Summary
Strabismus has been evident and documented at least since 2723 BC. Various perforated masks and glasses have been used in an attempt to realign the eyes, without success. Initial attempts at surgical correction have been credited to Chevalier John Taylor (1703–1772), a traveling charlatan, but the first actual strabismus procedure, medial rectus weakening, was performed by Johann Friedrich Dieffenbach, on October 26, 1839. Subsequent tenotomy procedures reduced overcorrections, and later modifications, including improved needles, sutures, anesthesia, incisions, and sterility, allowed for increased surgical accuracy. Transposition surgery, the faden operation, adjustable suture techniques, botulinum toxin, and the discovery of pulleys have enabled more complex strabismus problems to be corrected. Subsequent chapters will discuss many of these and other topics in greater detail.
1 The History of Strabismus Surgery
1.1 Egyptian History
The earliest known depiction of strabismus was a statue of Djoser, pharaoh of the Third Dynasty (2778–2723 BC), for whom the first pyramid was erected, probably by Imhotep at Saqqara, Egypt. 1 , 2 Another depiction of esotropia was found on the painted lid of the sarcophagus of Dame Isis, spouse of the artist Khabekhent (end of 18th Dynasty, 13th century BC). 1 The statue of Sesostris III, pharaoh of the 18th Dynasty (1878–1834 BC), demonstrated exotropia.
1.2 Etymology
Hippocrates (460–377 BC) referred to squinters as “streblos.” Strabos and strabismus are probably derived from the verb strebloun, meaning “to turn.” 1
1.3 Etiology
In the first German text of ophthalmology (Ophthalmodouleia, 1583, by Georges Bartisch of Dresden [1535–1606], considered to be the founder of German ophthalmology), Bartisch stated: “inherited and congenital strabismus/ as it is passed on from the mother’s womb…inherited from the parents and inborn…caused by negligence of the mothers/ as when they look at shining armor/ fire and storm/ lightning/ gunfire/ the sun reflecting in water/ also at dying people/ collapsing from severe infirmity/ …or look at people who are squinting themselves and don’t see well. 12 Through all this carelessness a woman will become slovenly/ cause damage to the fruit of her womb/ which is then passed to the children…” (Fig. 1‑1, Fig. 1‑2).
Strabismus was considered to be an imbalance due to a visitation of an evil spirit, and incurable. 3 , 4 Hippocrates stated: “We know that bald headed persons descend from bald persons, blue-eyed persons from those with blue eyes, squinters from squinters, at least in the majority of cases. The same holds true for the remaining parts of the body.” 1 Early treatment included potions, purification, and dust. 5 In antiquity, strabismus was thought to be a defect in one or another muscle. 6 In 1707 Maitre-Jean thought that abnormal convexity of the cornea caused strabismus, 6 , 7 in 1733 Ferrein thought it was caused by an oblique position of the lens, 6 , 8 and in 1737 Porterfield 6 , 9 suggested that a displacement of the most sensitive part of the retina was the cause. However, an earlier study by Saint-Yves explained strabismus as a discordance in position of one of the rectus muscles. 6 , 10 In adults, paralysis of an eye muscle was the suggested cause of strabismus. Saint-Yves discussed diplopia and the conception of corresponding areas of the retina. 6 , 10 Without giving credit to Saint-Yves, Taylor repeated many of the ideas of Saint-Yves. 6 , 11 Taylor also used an instrument or mask with movable holes to gradually correct an eye deviation, but apparently did not credit Saint-Yves.
In the first German text of ophthalmology (Ophthalmodouleia, 1583, by Georges Bartisch of Dresden [1535–1606], considered to be the founder of German ophthalmology), Bartisch stated: “inherited and congenital strabismus/ as it is passed on from the mother’s womb”…inherited from the parents and inborn”…caused by negligence of the mothers/ as when they look at shining armor/ fire and storm/ lightning/ gunfire/ the sun reflecting in water/ also at dying people/ collapsing from severe infirmity/ …or look at people who are squinting themselves and don’t see well. 12 Through all this carelessness a woman will become slovenly/ cause damage to the fruit of her womb/ which is then passed to the children”… (Fig. 1‑1, Fig. 1‑2).
In 1825, Pare noted that “children of strabismic parents became strabismic themselves because they imitated their parents.” 1 , 13 In 1842, Johann Friedrich Dieffenbach 1 , 14 (1794–1847) described imitation as a factor, but added that “one cannot deny that strabismus is passed on from parents to their children. I have seen it transmitted through three generations and not infrequently have observed strabismic mothers or fathers with numerous strabismic offspring.” Strabismus in infants since the Middle Ages has been blamed on an unfavorable position of the cradle by the window or close to a lamp or another conspicuous object. 1 , 15 , 16 It has also been observed on carrying the baby on the same arm or feeding from the same breast.
1.4 Nonsurgical Treatments
In the seventh century, Paullus Aiginites (Aegina) of Alexandria wrote: “strabismus in children, present since birth, can be cured by wearing a squint mask to force them to look straight ahead.” 1 , 17 Different squint masks, spectacles, tubes, and perforated bandages have been created to treat strabismus: in 1564 by Pare, in 1684 by Cornelius van Solingen, in 1693 by Johann Baptist Lamzweerde, in 1719 by Lorenz Heister, in 1749 by Marc Thomin, in 1773 by Pierre Dionis, in 1784 by Michael Underwood, and in 1808 by Jacob de Wenzel. 1 , 13 , 15 , 18 , 19 , 20 , 21 , 22 , 23
A contrasting opinion from Saint-Yves in 1722 noted that “as a rule, only the healthy eye looks through the hole, while the strabismic eye remains in its abnormal position.” 1 , 10 In 1831, von Rosas warned against strabismus spectacles, as they were rarely successful and occasionally caused deterioration. 1 , 24 Nasal or temporal spectacle occlusion with opaque tape or nail polish is, unfortunately, still recommended by many vision-training advocates. 25
1.5 Strabismus Surgery
The first surgical intervention for strabismus is credited to the notorious Chevalier John Taylor (1703–1772), one of the most extravagant of all the traveling charlatans and itinerant surgeons, with a carriage displaying his motto: “Qui Dat Videre, Dat Vivere,” or “Who gives sight gives life.” Taylor is credited with removing a strip of conjunctiva, likely inferior to the medial rectus (MR), and erroneously thinking that he was cutting through the nerve supplying the MR. He may have accidently sectioned an MR with a dramatic change in the eye position. He would bandage the unoperated eye, and the previously deviated eye would assume fixation, with John Taylor claiming a cure, as he left town. When the bandage was removed, the deviation, of course, returned, but John Taylor was long gone from the site of his operation (Fig. 1‑3). 1 , 2 , 3 , 4 , 6 , 25 , 26 , 27 , 28
The first actual strabismus operation was performed on October 26, 1839, by Johann Friedrich Dieffenbach. 1 , 2 , 3 , 4 , 6 , 25 , 26 , 27 , 28 Florent Cunier of Brussels performed the same operation a few days later and was considered to be the true inventor of the procedure, but credit has been assigned to Dieffenbach because he actually operated first. Dieffenbach sectioned the MR of a 7-year-old boy with esotropia, by incising the conjunctiva, hooking the MR, and sectioning the muscle 6 to 8 mm from its insertion. 29 By 1842, Dieffenbach published a book describing his experience of 2,000 cases. 14 His myotomy results were “excellent” for the lateral rectus (LR) and inferior oblique (IO), but his MR sectioning frequently led to exotropia with absence of adduction.
Later advancements in esotropia surgery were described, such as in 1857 when von Graefe described a partial tenotomy of the MR muscle, when a small effect was desired. 2 , 30 Advancements in esotropia surgery were described, and many subsequent variations were recommended by Abadie, 1880; Stevens, Ziegler, and Verhoeff, 1903; O’Connor, 1911; Blascovics, 1912; Bishop-Harmon, 1913; Astruc, 1913; Todd, 1914; Terrien, 1920; and others (Fig. 1‑4). 3 , 26
1.5.1 Incisions
The most popular, easily taught, and easily learned incision to achieve muscle exposure is the limbal incision, clearly described and illustrated by Helveston, in Parks’ Atlas of Strabismus Surgery, and in Wright’s Color Atlas of Ophthalmic Surgery (Fig. 1‑5, Fig. 1‑6). 3 , 31 , 32 For an MR procedure, an inferior radial incision is made through conjunctiva and Tenon’s capsule. Then a limbal peritomy is performed, followed by a second radial incision, parallel to the first incision, in the superior nasal quadrant. After the extraocular muscle (EOM) procedure is performed, the incision is closed by suturing the conjunctival “wings” to the limbus, where the peritomy was performed (Fig. 1‑7). Disadvantages include conjunctival suture irritation, corneal dellen formation, the need for very careful closure to avoid scarring, the potential for bleeding of episcleral vessels, possible loss of limbal stem cells, and interference with future trabeculectomy surgery. 3 , 33 , 34 , 35 Advantages include easier access when there is no surgical assistant, for use in older adults with friable conjunctiva, for postoperative adjustable suture manipulation, and when conjunctival recession is anticipated with certain reoperations. 3 The limbal incision was used by early strabismus surgeons after trial and error, but was actually first described in 1949 by Harms, and subsequently in 1968 by von Noorden, in reporting over 600 strabismus operations at the Wilmer Eye Institute of Johns Hopkins. 36 , 37 , 38
Another significant improvement in conjunctival incisions was reported by Swan and Talbot in 1954 in “Recession under Tenon’s Capsule.” 3 , 39 Helveston noted that the conjunctiva and anterior Tenon’s capsule are incised, isolating the muscle in the plane of the posterior Tenon’s capsule. 3 Access to the muscle is provided between anterior Tenon’s capsule and sclera, and there is direct access to and good exposure of the muscle insertion. 32 The negative aspect is that the incision is directly over the eye muscle insertion, and healing can create a raised, reddened ridge at the incision site. There is also a risk of injury to the EOM and ciliary vessels, with bleeding and hematoma formation. 34
Marshall M. Parks taught the Ocular Motility section of the Lancaster Ophthalmology Course at Colby College from 1960 to 2001. During one of his lectures on eye anatomy in the 1966 course, Dr. Parks thought about gaining access to the EOMs in surgery by a cul-de-sac approach, which he began using upon his return to Washington, DC (personal communication, 1971). Dr. Parks compiled his results, and in 1968, his landmark paper “Fornix Incision for Horizontal Rectus Muscle Surgery” was published. 40 Benefits of the cul-de-sac or fornix incision include the location being hidden by the eyelid, the possibility of incision closure without a suture due to eyelid pressure that keeps the incision together, improved patient comfort, and less disruption of collateral circulation to the anterior segment of the eye. 3 , 31 , 32 , 40 Disadvantages include increased technical difficulty, decreased field of exposure, difficulty with fragile conjunctiva in older adults, and difficulty with adjustable suture surgery (Chapter 23, Fig. 1‑8, Fig. 1‑9).
In a survey of members of the American Association for Pediatric Ophthalmology and Strabismus, Mikhail and coworkers summarized incision preference as follows: For first-time surgery in pediatric patients, 58.1% preferred fornix; 40.8%, limbal; and 1.1%, other incisions. 41 For first-time surgery in adults, 53.5% chose fornix; 40.1%, limbal; 1.4%, other incisions; and 4.9%, not applicable. For pediatric reoperations, 58.1% chose limbal; 39.1%, fornix; and 2.1%, other incisions. For adult reoperations, 63.4% chose limbal; 29.9%, fornix; 1.4%, other incisions; and 5.3%, not applicable. Conclusions were that limbal incisions provide greater intraoperative exposure and a better incision for teaching, while the fornix approach induced less postoperative pain and more rapid healing. The fornix approach was preferred by surgeons for first-time surgery in adults and children, while the limbal approach was preferred for pediatric and adult reoperations.
1.5.2 Needles and Sutures
For at least the last 50 years, eye muscle surgery sutures have been attached or swaged (atraumatic) to the needles. Needles for eye muscle surgery, classified as vertical cutting needles, were made with a sharp inferior surface (a “reverse cutting” needle) or with a sharp superior surface (a “curved cutting” needle). Dr. Parks collaborated with Sol Singerman of Davis & Geck to design the popular SLO-1 spatula needle, which was swaged to a 6–0 Dexon (polyglycolic acid) suture (personal communication, 1971). A similar product was subsequently created by Ethicon, on an S-29 needle. 31 The spatula needle reduces the risk of scleral perforation, which is substantial, because a recessed muscle is being attached to the thinnest area of sclera. The spatulated needle can be inserted into the sclera without perforating the sclera, because the needle’s narrow width and pliability allows for a longer intrascleral tunnel, especially useful for the crossed-swords approach of Parks. 3 , 31 , 32 White and Parks reported results for 116 patients in whom polyglycolic acid sutures were used, including 78 strabismus patients, 23 with cataracts, and 15 oculoplastic patients. 42 Each patient with strabismus had surgery on one eye performed with a polyglycolic acid suture and on the other eye with chromic catgut sutures. Postoperative reaction occurred in 3 of 78 (3.57%) patients’ eyes with polyglycolic acid sutures, and all responded to topical antibiotics. However, 26 of 78 with chromic catgut had an allergic-inflammatory type of reaction requiring topical antibiotic or corticosteroid-antibiotic combinations. One patient required systemic corticosteroids. White and Parks presented convincing evidence of the superiority of polyglycolic acid sutures over chromic catgut sutures for eye surgery.
1.5.3 Recession
P. C. Jameson popularized the MR recession procedures in 1922, by reattaching the muscle 3 to 6 mm behind the insertion. 26 , 43 , 44 , 45 Complications of eye muscle surgery decreased with the advent of spatulated needles. Earlier papers have reported retinal tears, scleral perforations, panophthalmitis, phthisis and enucleation, cataract, hyphema, endophthalmitis, lens dislocation, retinal detachment, vitreous hemorrhage, hypopyon keratitis, and orbital cellulitis after strabismus surgery (Chapter 7, Chapter 23). 26 , 46 , 47 , 48 , 49 , 50 , 51 , 52
1.5.4 Tendon and Muscle Lengthening
Lengthening procedures were first reported by Stephenson in 1902. Other methods followed, by Kuhnt, Gonin, Bamert, and Hollwich. Lengthening by fascia lata graft was proposed by Focosi and Ruzzi in 1978. 25 , 26 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 Other procedures have been proposed by O’Connor, Bishop-Harmon, Blaskovics, von Graefe, Abadie, Verhoeff, and Terrien (Fig. 1‑4). 3 , 26
1.5.5 Faden Operation
Also known as retroequatorial myopexy or the posterior fixation suture, the faden operation of Cuppers offered a new approach to strabismus surgery in 1975. 25 , 62 , 63 Using a limbal incision, the rectus muscle is exposed and temporarily disinserted. The posterior fixation sutures are applied to sclera 13 to 15 mm from the insertion, passed through the muscle belly, and tied. The muscle is then resutured to its original position. Caution must be used to avoid injury to the vortex veins and the long ciliary artery. Recession and resection may also be required to cure the basic deviation, as the faden operation is designed not to change alignment in the primary position (Chapter 33). 25 , 62 , 63 , 64
1.5.6 Resection
Vieusse first described resection, myectomy, and tenectomy procedures in 1875. 26 Techniques in use today were derived from Reese and Blaskovics. 26 , 65 Resection is generally classified as a muscle strengthening procedure, but the principal benefit may be to enhance the effect of a recession done on the antagonist muscle. 3 Resections can create more redness and conjunctival “fullness” because a thicker part of the tendon/muscle is advanced toward the original insertion, compared to a recession, where the tendon/muscle is placed more distal to the insertion, without thickening or fullness of the conjunctiva. Other concerns include palpebral fissure narrowing, which can occur after inferior rectus (IR) resection, and possible upper eyelid ptosis after superior rectus (SR) resection. The IO muscle can be inadvertently included with resection of an LR muscle (Chapter 23). 3
1.5.7 Inferior Oblique Surgery
Treatment of superior oblique (SO) palsy or weakness is usually treated by a weakening procedure of the IO, by myotomy, myectomy, recession, anterior transposition, or denervation/extirpation. 3 , 31 Strengthening the SO by tucking or resection can lead to an iatrogenic Brown syndrome. IO weakening is more predictable and effective (Chapter 8, Chapter 25).
1.5.8 Superior Oblique Surgery
SO anomalies include laxity or redundance, absence of the reflected tendon and trochlea, and congenital SO palsy. Treatment may include a strengthening procedure of a lax SO tendon, or if the SO is absent, weakening of the antagonist or yoke muscle, or weakening of the ipsilateral SR muscle (Chapter 9, Chapter 26). 3
Editor’s Comment
SR recession for SO palsy does decrease the hyperdeviation, but it also increases intorsion, so it is not advisable.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
