Strabismus Surgery Complications



Strabismus Surgery Complications


Jill C. Rotruck, MD



INTRODUCTION

All surgeries carry risks and may have unexpected outcomes. Fortunately, severe complications in strabismus surgery are rare. It is important to understand the most common and most severe complications of strabismus surgery in order to provide appropriate preoperative counseling and expeditious management of complications, when they arise.


INFECTION



  • Incidence:



    • Any 0.14%.1


    • Severe 0.06%.2


  • Organisms (see Table 54.1)


  • Intraoperative contamination



    • Sutures and needles have a 15%3-31%1 colonization rate during routine strabismus surgery, in spite of povidone-iodine prep.








      TABLE 54.1. Causative pathogens for poststrabismus surgery infections

















      Frequency

      Organism


      More common


      • Methicillin-susceptible Staphylococcus aureus (MSSA)a



      • Streptococcus pyogenes


      Less common


      • Methicillin-resistant Staphylococcus aureus (MRSA)



      • Staphylococcus epidermidis



      • Streptococcus pneumoniae


      Rare


      • Coagulase-negative Staphylococcus



      • Haemophilus influenzae



      • Pseudomonas aeruginosa


      a MSSA is the most common.




  • Risk factors1:



    • Poor hygiene.


    • Eye rubbing.


    • Young age.


    • Developmental delay.


    • Trisomy 21.


    • Immunocompromise.


    • Sinusitis.


    • Ear infection.


    • History of MRSA infection or colonization.


  • Infection types (see Table 54.2):



    • Conjunctivitis.


    • Preseptal cellulitis.


    • Orbital cellulitis.


    • Subconjunctival and sub-Tenon capsule abscess (Fig. 54.1).


    • Suture abscess.


    • Endophthalmitis.


  • Symptoms (usually rapidly progressing):



    • Pain.


    • Photophobia.


    • Red eye.


    • Ocular discharge.


    • Blurring.


    • Fever/fatigue.


  • Signs:



    • Decreased visual acuity.


    • Periorbital and eyelid edema.


    • Proptosis.


    • Mucopurulent discharge.


    • Conjunctival injection.


    • Bump or bulge under the conjunctiva or Tenon capsule, especially over the muscle (Fig. 54.1).


    • Chemosis.






      FIGURE 54.1. A lateral rectus abscess with a prominent bulge and opacity over the lateral rectus is seen following strabismus surgery with associated conjunctival chemosis and injection. This was the appearance 5 days after uncomplicated strabismus surgery in a child with Trisomy 21. (Courtesy of Laura B. Enyedi, MD.)



    • Intraocular inflammation—anterior chamber cell and fibrin, hypopyon, vitreous cell, blunting of red reflex.


    • Retinal holes or tears secondary to deep scleral passes, which may allow entry of pathogens into the eye.


    • Optic nerve swelling suggestive of orbital cellulitis.


    • Pain with extraocular movements.


    • Fever.


  • Timing:



    • On average, onset of clinical features occurs between 3 and 7 days postoperatively but may present the following day or not until weeks later.1


  • Evaluation:



    • Vision.


    • Pupils.


    • Color vision.


    • Motility.


    • Intraocular pressure.


    • External.


    • Anterior segment (slit lamp).


    • Posterior segment (dilated fundus examination).


  • Diagnosis and management (see Table 54.2).


  • Broad-spectrum antibiotics (see Table 54.3).


  • Prognosis:



    • When treated in a timely manner, postoperative infections rarely lead to permanent vision loss. Conjunctivitis, preseptal cellulitis, and sub-Tenon capsule abscesses that do not progress to orbital cellulitis generally do not permanently impact vision.


    • Prompt treatment of orbital cellulitis can prevent vision loss; however, vision can be compromised by inflammation or compression of the optic nerve or vasculature. Rarely, orbital cellulitis is complicated by meningitis or brain abscess.4


    • Unfortunately, the prognosis following post-strabismus surgery endophthalmitis is poor, with only an estimated 36% retaining normal vision.5 The prognosis for visual recovery is improved with early treatment within the first postoperative week.5


  • Prevention:



    • Treat blepharitis and address poor hygiene preoperatively.


    • Prep with povidone-iodine 5% in the fornix prior to surgery to decrease bacterial contamination of sutures and needles.5 Repeat use of 5% povidone-iodine in the fornix after placement of the speculum to further decrease contamination rates.5


    • Isolate eyelids and lashes with an adhesive drape to reduce contamination.3 (This has not been shown to reduce rates of infection following strabismus surgery.)


    • Place povidone-iodine 5% in the fornix at the conclusion of the case (noninferior for infection prevention compared to the use of topical antibiotic-steroid combination for 1 week postoperatively6).


    • Consider presoaking sutures in 5% povidone-iodine prior to use; this has been shown to reduce bacterial colonization of suture.7


    • Consider use of postoperative topical antibiotics. Note, no studies confirm their efficacy in preventing postoperative infections.


    • If known, treat modifiable infection risk factors, such as sinusitis or ear infection, prior to surgery.


    • Consider the use of prophylactic systemic antibiotics in high-risk patients, such as those with Trisomy 21 or immunocompromise.


    • Do not complete a known deep scleral pass and consider removal of sutures with a known deep scleral pass, as contaminated suture may pass into the intraocular space.3



3M Tegaderm transparent film is useful to isolate the lashes after prepping with povidone-iodine.









TABLE 54.2. Findings and management/treatment of poststrabismus surgery infections



























Infection type

Findings

Management/treatment


Conjunctivitis


  • Mild to severe conjunctival injection and chemosis



  • Absence of subconjunctival collection or signs of orbital cellulitis


  • Culture conjunctival incision site and/or drainage



  • Prescribe broad spectrum topical and oral antibiotics, as there is a high risk of orbital cellulitis through the surgical incision. Consider that conjunctivitis may also be due to allergic response to postoperative drops



  • Use a different drug class than initial antibiotic



  • Follow-up within 24 hours for signs of developing orbital cellulitis


Preseptal cellulitis


  • Eyelid swelling



  • Normal vision, pupils, motility, and optic nerve



  • Absence of proptosis


  • Culture conjunctival incision site and/or drainage



  • Prescribe a broad-spectrum oral antibiotic. Clindamycin provides good coverage for the majority of the reported pathogens following strabismus surgery, including community-acquired MRSA. Consider concomitant use of broad-spectrum topical antibiotics, as incision site is the likely entry point of infection



  • Follow-up within 24 hours for signs of orbital cellulitis


Subconjunctival or sub-Tenon capsule abscess (Figure 54.1)


  • Bump or bulge under the conjunctiva or Tenon capsule, often over the muscle



  • +/- signs of orbital cellulitis


  • Obtain CT or MRI imaging to evaluate for extent of infection into the orbit



  • Drain the abscess promptly and obtain cultures at the time of drainage. Consider involvement of an oculoplastic specialist for abscesses extending into the orbit



  • Treat with broad spectrum topical and systemic antibiotics



  • Consider admission for IV antibiotics


Orbital cellulitis


  • Eyelid swelling



  • Proptosis



  • Chemosis



  • Conjunctival injection



  • Limited extraocular movements



  • Decreased vision



  • Decreased color vision



  • Optic disc edema



  • Elevated intraocular pressure


  • Culture conjunctiva incision site and/or drainage



  • Obtain blood cultures



  • Obtain CT or MRI imaging to evaluate for orbital abscess. If an abscess is present, refer to an oculoplastic specialist to evaluate for abscess drainage



  • Admit to the hospital for broad spectrum IV antibiotics, including MRSA coverage


Endophthalmitis


  • Eyelid swelling



  • Conjunctival injection



  • Chemosis



  • Intraocular inflammation (anterior chamber cell, fibrin, hypopyon, vitreous cell and haze)



  • Decreased vision



  • Possible scleral or retinal penetration with suture visible on retinal examination


  • Carefully inspect the incision and muscle reattachment sites for signs of extraocular infection or abscess



  • Perform a detailed fundus examination to evaluate for evidence of scleral perforation with suture at the site of muscle reattachment, as this may have been the inciting event. Ensure no retinal holes or detachments are present. Consider referral to retinal or uveitis specialist



  • Perform vitreous aspiration or anterior chamber paracentesis for gram stain and cultures



  • Inject broad spectrum intravitreal antibiotics



  • Treat intraocular inflammation with topical steroids and a cycloplegic agent to prevent sequelae



  • Treat as above for signs of associated cellulitis or extraocular abscess










TABLE 54.3. Common antibiotic regimens for poststrabismus surgery infections






































Method of administration

Antibiotic

Coverage

Uses


Topical

Fortified vancomycin 25 mg/mL with either tobramycin 15 mg/mL or gentamicin 15 mg/mL

Broad spectrum coverage of the common causes of poststrabismus surgery infection (Table 54.1)

Severe infections

Moxifloxacin or gatifloxacin

Good gram-positive and gram-negative coverage, but do not cover MRSA and limited coverage of P. aeruginosa

Less severe infections without increased risk of MRSA

Polymyxin B sulfatetrimethoprim

Covers P. aeruginosa and staphylococcal species, including community-acquired MRSA (CA-MRSA); inconsistent coverage against H. influenzae, streptococcus species, and gram-negative bacteria

Can combine with a fluoroquinolone to add MRSA coverage


Oral

Clindamycin

Good coverage for most poststrabismus surgery pathogens, including CA-MRSA; however, does not provide coverage for H. influenzae, P. aeruginosa, or gram-negative bacteria

Consider an additional or alternative agent if noncovered pathogens are of particular concern, such as with concurrent sinusitis or history of pseudomonas infection


Intravenous

Vancomycin and piperacillintazobactam combined

Broad spectrum

Orbital cellulitis


Intravitreal

Vancomycin 1 mg/0.1 mL and ceftazidime 2 mg/0.1 mL

Broad spectrum

Endophthalmitis



ANTERIOR SEGMENT ISCHEMIA



  • Incidence—0.008%.8


  • Cause:



    • Tenotomy of the rectus muscles during strabismus surgery severs the anterior ciliary artery in the muscle capsule that serves the anterior segment.


    • More common when three or more muscles are operated but has been reported with disinsertion of only two rectus muscles.9


    • The risk is increased for surgery of multiple muscles, even at different time points.3


    • The risk is greatest for surgery of the vertical rectus muscles and least for the lateral rectus muscle.10


  • Risk factors9,10:



    • Older age.


    • Atherosclerosis.


    • Diabetes mellitus.


    • Hematologic disorders that increase blood viscosity.


    • Thyroid ophthalmopathy.


    • Scleral buckle placement.


  • Signs and symptoms:



    • Mild: pupillary abnormalities, decreased iris perfusion, iris atrophy.10


    • Severe: uveitis, keratopathy, corneal edema with possible scarring, cataract,10 phthisis bulbi.3







      FIGURE 54.2. Iris fluorescein angiography showing poor iris perfusion and pupil irregularity superotemporally consistent with anterior segment ischemia. (Courtesy of Federico Velez, MD.)


  • Course:



    • Typical onset occurs 1-2 days after surgery.


    • Most symptoms resolve within 2 weeks, but recovery of iris circulation may take up to 12 weeks in those with more significant ischemia and severe presentation.10


    • Iris atrophy is the most common sequelae.


  • Evaluation:

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May 10, 2021 | Posted by in OPHTHALMOLOGY | Comments Off on Strabismus Surgery Complications

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