Adult Strabismus Surgery

In the following case study, it is established that surgery for adult strabismus is worthwhile. Achieving alignment is more than cosmetic; it is reconstructive.

Surgery also achieves the elimination of diplopia, restoration of binocularity, expansion of binocular visual field in esotropes and improves psychosocial functioning.

Strabismus individuals have psychosocial problems. They have difficulty making eye contact and when talking to a group of people, they often look aside

Case Study

Mr. W.G. is a 28-year-old carpenter. At the age of 11 he had a penetrating knife injury to his right eye. He had a primary repair and has a full thickness scar over the visual axis, a slightly irregular pupil and is aphakic. His intraocular pressure is normal and the retina healthy. Over the past few years he has developed a right exotropia measuring 60PD at near and 50PD at distance. He wears a soft contact lens and the vision improves to 6/12 p. The left eye is structurally normal with 6/5 vision.

He is concerned about his cosmesis and has recently broken up with his fiancée. He finds social encounters and speaking to clients difficult due to being unable to make eye contact. He is aware of diplopia.

Mr. W.G. underwent a right lateral rectus muscle recession of 9.00mm on an adjustable suture and a right medial rectus muscle resection of 5.00mm. Three hours after the surgery, the suture was adjusted under local anaesthesia.

Postoperatively he is pleased with the outcome of his surgery. His eyes are well aligned and he is free of diplopia and has regained binocularity.

Alignment

In a retrospective analysis of 892 adult patients¹ who underwent surgery for strabismus it was found that 462 developed strabismus before visual maturation (BVM) and 312 after visual maturation (AVM). The remaining 118 patients had strabismus due to restrictive causes including thyroid eye disease, trauma and restrictive syndromes. Alignment was achieved in 74 per cent (0-15PD).

Diplopia

Preoperative diplopia (1) was present in 417 of the patients. Postoperatively, only 3 per cent were aware of diplopia. Of the 367 patients who had no preoperative diplopia, 1.4 per cent had postoperative diplopia. Diplopia was present in the immediate postoperative period in 39 per cent of the patients.

Binocularity

Binocularity can be restored in both the BVM group and the AVM group¹. The presence of binocularity was assessed by Worth 4 Dot and/or stereovision testing. In the BVM group, binocularity was restored in those with congenital esotropia in 29 per cent, acquired esotropia in 52 per cent and exotropia in 78 per cent. In the AVM group, binocularity was restored in those with fourth nerve palsy in 90 per cent, third nerve palsy 33 per cent, sixth nerve palsy 75 per cent and thyroid eye disease 90 per cent. In another series it was found that 86 per cent overall achieved binocularity when tested with Bagolini lenses². Achieving sensory fusion improves stability of alignment.

Expansion of Binocular Visual Field (Esotropia)

The binocular field of vision expands after surgery to correct esotropia. Expansion of the visual field is commensurate with the change in the angle of strabismus.^{2, 3}

Psychosocial Aspect

Strabismus individuals have psychosocial problems. They have difficulty making eye contact and when talking to a group of people, they often look aside. They often receive comments when engaged in conversation such as, “are you talking to me?” Duke Elder in 1949 wrote:

• “The psychological effects, indeed may be very potent.”
• “A squint is an ugly thing and young people are pitiless and heartless to a degree”

Studies in adults have shown a negative impact of strabismus on many aspects of the subject’s life.⁴ These include an impact on self image, securing employment, interpersonal relations, work and sport. There is a negative psychosocial implication in how others perceive an individual with strabismus. Strabismic photographs were judged significantly more negatively than orthotropic photographs, especially in communication skills and intelligence.

There are also psychosocial implications of large angle strabismic patients’ ability to obtain employment.^6,7 Women with normal ocular alignment received greater hiring preference scores than strabismic women. There was no difference in hiring preference scores between strabismic and non-strabismic male applicants. The esotropic pictured person was the least likely to be hired.

Psychosocial issues extend into relationships and dating. Patients with strabismus have a significantly decreased chance of being successful in finding a matching partner in a study looking at the opinion of dating agencies.⁸ Strabismus surgery found achieving alignment made a psychosocial impact on adults with strabismus.^9,10

Dr. Frank J Martin, FRACS, FRANZCO is a Sydney trained ophthalmologist. He sub-specialises in paediatric ophthalmology and strabismus. Dr Martin is a Clinical Professor at the Sydney University Medical School and is in private practice at Eyes on Macquarie, Sydney, phone (AUS) 02 9241 913.

References:

1. Scott WE, Kutschke PJ, Lee WR. 20th Annual Frank Costenbader Lecture – Adult Strabismus. J Pediatr Ophthalmol Strabismus 1995;32:348-52

2. Kushner B. Binocular Field Expansion in Adults after Surgery for Esotropia. Arch Ophthalmol 1994; 112:639

3. Wortham E, Greenwald M. Expanded Binocular Peripheral Visual Fields following Surgery for Esotropia. J Pediatr Ophthalmol Strabismus 1989;26:109

4. Satterfield D, Keltner J, Morrison T. The Psychosocial Aspects of Strabismus Study. Arch O Ophthalmol 1993;111:110

5. Olitsky S, Sudesh S, Graziano A, al. e. The Negative Psychosocial Impact of Strabismus in Adults. J AAPOS 1999;3:209-11

6. Coats D, Paysee E, Towler A, al.e. Impact of Large Angle Horizontal Strabismus on Ability to Obtain Employment. Ophthalmology 2000:402-405

7. Mojon-Azzi, SM, Mojon, DS. Opinion of Headhunters about the Ability of Strabismic Subjects to Obtain Employment. Ophthalmologica 2007; 221;430-433

8. Mojon-Azzi, SM, Potnik, W, Mojon, DS. Opinions of Dating Agents about Strabismic Subjects’ Ability to Find a Partner. BJO 2008;92:765-769

9. Burke, J, CM L, Davis H. Psychosocial Implications of Strabismus Surgery in Adults. J Pediatr Ophthalmol Strabismus 1997;34:159-164

10. Jackson S, Harrad RA, Morris M, Rumsey N. The Psychosocial Benefits of Corrective Surgery for Adults with Strabismus. Br J Ophthalmol 2006;90:883-8