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Johns Hopkins Pediatric

Advances in Strabismus Care for Adults and Children



Improving outcomes with Lancaster Red-Green testing and adjustable suture surgery

Strabismus is a common eye problem affecting both children and adults. At Wilmer Eye Institute, Dr. Edward Kuwera and team have been achieving successful outcomes with an underutilized test that better informs strabismus treatment, improves outcomes and enhances patient well-being.

“The use of Lancaster Red-Green (LRG) testing in adults provides a more complete picture of the total misalignment,” explains Dr. Kuwera, “for better understanding and treatment of strabismus.”

Location of the eye and the amount of torsion or twisting is critical data that is not universally examined. LRG is the only test that accomplishes this, showing torsion in every direction of the gaze. “It’s an under-appreciated and invaluable test because it gives insight into how to provide the best possible care,” says Dr. Kuwera.

LRG is a binocular, dissociative, subjective test that can quickly and accurately measure strabismus in the nine diagnostic positions of gaze. It allows for visualization of the alignment of each eye relative to the other and allows torsion to be easily assessed in all directions of gaze.

Because LRG is dissociating for the eyes, it prevents the patient from fusing and complicating strabismus measurements. The resulting diagram provides a format that makes the misalignment easier to understand and provides critical data that is crucial to surgical planning.

For instance, when a patch test identifies a patient who appears to have good alignment straight ahead, but misalignment in other directions, the LRG test can then allow doctors to determine if they can perform surgery without interfering with the patient’s straight-ahead vision.

“The insight from an LRG test can make or break a surgical plan.But it also allows patients to see what their eyes are doing, why it’s happening and gives context as to how they can make it better. When patients have a deeper understanding, it can make acceptance of the diagnosis easier.”

For pediatric patients needing surgical strabismus correction, Wilmer Eye Institute is one of the only hospitals in the world equipped to use the adjustable suture technique. Performed on children as young as a few months of age needing surgical strabismus correction, this procedure enables multiple adjustments to be made based on patient feedback until they are able to minimize the amount of double vision.

When patients are awoken from surgery, they are asked how they are feeling and what they are seeing. Adjustments can be made on the spot if they come out of surgery and vision is not where it needs to be.

“When necessary, multiple adjustments can be made for adults because they’re more sensitive and can call-out double vision. Children's brains are more flexible. If you can get it close enough, the brain can adjust,“ explains Dr. Kuwera.

Reflecting the philosophy of Wilmer Eye Institute of providing patient care that is humane, personalized, thoughtful, and grounded in science, Dr. Kuwera concludes, “We’re excited about the improved outcomes we’re experiencing using LRG. We encourage others to consider adopting this approach to achieve similar outcomes for their patients.”

For more information, connect with Dr. Kuwera on Doximity.

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