Dr Gemma Arblaster, Clinical Orthoptist and Lecturer in Orthoptics at the University of Sheffield, talks to Lucia Wilson.
If you are a newly diagnosed strabismus patient, an adult, you will very quickly meet an Orthoptist. You may not know what Orthoptists actually do. I certainly didn’t at my first strabismus appointment. I do wonder if, just as strabismus is not well-known, the Orthoptist role is something of a hidden, unsung profession within eye care. Orthoptists are, undoubtedly, vital in the care of strabismus.
Dr. Arblaster is a Lecturer in Orthoptics at the University of Sheffield, who also works clinically as an Orthoptist at Sheffield Teaching Hospitals NHS Foundation Trust. We are grateful that she has taken the time to be interviewed for our site so that we can help you, as patients and the parents of children with strabismus (also referred to as a squint) understand the role of the Orthoptist.
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Q1. Thank you Dr Arblaster , for giving us your time to answer some questions related to the role of the Orthoptist in the treatment and care of strabismus patients. Can I start by asking you for a layperson’s description of Orthoptics and the job of the Orthoptist?
Orthoptics is all about how the eyes are aligned, how the two eyes work together as a pair, and how the eyes move.
An Orthoptist is an Allied Health Professional *or AHP. There are fourteen different AHPs, including physiotherapists and radiographers, and Orthoptics is one of the smallest AHP professions. We are regulated by the Health and Care Professions Council **(HCPC). To become an Orthoptist, you need to study a degree or masters in Orthoptics at one of four UK universities that offer the course at present.
Most Orthoptists in the UK work in the NHS, in an eye department, so you may not have seen one before if you haven’t been to the specific part of the eye clinic where an Orthoptist works. Orthoptists are highly skilled at assessing children and adults of all ages and abilities.
The role of the Orthoptist is to measure vision, assess and measure eye position or eye alignment, investigate whether the eyes work together as a pair or not, and measure how well they can do this, and assess eye movements. We specialise in investigating, diagnosing and managing strabismus, as well as other eye conditions such as amblyopia, double vision (diplopia), nystagmus and other eye movement disorders and neurological problems.
The patients an Orthoptist would see are quite varied, ranging in age from birth to older adults. Patients can include children with amblyopia undergoing treatment, children or adults with strabismus – which may be a longstanding strabismus or a strabismus that has a more recent onset, patients may also be seen by an Orthoptist via an emergency route if they have sudden onset double vision (diplopia) symptoms, neurological symptoms or have suffered trauma, for example to the face or eye socket.
Many Orthoptists have developed enhanced or advanced skills, and some may have developed additional skills or extended roles to meet the needs of their clinical department. A new area of clinical practice for Orthoptists are the Advanced Clinical Practice (ACP) roles, so it may be that in the future you see an Orthoptist ACP as part of your eye clinic appointment.
Most Orthoptists work with Optometrists and Ophthalmologists, as well as other professionals in the eye clinic and the wider hospital.
- Optometrists are the experts at measuring whether patients require glasses or contact lenses, as well as assessing eye health. Most work on the high street, but some also work in the hospital setting.
- Ophthalmologists are doctors that have specialised in eyes. They are the ones who would plan and perform strabismus surgery if that was required.
In many cases, patients who are referred to an Ophthalmologist about a strabismus will also see an Orthoptist as part of the appointment. They may also see an Optometrist, either in the hospital or on the high street.
*https://www.england.nhs.uk/ahp/role/
** https://www.england.nhs.uk/ahp/role/
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Q2. Can you tell us a bit about your work in this field and what sparked your interest in this area of eye care?
As a teenager I was interested in medicine and careers allied to medicine. I was looking into studying optometry to become an Optometrist, when I came across orthoptics, which I didn’t know anything about at the time. I was lucky enough to be able to go and visit an Orthoptist working at Queens Medical Centre in Nottingham, and from that point onwards I felt like orthoptics was what I wanted to do.
I liked the fact the role of an Orthoptist was hospital based, seeing patients that had been referred in with a problem. I liked that the patients were all very different ages and with different health conditions. I also liked that the role involved spending time with people, communicating with them and trying to work out what the problem was, before ultimately trying to do something that helped make their problem better.
I studied Orthoptics at the University of Sheffield, before working clinically as an Orthoptist in Cambridge, Manchester, Nottingham and Sheffield. I completed my Masters at UMIST in Manchester and more recently I completed my PhD at the University of Sheffield, which was funded by the NIHR. The topic of my PhD was adults with strabismus and postoperative outcomes from strabismus surgery.
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Q3. At what stage in the diagnosis of strabismus will a patient meet an Orthoptist? I understand that Orthoptists work in a number of different settings, including schools, is that correct?
Patients with strabismus will have typically been referred to the eye clinic by an Optometrist, or a GP. Children can also be referred by their Health Visitor.
For many people with strabismus, children and adults, an Orthoptist will be the first clinician they see in the hospital eye clinic. That is because the orthoptic investigation and diagnosis of strabismus is typically needed before a management plan can be formed for the patient.
The Orthoptist would undertake some of the non-surgical management options which patients will hear described as “conservative treatment”. If strabismus surgery was required, the Ophthalmologist would plan and perform surgery. Other “invasive” management options for strabismus, such as an injection of BT (botulinum toxin) into an eye muscle would typically be performed by an Ophthalmologist.
Most Orthoptists work in hospital eye clinics, although as part of that role some do also visit schools to perform vision screening of children (typically aged 4-5 years old). Some also see patients following a stroke or with a neurological condition on a ward, or in a rehabilitation setting. Some Orthoptists also work in community clinics, special schools, low vision clinics or other healthcare settings
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Q4. Can you talk more specifically about Orthoptics in the treatment of strabismus, please?
Orthoptists investigate whether non-surgical (or conservative) management options would be suitable for the patient, either instead of, or in conjunction with a surgical procedure. Examples of the most common non-surgical management options include exercises, glasses or contact lenses, prisms, occlusion and advice on strategies such as head movements.
Exercises are suitable for some patients with strabismus and some types of eye movement problems, for example if there is a problem with converging the eyes (bring them in towards the nose in a coordinated manner) or controlling a specific type of strabismus.
Glasses or contact lenses can affect some types of strabismus more than others, so for some patients using glasses or contact lenses is an important part of their management. Typically, an Optometrist would prescribe the glasses or contact lenses. In some cases, the glasses or contact lens prescription can be manipulated a small amount for additional benefit.
Prisms are typically used to join double vision and or restore the use of the two eyes together as a pair (restore binocular single vision). Prisms can also be used to eliminate double vision, even if restoring binocular single vision is not possible. Prisms can be used temporarily by fitting them to glasses. These temporary prisms are called Fresnel prisms, they are a thin layer of plastic that are cut and fitted to the inside of a glasses lens. Prisms can also be used as a more permanent management option by incorporating them into glasses. This builds the prism into the lens so that it is part of the lens and is not visible.
For some patients it may also be appropriate to use occlusion, for example if they have double vision (diplopia) that can’t be joined or improved with prisms. Occlusion can be covering up one eye or covering a glasses lens fully or partially. Occlusion can include patches, different levels of frosted tape, different density filters or in some cases occlusive contact lenses.
For some patients it may be also appropriate to give advice on strategies such as head position, head movements and eye movements
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Q5. When I used to attend my appointments in the strabismus clinic at my local hospital, I was fascinated by the work of the Orthoptist. I knew they were helping me, but I knew nothing about their role. I hadn’t heard this job title before, even though I had worked in the NHS.
I think it would help patients reading this page to hear a bit about how Orthoptists assess
a) an adult and b) a child.
Are there any differences in how you assess an adult and how you assess a child?
As well as assessing vision, strabismus and eye movement problems, Orthoptists are the experts at assessing children and those with communication difficulties. Orthoptists can use different clinical tests that are suitable for children and adults of different ages and different abilities. This means that if a patient, adult or child, in the eye clinic is not able to read a standard letter chart, or has difficulties communicating what the letters are verbally, then they may have their vision measured by an Orthoptist.
When assessing a patient with a strabismus, the Orthoptist would use different clinical tests selected for the age and ability of the patient. The assessment would be aimed at measuring the same things, but the way this is done and the tests that are used would be different.
For example, measuring the size of the strabismus (or the amount the eye turns) is an important part of the investigation. Often measurements are taken with the eyes looking straight ahead, but with the patient looking at a target, both at near and at distance. For a young child, these measurements may involve the child sitting on the parents’ knee. The Orthoptist may then hold a small pen torch in front of the child and observing the reflections of the torch in their eyes. If it was possible, the Orthoptist would then hold prisms (either a prism bar or a loose prism) in front of one eye to measure the strabismus by observing the position of the reflections through the prism.
For an older child or adult these measurements would involve the Orthoptist covering the eyes in turn, observing the movements of the eyes and then holding prisms in front of one eye. This requires the patient to be cooperative enough to look at a target accurately with each eye and do this for a long enough time for the Orthoptist to measure the strabismus through the prisms.
If cooperation allows, for example in an adult who can concentrate and cooperate for longer, the measurements would then also be repeated with the patient looking in different positions. For example, they may look at the target straight ahead but turn their head, so the eyes are looking to each side, the eyes are looking up and then the eyes are looking down.
Having good cooperation and being able to undertake more of the measurements and investigations allows the Orthoptist to gather more information about the strabismus. Overall, gathering more information is useful and it adds the clinical picture of what is happening for each patient.
For younger children or those with less cooperation, or shorter concentration spans, the Orthoptist may have to gather the information over a number of visits.
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Q6. Do you, as an Orthoptist and Lecturer in Orthoptics, think it is important to treat strabismus? After all, some professional stakeholders consider strabismus to be, in general, a cosmetic condition with a minor impact on patients.
I think it is very important to have treatment options for strabismus. I see how much benefit patients can achieve from having strabismus treatment, so for me this is a very simple answer. Yes!
Different patients with strabismus will have different aims of treatment. All of this would be determined from the investigation and formulation of the management plan for the individual.
Aims of treatment may include:
• Elimination of double vision (diplopia)
• Restoration of the use of the eyes together as a pair (restoration of binocular single vision)
• Improve vision, which is typically by improving binocular single vision – or making it easier for the eyes to achieve binocular single vision with reduced symptoms or without symptoms
• Improve ‘psychosocial symptoms’ associated with having strabismus, by improving eye alignment or restoring a straighter eye position
As mentioned previously – some of these aims of treatment can be achieved by using conservative management options like glasses, contact lenses, prisms, exercises, occlusion etc. Or it may be that BT (botulinum toxin), or strabismus surgery is required. For some people, the conservative management options are used after strabismus surgery to help optimise the best result.
I would not describe strabismus as a ‘cosmetic’ condition. Strabismus is much more than something that just affects cosmesis or the way a person looks. It is a condition that affects a person’s life in many ways, it can affect their quality of life and wellbeing. Sometimes we group all of these aspects together and describe them as ‘psychosocial symptoms’.
It is also worth remembering the NHS does not fund surgery for cosmetic reasons. I would describe strabismus surgery for those without expected visual benefit to be described as: strabismus surgery that aims to improve eye alignment and reduce psychosocial symptoms. Strabismus surgery for psychosocial reasons has also been described as a “reconstructive” surgical procedure.
There has been a growing body of medical evidence in recent years supporting that strabismus can negatively affect quality of life and that having strabismus surgery, even when vision doesn’t improve, can improve quality of life. This has been the focus of my own PhD research, which has shown that patients having strabismus surgery for ‘psychosocial reasons’ can achieve some unexpected improvements in their vision and ability to perform tasks, reduced physical symptoms, as well as improved confidence and emotions, and quality of life.
The other important thing to mention relating to strabismus ‘treatment’ is there are often risks to consider. The investigation of strabismus and the discussions about the suitable management plans for each individual patient (with the Orthoptist and Ophthalmologist) need to carefully consider the risks of each treatment option.
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Q7. Do you have any advice for a) adult strabismus patients and b) the parents of children with strabismus that you would like to add here?
Strabismus is a complex condition that can occur at the same time as other problems affecting the eyes, the most common of which are:
Refractive error – or the need for glasses (or contact lenses) to improve vision
Amblyopia – this is most commonly reduced vision in one eye compared to the other
Ocular motility imbalance – or eye movement problems
So, for all patients with strabismus, it is helpful to understand that there may be more than one issue affecting their eyes and these different issues can be interconnected. The treatment of one of these issues can affect the others, so there is often more than ‘just the strabismus’ to consider.
The Orthoptist, working with the Ophthalmologist and Optometrist, will understand these issues and they will try to investigate what is happening to understand the strabismus as best they can. Management plans are made for each individual patient, based on many different factors. Not every option is suitable for every patient and the risks of each option need to be carefully considered. For example, there are some patients for whom strabismus surgery might not be appropriate or recommended. If you are interested in finding out more information about your strabismus and you have questions, the best people to see would be an Orthoptist and an Ophthalmologist specialising in strabismus. Those consultations should allow you to gather information and understand your options.
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Thank you so much, Dr Arblaster. It has been fascinating to learn about the role of the Orthoptist in strabismus care. I feel sure that any patients reading this will also be grateful, especially those who are early in their diagnosis and searching for support. The information you have shared with us is extremely useful.
| Dr Arblaster has highlighted the following sources of information and research : Home – British and Irish Orthoptic Society There is a section for patients and the public that you may find helpful. Royal College of Ophthalmologists For patients | The Royal College of Ophthalmologists Squint Clinic website link Squint Clinic – What is a Squint? Strabismus, Squint Treatment, Lazy Eye Information, Type of Squint, Squint Operation / Surgery, Divergent Squint, Convergent Squint, Botox treatment, Squint guide, Squint help, Squint Videos. Evidence published in the medical literature: Strabismus Surgery for Psychosocial Reasons—A Literature Review | British and Irish Orthoptic Journal Patient perspectives on their outcomes from strabismus surgery undertaken for psychosocial reasons | Eye |
| Dr Arblaster has also highlighted the following research re: QoL (quality of life) |
| https://www.researchgate.net/publication/286833801_The_Psychosocial_Improvement_after_Strabismus_Surgery_in_Iranian_Patients Authors: Guita Ghiasi – Ahmad Shojaei – Mostafa Soltan Saniari – Meysam Kosari – Mehdi Aslani |
| Improvement in patients’ quality-of-life following strabismus surgery: evaluation of postoperative outcomes using the Adult Strabismus 20 (AS-20) score | EyeAuthors: P Glasman – R Cheeseman – V Wong – J Young – J M Durnian |
| Does strabismus surgery improve quality and mood, and what factors influence this? | Eye Authors: H B McBain – K A MacKenzie – J Hancox – D G Ezra – G G W Adams – S P Newman |
| Long-Term Quality of Life in Adult Patients with Strabismus after Corrective Surgery Compared to the General Population | PLOS One Authors: Meiping Xu – Huanyun Yu – Yuanyuan Chen – Jinling Xu – Jingwei Zheng – Xingping Yu |
| Is strabismus the only problem? Psychological issues surrounding strabismus surgery – Journal of the American Association for Pediatric Ophthalmology and Strabismus (JAAPOS)Authors: Gillian G W Adams – Hayley McBain – Kelly MacKenzie – Joanne Hancox – Daniel G Ezra – Stanton P Newman |
| Psychosocial Implications of Strabismus Surgery in Adults – Journal of Pediatric Ophthalmology & Strabismus Authors : John P Burke – Carolyn M Leach – Helen Davis |
| Quality of Life in Adults With Strabismus – American Journal of Ophthalmology Authors: Melinda Y Chang – Federico G Velez – Joseph L Demer – Sherwin J Isenberg – Anne L Coleman – Stacy L Pineles |
Effects of corrective strabismus surgery on social anxiety and self-consciousness in adults – Journal of the American Association for Pediatric Ophthalmology and Strabismus (JAAPOS) Authors: Kimberly J Estes – Rebecca K Parrish – James Sinacore – Patricia B Mumby – James F McDonnell |
| Quality of life and cost-utility assessment after strabismus surgery in adults – Japanese Journal of Ophthalmology Authors : Keiko Fujiike – Yoshinobu Mizuno – Yoshimune Hiratsuka – Masakazu Yamada – The Strabismus Surgery Study Group |
| Responsiveness of Health-Related Quality-of-life Questionnaires in Adults Undergoing Strabismus Surgery – Ophthalmology Authors: Sarah R Hatt – David A Leske – Jonathan M Holmes |
| Changes in Health-Related Quality of Life 1 Year Following Strabismus Surgery – American Journal of Ophthalmology Authors: Sarah R Hatt – David A Leske – Laura Liebermann – Jonathan M Holmes |
Incorporating Health-related Quality of Life Into the Assessment of Outcome Following Strabismus Surgery – American Journal of Ophthalmology Authors: Sarah R Hatt – David A Leske – Laura Liebermann – Jonathan M Holmes |
The psychosocial benefits of corrective surgery for adults with strabismus – British Journal of Ophthalmology Authors: S Jackson – R A Harrad – M Morris – N Rumsey |
| Does restoration of binocular vision make any difference in the quality of life in adult strabismus – British Journal of Ophthalmology Authors: Feray Koc – Yenal Erten – Nazife Sefi Yurdakul |
| Improvement in specific function-related quality-of-life concerns after strabismus surgery in nondiplopic adults – Journal of the American Association for Pediatric Ophthalmology and Strabismus (JAAPOS) Authors: Laura Liebermann – Sarah R Hatt – David A Leske – Jonathan M Holmes |
The impact of strabismus on quality of life in adults with and without diplopia: a systematic review – Survey of Ophthalmology Authors: Hayley B McBain – Charis K Au – Joanne Hancox – Kelly A MacKenzie – Daniel G Ezra – Gillian G W Adams – Stanton P Newman |
| The psychosocial aspects of strabismus in teenagers and adults and the impact of surgical correction – Journal of the American Association for Pediatric Ophthalmology and Strabismus (JAAPOS) Authors: Bradley A Nelson – Kammi B Gunton – Judith N Lasker – Leonard B Nelson – Lea Ann Drohan |
| Investigation of factors associated with the success of adult strabismus surgery from the patient’s perspective – Journal of the American Association for Pediatric Ophthalmology and Strabismus (JAAPOS) Authors: Peng Yong Sim – Charles Cleland – Jonathan Dominic – Saurabh Jain |
The Psychosocial Effects of Strabismus Before and After Surgical Correction in Chinese Adolescents and Adults – Journal of Pediatric Ophthalmology & Strabismus Authors: Jinling Xu – Xinping Yu – Ying Huang – Jie Chen – Huanyun Yu – Yuwen Wang – Fang Zhang |