Providing premier service for eye misalignment in adults

Mari Takino graduating from the Stanford Graduate School of Business.

The Byers Eye Institute at Stanford provides a premier specialty clinic for adult strabismus patients. Strabismus, also known as eye misalignment, can occur due to issues with restriction—eye muscles not functioning properly—or with paresis—when the nerves to the eye muscles are not functioning properly. It can lead to double vision, poor depth perception, and social problems. Adult strabismus patients can encounter symptoms from a residual childhood diagnosis, or it can onset for the first time in adulthood. Depending on the cause, management approaches vary.  

At the Byers Eye Institute, strabismus patients are treated under the supervision of any one of our specialists on the adult strabismus team, including Euna Koo, MD, clinical assistant professor of ophthalmology; Andrea Kossler, MD, FACS, associate professor of ophthalmology; Scott Lambert, MD, professor of ophthalmology; and Ann Shue, MD, clinical assistant professor of ophthalmology.

“The most common treatment for adult strabismus is using prisms ground into or attached to eyeglass lenses, injecting botulinum toxin into an eye muscle, or eye muscle surgery,” Lambert said. “Strabismus surgery is generally performed on an outpatient basis by repositioning the eye muscles. In some cases, fine adjustments are made to the position of the eye muscles in the recovery room to optimize the alignment of the eyes.”


A non-surgical treatment route

Mari Takino, MBA, always defined herself as career-oriented, a go-getter, traveling around the world for her education and career. She grew up in the United Kingdom, then after a stint in finance in Hong Kong, she moved to the Bay Area to attend the Stanford Graduate School of Business.

On paper, Takino was excelling professionally, but she was fighting vision problems not always apparent to others. Around the age of 18 years old, she noticed the first signs of strabismus.

“Every now and then, I would wake up with crossed eyes,” Takino said. “I also noticed that dim lighting or focusing my eyes on certain angles for extended periods of time triggered them.”

Initially, Takino could realign her eyes within 20 to 30 minutes, but as her strabismus worsened, she spent up to an hour every morning realigning her eyes. She avoided environments that triggered her eyes to cross, such as concerts and movie theaters. Even with an abundance of caution, her eyes still crossed often, causing her to shy away from others’ attention and avoid photos.

“It affected my life in small ways that built up psychologically because I’d constantly stress about my eyes even if they weren’t crossed,” Takino said. “The breaking point was when I attended an admit weekend for a graduate school; my eyes crossed after a presentation in a lecture room so I hid in the bathroom for hours to get them to align but to no avail. I knew then I needed to seek medical attention.”

Takino was referred to Stanford and seen by Euna Koo, MD, for her treatment. Koo diagnosed Takino with intermittent esotropia, a type of strabismus common in nearsighted people where the eye(s) intermittently turn inward.  

“After discussing various treatment options, including incisional surgery and Botox, Mari elected to try Botox,” Koo said. “Given that her strabismus was only intermittent and Mari’s hesitancy to proceed with surgery, Botox was elected as the initial management approach.”

Koo injected Takino’s eye muscle with Botox twice, with each injection’s effects lasting about three months. The effects were immediate. Takino’s eyes no longer crossed, and she felt liberated from the stress and anxiety she had been carrying for years.

For the first time in seven years, she went to a movie theater. She trekked across Patagonia in Chile with her Stanford classmates for a week. Not once did her eyes cross. She graduated from Stanford Graduate School of Business in summer 2022.

“I appreciate Dr. Koo’s ability to understand needs and preferences specific to my condition and busy lifestyle,” Takino said. “This treatment gave me back more than my normal visual function; it improved my life. I now feel more confident to tackle my career and day to day life.”

Merging specialties for patient care

Lorinda Lahiff two months post-surgery.

Lahiff is back to snowboarding with her family

Lorinda Lahiff is no stranger to long drives, as she commuted daily between Cupertino and Livermore for work, and often would take long roadtrips to go snowboarding with her family. But about three years ago, Lahiff had to take a hiatus from her beloved hobby and long distance driving when she began experiencing double vision and eye pain. 

“I was walking into doorways and running into people when snowboarding. Depth perception was becoming an issue, and driving through toll booths or any other confined spaces was very difficult,” Lahiff said. “ My double vision became a safety issue and daily life routines were a challenge.”

When her vision started to affect her ability to drive, she went to Stanford and was diagnosed with thyroid eye disease (TED) and strabismus, related to persistent Graves’ disease, her hyperthyroid condition that she had been treating with medication for approximately two decades. After a thyroid biopsy, she underwent surgery to remove her thyroid.

At the Byers Eye Institute, Lahiff was seen by Andrea Kossler, MD, FACS, co-director of the multidisciplinary Thyroid Eye Disease Clinic. Lahiff was treated with a new biologic therapy, known as Tepezza, for her TED. Prior clinical studies demonstrated improvement in eye bulging, double vision, eye pain, redness, and swelling.

Lahiff noticed improvement in her TED symptoms, however she was still in need of strabismus surgery to correct her double vision. Koo performed strabismus surgery, and Lahiff proceeded with postoperative eye drops and follow-up appointments.

“After surgery, the results were almost immediate,” Lahiff said. “I was able to cautiously resume my daily activities, including snowboarding a few months after the surgery, and completed a 16-hour drive to Colorado for our daughter’s snowboard competition. That type of drive with twists and turns through canyons would not have been possible a few years ago.”

“Multiple family members of mine have had excellent care at Stanford,” Lahiff said. “Both Drs. Koo and Kossler were exceptional in listening to my story and tailoring treatment to my specific needs. I’m grateful to them for restoring not only my vision, but my quality of life.”

A family’s journey

Zila Horvitz poses for a photo before her surgery at Byers Eye Institute at Stanford.

Horvitz smiles fully recovered in a photo after her surgery performed by Scott Lambert, MD.

When Zila Horvitz and her husband Uri both began experiencing eye misalignment at their home in Israel, they set out to find the best physician for their care. They visited four different ophthalmologists in Israel to treat Zila’s symptoms as hers were the most severe, yet none could promise a full recovery following operation, and suggested that two operations may be needed. 

“I was seeking a full recovery,” Zila said. “At that point my Graves’ disease and strabismus were causing my eyes to swell.” As a retired high school literature teacher, reading was one of Zila’s favorite pastimes, and she hadn’t been able to read or drive confidently for two years.

Their son, Omer was living in San Francisco and reached out to a friend who had been a patient of Mark Blumenkranz, MD, MMS, H.J. Smead professor emeritus of ophthalmology. Blumenkranz recommended Scott Lambert, MD, for their care.

Zila and Uri often would travel to the states to visit Omer, and decided to make the trip from Israel to California to receive consultation at the Byers Eye Institute. “When we first met with Dr. Lambert, he asked why we would travel so far for a consultation,” Zila said. “I told him I read about him and was assured he was the best in the world. He was the only doctor that I felt confident could ensure us full recovery and correction in one surgery.”

Four days later, Zila went into surgery and three weeks later she was fully recovered. Seeing the success of his wife’s operation, Uri, who was experiencing headaches from his strabismus, went in and confirmed that he too had strabismus. He later went in for surgery, and reached the same successful results.

“What Dr. Lambert did for us truly felt like a miracle,” Uri said. “Zila can read and drive again, and I was able to return to work just days after surgery. Dr. Lambert was efficient and professional.”

“I am eternally grateful to the entire Stanford institution,” Omer said. “Having my parents get their vision and life back is priceless. I think I speak for all of us in that when you brush into someone for a few months, and they change the course of your life, it’s magic. We are very happy we ended up at Stanford and very grateful to the team for what they did.”


Kathryn Sill is the former web and communications specialist for the Byers Eye Institute in the Department of Ophthalmology, at Stanford University School of Medicine.