Wednesday, October 8, 2014

October 2014 Strabismus Rounds

So this is our 2nd strabismus rounds of the year- same rules as last time. Pick a case, devise a rational surgical plan, submit your plan in the comments section, and then go to the wet lab and show me what you can do.

Case 1: This 18 year old girl has had double vision since suffering a head injury in a car accident 6 months ago:

She has an inability to abduct the right eye past midline and has an otherwise normal ocular exam. She measures ET 35 in primary, ET 50+ in right gaze, and ET 10 in left gaze. (Top photo is left gaze, bottom photo is attempted right gaze.)

What is your surgical plan?

Case 2: This 15 year old boy has had double vision since suffering a concussion in a football game last year.

He had a left inferior oblique recession by a trusted colleague 3 months ago, but has persistent diplopia, especially in primary and right gaze. He has LHT 8 in primary, LHT 20 in right, orthotropia in left gaze, and LHT 8 in downgaze. Double Maddox Rod testing shows minimal (2 degrees) of excyclotorsion.

What is your surgical plan? (Hint- let's not mess with the obliques in the wet lab yet.)

Case 3: A 25 year old woman seeks your care for correction of her strabismus. She notes that she tends to adopt a chin-up head position.

You note XT25 in primary, increasing to XT 40 in upgaze, and XT 8 in downgaze. There is no inferior oblique or superior oblique dysfunction, and her ocular exam is normal. Of note, she was diagnosed with plagiocephly as an infant, but is otherwise healthy.

What is your surgical plan?


  1. Liegel

    Case 1: recess right medial rectus; resect right lateral rectus
    Case 2: recess right inferior rectus OR recess left superior rectus
    Case 3: displace medial recti one half the tendon width downward; displace lateral recti one half the tendon width upward

    1. 1) If there is complete paresis (no abduction past midline), I usually avoid resecting the ipsilateral LR (tends to loosen over time due to lack of innervation, and the anterior ciliaries may be needed later.) The exception is if the MR is tight on forced ductions, then I may do a R&R.
      2) OK- LSR Rec may be appropriate if it is tight, but would expect more effect in left gaze, and may still have issues in downgaze.
      3) OK

  2. 1) Transposition of right SR and IR to LR
    2) R IR recession
    3) L MR resection with inferior displacement; LLR recession with superior displacement

  3. 1) I will usually check forced ductions to see if there is MR contracture- if so, you will need to add ipsilateral MR recession. If so, you need to consider anterior segment ischemia if you do full transpositions of the SR/IR. Options include splitting the SR/IR tendons (Hummelscheim), vessel-sparing techniques, or doing just a SR transposition.
    2) Yes- possibly with adjustable or adding a LIO weakening procedure
    3) Yes, or BLR recession, supraplaced