Strabismus Surgery: Procedure and Benefits
Strabismus surgery is a surgical procedure that realigns misaligned eyes by modifying the length or position of the extraocular muscles that control eye movement. 1 This surgery is performed by ophthalmologists specialized in strabismus management, typically pediatric ophthalmologists or strabismologists.
Surgical Techniques
Strabismus surgery involves several techniques:
- Recession: Moving a muscle's attachment point further back on the eye to weaken its action
- Resection: Removing a section of muscle to shorten and strengthen its action
- Adjustable sutures: A technique allowing post-operative fine-tuning of alignment
- Tenotomy: Partial cutting of a muscle tendon to reduce its action
- Myopexy: Creating adhesion between adjacent muscles without attaching to sclera
- Botulinum toxin augmentation: Used alongside surgery for large deviations 1, 2
Indications for Surgery
Strabismus surgery is indicated for:
- Ocular misalignment causing cosmetic concerns
- Diplopia (double vision)
- Abnormal head posture to compensate for misalignment
- Asthenopia (eye strain)
- Reduced binocular vision 1, 3
Surgical Planning
Surgical planning requires:
- Measurement of deviation: Using prism and alternate cover test when possible
- For poor vision cases: Krimsky, modified Krimsky, or Hirschberg tests
- Assessment of vision: Treating any correctable vision loss before surgery
- Consideration of anesthesia: General anesthesia for complex cases; local anesthesia possible for some adults 1
Success Rates and Outcomes
- Alignment success: Approximately 80% achieve satisfactory alignment with one procedure, and up to 95% with a second procedure 1, 3
- Binocular function: Most adults experience improvement in binocular function, even with longstanding strabismus 3, 4
- Diplopia resolution: Over 95% resolution of diplopia in primary position for those with pre-existing diplopia 1
- Binocular vision improvement: After surgery, studies show significant improvements:
- Before surgery: 63.9% had no binocular vision
- After surgery: Only 22.4% had no binocular vision 4
Complications
Complications can range from mild to serious:
Mild concerns:
- Visible muscle insertion
- Visible/dark sclera
- Persistent injection over surgical site
- Pyogenic granuloma (2.1%)
- Tenon's prolapse 1
More serious concerns:
- Overcorrection or undercorrection
- Diplopia (0.8%, more common in adults)
- Limitation of eye movements
- Loss of binocular function
- Altered eyelid position
- Slipped muscle (1 in 1,500)
- Lost muscle (1 in 4,500)
- Retinal detachment (1 in 10,000 to 1 in 40,000) 1
Special Considerations for Adults
Adult strabismus surgery presents unique challenges:
- Anticoagulants: May continue during surgery with proper planning
- Adjustable sutures: Particularly helpful for unpredictable cases
- Small deviations: Can be treated with tenotomy or single muscle recession
- Complex strabismus: Higher incidence in adults due to previous surgeries, trauma, or other ocular procedures
- Anesthesia options: Local or general depending on complexity 1
Non-Surgical Alternatives
Before considering surgery, other options may be explored:
- Prism correction: Temporary or long-term relief
- Orthoptic exercises: More effective when office-based
- Botulinum toxin injections: Can yield long-term improvement in some cases 1, 2
Benefits Beyond Cosmetic Improvement
Strabismus surgery provides significant functional benefits:
- Expansion of binocular visual fields
- Potential recovery of stereopsis
- Reduction of asthenopia
- Psychological and interpersonal benefits
- Improved quality of life 5, 3
Strabismus surgery in adults is not merely cosmetic but provides functional visual improvements and significant psychosocial benefits that positively impact quality of life.