Surgical Options for a Woman With Cataract and Strabismus
- Journal of Pediatric Ophthalmology and Strabismus
- March/April 2008 - Volume 45 · Issue 2: 70
The area’s leading cataract surgeon refers prominent and active 72-year-old Mrs. D. Her medical records show she began to complain of intermittent diplopia when reading 12 years ago. Ten years ago, 2 base out prism was needed to control the diplopia in this myopic and presbyopic patient. Your colleague continued to place increasing amounts of prism until a total of 14 base out prism was required to eliminate diplopia. Last year, cataract extraction in the right eye with intraocular lens implantation resulted in uncorrected distance visual acuity of 20/25 and 20/20 with +0.50 -0.75 3 180. However, Mrs. D now has 18 to 20 prism diopters of esotropia. She has also developed a cataract in the left eye. Best-corrected visual acuity in the left eye is 20/50- with -3.25 -1.25 3 175. However, she can see 20/30 uncorrected at near and tells you that she often just removes her eyeglasses to read comfortably. Mrs. D finds the eyeglasses heavy and annoying because in her mind their only purpose is to help control diplopia at distance. Your anterior segment colleague wants to know if cataract surgery should precede strabismus correction or vice versa?
How would you guide your friend’s decision?
Responses to Last Issue's Case
Our readers were asked for their opinions regarding the treatment of a 15 year old with a large angle exotropia and dense left amblyopia. This patient had previous surgery on the left eye with noticeable conjunctival scarring and resultant abduction and adduction deficits.
The majority of respondents believed that further should be performed. Prior to surgery, many recommended the use of passive and active forced ductions and saccadic velocities to obtain as much functional information as possible. However, all respondents indicated that because of the gaze restrictions and imprecise previous operative reports, no definitive surgical plan should be conceived until the area was explored.
Releasing adhesions with exploration and (if found necessary) advancement of the left medial rectus was a common starting point. However, beyond this point all consensus among our readers ended.
Some recommended performing the surgery in multiple stages. Primarily operate on only the left medial rectus or only free the adhesions and then, after healing, return for further surgery on the left lateral rectus. Others recommended that the second stage might include a single muscle in the opposite (non-amblyopic) eye.
Other respondents suggested trying to correct the entire problem with a single surgery. Approximately 25% advocated the use of adjustable sutures for a left eye recession-resection procedure. Some surgeons recommended a primary surgery on the opposite (non-amblyopic) eye.
Although mentioned, no respondents actually advocated the use of mechanical or pharmaceutical means to prevent the recurrence of adhesions.
One surgeon cautioned us by relating his personal knowledge of two distinct cases in which operative complications of strabismus surgery resulted in blindness of the non-amblyopic eye.
We had responses from Egypt, India, Saudi Arabia, Turkey, and the United States. Thank you all.