The Vision Therapy Sandwich –
How Vision Therapy and Strabismus Surgery Can Work Together for Better Outcomes
Jesse Willingham, OD
Strabismus is a condition that affects someone’s ability to align both eyes on a single point. It impacts children and adults alike, affecting up to 4% of the population. And while eye misalignment may seem like a purely cosmetic concern, the reality is far more complex. In a first-of-its-kind article recently published in Advances in Ophthalmology and Optometry, Dr. Samantha Del Campo and Dr. Thomas Lenart argue for a major shift in how we approach strabismus treatment: not as a solo discipline, but as a collaborative partnership between ophthalmology and optometry.
More Than Meets the Eye: Understanding Strabismus
Strabismus isn’t just a physical misalignment of the eyes. Especially in children, it represents a disruption in the development of binocular vision—how the brain integrates visual input from both eyes into a single coherent image. When that process is derailed early in life, or never allowed to develop in the first place, the consequences can ripple far beyond cosmetic concerns. These children often face challenges with reading, coordination, depth perception, and even confidence in social or academic settings, problems that can follow them into adulthood.
Even after eye muscle surgery successfully realigns the eyes, visual problems can persist. That’s because the brain may still suppress input from one eye to avoid double vision, or it may adopt alternative visual strategies (like anomalous correspondence) that interfere with true binocular cooperation. Surgery may fix the hardware—but what about the software? This also leads to the significant possibility that good eye alignment won’t be gained by surgery alone in many patients, even after multiple surgeries.
A New Model: Collaborative, Customized Care
Thankfully, this article makes a powerful case for a combined treatment approach that includes both surgical re-alignment and optometric vision therapy (OVT). While ophthalmologists specialize in the anatomical and motor correction of the eyes, developmental optometrists have additional training in the neural, functional, and perceptual aspects of vision.
Vision therapy doesn’t just train the eyes—it rewires the brain to use them together more effectively. Patients engage in customized procedures using lenses, prisms, and visual targets to build essential visual skills like tracking, focusing, and binocular integration, while also calibrating the visual system’s integration with the rest of the body’s sensory and motor systems.
When done before surgery, vision therapy can prepare the visual system, making surgery more effective. After surgery, therapy acts as a safeguard, helping the brain maintain the new alignment and reducing the risk of regression. This new article provides five compelling case studies to illustrate this approach in action. Across these cases, vision therapy was used to:
* Improve visual skills and stamina before surgery
* Guide surgical planning through detailed sensory testing
* Reinforce binocular integration after surgery
* Support cosmetic goals and boost patient confidence
In each case, the combination of vision therapy and surgery produced results that neither approach could fully achieve alone—including improved depth perception, reduced or eliminated need for prism correction, better eye coordination, reduced time to achieve goals for vision and eye alignment, and enhanced quality of life.
Strabismus is more than eye misalignment—it’s a neurovisual disorder. And it deserves a plan that addresses both the eyes and the brain. When optometrists and ophthalmologists collaborate, patients win.
Why Does This Article Matter?
Historically, the relationship between ophthalmology and optometry in strabismus care has been fragmented, if there is any relationship at all. This article demonstrates that patients benefit most when both disciplines work together, not in silos. It’s a call to action for professionals on both sides: to communicate more openly, to coordinate care, and to center treatment around the full spectrum of the patient’s visual needs.
The authors emphasize the need for ongoing research, better diagnostic tools, and patient-reported outcome measures to fully capture the impact of strabismus and its treatment.
But the message is clear: a unified, multidisciplinary model isn’t just ideal—it’s essential for achieving the best outcomes. When children’s eye specialists work together, patients win.
It’s Not Too Late For Adults
There is growing evidence that neuroplasticity is possible in adults past the critical period of visual development. This is evident by improved binocularity in adults with strabismus after surgery, improved amblyopic eye visual acuity in adults with patching and binocular therapy, and improved oculomotor skills in adults with vision therapy adult neuroplasticity.
The brain does not stop being plastic as we mature.
