To use this program as a guide in treating a specific strabismus case, it is first necessary to ascertain from the clinical diagnosis whether the strabismus is constant or occasional and whether it is associated with normal or anomalous correspondence. Once this information is known, use the next portion of the program to enter these data plus any associated conditions (amblyopia, dissociated vertical, etc.). The program will then give you a list of and suggested order of treatment options for your individual patient. Additionally, the program will allow you to ask for extra information about each individual treatment option to use when making decisions so that treatment is directed toward the most efficacious management. Thus, use of the model allows one to be guided into thinking about the order in which different treatment procedures should be considered for efficient and successful management of a specific "kind" of binocular anomaly case.
In the clinical management of strabismus, it is worth remembering that the prognosis for functional correction is generally better for exotropes than esotropes. The reason stems from the fact that most (80% of) exotropes are occasional and exhibit fairly normal binocular vision at least occasionally, whereas most (75% of) esotropes are constant and have only rudimentary aspects of normal binocular vision. A corollary of this fact is that exotropes generally have few major deterrents to normal binocular vision while esotropes typically have deterrents such as anomalous correspondence, substantial amblyopia, and deep suppression. As a result, the treatment of exotropia is usually directed at solidifying and improving the existing sensory and motor fusion, whereas the challenge in treating esotropia is to overcome the deterring conditions and to establish fusion --- often a difficult task that reduces the prognosis for functional correction of esotropia. In spite of the observation that esotropes generally are different from exotropes, there is marked similarity in the treatment sequence of esotropes and exotropes when they have the same combination of constancy and retinal correspondence. In other words, an occasional esotrope with normal correspondence should, in our treatment model, receive the same sequence of treatment considerations as an occasional exotrope with normal correspondence. The point here is that the direction of the strabismus does not influence the order in which the different treatment options are considered; the direction does, however, determine certain specifics of the treatment, such as whether a plus or minus added lens power or a base-out or base-in prism should be used.
Having developed the rationale and the detailed sequence for considering the various treatment options for the four kinds of strabismus cases, we summarize here the key points in the nonsurgical treatment of strabismus.
Occasional with NRC:
refractive correction
added lens power and prisms,
suppression treatment
sensory/motor training
Constant with NRC:
refractive correction
suppression (and any amblyopia) treatment,
aggressive use of prisms & added lens power
sensory/motor training
Occasional with ARC:
refractive correction,
limited cautious use of prisms & added lenses
suppression treatment
fusional vergence training (co-variation)
Constant with ARC:(functional)
refractive correction
amblyopia (and any suppression) treatment
fusional vergence training (co-variation) or
ARC treatment for esotropes over 20 p.d.
limited cautious use of prisms & added lenses
(cosmetic)
refractive correction
amblyopia treatment
reverse prisms