Global financing of strabismus surgery: a literature review supported by an international survey.

PURPOSE: Strabismus surgery is a well-established intervention with demonstrated functional and psychosocial benefits, supported by extensive clinical and economic literature. Despite this evidence, reimbursement policies remain highly heterogeneous worldwide, often influenced by the persistent ambiguity between functional and cosmetic indications. A comprehensive synthesis of existing cost data, combined with real-world reimbursement practices, is required to better understand barriers to equitable access to care. METHODS: We conducted a targeted literature review to identify published data on hospital package costs and physician fees for strabismus surgery across different countries. This review was complemented by a cross-sectional web-based survey distributed to members of the European Strabismological Association between January and April 2025. The 37-item questionnaire explored national health-insurance structures, reimbursement mechanisms, professional fees, and reoperation coverage. Quantitative data were analyzed descriptively, and qualitative responses were reviewed thematically. All monetary values were inflation-adjusted and expressed in 2024 purchasing power parity (PPP)-adjusted U.S. dollars. One-sample Student's t-tests were used to compare international mean costs with French reference tariffs. RESULTS: The literature review identified six peer-reviewed studies reporting direct costs of strabismus surgery across North America, Europe, Asia, and the Middle East. Survey analysis included 100 complete responses from 39 countries; 90% of respondents were ophthalmologists and 10% orthoptists, mostly practicing in mixed public-private settings. According to OECD classifications, three principal health-financing models were identified: Beveridge, Bismarck, and liberal systems. Public reimbursement of strabismus surgery was reported in 92% of countries when performed in public hospitals, but in only 50% when performed in private facilities. Coverage for aesthetic or psychosocial indications varied widely.The pooled mean international hospital package cost derived from survey and literature data was 2 303 ± 1 543 USD PPP, not significantly different from the French "GHS/GHM" reference tariff (2 233 USD PPP; p = .87). In contrast, the mean international surgical fee (676 ± 391 USD PPP) was significantly higher than the French "CCAM" benchmark (223 USD PPP; p < .05). CONCLUSION: This combined literature review and international survey highlights substantial disparities in the financing of strabismus surgery worldwide. While institutional costs appear broadly comparable across countries, physician remuneration varies markedly and remains particularly undervalued in some systems. Persistent ambiguity regarding functional versus cosmetic indications continues to influence reimbursement policies. Greater harmonization and recognition of strabismus surgery as a functional intervention may improve equity of access and sustainability of care.