Adult Strabismus
Adult Strabismus
VO L U ME X X VI I , NUM B E R 1 2
D EC EMB ER 2 0 0 9 ( MO DULE 3 OF 3 )
Adult Strabismus
David K. Coats, MD
C. Gail Summers, MD, Editor for Pediatric Ophthalmology & Strabismus Robert A. Clark, MD
Jeffrey N. Bloom, MD, Basic and Clinical Science, Course Faculty, Section 6 Sylvia R. Kodsi, MD
Harold E. Shaw Jr, MD, Practicing Ophthalmologists Advisory Committee for Education
Focal Points Editorial Review Board
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Cover. Top: adult with exotropia and left hypotropia.
settings. The FDA has stated that it is the responsibility of the physician Bottom: adult with right hypertropia. (Images courtesy
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Clinicians’ Corner 10
Financial Disclosures
The authors, reviewers, and consultants disclose the following finan-
cial relationships. Jeffrey N. Bloom, MD: (C, O) WMR Biomedical.
Robert A. Clark, MD: (S) National Eye Institute. D. Michael
Colvard, MD, FACS: (C) Advanced Medical Optics, Bausch & Lomb; Introduction
(P) OASIS Medical. Steven I. Rosenfeld, MD, FACS: (L) Allergan.
It has been estimated that up to 4% of the adult popu-
C. Gail Summers, MD: (C) McKesson. Albert T. Vitale, MD:
lation has strabismus, and strabismus surgery is com-
(C) Bausch & Lomb Surgical; (P) OASIS Medical.
monly performed on Medicare-aged patients. Childhood
The following contributors state that they have no significant financial strabismus may persist into or recur in adult life. Adults
interest or other relationship with the manufacturer of any commer- may also develop new-onset strabismus as a result of
cial product discussed in their contributions to this module or with such varied conditions as microvascular cranial neuropa-
the manufacturer of any competing commercial product: William S. thies, trauma, thyroid-related ophthalmopathy, cerebro-
Clifford, MD; David K. Coats MD; Bradley S. Foster, MD; Sylvia R. vascular disease, or as a consequence of previous ocular
Kodsi, MD; Anil D. Patel, MD; Eric P. Purdy, MD; Harold E. Shaw Jr, or orbital surgery such as a scleral buckling procedure.
MD; George A. Stern, MD. The clinical presentation of strabismus in adults can
vary from an asymptomatic intermittent or constant
C = Consultant fee, paid advisory boards or fees for attending a
deviation to symptomatic diplopia, asthenopia, and a
meeting
compensatory head posture. Despite significant signs
L = Lecture fees (honoraria), travel fees or reimbursements when
and symptoms, surgical treatment of strabismus is often
speaking at the invitation of a commercial entity
O = Equity ownership/stock options of publicly or privately traded
delayed. One study has reported that almost half of adult
firms (excluding mutual funds) patients delayed surgical treatment for a year or more,
P = Patents and/or royalties that might be viewed as creating a with an average delay of 19.9 years (range, 1 to 72 years)
potential conflict of interest between the onset of strabismus and the time of surgery.
S = Grant support Often the reason for delaying surgical intervention was
misinformation about the success of strabismus surgery
in adults.
The most common systemic conditions associated
with new-onset strabismus in adults are microvascu-
lar diseases such as diabetes mellitus and hypertension.
Abducens palsy is the most common cause of acquired
cranial neuropathy in adults. Sequential cranial nerve
palsies caused by microvascular diseases have been
reported. Examples of other medical conditions that can
Clinical Evaluation a
likely to sustain optimal ocular alignment following Use of Double Maddox Rod Test To Assess Cyclotropia,
surgical intervention, and demonstration of this ability 1 min 06 sec
prior to surgery may aid in preoperative planning and
Binocular Visual Field Testing. This test can be useful
patient education. However, the absence of ability to fuse
in quantifying the size and location of the field of sin-
is not a contraindication to strabismus surgery.
gle binocular vision in a patient who is able to achieve
fusion in some positions of gaze. For the test, the patient
Motor Fusional Amplitudes. Evaluation of motor
is seated at the Goldmann perimeter with both eyes open
fusional amplitudes can be helpful in selected patients.
and is asked to follow a target from the binocular to the
Knowledge about the diplopic patient’s convergence and
diplopia field in several meridians (Figure 3). The patient
divergence amplitudes, for example, can facilitate preop-
reports when diplopia is noted in each meridian. The
erative discussions about the risk of postoperative diplo-
treatment plan should seek to expand the field of single
pia should an over- or undercorrection occur following
binocular vision and maximize this field around the pri-
surgery for horizontal strabismus. Patients with good
mary and reading positions.
motor fusional amplitudes are more likely to be able to
fuse following surgery.
a b
Success
The success of strabismus surgery can be measured David K. Coats, MD, is chief of ophthalmology at Texas
through various subjective and objective parameters. Children’s Hospital, and professor of ophthalmology
Patients are usually very pleased with accurate align- and pediatrics, Baylor College of Medicine, in Houston,
ment of the eyes following surgery, and this alone is a Texas.
Clinicians’ Corner provides additional viewpoints on 1. What changes do you make in your surgical
approach for patients with strabismus who have
the subject covered in this issue of Focal Points. Con- had previous scleral buckling or glaucoma implant
procedures?
sultants have been invited by the Editorial Review
Dr. Clark: The single most important difference is the
Board to respond to questions posed by the Acade- close coordination between the retina or glaucoma spe-
cialist and the strabismus surgeon. Often, the implanted
my’s Practicing Ophthalmologists Advisory Committee devices are the direct cause of the strabismus, either by
mechanical restriction or by compromised extraocular
for Education. While the advisory committee reviews muscle function, and the periocular elements need to
be removed or repositioned to solve the eye alignment
the modules, consultants respond without reading the problem. The other specialist should state in writing for
the medical record that it is either safe to remove the
module or one another’s responses. – Ed. implanted elements or that an alternative treatment,
either replacement or repositioning, is required.
During surgery, careful dissection is required to iso-
late the extraocular muscles through the scar tissue.
Often, the implanted element can actually aid in the dis-
section because the encapsulated scar provides a space
to place muscle hooks and other instruments. Once the
extraocular muscles are isolated, repeat forced duction
testing is needed to ensure adequate release of restric-
tions. Also, multiple adjustable sutures can help restore
the alignment and balance the range of eye movement.
I rarely recess the medial rectus during the same pro- gaze deviation is worse on upgaze, I typically recess the
cedure, particularly in an older adult, regardless of the ipsilateral superior rectus. If it is worse on downgaze, I
amount of esotropia and medial rectus contracture. The typically recess the contralateral inferior rectus. I may
medial rectus can always be recessed during a later pro- also transpose the vertical rectus muscles to help mini-
cedure, if needed, to fine-tune the primary gaze align- mize torsion. I rarely tuck the superior oblique muscle
ment and expand the binocular visual field. because this procedure cannot be adjusted postopera-
tively to eliminate the diplopia.
Dr. Kodsi: I would consider surgical intervention if a year
after the injury a patient has persistent diplopia and a Dr. Kodsi: As with a sixth nerve palsy, I would con-
significant deviation. The preoperative evaluation of the sider surgical intervention if a year after the injury a
lateral rectus muscle is the single most important fac- patient has persistent diplopia and a significant devia-
tor in determining which surgical procedure to perform. tion. Fourth nerve palsies are not as straightforward as
If the patient has normal saccades with abduction and sixth nerve palsies because of the vertical and torsional
good lateral rectus function on forced generation testing, components. Also many traumatic fourth nerve palsies
I would recess the medial rectus muscle and resect the are bilateral in nature. Preoperatively you must identify
lateral rectus muscle in the involved eye. If the patient if the patient is bothered by torsional diplopia, vertical
has slow saccades on abduction and poor lateral rectus diplopia, or both. If the diplopia is purely torsional in
function on forced generation testing, my surgical choice nature, my procedure of choice is the Harada-Ito pro-
would be a full tendon transposition procedure of the cedure. This will correct the excyclotorsion without
superior and inferior rectus muscles to the lateral rectus changing the vertical deviation. For patients with verti-
muscle with the “Foster modification.” In 1997 Dr. Scott cal and torsional diplopia, you must determine the size
Foster popularized the technique of using 2 nonabsorb- of the deviation and in which gaze the diplopia is great-
able sutures 14 mm posterior to the insertion of the lat- est. Based on your measurements, you must also decide
eral rectus to bring the temporal inferior rectus fibers whether or not to recess the ipsilateral inferior oblique
as well as the temporal superior rectus fibers closer to muscle or tuck the paretic superior oblique muscle. Two
the lateral rectus muscle. This allows for more abduction points to remember: the superior oblique tendon is nor-
effect of the transposition procedure. I find that with the mal (not lax) in a true acquired traumatic fourth nerve
Foster modification, the esotropia is fully corrected and palsy, and you will perform a much smaller tuck for an
botulinum injection into the medial rectus or a medial acquired fourth nerve palsy than you would in a congeni-
rectus recession at a later date is usually not necessary. tal fourth nerve palsy.
4. Discuss the surgical management of traumatic 5. Discuss the surgical management of traumatic
fourth cranial nerve palsies in adults. third cranial nerve palsies in adults.
Dr. Clark: I typically observe a traumatic fourth nerve Dr. Clark: Third nerve palsies are the most difficult to
palsy for at least 6 months to see if the superior oblique treat surgically because most of the extraocular muscles
regains some of its function. After 6 months, the surgical are involved and multiple axes of misalignment occur.
management depends on the deviation in primary and The possibility of successfully restoring any useful binoc-
secondary gazes and the amount of ocular torsion. As a ular vision is directly dependent on the amount of recov-
practical point, if the primary gaze deviation is small, ery of some third nerve function. I observe these patients
less than 10 to 15 prism diopters, I will operate on only 1 for a longer period, 9 to 12 months, in the hopes that the
muscle, usually recessing the ipsilateral inferior oblique. third nerve will show at least partial recovery.
If the deviation is larger, I will usually recess the inferior After that time, if the third nerve palsy is complete
oblique and also recess 1 vertical muscle on adjustable I typically do not offer surgery unless the patient has
suture, with the vertical muscle chosen based on where developed significant suppression of vision in the devi-
the secondary gaze deviation is worse. If the secondary ated eye. In my experience, supramaximal lateral rectus
Suggested Reading Goldberg RA, Rosenbaum AL, Tong JT. Use of apically based
periosteal f laps as globe tethers in severe paretic strabismus.
American Society of Anesthesiologists. Statement on routine Arch Ophthalmol. 2000 Mar; 118:431–417.
preoperative laboratory and diagnostic screening. www.asahq.
org/publicationsAndServices/standards/28.pdf; accessed 12 Kushner BJ. Binocular field expansion in adults after surgery
June, 2007. for esotropia. Arch Ophthalmol. 1994;112:639–643.
Beauchamp GR, Black BC, Coats DK, et al. The management of Repka MX. Strabismus surgery among aged Medicare benefi-
strabismus in adults—I. Clinical characteristics and treat- ciaries. J AAPOS. 1997;1:231–234.
ment. J AAPOS. 2003;7:233–240. Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of
Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus study. Arch Ophthalmol. 1993;111:1100–1105.
strabismus in adults—III. The effects on disability. J AAPOS. Saunders RA, Bluestein EC, Wilson ME, Berland JE. Anterior
2005;9:455–459. segment ischemia after strabismus surgery. Surv Ophthalmol.
Coats DK, Olitsky SE. Strabismus Surgery and its Complications. 1994;38:456–466.
Berlin Heidelberg: Springer-Verlag, 2007.
Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large Related Academy Materials
angle horizontal strabismus on ability to obtain employment. Lee MS. Diplopia: Diagnosis and Management. Focal Points,
Ophthalmology. 2000;107:402–405. Clinical Modules for Ophthalmologists, Module 12, December
Coats DK, Stager DR Sr, Beauchamp GR, et al. Reasons for 2007.
delay of surgical intervention in adult strabismus. Arch OTAC Pediatric Panel. Strabismus Surgery for Adults [Ophthalmic
Ophthalmol. 2005;123:497–499. Technology Assessment]. 2004.
Comer RM, Dawson E, Plant G, Acheson JF, Lee JP. Causes and
outcomes for patients presenting with diplopia to an eye
casualty department. Eye. 2007;21:413–418.