Pediatric Ophthalmology Strabismus Surgery

Strabismus is misalignment of the eyes preventing binocular fusion. Childhood types include congenital esotropia (large angle, present <6 months, surgical), accommodative esotropia (managed with hyperopic glasses ± bifocals), intermittent exotropia (most common exotropia), and pattern strabismus (A or V pattern with oblique muscle dysfunction). Adult strabismus arises from cranial nerve palsies (VI, IV, III), thyroid eye disease, orbital trauma, and decompensated childhood strabismus.

Surgical principles include weakening procedures (recession: posterior reattachment of muscle to weaken its action), strengthening procedures (resection: shortening muscle to strengthen action), transposition (moving non-paralyzed muscle to substitute for paralyzed muscle, e.g., Hummelsheim, Jensen for sixth nerve palsy), and adjustable suture technique (Jampolsky, allows postoperative refinement under topical anesthesia).

Modern enhancements include intraoperative cycloplegic refraction adjustment, minimally invasive strabismus surgery (MISS) with limbal incisions, botulinum toxin chemodenervation as alternative to surgery for sixth nerve palsy, and small incision parents (SIPS) with conjunctival peritomy. Goals include amblyopia treatment (preventing irreversible visual loss), establishing peripheral fusion, eliminating diplopia, and improving social functioning.