Strabismus, often called a squint or eye misalignment, happens when both eyes don’t look at the same spot at the same time. One eye might turn inward, outward, upward, or downward while the other stays focused. This isn’t just a cosmetic issue-it affects how the brain processes vision and can lead to long-term problems if left untreated. About 5 in every 100 children have it, and it can also develop in adults due to stroke, injury, or nerve damage. The good news? There are clear ways to fix it, including surgery when needed.
What Does Strabismus Look Like?
You can spot strabismus easily in many cases. One eye turns in (esotropia), out (exotropia), up (hypertropia), or down (hypotropia). Esotropia is the most common, making up about half of all cases. Exotropia comes next, followed by upward and downward misalignments. Sometimes the misalignment is always there; other times, it only shows up when someone is tired, sick, or looking at something far away.
People with strabismus often report double vision, especially adults. That’s because their brain can’t combine the two different images from each eye. Kids don’t always complain of double vision-they often just shut off the image from the misaligned eye. That’s how lazy eye (amblyopia) starts. Other signs include:
- Head tilting to see better (seen in 42% of children)
- Eye strain or pain around the eyes (78% of adults)
- Difficulty reading or focusing in school (57% of affected children)
- Avoiding eye contact or seeming shy (often due to embarrassment)
- Increased sensitivity to bright light (29% of adults)
If you notice any of these in yourself or a child, don’t wait. Early detection matters.
Why Does Strabismus Happen?
Most cases aren’t caused by weak eye muscles. They’re caused by the brain not sending the right signals to the muscles that control eye movement. This is especially common in kids with a family history-about 30% of pediatric cases run in families.
In adults, the biggest causes are strokes, head injuries, or nerve damage. Paralytic strabismus, which happens when one of the cranial nerves (usually IV or VI) stops working, accounts for about 12% of adult cases. It often comes on suddenly with dizziness and nausea.
Some kids are born with it (congenital esotropia). Others develop it later due to uncorrected farsightedness. Glasses can sometimes fix this type because it’s tied to how the eye focuses, not how it moves.
Non-Surgical Treatments First
Surgery isn’t the first step. Doctors always try simpler, safer options first:
- Corrective glasses - Especially for farsighted kids. Glasses can help the eyes align naturally by reducing focusing effort.
- Patch therapy - Covering the stronger eye forces the weaker one to work. This prevents or treats lazy eye.
- Vision therapy - A series of exercises designed to train the eyes and brain to work together. Studies show it works well for intermittent exotropia in kids aged 4-10, reducing the need for surgery by up to 35%.
These methods are most effective when started early. For children under age 2 with constant inward turning, early intervention can make a huge difference in developing depth perception.
When Is Surgery Needed?
Surgery becomes necessary when:
- The misalignment is constant and greater than 15 prism diopters (a unit doctors use to measure eye turn)
- Double vision doesn’t go away even with prism glasses
- The person tilts or turns their head constantly to see clearly
- Non-surgical treatments have failed after 3-6 months
For children with large-angle congenital esotropia, surgery is now recommended as early as 3-4 months old, based on new research showing better outcomes for binocular vision development.
What Happens During Surgery?
The goal of surgery is to rebalance the eye muscles so both eyes point in the same direction. Surgeons don’t cut into the eyeball. They work on the muscles on the outside of the eye.
Two main techniques are used:
- Recession - The muscle is detached and moved backward to weaken it. This is common for inward-turning eyes.
- Resection - A portion of the muscle is removed and reattached tighter to strengthen it. Used for outward-turning eyes.
The most common procedure is a bilateral medial rectus recession for esotropia. For adults, about 68% of surgeries now use adjustable sutures. This means the surgeon can fine-tune the alignment the same day or within 24 hours after surgery while the patient is awake. It’s a game-changer for precision.
Surgery takes 45-90 minutes. Kids get general anesthesia. Adults usually get local anesthesia with sedation.
Success Rates and Risks
Success isn’t always perfect alignment. Doctors aim for alignment within 10 prism diopters-close enough to look natural and function well.
- Success rate for children under 2: 75-85%
- Success rate for adults: 55-65%
- Overall success rate (all ages): 60-80%
But there are risks:
- Undercorrection - The eye still turns. Happens in 20-30% of cases. Often needs a second surgery.
- Overcorrection - The eye turns the other way. Seen in 10-15% of cases.
- Temporary double vision - Nearly 80% of patients feel this right after surgery. It usually clears up in days or weeks.
- Retinal detachment - Extremely rare (0.1%) but serious.
- Endophthalmitis - Infection inside the eye. Happens in 0.04% of cases.
Surgeons need special training. Only about 35% of general ophthalmologists perform these surgeries. Most have completed a fellowship in pediatric or neuro-ophthalmology.
Recovery and Aftercare
Recovery is usually quick but requires discipline.
- Daily antibiotic and anti-inflammatory eye drops for 2 weeks (98% of patients follow this)
- Redness and swelling fade in 1-2 weeks
- Most people return to normal activities within 10 days
- Vision therapy often starts 4-6 weeks after surgery to help the brain relearn how to use both eyes together
- Follow-up visits at 1 day, 1 week, 3 weeks, and 6 weeks
Some adults take longer than 6 weeks to fully recover. If double vision lasts beyond 2 months, talk to your doctor-it might need more treatment.
What Patients Say
Real-world experiences tell a powerful story.
On patient forums, 82% of people who had strabismus surgery say it was worth it. Common comments:
- “Finally able to make eye contact at work without embarrassment.”
- “Reading without double vision after 30 years changed my life.”
- “I stopped avoiding photos. My confidence shot up.”
But not everyone is happy. About 12% report dissatisfaction with how their eyes look-even if they can see better. That’s why pre-surgery counseling matters. Patients who understand the risks, recovery, and realistic outcomes have 40% higher satisfaction rates.
What’s New in 2026?
Technology is improving outcomes:
- The Steger hook, approved in March 2023, lets surgeons measure muscle tension down to 0.5 grams during surgery-making adjustments far more precise.
- Virtual reality training before surgery has been shown to improve success rates by 18% by helping the brain prepare for coordinated eye movement.
- Botulinum toxin injections are being used before surgery to temporarily weaken overactive muscles, reducing how much surgery is needed.
- Robotic-assisted surgery is in early trials at Johns Hopkins, with initial results showing 32% greater precision in muscle placement.
These advances mean better alignment, fewer repeat surgeries, and faster recovery.
Access and Cost
The global market for strabismus surgery is growing fast-projected to hit $1.8 billion by 2027. But access isn’t equal.
In the U.S., about 120,000 surgeries are done yearly. In Germany, the rate is higher per capita. In developing countries, only 28% of children with constant strabismus get evaluated by age 5, compared to 72% in developed nations.
Insurance can be a hurdle. Medicare cut reimbursement by 4.2% in 2023. Many private insurers now require proof that glasses, patches, or vision therapy failed for at least 6 months before approving surgery.
Nonprofits like NORA help low-income families cover costs. They assist with 200-300 surgeries each year.
What Should You Do?
If you or your child has signs of strabismus:
- See an ophthalmologist who specializes in strabismus or pediatric eye care.
- Get a full eye exam including cover tests, prism measurements, and binocular vision checks.
- Try non-surgical options first-glasses, patching, vision therapy.
- If alignment doesn’t improve after 3-6 months, or if double vision or head tilting persists, ask about surgery.
- Ask your surgeon about adjustable sutures and what success rates they’ve seen with patients like yours.
Strabismus isn’t just about how your eyes look. It’s about how you see the world-and how the world sees you. Fixing it can bring back confidence, comfort, and clarity.
