PURPOSE: To clarify the actual status of strabismus surgery and botulinum toxin (BTX) therapy in Japan in the year 2021. STUDY DESIGN: Cross-sectional study. METHODS: We conducted a national survey of strabismus treatment in 2021 using a questionnaire consistent with a previous 2013 survey, incorporating additional questions about BTX therapy. RESULTS: Among the 378 responding institutions, strabismus surgery or BTX therapy, or both, was performed at 185 institutions (49%
total cases, 10,767). In 151 (40%), 32 (8%), and 2 (1%) institutions, surgery only, surgery and BTX therapy, and BTX therapy only were performed, respectively. The distribution of institutions where strabismus surgery was performed consisted of 4 prefectures, accounting for 48% of the total, whereas no strabismus surgery was performed at any institution in 3 prefectures. Although the highest percentage of patients (23%) was aged between 10 and 19 years, 48.2% of the patients were aged 20 years or older, and 17% of them were aged 60 years or older. Exotropia (XT) was the most common type of strabismus (55%) followed by esotropia (ET) (24%). In terms of complex surgeries, 80.2% (more than 100 cases) were performed at institutions with more than 100 cases. Of the 34 institutions where BTX therapy was performed, 52% were performed at a single institution, and 18% were performed at 2 institutions where no strabismus surgery was performed. Patients with scarring in the extraocular muscles, such as thyroid eye disease, were the most treated, followed by those with ET, who were mainly given injection treatment. CONCLUSION: Institutions where strabismus surgery and BTX therapy could be performed were concentrated and limited.