Current management approaches and future trends in horizontal sensory strabismus: a literature review

PURPOSE: To provide a comprehensive overview of the current diagnostic methods and evolving management options for horizontal sensory strabismus, with a focus on emerging surgical techniques and predictors of outcomes. METHODS: We conducted a narrative review of the literature on sensory esotropia and exotropia, including diagnostic criteria, non-surgical management, and conventional and advanced surgical techniques. Evidence regarding success rates, surgical dosing, and predictive factors was synthesized to propose an angle-based surgical nomogram. RESULTS: Accurate evaluation requires measurement of the deviation and identification of the underlying sensory deficit. Common causes include trauma and anisometropia-associated amblyopia. Management ranges from optical correction and pharmacologic interventions (e.g., botulinum toxin A and bupivacaine) to multiple surgical options. Recession-resection and fenestration are effective for deviations < 50 PD, whereas supramaximal recession-resection and true muscle transplantation have been used for deviations > 60-70 PD. Reported success rates across techniques ranged from 73.2% to 90.6%, with higher success in exotropia than esotropia. Newer methods, particularly muscle transplantation, demonstrated substantial correction with minimal motility limitation. Based on the synthesized evidence, a deviation-based nomogram for surgical planning in horizontal sensory strabismus is proposed. CONCLUSIONS: Treatment of horizontal sensory strabismus should be individualized according to deviation magnitude, visual prognosis, and ocular comorbidities. Advanced techniques expand options for large-angle cases. A deviation-based nomogram may help guide surgical planning. Further studies are needed to assess long-term stability and functional outcomes.