Principles and Management of Complex Strabismus

Abstract

• Perform a thorough history. Most of the information needed to manage complex strabismus is obtained by the history.

• Keep an open mind until the diagnosis is certain. Do not try to fit the patient into your first diagnostic impression.

• Allow time for thorough evaluation, and measure ocular motility yourself. Schedule a return office visit, if necessary.

• Additional diagnostic tests are selectively chosen as needed; orbital CT scan to rule out fracture, chronic sinusitis and view extraocular muscles, MRI scan of brain, tensilon test, laboratory tests for thyroid function, and rheumatologic disease.

• Final diagnosis may await the intraoperative assessment, including forced ductions to rule out fibrosis, restrictions, or weakness, and direct visualization of the extraocular muscles to rule out trauma, malposition, or healing abnormality following prior strabismus surgery.

• During surgery, be flexible in approach to allow for unexpected findings. After repair, use spring-back test to assure centration of the eye, and reposition muscle(s) if necessary. Use non-absorbable sutures when poor healing is suspected or tendons are under high tension.

• Postoperatively tailor steroid use to the condition, and use adjunctive procedures such as motility exercise and in-office forced duction to expand range of motion.