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The psychosocial effects of adult strabismus: a review
  1. Jonathan M Durnian1,
  2. Carmel P Noonan2,
  3. Ian B Marsh2
  1. 1St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
  2. 2University Hospital Aintree, Walton Hospital, Rice Lane, Liverpool, UK
  1. Correspondence to Mr J M Durnian, St Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK; jondurnian{at}

Correction of adult strabismus is not a cosmetic procedure but one that restores normality to an individual's appearance that has been altered by a disease process. Two fundamental principles underpinning facial attractiveness are symmetry and averageness—manifest strabismus affects both of these giving an unconscious signal of poor genetic history. The presence of manifest strabismus adversely affects many aspects of patients' lives including finding a partner, job prospects and interaction with peers, and may manifest more seriously as psychiatric disorders. Surgical correction has been shown to be safe and effective for the functional problems of strabismus in adults but the hugely positive effects on the psychosocial aspects are only now becoming apparent. The advent of a new adult strabismus specific quality-of-life questionnaire and its subsequent validation will make this quantification of improvement easier. The wider medical community and the public at large should be made aware of the benefits of corrective strabismus surgery in adults.

  • Adult strabismus
  • surgery
  • psychosocial effects
  • quality of life
  • questionnaire development
  • muscles
  • diagnostic tests/investigation
  • treatment surgery
  • rehabilitation

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Adult strabismus is a common problem, present in approximately 4% of the population.1 Visual maturity occurs at approximately 8 years of age. If strabismus occurs after this age, then functional problems such as diplopia give a clear indication for treatment. Diplopia is not usually an issue for those adult patients in whom strabismus developed before visual maturity. Strabismus has been shown to have a more detrimental effect to patients' quality of life (QoL) than diabetic retinopathy, with levels similar to that seen with macula degeneration or following a mild cerebrovascular accident.2

The treatment of adult strabismus in those patients without binocular potential or who are not suffering from diplopia is regarded, by some, as ‘cosmetic’—this terminology is incorrect. Cosmetic surgery enhances or beautifies. Strabismus is the result of a disease process, which leads to a deviation from normality. Strabismus surgery is performed to restore normality.

There is significant evidence that shows that adult strabismus is associated not only with functional effects but also with negative psychosocial changes that have wide-ranging effects on all aspects of the patients' lives. This review brings together the current published literature with regard to human perceptions of facial attractiveness and the deep-rooted prejudices associated with deviations from normality, along with the psychosocial effects of strabismus and the current work in developing tools to quantify these difficulties and finally document the effects of surgery on these patients.

Perceptions of body image and attractiveness

It takes just 150 ms to judge a stranger's facial attractiveness3 and when doing this, the centre of the eyes, mouth and nose are the targets for gaze.4 Facial attractiveness preferences are present from an early age, long before environmental influences have been acquired5 and are similar across cultures6–8 indicating that attractiveness has a large evolutionary component. Evolutionary psychologists believe that facial attractiveness is an ‘honest’ indicator of health and reproductive value, playing an important part in the sexual selection of species.6 9–18 Facial attractiveness gives an impression of being nicer, more intelligent and healthier.9 It has even been shown that more attractive defendants are given lighter sentences in the judicial system.19 But what constitutes attractiveness? Is it really in the eye of the beholder?

There are four major cues underpinning facial attractiveness:

  • averageness;

  • symmetry;

  • sexual dimorphism (males having masculine features and females, feminine);

  • youthfulness.

Average and symmetrical faces may reflect resistance to developmental stressors, both environmental and genetic.13 The neoclassical canons describing average facial proportions date back to the Renaissance artists and earlier.9 Out of the original 10 canons, two include references to the ratio of the interocular distance to other aspects of the facial features: (1) the distance between the eyes is equal to the width of the nose and; (2) the distance between the eyes is equal to the width of each eye. These ‘golden ratios’ are substantiated in the modern literature, with the ideal female facial features having an interpupillary distance of 46% of face width.20 Ocular facial features are thought of as being incorporated into both a ‘length ratio’—the vertical distance between the eyes and the mouth and the ‘width ratio’—the interpupillary distance. The eye–mouth–eye angle has also been reported to be a good indicator of both masculinity and symmetry.21

Obvious asymmetry of facial features is immediately unattractive, but as a species we have evolved into finding facial asymmetry a more basic, genetic warning sign. In nature, many animal species depend on their ability to perceive symmetry in potential mates, and it may be a marker of both developmental stability and phenotypic quality.6 Asymmetry implies poor health and bad genes with symmetry of physical traits being a sign of ‘high quality’ development.6 Facial symmetry may be an indication of good health rather than attractiveness.10 This can be supported by studies finding males with less asymmetrical features having more sexual partners, better sperm counts and more offspring.22–24 More symmetrical females have increased fertility.25

Psychometric testing has shown that in male faces, both increasing symmetry and averageness had a positive effect on attractiveness, whereas the effect of symmetry was less important for female faces.26 27 Separate studies show that females show more minor elements of asymmetry than males28 but prefer symmetrical features in a chosen mate.29 This visual preference increases during the more fertile days of the menstrual cycle.30 31

Several studies have indicated that acute alcohol intoxication reduces the ability to detect asymmetry, and there is a concurrent increase in the attractiveness ratings of photographs.32 33 Chronic alcohol use may cause this reduction in asymmetry detection to become a permanent trait.29

Manifest strabismus is not a feature of the average human face. Its presence affects both the golden ratio and the width ratio, and increases the amount of visible asymmetry greatly. Although perceptions of ‘beauty’ may be a higher cognitive function,34 unconscious sexual selection is a far more deep-rooted instinct, and the presence of ocular misalignment sends out messages of poor genetic history. A common complaint in strabismic adults is difficulty in finding a life partner. This may be a partial explanation.

Objective and subjective views of strabismus

Strabismic individuals are likely to encounter social difficulties at all stages of life. Negative responses of children to a strabismic peer are evident from the age of five, with children as young as four describing ‘differences’ when presented with an altered, strabismic toy.35 Patching regimes have also been shown to have a negative impact on a child's psychosocial well-being, increasing bullying and stigmatisation,36 which can continue into adulthood.37 Negative psychosocial consequences have been documented in parents of strabismic children, causing some difficulties in undertaking the motherhood role.38

Reports of the negative psychosocial effects of strabismus in adults were first published in 1993, with patients reporting all aspects of their lives being affected by manifest strabismus—self image, job prospects, relationships, education and sports39—and have been confirmed by many since.37 40–44 These difficulties have been reported to worsen both with increasing age39 and with increasing strabismus size,43 especially if the magnitude of deviation is greater than 25 prism dioptres.42 Young strabismic adults report difficulties in making and maintaining relationships, both sexual and platonic, with members of the opposite sex—describing a lack of confidence and low self-esteem as the main contributing factors.37 39 42 It has been suggested that patients perceive that others would rate themselves less negatively than they would rate themselves in various personality traits, indicative of an inherent lack of confidence.40 More serious manifestations include an increased incidence of psychiatric disorders in young adults who developed strabismus, especially exotropia, as a child. One report found that 41.3% of strabismic patients developed mental health problems compared with 30.7% of controls.45–47 There are reports of a genetic linkage between constant exotropia and schizophrenia in the PMX2B gene.48

When viewed by others, strabismic individuals are rated more negatively than controls in various attributes including: perceived health,49 communication skills,50 intelligence,50 51 attractiveness52 and successfulness.52 53 These perceptions seem to translate into real difficulties gaining employment. One study reported that more than 70% of employment headhunters would consider patients with strabismus to have great difficulty in finding employment, with only severe acne and visible missing teeth being the only facial anomalies rated more negatively.51 Large-angle horizontal strabismus has also been shown to be detrimental in gaining employment when the patients are judged against orthophoric controls.54 Those with manifest strabismus have been shown to be more unlikely to gain promotion or further their career in the US military.53 When questioned, 92.5% of dating agencies stated that strabismic individuals would struggle to find a partner, as they are perceived as less attractive and less erotic.52

There is overwhelming evidence describing these negative effects on patients. There is debate on the effect of both direction of deviation and sex of the patient. In studies with patients self-reporting experiences, generally there is no difference between the difficulties faced between those with eso- and exo-deviations.37 39 42 Esotropic males report that they have their intelligence underestimated more and are discriminated against in the workplace more than exotropic males.42 When being rated by others, esotropes are generally rated worse.49 50 53 A 2007 study found that asymmetry of the face is rated as more unattractive, the more medial the asymmetrical feature is. With esotropia the pupil is much closer to the midline than in exotropia, and this may explain this finding.55

When it was reported, strabismic females were rated more negatively than males by others.52–54 Women, in particular, are detrimentally affected by the idealised image of the female body portrayed by the media,56 57 and we suggest that a similar response is seen in strabismic patients.

There is inherent bias in papers dealing with a cohort of patients who have presented themselves for treatment. A large number of people with manifest strabismus often do not present for treatment. Does this self-selected group not show any negative psychosocial effects? Or is it that they (and maybe their primary care provider) are still unaware of the treatment options?1 The development of robust tools to document the improvement that can be gained from strabismus surgery has been previously recommended.58 The subsequent dissemination of results would help in making the wider medical community aware of the potential health (both physical and mental) benefits.

Development of assessment tools quantifying psychosocial difficulties

Unlike generic methods, condition-specific QoL assessment tools focus on problems associated with the pathology of interest; it is therefore important that these tools are developed. Development of a strabismus-specific questionnaire is important primarily to assess the success or failure of service delivery in a clinical setting and also to identify those patients who may require psychosocial counselling. Previous attempts have been made to quantify the negative effects of strabismus by using various generic questionnaires39 43 45 59, non-strabismus-specific ophthalmic instruments41 and locally produced questionnaires.37–40 42 60

Until recently there were no strabismus-specific questionnaires dealing with the psychosocial aspects of strabismus. The Amblyopia and Strabismus Questionnaire has been previously used; however, only four of the 26 questions deal with the psychosocial elements of strabismus which, although perfectly adequate when dealing with the subject as a whole, is not sufficient when the psychosocial aspects are to be investigated and documented.61 The 20-item Adult Strabismus questionnaire (AS-20) has been made available. It was developed by distilling down a 181-item questionnaire, gained from patient interviews, to 20 questions, 10 dealing with the psychosocial elements of strabismus and 10 with the functional problems.62 The questions used are the best discriminators. The AS-20 is a freely available QoL questionnaire developed specifically for strabismic adults. The overall score is the mean of all the questions answered, with a score from 0 to 100 (0 being worst and 100 being best). The threshold for a normal, non-strabismic, score is 84.63 The test–retest reliability of the AS-20 is good, indicating its potential use in assessing changes in strabismus over a long time period.64

The AS-20 has been compared directly to the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) in strabismic adults, and although both detected the reduction in health-related QoL, the AS-20 had a greater sensitivity to the effects of strabismus. The VFQ-25 identified strabismus with diplopia far better than non-functional strabismus, a representation of how it was designed.63 The AS-20 also showed a strong correlation to the widely used Derriford Appearance Scale 59 (DAS59) QoL research tool, again being more specific to strabismus patients and not being influenced by other bodily factors that can impinge on a patient's perception of their own appearance.44

Effects of strabismus surgery

A report from the American Academy of Ophthalmology (2004) concluded that strabismus surgery in adults is safe and effective in: (1) restoring ocular alignment; (2) eliminating diplopia; (3) restoring binocularity when achievable; (4) expanding the visual field; and (5) improving any head position. It did not have any conclusions regarding subjective or psychosocial benefits due to a lack of studies at that time.58 The cost-effectiveness of strabismus surgery has been estimated at $1632/quality of life year, less than cataract surgery or vitrectomy for diabetic vitreous haemorrhage, and these figures are further improved the earlier surgery is performed.2

All aspects of psychosocial problems have been shown to improve following surgery. The first report by Satterfield in 1993 documented the negative psychosocial effects of strabismus but did not try to quantify the effects of strabismus surgery.39 Burke retrospectively reported on 15 psychosocial personality traits in 31 strabismic adults, and all traits improved following surgery. The traits most improved with surgery were: confidence, attractiveness, self-esteem, being at ease, being sociable and interactions with the opposite sex. Patients perceived that people viewed them more positively after surgery but did feel that others would rate them less highly than they rated themselves, and all scores were significantly less than they would have been in an ‘ideal world.’ Females had a more positive effect from surgery than males, as did esotropes. There was no difference in scores when correlated with age.40

Jackson prospectively reported on the results of three different scores of social anxiety and depression in 46 patients. The early signs of mental health issues related to strabismus improved following surgery, with social anxiety scores and social avoidance decreasing to a normative level and general anxiety levels improving. There was no direct correlation between the magnitude of deviation improvement and any quantitative score. In contrast to Burke, they reported that exotropic patients obtain greater benefits from the surgery.43

Menon reported prospectively on 40 young adults; 97.5% improved their subjective appearance, and 95% had a significant improvement in self-confidence and personal relationships following correction of their strabismus.37 Beauchamp retrospectively reported on 101 patients, and significant improvements were found in: health, daily tasks, social interactions, concerns, self image and job prospects.60

Nelson retrospectively reported on 128 strabismic adults, 85% had improved self-esteem following surgery, with 65% having an improved ability to meet new people; this was more significant for females than for male patients. Patients below the age of 35 had a better psychosocial improvement following surgery with respect to self-esteem, meeting new people and trying new activities. Job opportunities also improved, with females reporting a 15% increase in opportunities, and males 6%.42

The published reports of the psychosocial benefits of strabismus surgery show that patients do improve greatly with surgery, and this element of strabismus practice should become paramount in the minds of clinicians. The idea of adult strabismus surgery being ‘cosmetic’ is misleading and underappreciates the value of restoring normal appearance to these patients. There is a paucity of prospective studies; however, the introduction of the AS-20 tool and its subsequent validation should be useful in increasing this body of evidence. The levels of psychosocial distress experienced by strabismus patients are beyond the clinical environment, affecting all aspects of lives—from the most basic needs of finding a life-partner to their job prospects and subsequent career. Providing patients with additional psychosocial support in the future will have to address this and will clearly require a multidisciplinary response.



  • Linked articles 188326, 185793.

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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