Strabismus Surgery in Adults: Benefits, Risks and What to Expect

Strabismus surgery is not just for children. Here's what the current evidence shows about outcomes for adults — including the specific and often unanswered question of whether to operate on the second eye if you had surgery on one eye as a child.

Strabismus — misalignment of the eyes — affects approximately 4 to 5% of the population. It is most commonly treated in childhood, where the goals are to prevent amblyopia, develop binocular vision, and achieve alignment before the visual system matures. But a significant proportion of adults live with strabismus that was either untreated in childhood, partially treated, or has developed or recurred in adult life. Many of them do not know that surgery in adulthood is both possible and frequently effective.

Strabismus surgery in adults achieves satisfactory alignment with one operation in approximately 80% of patients, depending on the specific nature of the problem. Risks of adult strabismus surgery are relatively low, and serious complications are anecdotal and rare. Even if the strabismus has been long-standing, most adults will experience some improvement in binocular function after strabismus surgery. Consequently, adult strabismus surgery should not be considered merely cosmetic in most cases.

That last point matters. The NHS has historically classified adult strabismus surgery as cosmetic for funding purposes — a classification that the clinical evidence does not support, and one that has been the subject of sustained challenge from ophthalmologists and patient groups.

TL;DR

• Strabismus surgery achieves satisfactory alignment in approximately 80% of adults with one operation. Most adults experience some improvement in binocular function even with long-standing strabismus.
• Functional benefits include elimination of diplopia, development of binocular fusion, expansion of binocular visual fields, and improvement of head position.
• Strabismus surgery for psychosocial reasons is considered low cost, relatively low risk, highly cost effective and beneficial for patients.
• Risks include unplanned reoperation in up to 21% of patients for standard cases, postoperative diplopia in 1 to 14%, and scleral perforation in 0.8 to 1.8%.
• A 2025 American Journal of Ophthalmology study of 165 patients aged 80 to 94 found diplopia resolved in 75% after one procedure and 87% after up to two, with no significant complications — confirming benefits at any age.
• Amblyopia cannot be treated in adults, but if the eyes are misaligned they can still be straightened even if amblyopia is present.
• Alternative treatments include prism glasses, botulinum toxin injection, and vision therapy — each appropriate for specific indications and often used alongside or before surgery.
• For adults who had surgery on one eye as a child, surgery on the second eye is a separate question requiring individual assessment.

What Strabismus Is and Why Adults Seek Surgery

Adult strabismus — a misalignment of the eyes that occurs when the muscles in each eye are unable to move the eyes together — can be a recurrence from childhood, or it can be acquired in the adult years. Strabismus that develops later can be caused by stroke, ischaemic disease, tumours, thyroid eye disease, diabetes, or certain neurological conditions. It can also develop following eye surgery for cataracts, glaucoma, or retinal detachment.

Adults with strabismus experience two categories of problem. The first is functional — double vision or visual confusion is common in adults with strabismus. Others find that their eyes begin to wander involuntarily, resulting in discomfort and eye strain. The second is psychosocial. The presence of strabismus has been considered a disabilityty because it has serious social consequences like the loss of normal eye contact, which may affect employment opportunities and interpersonal relationships.

The psychosocial burden of strabismus in adults is substantial and consistently underestimated by those who have not experienced it. The majority of adults surveyed with strabismus would trade a portion of their life expectancy to be rid of their strabismus.

How Strabismus Surgery Works

Strabismus surgery corrects the misalignment by adjusting the tension in the extraocular muscles — the six muscles attached to each eye that control its movement. The surgeon either weakens a muscle by moving its attachment point further back on the eye (recession) or strengthens a muscle by shortening it (resection). In most cases, both recession and resection are performed on one or both eyes during the same procedure.

The surgery is performed under general anaesthesia in children and typically under local or topical anaesthesia in adults — which makes it suitable as a day-case procedure with a relatively short recovery period. Adjustable sutures — a technique in which the muscle position is fixed loosely at the time of surgery and then fine-tuned later the same day or the following morning, after the patient is awake and able to give feedback on their alignment — are a significant advance available in many adult strabismus services.

The adjustable suture technique improves the precision of the result and reduces the rate of unplanned reoperation. Not all patients are candidates — it requires cooperation and the ability to tolerate minor adjustment under topical anaesthesia — but it is worth specifically asking about when discussing surgery with a specialist.

The Benefits: What the Evidence Shows

Diplopia Resolution

For adults who experience double vision from strabismus, surgery is the most effective treatment available. Functional benefits of surgical treatment include elimination of diplopia, development of binocular fusion, expansion of binocular visual fields, and improvement of head position.

The 2025 study of strabismus surgery in patients aged 80 to 94 — a population for which surgical intervention is often withheld on the assumption of unacceptable risk — found that diplopia was resolved in 75% after the first procedure and in 87% after up to two procedures, with a reoperation rate of 13% and no significant intraoperative or anaesthetic complications.

Binocular Vision

The possibility of recovering or developing binocular vision is one of the most clinically significant and most surprising aspects of adult strabismus surgery for many patients.

Binocularity can be achieved in most patients undergoing strabismus surgery regardless of the type of preoperative deviation, duration of strabismus, or depth of amblyopia in the deviating eye if present. Adult patients with strabismus who have not been surgically aligned during early childhood might develop fusion after strabismus surgery.

In esotropic patients, improvement in binocular function typically takes the form of an expansion of binocular visual fields. However, some patients may also regain stereopsis.

Psychosocial Benefits

In adults who underwent strabismus surgery for psychosocial reasons, improved postoperative ocular alignment and improved health-related quality of life were common.

The psychosocial benefits extend beyond improved self-confidence and eye contact to measurable employment and economic outcomes. Adults with strabismus consistently report difficulties in job interviews and professional interactions. Multiple studies have documented improvements in employment outcomes following surgical correction.Cheralleads to significant improvements in quality of life up to 6 months postoperatively. There are however a group of patients who do not experience these benefits. A series of clinical and psychosocial factors have now been identified, which will enable clinicians to identify patients who may be vulnerable to poorer outcomes post-surgery.

The Risks: What the Evidence Shows

The risk profile of adult strabismus surgery is generally favourable — it is not a high-risk operation, and serious complications are uncommon.

Unplanned reoperation — unplanned reoperations were needed in up to 21% of patients in large case series of comitant strabismus, and in up to 50% of patients with thyroid ophthalmopathy. This is the most common adverse outcome — not a complication in the sense of surgical harm, but a need for further surgery to achieve acceptable alignment.

Postoperative diplopia — new postoperative diplopia occurs in 1 to 14% of patients. This is one of the most distressing potential outcomes — a patient who had no double vision before surgery developing it afterwards. It is most likely in patients with suppression who achieve a straighter alignment than their visual system was adapted to. Pre-surgical assessment should include evaluation of suppression and diplopia potential to anticipate this risk.

Scleral perforation — scleral perforation occurs in 0.8 to 1.8% of cases. This is a rare but serious intraoperative complication in which the needle used to reattach the muscle passes through the wall of the eye. In most cases it is managed without lasting consequence, but it carries a risk of retinal detachment and vision loss in rare instances.

Infection — endophthalmitis following strabismus surgery is rare, occurring in less than 0.05% of cases, but is a sight-threatening emergency requiring immediate treatment.

Refractive change — strabismus surgery can produce small changes in refraction, particularly towards myopia and with-the-rule astigmatism in the operated eye. Spectacle prescription should be rechecked following surgery.

Anaesthetic risks — general anaesthesia carries the standard small risks of any surgical anaesthetic. In adults, many surgeons prefer local or topical anaesthesia, which significantly reduces anaesthetic risk and allows adjustable sutures to be used.

Alternative Treatments: What Else Is Available

Surgery is not the only treatment for adult strabismus. Depending on the type, degree, and cause of the deviation, several non-surgical or less invasive approaches may be appropriate — either as standalone treatment, as a bridge to surgery, or as a complement to surgical correction.

Prism Glasses

Prism lenses are optical devices incorporated into spectacles that alter the path of light entering each eye, effectively compensating for the misalignment and eliminating diplopia without changing the underlying eye position. Conservative options include prisms to realign the visual axes where both eyes can subsequently work as a pair.

Prism therapy proves particularly effective for deviations under 20 prism diopters and can serve as either standalone treatment or bridge therapy while planning other interventions.

Prisms are the most immediately accessible treatment for diplopia in adults — they can be prescribed by an optometrist or orthoptist without a surgical referral and provide relief within days. Their limitations are practical: large deviations require thick and heavy lenses, prisms do not work for all types of misalignment, and they address symptoms without correcting the underlying deviation.

Fresnel press-on prisms — thin plastic films that adhere to an existing spectacle lens — are a useful temporary option for assessing prism tolerance or managing acute-onset diplopia while awaiting assessment or surgery.

Botulinum Toxin Injection

Botulinum toxin injected into an extraocular muscle temporarily weakens it, altering the balance of muscle forces around the eye and shifting the eye position. Chemodenervation using botulinum toxin is an alternative to surgery, and in some patients it is the only option.

Botulinum toxin temporarily paralyses the extraocular muscle and results in a changed ocular alignment that resolves over time — usually a two to three month time interval. During this period of altered eye position, the visual axes may adopt an alignment that permits binocular single vision.

Recent studies report success rates of up to 72% with Botox therapy, particularly when used as an alternative to surgery in carefully selected cases.

Botox is most useful in specific clinical scenarios: acute-onset paralytic strabismus where temporary correction during recovery is the goal, assessment of likely surgical outcomes before committing to permanent correction, patients who are not medically fit for surgery or general anaesthesia, and as an adjunct to surgery for fine-tuning alignment.

The main practical limitation is the temporary nature of the effect — most patients require repeat injections every two to four months for sustained benefit. The main risk is that the injection can spread beyond the target muscle, temporarily causing drooping of the eyelid or vertical misalignment. These side effects resolve spontaneously as the toxin wears off.

Vision Therapy and Orthoptic Exercises

Orthoptic exercises promote and establish binocular control of ocular alignment where both eyes can subsequently work as a pair. Vision therapy involves structured exercises carried out with an orthoptist and at home, designed to improve the coordination of the eyes and the brain's ability to fuse images from both eyes.

The evidence for vision therapy as a standalone treatment for structural strabismus in adults is limited. It is most effective for convergence insufficiency — a specific type of near-vision misalignment — where it has strong evidence from randomised trials. For other types of strabismus, it is typically used as a complement to surgical or optical treatment rather than a replacement for it.

Combining surgical and non-surgical methods — including pre-surgical and post-surgical vision therapy — has shown to enhance outcomes in adult patients by preparing the visual system and maintaining stability post-intervention.

Spectacle Correction

For strabismus caused by or associated with refractive error — particularly hypermetropia-related esotropia, where the eye turns inward due to the effort of focusing — spectacle correction alone can significantly reduce or eliminate the deviation without surgery. Refractive correction is always the first step in assessment and should precede surgical planning.

The Question of Surgery in Older Adults

The assumption that strabismus surgery is not worth pursuing in older adults — or that the risks are unacceptable — is not well supported by current evidence.

The 2025 American Journal of Ophthalmology study specifically examined 165 patients aged 80 to 94 years treated at UCLA's Stein Eye Institute between 2014 and 2024. The mean age was 83 years. Diplopia was the primary complaint in 94% of patients. The study found diplopia was resolved in 75% after the first procedure and 87% after up to two procedures. The mean American Society of Anesthesiologists classification was 2.6 — reflecting a medically complex population — yet no significant intraoperative anaesthesia or surgical complications were noted. The authors concluded that octogenarians derive substantial functional benefit from surgery with acceptable surgical risk.

If You Had Surgery on One Eye as a Child: Should You Have the Other Eye Done Now?

This is one of the most common questions raised by adults who had strabismus surgery in childhood — and one that does not have a single universal answer. The clinical picture depends on several factors that require individual assessment.

What Childhood Strabismus Surgery Does and Does Not Achieve

When strabismus surgery is performed on a child, the primary goals are alignment, development of binocular vision, and prevention or treatment of amblyopia. In some cases, surgery on one eye is sufficient to achieve these goals. In others, surgery on the second eye is planned as a staged procedure. And in some, residual deviation remains in the non-operated or less-operated eye that was not addressed at the time.

When strabismus begins in childhood, the brain learns to ignore the image from one eye just to avoid double vision. Amblyopia cannot be treated in adults, but if the eyes are misaligned they can still be straightened even if amblyopia is present.

This distinction is critical. Surgery on the second eye in adulthood cannot recover vision that was lost to amblyopia during childhood — that window is closed. What it can do is improve alignment, reduce the visibility of the deviation, potentially improve binocular function if suppression rather than true amblyopia is present, and address the psychosocial burden of a visible squint.

When Surgery on the Second Eye Is Worth Considering

Visible residual deviation — if the eye that was not operated in childhood continues to deviate visibly, surgery to improve alignment can produce significant psychosocial benefits and may improve binocular function even without full restoration of stereopsis.

Suppression rather than amblyopia — some adults who had strabismus as children have suppression — the brain actively ignoring the image from the deviating eye — rather than true amblyopia. Suppression is different from amblyopia in that the eye itself is not permanently impaired. In these patients, surgical alignment can sometimes result in unexpected recovery of binocular function. A careful pre-surgical assessment including prism testing and evaluation of fusion potential will identify whether this possibility exists.

Diplopia developing in the deviating eye — adults with childhood strabismus sometimes develop diplopia in adulthood when the suppression that has been protecting them from double vision breaks down, often in the context of illness, fatigue, or ageing. When this happens, surgery on the deviating eye to restore alignment can resolve the diplopia.

Progression of deviation — some strabismus that was adequately managed in childhood progresses in adulthood, producing increasing misalignment. This is particularly common with exotropia and in the context of ageing changes in the extraocular muscles.

When Surgery on the Second Eye Is Less Likely to Help

True amblyopia with dense suppression — if the eye has permanent amblyopia from childhood and there is no residual binocular potential, surgery will improve alignment and appearance but will not change the underlying visual function. This is still a valid reason for surgery — the psychosocial benefits are real — but expectations should be calibrated accordingly.

Small or cosmetically insignificant deviation — if the residual deviation in the non-operated eye is small and not causing functional or psychosocial distress, surgery may not produce sufficient benefit to justify its risks.

The Assessment Process

Adults considering surgery on a second eye following childhood strabismus should be assessed by a consultant ophthalmologist or orthoptist with specific expertise in adult strabismus. The assessment should include measurement of the deviation in all positions of gaze, evaluation of binocular potential with prism testing, assessment of whether suppression or amblyopia is the operative mechanism, and discussion of realistic expectations for functional and psychosocial outcomes.

Orthoptists are the appropriate first point of contact for many adults with longstanding strabismus. A GP referral to an orthoptist or directly to an adult strabismus clinic is the appropriate starting point in the NHS.

NHS Access and the Cosmetic Classification Problem

Access to adult strabismus surgery on the NHS has been inconsistent across England, with some integrated care boards classifying it as cosmetic and refusing to fund it for non-emergency indications.

This classification conflicts with the clinical evidence. Adult strabismus surgery should not be considered merely cosmetic in most cases. The Royal College of Ophthalmologists has published guidance supporting NHS funding for adult strabismus surgery where there is a functional indication — which encompasses the majority of cases including those where the primary driver is the psychosocial burden of a visible misalignment affecting employment, relationships, and quality of life.

If you are refused an NHS referral for adult strabismus surgery on cosmetic grounds, it is worth asking the GP to document the functional impact — diplopia, visual confusion, employment effects, quality of life impact — and requesting a second opinion from a consultant ophthalmologist. Private surgery is available across the UK at specialist strabismus centres, typically ranging from £2,000 to £4,000 per operation.

Frequently Asked Questions

Can adults have strabismus surgery?

Yes — strabismus surgery in adults achieves satisfactory alignment with one operation in approximately 80% of patients. Most adults will experience some improvement in binocular function after strabismus surgery even if the strabismus has been long-standing. Adult strabismus surgery should not be considered merely cosmetic in most cases.

What are the benefits of strabismus surgery in adults?

Functional benefits include elimination of diplopia, development of binocular fusion, expansion of binocular visual fields, and improvement of head position. Psychosocial benefits — improved self-confidence, better eye contact, improved employment outcomes, and improved quality of life — are well-documented and significant.

What are the risks of strabismus surgery in adults?

Risks include unplanned reoperation in up to 21% of patients, postoperative diplopia in 1 to 14%, and scleral perforation in 0.8 to 1.8%. Serious complications are rare. The most common adverse outcome is the need for further surgery to achieve acceptable alignment.

What are the alternatives to strabismus surgery?

The main alternatives are prism glasses — which compensate optically for the misalignment and are most effective for deviations under 20 prism diopters — botulinum toxin injection, which temporarily weakens a muscle to shift eye position and has success rates of up to 72% in selected cases, and vision therapy or orthoptic exercises, which are most effective for convergence insufficiency. Spectacle correction alone can manage some cases of refractive strabismus. Chemodenervation using botulinum toxin is an alternative to surgery and in some patients it is the only option.

I had strabismus surgery on one eye as a child. Should I have the other eye done now?

This depends on individual assessment. Surgery on the second eye in adulthood cannot recover vision lost to amblyopia in childhood. However, it can improve alignment and appearance, and in some adults with suppression rather than true amblyopia, it may produce unexpected improvements in binocular function. An assessment by a consultant ophthalmologist or orthoptist with adult strabismus expertise is the appropriate first step.

Is adult strabismus surgery available on the NHS?

NHS access is inconsistent across England. Some integrated care boards classify adult strabismus surgery as cosmetic and refuse funding. The Royal College of Ophthalmologists does not consider it cosmetic where there is a functional indication. If refused on cosmetic grounds, request that the functional impact is documented and consider requesting a second opinion from a consultant ophthalmologist.

Can strabismus surgery help with double vision in older adults?

Yes — a 2025 study of 165 patients aged 80 to 94 years found diplopia was resolved in 75% after one procedure and 87% after up to two procedures, with no significant complications. Age alone should not be a barrier to surgical consideration for adults experiencing functionally limiting double vision from strabismus.

The Bottom Line

Adult strabismus surgery is effective, relatively safe, and consistently underutilised. The evidence supports it as a functional rather than cosmetic intervention in the majority of adults with strabismus — producing meaningful improvements in diplopia, binocular function, and psychosocial wellbeing across all age groups including patients in their 80s and 90s.

For those who prefer or require a non-surgical approach, prism glasses provide immediate optical relief, botulinum toxin offers a reversible temporary correction, and vision therapy builds the binocular function that surgery or optical correction creates the conditions for. These alternatives are not consolation prizes — they are clinically appropriate first-line or adjunctive options for specific presentations.

The specific question of surgery on a second eye following childhood treatment does not have a universal answer — but it is worth a proper assessment by a specialist who can evaluate binocular potential, the presence of suppression versus amblyopia, and the realistic functional and psychosocial benefit of surgical correction.

The starting point in the NHS is a GP referral to an orthoptist or adult strabismus clinic. If you are meeting resistance on cosmetic grounds, the Royal College of Ophthalmologists' clinical guidance supports functional indications for surgery — and most adults with strabismus affecting their daily life have a functional indication.

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