Summary
Reoperations in strabismus surgery can pose a challenge for the surgeon, as the surgery is typically less predictable and scar tissue may be present. Prior operative reports are also not always available, although clues during the preoperative history and examination, such as the patient family’s recall of the original deviation and evidence of conjunctival scarring, as well as exploration of the muscles during surgery are useful in finalizing the surgical plan. This chapter focuses on reoperation of the rectus muscles, but the principles can be applied to the oblique muscles as well.
8 Reoperations
8.1 Goals
The goal of a reoperation in strabismus surgery is to improve a recurrent or residual strabismus, or correct an overcorrection of prior surgery while preserving the blood supply of the anterior segment, minimizing additional scar formation, and aiming for an optimal long-term surgical outcome with the hopes of not needing additional surgery. Minimizing additional scar formation decreases the risk of restriction, may improve cosmesis and patient discomfort, and lessens the difficulty of future reoperations if they are needed.
8.2 Advantages
In most cases, strabismus surgery on an extraocular muscle can be performed multiple times, keeping in mind that with each surgery, additional scar tissue can develop, further altering normal surgical anatomy and increasing the difficulty of subsequent surgery.
8.3 Expectations
The rate of reoperation in strabismus surgery in the United States has been reported to be 6.7% within one year after strabismus surgery. 1 This rate may be higher beyond the first year after surgery. The expectation of additional strabismus surgery is improvement of persistent strabismus, which may or may not be associated with diplopia. 1
8.4 Key Principles
Prior operative reports, if available, are reviewed to determine the original deviation, the muscles that were operated on, and the amount of surgery that was performed.
Assessment of conjunctival scarring, versions and ductions, the presence of secondary deviations, as well as intraoperative forced duction testing are used for surgical planning for reoperations.
Anticipate and address the presence of scar tissue if additional surgery is being performed on previously operated muscle(s). A fornix incision may be used in reoperations and is described in this chapter, but some surgeons prefer limbal incisions for greater exposure. In some cases, exploration of the extraocular muscles is needed to determine or confirm the sites of insertion, and to determine the final surgical plan.
Reoperations of rectus muscles include re-recession or advancement of previously recessed muscles and re-resection or recession of previously resected muscles.
8.5 Indications
Recurrent strabismus and overcorrections, which can occur months to years following prior strabismus surgery.
8.6 Contraindications
For patients who have previously undergone multiple eye muscle surgeries on multiple extraocular muscles for complex strabismus, the potential benefits and risks of additional surgery should be understood by the family. If the expectations are not realistic or the expected benefits are deemed to be potentially outweighed by the risks, additional surgery may not be recommended but can be considered again at a later time if the deviation persists or changes.
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