Adult Strabismus Surgery: Special Considerations
Matthew D. Gearinger, MD
PREOPERATIVE CONSIDERATIONS
Adult strabismus patients are more likely to have had prior ocular surgery and experience diplopia than pediatric patients. In addition, many adult patients will have incomitant strabismus as a result of neurologic disease or orbital processes and may have limited improvement with prism.
Patient Expectations
It is important to establish appropriate expectations of outcomes prior to surgery. The following indications may be improved in adults with strabismus:
Diplopia: An appropriate surgical goal is to create a large area of single binocular vision surrounding primary position and downgaze. Patients should be counseled preoperatively if there is a reasonable expectation of postoperative diplopia in eccentric gaze. A secondary goal is to reduce incomitance and the angle of strabismus to allow use of prism spectacles to create a large field of single binocular vision.
Anomalous head position: Adults with strabismus or nystagmus may adopt a face turn or head tilt to improve ocular alignment or to utilize a null-point. Strabismus surgery can be performed to improve head position and visual functioning.
Cosmesis/Reconstruction: Unfortunately, many adult patients with strabismus have been counseled by their primary physicians and eye care providers that strabismus surgery is not possible. These patients can suffer from poor self-esteem, employment bias, and social anxiety. Strabismus surgery can restore physical appearance and improve binocularity.
Latent Hyperopia
Prepresbyopic patients with latent hyperopia may develop asthenopia or manifest strabismus with diplopia similar to accommodative esotropia. A cycloplegic refraction can be useful to determine if the patient has been chronically over-minused or can accept a more hyperopic correction.
Role of Imaging
Adult-onset strabismus may be due to cranial neuropathy or orbital processes, (including myopathy, slipped muscle, mass, or anomalies of the pulleys and intramuscular septum). Direct communication with the radiologist including the likely localization of pathology can improve diagnostic yield. Personal review of the images can help surgical planning (see Chapter 57).
Anomalous Retinal Correspondence
Adults with long-standing strabismus since childhood may have anomalous retinal correspondence (ARC) and experience diplopia postoperatively with good motor alignment. An indication of ARC is if diplopia persists when a prism is used to neutralize the deviation. This test can be augmented by using a red filter over the fixating eye in a darkened room. If ARC is present preoperatively, a trial with a temporary prism that simulates motor alignment can determine if the ARC can be overcome before performing surgery.
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