Refractive surgery has revolutionized vision correction, significantly improving patients’ quality of life. However, a rare but notable complication is the decompensation of strabismus and binocular vision with a low prevalence (estimated between 0.002% and 0.004%). Pre-existing latent or manifest strabismus is the primary risk factor for postoperative diplopia. Additionally, improper centration of the treatment or monocular correction can lead to the decompensation of a phoria into a tropia. A thorough preoperative assessment is crucial to identify at-risk patients through specific tests for ocular alignment and binocular fusion. In cases of refractive regression, patients with pre-existing strabismus may develop diplopia or ocular misalignment. Furthermore, presbyopia correction with monovision must be carefully evaluated in individuals with fragile binocular fusion. While refractive surgery can unmask strabismus in some patients, it can also treat underlying hyperopic refractive error in accommodative esotropia, improving alignment, uncorrected visual acuity, and stereopsis. Both accommodative and nonaccommodative strabismus may achieve orthophoria or microtropia postoperatively. Refractive surgery can also benefit children with strabismus and amblyopia who fail spectacle or contact lens therapy. Treatment strategies include the use of prism glasses, refractive retreatments, botulinum toxin injections, or strabismus surgery. However, prevention remains the best approach: careful patient selection and precise surgical execution can significantly reduce the risk of strabismus-related complications following refractive surgery.