What are the treatment options for strabismus (cross-eyed) in an adult with a history of poliomyelitis (polio)?

Treatment Options for Strabismus in Adults with History of Polio

Surgical correction is the primary treatment for strabismus in adults with a history of poliomyelitis, with approximately 80% of patients achieving satisfactory alignment with one procedure and up to 95% with a second procedure. 1

Evaluation Considerations for Post-Polio Strabismus

• Strabismus in adults with history of polio may be related to:

  • Neurological damage from the poliovirus affecting cranial nerves
  • Residual muscle weakness or imbalance
  • Compensatory mechanisms developed over time
  • Possible sensory strabismus if polio affected vision

• Important examination elements:

  • Assessment of ocular alignment using prism and alternate cover test
  • Evaluation of extraocular muscle function and restrictions
  • Testing for binocular fusion potential and stereopsis
  • Checking for abnormal head posture that may have developed as compensation

Treatment Algorithm

Non-Surgical Options (Initial Approach)

1. Optical Correction

   • Full correction of refractive error, including hyperopia and astigmatism
   • Appropriate bifocal or progressive lenses for adults with presbyopia
   • Reversal of monovision if applicable 2

2. Prism Therapy

   • Fresnel prisms for temporary relief of diplopia
   • Ground-in prisms for long-term management of stable deviations
   • Success rate approximately 70-80% for appropriate candidates 3

3. Botulinum Toxin Injections

   • Can yield long-term improvement in some cases 2
   • Particularly useful for:
     • Small-angle deviations
     • Enhancing impact of traditional surgery
     • Preventing contracture of antagonist muscles in paralytic strabismus 2

Surgical Management

Surgical intervention is indicated when:

• Non-surgical options fail to provide adequate alignment
• Significant cosmetic concerns exist
• Diplopia persists in primary position or downgaze
• Abnormal head posture is present

Surgical techniques include:

1. For Standard Comitant Deviations

   • Recession/resection procedures
   • Adjustable sutures (particularly beneficial in adults)

2. For Complex/Restrictive Strabismus

   • Muscle transposition procedures if a muscle is severely paretic
   • Posterior fixation sutures to address incomitant deviations
   • Scott procedures (recess/resect) on the unaffected eye 2

3. For Small Deviations

   • Tenotomy procedure (partial, central snip)
   • Single rectus muscle recession 2

Special Considerations for Post-Polio Patients

• Anesthesia Choice: General anesthesia may be preferable for complex cases; local anesthesia with monitored sedation possible for simple unilateral procedures 2

• Adjustable Sutures: Particularly valuable in post-polio patients due to potential unpredictability of outcomes; provides a second chance at obtaining satisfactory alignment 2

• Realistic Expectations: Complete elimination of diplopia may be difficult if the misalignment is incomitant; expanding the field of binocular single vision is often a more realistic goal 2

• Multiple Procedures: Patients should be counseled that more than one surgery may be required

Outcomes and Prognosis

• Over 90% of adults treated with strabismus surgery demonstrate improvement in alignment or binocular function 2
• As many as 25% achieve both improved alignment and binocular function 2
• Persistent diplopia after successful surgery occurs in 1% or fewer patients 2
• Significant psychosocial benefits include improved self-image, enhanced emotional health, and better social interactions 2

Potential Complications

• Overcorrection or undercorrection
• Transient diplopia (common but usually resolves)
• Limitation of eye movements
• Altered eyelid position
• Slipped or lost muscle (more common in adults with previous surgeries) 2

Adults with strabismus and history of polio should be referred to an ophthalmologist specializing in strabismus management, as these cases often require expertise in managing complex ocular motility disorders.