When Refractive Surgery Unmasks Latent Strabismus: Occurrence, Mechanisms, And Risk Indicators Of Postoperative Binocular Decompensation

Published 2026 - 44th Congress of the ESCRS

Reference: FP07.14 | Type: Free paper | DOI: 10.82333/xmng-1v23

Authors: Dr Dana Nourallah* ¹

¹Ophthalmology ,Saudi German Hospital ,Dubai ,United Arab Emirates

Purpose

To report the occurrence of binocular diplopia and strabismic decompensation following corneal refractive surgery, to analyse the underlying mechanisms, and to identify preoperative risk indicators associated with postoperative binocular instability.

Setting

Single-centre retrospective study conducted at a tertiary referral ophthalmology centre with dedicated refractive and strabismus services in Dubai , United Arab Emirates.

Methods

A retrospective review was conducted of patients presenting with persistent new-onset binocular diplopia following LASIK, PRK, , or blended vision laser treatment between April 2021 and December 2025.

Preoperative assessment included distance and near phoria measurements, fusional vergence amplitudes, AC/A ratio evaluation, stereoacuity , ocular dominance testing, history of strabismus or amblyopia, and planned refractive strategy, including monovision or blended profiles. All affected patients underwent comprehensive orthoptic evaluation postoperatively. Mechanisms of decompensation were classified based on clinical findings and correlated with preoperative characteristics

Results

Ten patients (0.5%) developed symptomatic binocular decompensation within three months of surgery. Mean age was 38.6 ± 7.9 years.

Preoperative risk factors included baseline heterophoria (≥8 prism diopters), reduced positive fusional vergence (<15Δ), prior strabismus or amblyopia, high AC/A ratio , and planned monovision or blended correction.

Postoperative instability was linked with 4 mechanisms: sensory disruption with suppression breakdown; refractive imbalance including residual anisometropia or hyperopic shift; monovision/blended vision–associated instability, including dominance alteration and torsional decompensation; and vergence or AC/A-related imbalance.

Conclusions

Binocular decompensation following refractive surgery is uncommon but clinically significant. It appears to occur predominantly in patients with pre-existing binocular vulnerability, particularly those with limited fusional reserves, baseline phoria, prior strabismus history, or undergoing monovision or blended correction. Structured binocular and dominance assessment should be considered as part of routine refractive screening to optimise patient selection and minimise postoperative morbidity.