Strabismus surgery

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Isolating the inferior rectus muscle

Disinserting the medial rectus muscle

Strabismus surgery (also: extraocular muscle surgery, eye muscle surgery, or eye
alignment surgery) is surgery on the extraocular muscles to correct strabismus, the
misalignment of the eyes. With approximately 1.2 million procedures each year,
extraocular muscle surgery is the third most common eye surgery in the United
States.[1] The earliest successful strabismus surgery intervention is known to have
been performed on 26 October 1839 by Johann Friedrich Dieffenbach on a 7-year-old
esotropic child; a few earlier attempts had been performed in 1818 by William
Gibson of Baltimore, a general surgeon and professor at the University of Maryland.
[2]

The idea of treating strabismus by cutting some of the extraocular muscle fibers
was published in American newspapers by New York oculist John Scudder in 1837[3]

Contents [hide]
1 Types
2 Outcomes
2.1 Alignment and functional changes
2.2 Complications
3 See also
4 References
5 Further reading
6 External links
Types[edit]
Eye muscle surgeries typically correct strabismus and include the following:[4][5]
Loosening / weakening procedures
Recession involves moving the insertion of a muscle posteriorly towards its origin.
Myectomy
Myotomy
Tenectomy
Tenotomy
Tightening / strengthening procedures
Resection involves detaching one of the eye muscles, removing a portion of the
muscle from the distal end of the muscle and reattaching the muscle to the eye.[6]
Tucking
Advancement is the movement of an eye muscle from its original place of attachment
on the eyeball to a more forward position.
Transposition / repositioning procedures
Adjustable suture surgery is a method of reattaching an extraocular muscle by means
of a stitch that can be shortened or lengthened within the first post-operative
day, to obtain better ocular alignment.[7][8]
Strabismus surgery is a one-day procedure. The patient spends only a few hours in
the hospital with minimal preoperative preparation. The average duration of the
surgery is variable. After surgery, the patient should expect soreness and redness.
In cases of re-operations, more pain is expected. Resection of the muscles is more
painful in the post operative period than recession. It also leaves redness that
lasts longer and may cause some vomiting in the early post operative period.

The surgeon will provide the patient with a cover for his or her eyes that prevents
light from entering. It is advisable for the patient to wear this, since stimulus
to the eye (e.g., light, rolling of eyes) will cause discomfort.
Outcomes[edit]
Alignment and functional changes[edit]
Over- and undercorrection: Surgical intervention can result in the eyes being
entirely aligned (orthophoria) or nearly so, or it can result in an over- or
undercorrection that may necessitate further treatment or another surgical
intervention. The likelihood that the eyes will stay aligned over the longer term
is higher if the patient is able to achieve some degree of binocular fusion after
surgery than if not. In a study on infantile esotropia patients who had either
small-angle (8 diopters) esotropia or small-angle exotropia of the same size six
months after the intervention, it was found that those who had the small-angle
esotropia were more likely to have aligned eyes five years after the intervention
than those with small-angle exotropia.[9] There is tentative evidence that children
with infantile esotropia patients achieve better binocular vision post-operatively
if the surgical treatment is performed early (see: Infantile esotropia#Surgery).

Other deviations: Strabismus surgery for oblique muscle disorders may result in
consecutive misalignment of the eyes. First of all, dissociated vertical deviation
may occur. There are indications that the severity of this deviation may be lower
if a child is operated at a very young age.[10] Secondly, strabismus surgery may
also result in subjective and objective cyclodeviation, possibly resulting in
cyclotropia and rotational double vision (cyclodiplopia) if the visual system
cannot compensate for it.[11][12]

For pure horizontal rectus muscle surgeries, it is known that vertical deviations,
A and V patterns and cyclotropia can be anticipated or avoided by taking certain
surgical precautions.[13]

Functional considerations: A frequent outcome of strabismus surgery is consecutive

microtropia (also known as monofixation syndrome).[14]

Functional improvements and further benefits: For a long time it was thought that
adult patients with long-standing strabismus could achieve only cosmetic
improvement; in recent years there have been cases in which sensory fusion has
occurred also in this type of patients provided that postoperative motor alignment
is very high.[15] In case of pre-operative inward squint the correction expands the
binocular visual field of the patient, improving peripheral vision. Furthermore,
the restoration of ocular alignment can bring about psychosocial and economic
benefits to the patient (see also: Psychosocial effects of strabismus).[15]

Complications[edit]
Diplopia occurs rather frequently in the first few weeks following surgery.

Complications that occur rarely or very rarely following surgery include: eye
infection, hemorrhage in case of scleral perforation, muscle slip or detachment, or
even loss of vision.

Eye muscle surgery gives rises to scarring (fibrosis); if scarring is extensive, it

may be seen as raised and red tissue on the white of the eye. Fibrosis can be
reduced by use of mitomycin C during surgery.[16]

A relatively new method, primarily devised by Swiss ophthalmologist Daniel Mojon,

is minimally-invasive strabismus surgery (MISS)[17][18]which has the potential to
reduce the risk of complications and lead to faster visual rehabilitation and wound
healing. Done under the operating microscope, the incisions into the conjunctiva
are much smaller than in conventional strabismus surgery. A study published in 2017
documented fewer conjunctival and eyelid swelling complications in the immediate
postoperative period after MISS with long-term results being similar between both
groups.[19] MISS can be used to perform all types of strabismus surgery, namely
rectus muscle recessions, resections, transpositions, and plications even in the
presence of limited motility.[20]

Very rarely, potentially life-threatening complications may occur during surgery

due to the oculocardiac reflex.

See also[edit]
Eye surgery
Orthoptist
SEE-KID - Computer-assisted Simulation and Treatment of Eye Motility Disorders
Stereopsis recovery
References[edit]
Jump up ^ Hertle, Richard. "Eye Muscle Surgery and Infantile Nystagmus Syndrome"
(Microsoft Word document). American Nystagmus Network. Retrieved 2006-10-10.
Jump up ^ Gunter K. von Noorden: Binocular Vision and Ocular Motility: Theory and
management of strabismus, Chapter 26: Principles of Surgical Treatment,
telemedicine.orbis.org
Jump up ^ Leffler CT, Schwartz SG, Le JQ (2017). "American Insight into Strabismus
Surgery before 1838". Ophthalmology and Eye Diseases. 9: 1179172117729367.
Jump up ^ Surgery Encyclopedia - Eye Muscle Surgery
Jump up ^ Strabismus Surgery
Jump up ^ Strabismus.com - Strabismus Surgery
Jump up ^ Parikh, RK; Leffler, CT (July 2013). "Loop suture technique for optional
adjustment in strabismus surgery". Middle East African Journal of Ophthalmology. 20
(3).
Jump up ^ Eye Procedures > Adjustable Suture Strabismus Surgery - EyeMDLink.com
Jump up ^ Kushner BJ1 Fisher M (1996). "Is alignment within 8 prism diopters of
orthotropia a successful outcome for infantile esotropia surgery?". Arch
Ophthalmol. 114 (2): 176180. doi:10.1001/archopht.1996.01100130170010. PMID
8573021.
Jump up ^ Yagasaki, T.; Yokoyama, Y. O.; Maeda, M. (Jul 2011). "Influence of timing
of initial surgery for infantile esotropia on the severity of dissociated vertical
deviation". Jpn J Ophthalmol. 55 (4): 383388. doi:10.1007/s10384-011-0043-1. PMID
21647566.
Jump up ^ See section "Discussion" in: Pradeep Sharma; S. Thanikachalam; Sachin
Kedar; Rahul Bhola (JanuaryFebruary 2008). "Evaluation of subjective and objective
cyclodeviation following oblique muscle weakening procedures". Indian Journal of
Ophthalmology. 56 (1): 3943. doi:10.4103/0301-4738.37594. PMC 2636065?Freely
accessible. PMID 18158402.
Jump up ^ H. D. Schworm; S. Eithoff; M. Schaumberger; K. P. Boergen (February
1997). "Investigations on subjective and objective cyclorotatory changes after
inferior oblique muscle recession". Investigative Ophthalmology & Visual Science.
38 (2). pp. 405412.
Jump up ^ Khawam, E.; Jaroudi, M.; Abdulaal, M.; Massoud, V.; Alameddine, R.;
Maalouf, F. (2013). "Major review: Management of strabismus vertical deviations, A-
and V-patterns and cyclotropia occurring after horizontal rectus muscle urgery with
or without Oblique Muscle Surgery". Binocul Vis Strabolog Q Simms Romano. 28 (3):
181192. PMID 24063512.
Jump up ^ Guthrie, ME; Wright, KW (September 2001). "Congenital esotropia".
Ophthalmol Clin North Am. 14 (3): 41924, viii. doi:10.1016/S0896-1549(05)70239-X.
PMID 11705141.
^ Jump up to: a b Edelman PM (2010). "Functional benefits of adult strabismus
surgery". Am Orthopt J. 60 (60): 4347. PMID 21061883.
Jump up ^ Kersey, J. P.; Vivian, A. J. (JulSep 2008). "Mitomycin and amniotic
membrane: a new method of reducing adhesions and fibrosis in strabismus surgery".
Strabismus. 16 (3): 116118. doi:10.1080/09273970802405493. PMID 18788060.
Jump up ^ Mojon DS: Minimally invasive strabismus surgery. In: Eye. (Lond). 29,
2015, S. 225233.
Jump up ^ Mojon DS: Comparison of a new, minimally invasive strabismus surgery
technique with the usual limbal approach for rectus muscle recession and plication.
In: Br J Ophthalmol. 91, 2007: 7682.
Jump up ^ Gupta P, Dadeya S, Kamlesh, Bhambhawani V: Comparison of Minimally
Invasive Strabismus Surgery (MISS) and Conventional Strabismus Surgery Using the
Limbal ApproachJ Pediatr Ophthalmol Strabismus. 2017;54:208-215..
Jump up ^ Asproudis I, Kozeis N, Katsanos A, Jain S, Tranos PG, Konstas AG : A
Review of Minimally Invasive Strabismus Surgery (MISS): Is This the Way Forward?
Adv Ther. 2017;34:826-833.
Further reading[edit]
Wright, Kenneth W.; Thompson, Lisa S.; Strube, Yi Ning; Coats, David K. (August
2014). "Novel strabismus surgical techniquesnot the standard stuff". Journal of
American Association for Pediatric Ophthalmology and Strabismus (JAAPOS). 18 (4):
e47. doi:10.1016/j.jaapos.2014.07.152.
Kushner, Burton J. (2014). "The Benefits, Risks, and Efficacy of Strabismus Surgery
in Adults". Optometry and Vision Science. 91 (5): e102e109.
doi:10.1097/OPX.0000000000000248. ISSN 1040-5488. PMID 24739461.
Engel JM (September 2012). "Adjustable sutures: an update". Current Opinion in
Ophthalmology. 23 (5): 3736. doi:10.1097/ICU.0b013e3283567321. PMID 22871879.
External links[edit]
Strabismus Surgery, Horizontal on EyeWiki from the American Academy of
Ophthalmology
Strabismus Surgery Complications on EyeWiki from the American Academy of
Ophthalmology
Categories: Eye surgery
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