not change if surgical patients were eliminated or in the subgroup with initial distance deviation of 0 PD in full hyperopic correction.

CONCLUSIONS

Despite their widespread use, there is no evidence that bifocals improve outcomes in children with accommodative esotropia with high AC/A. In our retrospective review, children with bifocals had higher surgical rates and a smaller improvement in near deviation over time. Although our results suggest that eliminating bifocals could reduce the cost and complexity of care while potentially improving quality, prospective, randomized controlled trials are needed to determine whether a change in practice is warranted.

Measuring Health-Related Quality of Life in Strabismus: A Modification of the Adult Strabismus-20 (AS-20) Questionnaire Using Rasch Analysis

Purpose

To evaluate the psychometric properties of the Adult Strabismus-20 (AS-20)- a health-related quality of life (HRQoL) questionnaire in adults with strabismus, and if flawed, to revise the AS-20 and its subscales creating valid measurement scales.

Methods

584 adults (meanage, 27.5 years) with strabismus were recruited from an outpatient clinic at a South Indian tertiary eye care centre and were administered the AS-20 questionnaire.The AS-20 was translated and back translated into two Indian languages. The AS-20 and its two 10-item subscales – ‘psychosocial’ and ‘function’were assessed separately for fit to the Rasch model, including an assessment of the rating scale, unidimensionality (by principal components analysis), measurement precision by person separation reliability, PSR, targeting, and differential item functioning (DIF; notable > 1.0 logits).

Results

Response categories were not used as intended, thereby, required re-organization and reducing their number from 5 to 3. The AS-20 had adequate measurement precision (PSR = 0.87) but lacked unidimensionality; however, deletion of the six multi-dimensionality causing items and an additional three misfitting items resulted in 11-item unidimensional questionnaire (AS-11). Two items failed to satisfy the model expectations in the ‘psychosocial’ subscale and were deleted – resulting in an 8-item unidimensional scale with adequate PSR (0.81) and targeting (0.23 logits). One item misfit in the ‘function’ subscale and was deleted—resulting in a 9 item Rasch-revised unidimensional subscale with acceptable PSR (0.80) and targeting (0.97 logits).None of the items displayed notable DIF by age, gender and level of education.

Conclusions

The AS-11 and its two Rasch-revised subscales – 8-item psychosocial and 9-item function subscale may be more appropriate than the original AS-20 and its two 10-item subscales for use as unidimensional measures of HRQoL in adults with strabismus in India. Further work is required to establish the validity of the revised rating scale.

Impact of strabismus surgery on health-related quality of life in adults

PURPOSE OF REVIEW

Adult strabismus can cause many symptoms, which have generally been divided into functional complaints and social complaints. The validity of surgical correction has historically been based on the restoration of functional improvement. In the absence of this expectation, surgery was labeled cosmetic. Yet, many studies have revealed the immense impact of ocular misalignment on psychosocial variables. The purpose of this article is to review the potential functional and psychosocial benefits of strabismus surgery and to summarize the development and status of questionnaires to help quantify these benefits.

RECENT FINDINGS

Functional benefits of strabismus surgery have been recently summarized with a meta-analysis. Several questionnaires have been evaluated to assess the functional and psychosocial factors in adult strabismus. Two strabismus-specific questionnaires, the Amblyopia and Strabismus Questionnaire and the Adult Strabismus-20, reveal improvements in adults following surgery. The appropriate patient population, impact of comorbidities on the scores, and the timing of the administration of the questionnaire postoperatively still need to be determined.

SUMMARY

Future studies of the impact of strabismus surgery in adults will need to report not only objective motor results, but also the impact on health-related quality of life to encompass all the benefits of strabismus surgery.

Strabismus genetics across a spectrum of eye misalignment disorders

Eye misalignment, called strabismus, is amongst the most common phenotypes observed, occurring in up to 5% of individuals in a studied population. While misalignment is frequently observed in rare complex syndromes, the majority of strabismus cases are non-syndromic. Over the past decade, genes and pathways associated with syndromic forms of strabismus have emerged, but the genes contributing to non-syndromic strabismus remain elusive. Genetic testing for strabismus risk may allow for earlier diagnosis and treatment, as well as decreased frequency of surgery. We review human and model organism literature describing non-syndromic strabismus, including family, twin, linkage, and gene expression studies. Recent advances in the genetics of Duane retraction syndrome are considered, as relatives of those impacted show elevated familial rates of non-syndromic strabismus. As whole genome sequencing efforts are advancing for the discovery of the elusive strabismus genes, this overview is intended to support the interpretation of the new findings.

Visuomotor control following surgical correction of strabismus in adults

OBJECTIVE

To determine whether surgery to correct decompensated exotropia in adulthood had an impact on common visually guided manual tasks in the postoperative period.

DESIGN

Case report.

PARTICIPANTS

Three adult patients with long-standing strabismus.

METHODS

Three adult patients took part in a series of preoperative and postoperative binocular and monocular reaching and grasping tasks before and after undergoing strabismus surgery. Tasks were designed to examine normal goal-directed actions (reaching to visual targets, grasping blocks) and to highlight differences between binocular and monocular control of action (grasping visible object in dark environment).

RESULTS

A consistent pattern of change was not found in the 6- to 12-month postoperative period with the tasks provided.

CONCLUSIONS

Surgery in adulthood to correct strabismus may not have a significant impact on the control of visually guided actions, at least in the first 6 to 12 months after surgery. Possibly, compensatory strategies used throughout their development (e.g., monocular cues) may continue to be used in the initial period postoperative period. More subjects and longer study period are recommended to make a definitive conclusion.

Improved ocular alignment with adjustable sutures in adults undergoing strabismus surgery

OBJECTIVE

To assess whether outcomes of strabismus surgery are improved by using the adjustable suture technique and to determine which subgroups of strabismus patients benefit most from the adjustable suture technique.

DESIGN

A retrospective chart review.

PARTICIPANTS

A total of 535 adults who underwent strabismus surgery between 1989 and 2010.

METHODS

Success was defined as ≤10 prism diopters (PD) for horizontal deviations and ≤2 PD for vertical deviations. Differences in the proportion of successful strabismus surgery were analyzed using a chi-square test with an alpha of 0.05.

MAIN OUTCOME MEASURES

Ocular alignment in primary position at a 7-day to 12-week follow-up examination.

RESULTS

A total of 491 patients met the inclusion criteria (nonadjustable suture, n = 186; adjustable suture, n = 305). The success rates for the nonadjustable and adjustable groups were 61.3% and 74.8%, respectively (χ(2)=9.91, P=0.0016). Adjustable suture use was particularly beneficial for patients undergoing a reoperation for childhood strabismus (success rate: nonadjustable, 42.4%; adjustable, 65.7%; P=0.0268; n = 100). The differences in outcomes were not statistically significant for patients with childhood strabismus undergoing a primary surgery (nonadjustable, 65.0%; adjustable, 81.4%; P=0.1354; n = 90) or with thyroid orbitopathy (nonadjustable, 76.7%; adjustable, 74.1%; P=0.8204; n = 57).

CONCLUSIONS

Strabismus surgery using adjustable sutures was associated with improved short-term ocular alignment compared with strabismus surgery without the use of adjustable sutures. Adjustable sutures were most beneficial for patients undergoing reoperations for childhood strabismus.

Strabismus and employment: the opinion of headhunters

PURPOSE

 The aim of this study was to determine the influence of strabismus on an individual's ability to find employment based on the opinion of Swiss headhunters.

METHODS

Forty Swiss headhunters retrieved from a Swiss online telephone directory were interviewed using a validated questionnaire in order to determine if strabismus would have an impact on a person's ability to find employment. Photographs of a strabismic man and woman as well as of other computer-generated facial anomalies could be downloaded from the Internet during the interview.

RESULTS

72.5% of headhunters judged that strabismic individuals would have more difficulties in finding a job than orthotropic persons. These difficulties were judged to be stronger in women than in men (P = 0.006), and in exotropic compared to esotropic persons (P = 0.01). Asked about seven facial anomalies, exotropia was found to have the third and esotropia the fourth (women) or fifth (men) most strongly negative impact on finding employment, after having strong acne and a visible missing tooth. Headhunters judged that persons with strabismus are significantly perceived as less attractive and less intelligent by potential employers.

CONCLUSION

Visible strabismus negatively influences individuals' ability to find a job and therefore has an impact on their economic status. Successful strabismus surgery realigns the visual axes, producing a normal facial appearance and therefore eliminating the negative impact of strabismus on employability.