Lecture given to St. Luke's Medical Center QC Ophthalmology Residents during quarantine

1. Principles of
Strabismus
Management
Part 3 of 3
ALVINA PAULINE D. SANTIAGO, MD
MAY 9, 2020
https://youtu.be/DrZZhK24qeI?t=13

2. Goals of strabismus surgery
uSensory fusion
uMotor fusion
uCosmesis
uPsychological well-being
uExpanding binocular fields

3. Factors affecting surgical success
u Timing of surgery
u Surgical tables and target angles
u The correct ruler
u Where to put your needle
u Artifacts introduced during surgery

4. How to use a surgical dose table
u Target angle
u Technique of
author
u Reading a
strabismus surgical
table
u Desired postop
alignment
ESOTROPIA MR Recess LR Resect
15 3 4
20 3.5 5
25 4 6
30 4.5 7
35 5 8
40 5.5 9
50 6 10
60 7 10
Parks Surgical Dose Table

5. Parks Surgical Dose Table: Exotropia
Know desired postop alignment
u Non amblyopic, 50PD XT
u 30PD: LR 7, MR 6. corrects 40PD
u 10PD LR 5, corrects 15PD
u Adjust:
u LR 6 OU: corrects ~35PD
u MR 4: corrects ~15PD
u OR
u LR 6 + MR 5 : corrects ~35PD
u LR 5: corrects ~15 PD
EXOTROPIA LR Recess MR Resect
15 4 3
20 5 4
25 6 5
30 7 6
AMBLYOPIC
EXOTROPIA
LR Recess MR Resect
40 8 6
50 9 7
60 10 8
70 10 9
80 10 10

6. Weakening surgical procedures
Myectomy
Recession
Fadenoperation or
posterior fixation
Anterior
transposition
Recession
Rosenbaum & Santiago 1999
Myotomy
https://image.slidesharecdn.com

7. Strengthening surgical procedures
u Resection
u Rosenbaum & Santiago 1999

8. Horizontal strabismus surgery:
Plication
https://www.aao.org/master-class-video/medial-rectus-plication

9. Horizontal strabismus surgery:
Recession
u Handling the conjunctiva & Tenon’s
u Tagging muscle
u Securing muscle
u Measuring with caliper
u Entry of needle
u Closure of conjunctiva

11. The Limbal 7:
S. Larsonhttps://youtu.be/IfKUMeFm420?t=2
Relaxing incision
hidden by upper lid

12. Modification:
“7” paralimbal incision
1 mm paralimbal
Relaxing incision in the
superotemporal or
superonasal quadrant
Hidden from “oglers”
because of Bell phenomenon
1 less relaxing incision Fig from Sami D, 2007

13. Modified:
Paralimbal “7”-incision

14. Conjunctival Opening
Fornix
Limbal
Paralimbal
Variations

15. Caputo’s one snip
works best for medial rectus
Caputo AR, Guo S, DeRespinis P, et al. Simplified limbal incision for extraocular rectus muscle surgery. Ophthalmic Surg 1991; 22: 406-408.
Fig from Sami D, 2007

16. Measuring the recession
Fig from Rosenbaum & Santiago, 1999

17. Anchoring Muscle
Parks Crossed Swords Hang backAnchor to Sclera
Fig from cybersight.org Fig from Rosenbaum & Santiago 1999

18. Conjunctival Closure
Anatomic Closure
Recess Conjunctiva
Glue (fibrin)
Guo S, Wagner RS, Forbes BJ et al.
Sutureless conjunctival closure. JPOS
2010: 47 (4) 228-230.
less inflammation, less discomfort
Reduced surgery time, less anaesthesia
Held well
Fig from Rosenbaum & Santiago, 1999

19. Horizontal strabismus surgery:
Resection
u Handling the conjunctiva & Tenon’s
u Holding muscle for resection
u Measuring Resection
u Tagging muscle
u Securing muscle
u Entry of needle
u Closure of conjunctiva

20. Measuring the Resection
https://entokey.com/rectus-muscle-tightening-procedures/

21. Anchoring Muscle:
Resection
anchored to muscle stump
anchored to scleral insertion
muscle thinnest at insertion
Fig from Rosenbaum & Santiago, 1999

22. Horizontal strabismus surgery:
Plication
https://www.aao.org/master-class-video/medial-rectus-plication

23. References
u Mojon DS (2015). Review: Minimally Invasive Strabismus Surgery. Eye, 29: 225.
u Caputo AR, Guo S, DeRespinis P, et al. Simplified limbal incision for extraocular rectus muscle surgery.
Ophthalmic Surg 1991; 22: 406-408.
u Demer JL, Clark RA, Engel EC. Magnetic Resonance Imaging Evidence For Widespread Orbital
Dysinnervation in Congenital Fibrosis of the Extraocular Muscle Due to Mutations in K1F21A. Invest
Ophtha Vis Sci 2005; 46: 530-539.
u Gonçalves AC, Gebrim EM, Monteiro ML. Imaging studies for diagnosing Graves' orbitopathy and
dysthyroid optic neuropathy. Clinics (Sao Paulo). 2012;67(11):1327–1334. doi:10.6061/clinics/2012(11)18
u Guo S, Wagner RS, Forbes BJ et al. Sutureless conjunctival closure. J Pediatr Ophthalmol Strabismus
2010: 47 (4) 228-230.
u Rosenbaum AL, Santiago AP. Clinical Strabismus Management, Principles and Technique. Elsevier
1999.

24. References
u Sami DA. Conjunctival incisions for strabismus surgery: a comparison of techniques. Techniques in
Ophthalmology 2007; 5(3): 125-129.
u Santiago AP, Isenberg S, Neumann D, et al. The paralimbal approach with deferred conjunctival
suture for adjustable Strabismus Surgery. Ophthalmic Surg Lasers 1998; 29: 151-156.
u Scott WE, Gole GA. A modified curved ruler for strabismus surgery. Arch Ophthalmol. 1985;103(5):625.
u Strube YNJ. Rectus Muscle Tightening Procedures. https://entokey.com/rectus-muscle-tightening-
procedures/. Accessed May 8, 2020.
u Tan RJ, Demer JL. Heavy eye syndrome versus sagging eye syndrome in high myopia. J AAPOS.
2015;19(6):500–506. doi:10.1016/j.jaapos.2015.08.012
u Wright KW. Medial Rectus Plication. https://www.aao.org/master-class-video/medial-rectus-plication.
Accessed May 8, 2020.