OBJECTIVE: Strabismus in the elderly can cause functional and psychological difficulties, particularly due to the impact of diplopia. Surgical intervention may alleviate diplopia and diminish psychosocial impact. However, the complexity of strabismus types, along with related ocular conditions and general health issues, pose unique challenges. This study explores the indications, safety, and outcomes of strabismus surgery in patients aged 80 years or more. DESIGN: Retrospective clinical cohort study. METHODS: We reviewed patients aged 80 years and older who underwent strabismus surgery at Stein Eye Institute, University of California, Los Angeles, between 2014 and 2024. RESULTS: The study included 165 patients with a mean age of 83 ± 3 (standard deviation, range 80-94) years, of whom 52% were female. Diplopia was the primary complaint in 94% of patients, with 5 ± 9 years mean symptom duration. The most prevalent diagnosis was sagging eye syndrome, which accounted for 46% of cases. The most common preoperative deviation was combined esotropia and hypertropia (30%). Surgery was performed in 48 patients under general anesthesia and 116 under topical anesthesia. The mean American Society of Anesthesiologists physical status classification score was 2.6 ± 0.5 (range 1-4). No complications occurred during anesthesia or surgery. Diplopia resolved in 124 patients (75%) after the initial surgery, increasing to 145 patients (87%) after one or two additional surgeries. Reoperation was required in 13% of patients overall. CONCLUSION: Strabismus surgery in patients over 80 years resolves diplopia and improves binocular alignment and stereopsis, without significant complications.