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1 Double Trouble: Post surgical surgical Strabismus I have no financial interests to disclose. Anya Trumler, MD Wilmer Pediatric Ophthalmology What is strabismus? DIPLOPIA Misalignment of the eyes Strabismus Double Can have double vision out of one eye Some patients only use one eye at a time. Causes of Binocular Double Vision Infantile / Childhood onset Need for glasses Cranial nerve palsy Tendency for eye misalignment that decompensated Trauma Thyroid eye disease Loss or poor vision in one eye Post surgical Anesthesia Post Surgical Strabismus Cataract surgery Refractive surgery Retina Glaucoma

2 Anesthesia Retrobulbar Block Reported incidence of new onset diplopia after cataract surgery: Retrobulbar anesthesia: 1% Topical anesthesia: 0% 0.2% Yangüela J, Gómez Arnau JI, Martín Rodrigo JC, Andueza A, Gili P, Paredes B, Porras MC, González del Valle F, Arias A. Diplopia after cataract surgery: comparative results after topical or regional injection anesthesia. Ophthalmology Apr;111(4): What is it about the block? Needle injury to muscle? Ischemia? Injection in perimusclar space causing compression Neurogenic injury? Toxic effect of the meds? Lidocaine Marcaine Hyaluronidase Epinephrine A 1.5 inch retrobulbar needle from the inferiortemporal approach can reach any extraocular muscle. Incidence: Inferior rectus > Superior rectus > all others Capo H, Roth E, Johnson T, Munoz M, Siatokowski RM. Vertical strabismus after cataract surgery. Ophthalmology. 1996; 103: Guyton DL. Strabismus compliations of local anesthetics. Seminars in Ophthalmology. 2008; 23: Anesthetic Agent All anesthetic agents directly injected into muscle are myotoxic Bupivicaine (Marcaine) is most and Procaine least Hyaluronidase protective Dispersive Initial paresis in in some followed by progressive segmental fibrosis. Reversal of direction of diplopia. Hyaluronidase Medication added to help spread the anesthetic In 2002 there was a shortage of Hyaluronidase throughout world In a single French hospital, 7205 cataract surgeries were performed under RB anesthesia between : 2003: Wydase available 3582 patients no diplopia No Wydase available 3623 patients 27 with diplopia (0.75%) Hamada S, Devys JM, Xuan TH, Ganem S, Sahel JA, Héran F, Plaud B. Role of hyaluronidase in diplopia after peribulbar anesthesia for cataract surgery. Ophthalmology May;112(5): Jehan FS, Hagan JC 3rd, Whittaker TJ, Subramanian M. Diplopia and ptosis following injection of local anesthesia without hyaluronidase. J Cataract Refract Surg Nov;27(11):

3 Bupivicaine to treat esotropia Cataract Surgery 1,600,000 cataract surgeries performed in US each year. Incidence of complications: 0.1% to 6.8% Pre injection 5 months post injection 1 1 year post injection 2 ET 25 ET 15 ET 11 Images pre (A) and post (B) injection of Bupivicaine Scott AB, Alexander DE, Miller JE. Bupivacaine injection of eye muscles to treat strabismus. Br J Ophthalmol : Risks: Endophthalmitis Retinal Detachment Cystoid Macular Edema Posteriorly dislocated lens material Suprachoroidal hemorrhage Increased dintraocular pressure Loss of eye Diplopia H, Kersey JP, Oystreck DT, Cline RA, Lyons J. Diplopia following cataract surgery: a review of 150 patients. Eye : Cataract Surgery 1950 s 1970 s 1980 s to present Patients left aphakic (no lens implant) High power glasses magnify Create difference in image size IOL s and Phaco Increased patient expectations Diplopia is discussed more often in literature Why would patients in today s age get double vision? Retrobulbar anesthesia Patients with previous eye misalignment Monovision Monovision Correct one eye to make distance sharp and the other eye to make near vision sharp. Contact lenses, cataract surgery, refractive surgery Benefit: No glasses needed dd Drawback: Double vision, decreased depth perception 70% of patients developed diplopia two years after monovision 50% recovered 4 months after discontinuing monovision. Pollard ZF, Greenberg MF, Bordenca M, Elliott J, Hsu V. Strabimus precipitated by monovision. Am J Ophthalmol Sept;152(3):

4 Refractive Surgery What should be included in the pre operative evaluation? Does strabismus preclude a patient from refractive surgery? Can some forms of strabismus be treated with ih refractive surgery? Pre operative Evaluation History of strabismus / diplopia p BCVA Manifest Refraction If hyperopic check cycloplegic refraction Use a lensometer make sure no prism Cross Cover Trial of contact lenses if not aiming for emmetropia Kushner BJ, Kowal L. Diplopia after refractive surgery: occurrence and prevention. Arch Ophthalmol Mar;121(3): Can refractive surgery correct an eye misalignment? In a study of 16 hyperopic esotropes and 12 myopic exotropes. Improved ocular alignment in all. No patient experienced decompensation of strabismus or diplopia. Why? The patients need for glasses is contributing to the eye misalignment. Treatment If strabismus have them evaluated by a strabismus specialist Under promise and over deliver ethos Clear documentation of discussion and awareness of all relevant issues is imperative i Kirwan C, O'Keefe M, O'Mullane G, Sheehan C. Refractive surgery in patients with accommodative and non accommodative strabismus one year prospective follow up. Br J Ophthalmol Nov 30 Retinal Detachment Diplopia p is a well known complication of scleral buckling for retinal detachment. 3 20% for retrospective 73% with transient diplopia in prospective. Why? Scarring of eye muscles Decreased vision post operatively Macular not in same position Large change in glasses prescription buckle and/or oil Sauer A, Bouyon M, Bourcier T, Speeg Schatz C. Diplopia complicating scleral buckling surgery for retinal detachment. J Fr Ophtalmol Oct;30(8): Kasbekar SA, Wong V, Young J, Stappler T, Durnian JM. Strabismus following retinal detachment repair: a comparison between scleral buckling and vitrectomy procedures. Eye. 2011: 25: Type of Diplopia Diplopia popa0.5% 20% ate after retinal detachmente t Hypertropia 58% Horizontal deviation 17% Torsional 46% More common in those with a scleral buckle. Cooper LL, Harrison S, Rosenbaum AL. Ocular torsion as a complication of scleral buckle procedures for retinal detachments. J AAPOS Oct;2(5):

5 Scleral Buckle Treatment Time Prisms Blurring of second image Scleral buckle removal??? Strabismus surgery Santiago AP, Rosenbaum AL. Strabismus following scleral buckle. In: Rosenbaum AL, Santiago AP. (eds). Clinical Strabismus Management - Principles and Surgical Techniques, Chap. 28. WB Saunders Company: Philadelphia, Treatment Removal of buckle has minimal improvement on strabismus. Re detachment rate of 4 33% for scleral buckle removal for various reasons. Recommend minimizing i i i tissue manipulation i to perform strabismus surgery. Diplopia Glaucoma Trabeculectomy Glaucoma drainage device Wong V, Kasbekar S, Young J, Stappler T, Marsh I, Durnian JM. The effect of scleral exoplant removalon strabismus following retinal detachment repair. J of APPOS. 2011;14: Goezinne F, Berendschot TJM, Van Daal EWM, Janssen LCH, Liem ATA, Lundqvist IJ, Hendriskse F, Heij EC. Diplopia was not predictable and not associated with buckle position after scleral buckling surgery for retinal detachment. Retina. 2012;32 (8); Glaucoma Drainage Devices Molteno and Double Plate Molteno Type of Implant Highest incidence cde cewith Baerveldt e and Krupin glaucoma implant. Largest plates. Plates are tucked under rectus muscles Baerveldt Krupin Ahmed Molteno 3 Frank JW, Perkins TW, Kushner BJ. Ocular motility defects in patients with the Krupin valve implant. Ophthalmic Surg May Jun;26(3): westcoastglaucoma.com

6 Etiology Space occupying effect from the plate. Ischemia, Necrosis or Muscle trauma. Poor vision causing sensory exotropia Scarring Limits movement in the direction of action of the muscle. Santiago AP, Rosenbaum AL. Strabismus following glaucoma drainage device. In: Rosenbaum AL, Santiago AP. (eds). Clinical Strabismus Management Principles and Surgical Techniques, Chap. 28. WB Saunders Company: Philadelphia, Surgical Treatment Discussion between glaucoma and strabismus specialist. Treatment: Complete removal scarring around implant. Size reduction of the implant plate is hlfl helpful. In one study of 7 patients, it did not interfere with IOP control. Strabismus surgery on the contralateral eye if mild restriction. Diplopia after Eye Surgery Not as uncommon as we would like Try and identify those patients at risk Modify surgical techniques to limit i risk. ik Thanks and have a great evening!

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