Round table: Tips for the occasional strabismus surgeon

Keeping the plan simple and being honest in the event of complications are among the recommendations from a panel of experts.

Round Table Participants Moderator Robert S. Gold David K. Coats Evelyn A. Paysse Naval Sondhi

Robert S. Gold, MD: The topic of this round table is tips for the occasional strabismus surgeon. Each panel member will offer suggestions for a general ophthalmologist who occasionally delves into the world of strabismus surgery.

David K. Coats, MD: The comprehensive ophthalmologists in my area, which is Houston, are pretty smart. They know what they are capable of and what they are not capable of. There are a number of people who do strabismus surgery. Most may do relatively straightforward procedures, like horizontal rectus muscle surgery, but we also have some who will do vertical surgery, a few that will do inferior oblique surgery, and even a few comprehensive ophthalmologists who will operate on the superior obliques. In our area, we tend to have well-trained, savvy ophthalmologists, who do not tend to get into trouble.

I would suggest, just as sort of basic guideline, that the occasional strabismus surgeon should choose their patients carefully, and make sure that they understand the disease and its treatment before engaging in the patient’s care. Carefully review the techniques involved and make sure that they are in your current level of capability before deciding to operate.

Evelyn A. Paysse, MD: I agree with David on those points. I’m also located in Houston.

Here’s a tip for the occasional strabismus surgeon. I think that Moody locking forceps are great. They allow you to let the forceps hang so you do not have to use your assistant so much in almost every step of your strabismus surgery. The forceps vault over the cornea, allowing them to hang.

When I was training as a resident we had straight Castroviejo locking forceps, and you always had to have an assistant holding them. These Moody forceps I use to keep the conjunctiva open. You can use them to rotate the eye into position so you can get your scleral passes in easily. I use them all the time, and they make me almost independent of my assistant. I think they would be helpful for the occasional strabismus surgeon.

Naval Sondhi, MD: Speaking both locally within the city and within the state, we certainly have an excellent group of comprehensive general ophthalmologists in my area, which is Indianapolis. A lot of them would probably be classified as doing the more common types of strabismus surgery. In other words, procedures involving the horizontal recti. We have a few comprehensive ophthalmologists who perform vertical and oblique muscle surgery.

Most of them do good, safe surgery and are not reluctant to refer patients if they find that the have now reached a stage where they are not comfortable dealing with them.

Dr. Coats: Here are some reasonable recommendations for occasional strabismus surgeons.

First, keep the surgical plan simple.

Second, control bleeding throughout the case so that you are less likely to get lost and do something that you regret later.

Third, even more carefully than you do for operations that you do more frequently, prepare the patient preoperatively. Make sure they know what to expect. Make sure they understand and hear the words “double vision” more than once, so that they are prepared in the event that it is present after surgery.

Fourth, while it is probably not mandatory to do so, I think magnification in the form of surgical loupes is helpful, and probably even more helpful for the occasional strabismus surgeon.

And last, as Dr. Sondhi said, have a low threshold for referral, or at least call your strabismus colleagues if you think something is not going smoothly either intraoperatively or postoperatively.

Dr. Gold: I agree 100%. Those criteria are excellent. The threshold for referral has to be low. If the occasional strabismus surgeon feels that there is something wrong postoperatively, even if it is a day or 2 or 3 postoperatively, then the patient must be referred. I have had several occasions in my area where referring was delayed, and there has been an occasional slipped muscle, or an incorrect muscle was inadvertently cut, and it took more than I would have liked to repair the problem. The situation can certainly be difficult.

Dr. Sondhi: I agree with all David’s criteria, but I would add a word of caution on doing strabismus surgery in adults. David touched on that, using the word diplopia, but in addition testing in those patients preoperatively is critically important. It will save the occasional strabismus surgeon a lot of embarrassment and a difficult postoperative period if that is done.

Probably the simplest test, if I could recommend one, is to use prisms in free space to correct the strabismus angle and see how the patient feels. If they complain of diplopia, discomfort, or any other kind of ocular symptom, I would consider getting a second opinion from a strabismus colleague.

Avoiding common mistakes

Dr. Coats: Here are three important mistakes and what the comprehensive ophthalmologist can do to avoid them.

The first is overreaction to perforation of the globe intraoperatively. We have seen cases in which the surgeon’s response to perforation was to immediately begin to cryo the area of the perforation. This may not be the optimal approach to this complication, and it can lead to significant complications down the line. The recommendation would be, if a perforation occurs, to replace the needle in another location, rather than leaving the suture in that suture track, inspect the retina, and consider getting a retina consultation. You do not have to make that consultation decision intraoperatively, it can be done later. Without any data to support this, it is our policy to cover patients well with antibiotics postoperatively, to reduce the risk of intracoular infection. We put antibiotic drops on the operative site, we give them subconjunctivally sometimes, we give a dose of antibiotics intravenously, and put the patient on oral antibiotics postoperatively, and then follow the patient carefully, and by all means, inform the patient of the complication. Do not overreact by using cryo, and do not fail to let the patient know.

The second complication that we see is returning the patient to operating room too soon when there’s an under- or overcorrection in the immediate postoperative period. Things change over time, and unless there is a slipped or lost muscle or some other compelling reason to go back to surgery, wait at least a couple of months to see what is going to happen. Temporize the patient with prism or get a second opinion, but don’t run back to the operating room too quickly.

Third, when operating on the lateral rectus muscle it is not infrequent for both seasoned and occasional strabismus surgeons to accidentally simultaneously hook the inferior oblique muscle when they hook the lateral. If this is not recognized and rectified, the patient can end up with serious restrictive strabismus problems that are difficult to treat. So the surgeon should look at the lateral rectus muscle insertion after hooking it, and make sure that they haven’t also accidentally hooked the lateral rectus muscle.

Dr. Sondhi: As we are now talking about more specific things, here is one to consider. The surgeon must use proper suturing technique when applying sutures to the muscles before taking them off the globe. If that technique is not properly performed, slipped muscles are a common problem, and those of us who are doing repeat strabismus surgery on a regular basis see this complication with some frequency.

Patients do not recognize the problem. In fact, often the referring ophthalmologist cannot recognize that there is limitation of movement or duction of that eye because of the slipped muscle. I would like to emphasize this point. And if you are not sure, certainly there are excellent colleagues in your area who would be happy to go over the technique with you.

Dr. Gold: One point that has been made here that bears repeating is that the occasional strabismus surgeon, just like any surgeon, must be honest with the patient. If something has not gone the right way, tell them what is going on, tell them what to expect, tell them that it may take several weeks for things to stabilize. That’s a very important point. Honesty is the best policy.

Dr. Sondhi: There is no insurance policy better than a patient who likes you and appreciates your honesty. That is still your best protection.

Dr. Paysse: Another technique comment about limbal surgery. When the surgeon is putting the conjunctiva back together, frequently I find when I am teaching residents or fellows that they do not find that little corner for the limbal incision.

The trick to finding it easily is to pull up the conjunctiva with forceps and go underneath to grab Tenon’s, and then pull the Tenon’s forward. That will allow the conjunctival corner to pull back, and it’s easily visible, and then you grab that. Then you do the same on the other side. This trick will always unroll the conjunctiva to where you can put it back properly.

It’s a nice way of ensuring that you have got that corner identified.

Dr. Gold: I am sure our colleagues have run across a similar situation. Adult conjunctiva is like plastic wrap. It can rip easily, and even for the seasoned strabismus surgeon this can be a nightmare. So for the occasional strabismus surgeon, be careful that your forceps are picking up the correct tissue as you are suturing things closed because it may not be conjunctiva.

Endophthalmitis and other complications

Dr. Coats: We should mention the signs and symptoms of endophthalmitis. Endophthalmitis must be the worst ophthalmologic complication that can occur postoperatively in a patient who has undergone strabismus surgery. Fortunately, it is rare, but its rarity also tends to make it less likely to be recognized. While I have never had a case of endophthalmitis, I have looked at the literature carefully on the topic, and there are some key things that ophthalmologists should recognize.

Endophthalmitis has been reported anywhere from 1 day to weeks after surgery. Reported cases often have had several things in common, including asymmetric or atypical redness and swelling postoperatively. In some reported cases, the child has been acting normally for a few days after surgery and then begins to show signs of systemic illness, lethargy, poor appetite and so on.

It is not uncommon for children to be seen by their pediatrician for these complaints and to be treated for several days for a suspected systemic viral illness, and the recognition does not come until days later that it was actually endophthalmitis producing these symptoms.

Finally, fever is also occasionally the presenting sign of endophthalmitis.

So the bottom line is really anything unusual warrants having the patient come in for examination to make sure there’s not an infection.

Dr. Sondhi: I would like to add another rare but devastating complication: anterior segment ischemia.

If the occasional strabismus surgeon does not recognize that the patient has had previous ocular surgeries, or if there are other mitigating medical history circumstances that would predispose a patient to anterior segment ischemia, that can lead to this visually devastating problem.

In any patient who has had previous eye muscle surgery, or even any other type of eye surgery, one should be particularly cautious, especially in adult patients.

Dr. Gold: If you get a phone call from the family for an adult postop patient, you have to take it seriously. Do not say, “I will see you in 3 weeks.” It is important to make sure that we identify these kinds of problems.

Dr. Coats: Several years ago, I had had a couple of patients with postoperative concerns who said they had a difficult time getting through to me. Since then, I have started giving every patient undergoing surgery my home office and pager operator number. I tell them to call me, with a very low threshold. I have found that that is well received and is comforting to patients. With the exception of the very rare patient, I get calls only when it is appropriate. It is not only comforting for the patient to have that access, but it is comforting for me as well.

For more information:

• Robert S. Gold, MD, is in private group practice in Longwood and Winter Park, Fla. He can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407- 767-8160; e-mail: rsgeye@aol.com.
• Naval Sondhi, MD, is in private group practice and is a clinical professor at Indiana University. He can be reached at Midwest Eye Institute, 201 Pennsylvania Parkway, Indianapolis, IN 46239; 317-817-1333; fax; 317-817-1331.
• David K. Coats, MD, is an assistant professor of ophthalmology at Baylor College of Medicine. He can be reached at 6701 Fannin St., CC 640.00, Houston, TX 77030; 713-824-3230; fax: 713-796-8110; e-mail: dcoats@bcm.tmc.edu.
• Evelyn A. Paysse, MD, is an assistant professor of ophthalmology at Baylor College of Medicine. She can be reached at 1102 Bates St., Suite 300, CC 640.00, Houston, TX 77030; 832-822-3234; fax: 713-796-8110; e-mail: epaysse@bcm.tmc.edu.