CME Complex Strabismus

Treatment of Thyroid Related Strabismus

Differential diagnosis

Thyroid strabismus should be differentiated from other acquired adult
strabismus including acute orbital inflammations, oculomotor palsies
and Myasthenia Gravis. Small fibrosis of the IR with no apparent
activity phase may resemble a paresis of the IV contralateral nerve.
In the activity phase, especially when the patient is euthyroid, the
condition should be differentiated from myositis and inflammatory
pseudotumor. Other pictures to consider are tumoral muscle
infiltration, metastatic cavernous hemangioma, external progressive
chronic ophthalmoplegia, progressive supranuclear palsy, sagging eye
syndrome and restrictive myopic strabismus.

Medical history, presence of ptosis, passive duction, laboratory
and imaging tests will help the diagnosis. In certain cases, with no
systemic, involvement the type of extraocular muscle thickening
is very characteristic of TED and evolution confirms the suspected
diagnosis.

Treatment

The treatment of these patients consists of controlling the hormonal
levels, inflammation and orbital proptosis, diplopia, as well as eyelid
retraction. It is important that the patient stops smoking. Patients who
smoke and have TED are twice as likely to need strabismus surgery. A
better evolution of orbitopathy in patients treated with statins has been
linked.26 Mild forms are treated with eye lubricants and selenium. In
moderate or severe forms systemic steroid treatment, radiation therapy,
rituximab, tocilizumab and in recent years teprotumumab have been
shown to be effective in improving TED orbital fat volume, muscle
thickening, ocular restrictions, and diplopia27,28,29.

The treatment of diplopia is complex, due to the dynamic and
progressive nature of the disease, the involvement of multiple
muscles, the different behavior of fibrotic muscles and the fact that it
requires stability before surgery. This stability usually occurs between
18 months and 3 years after the onset of the process. Management
becomes even more complicated when associated with Ocular
Myasthenia.

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When diplopia appears suddenly the patient required occlusion for
some activities, and in small and stable deviations prisms can be
used. Prisms are also used in the postoperative period to compensate
for residual deviation in some gaze position or to reduce torticollis.
Prisms can be built integrated into the glasses with powers of up to
10 -14 PD vertical diopters and 16-18 PD horizontal. Fresnel Prisms
can be used for larger amounts of deviations but worse tolerated since
they reduce vision and induce difractive problems. If the deviation
is horizontal and vertical, an oblique prism can be placed. When a
vertical prism is needed, patient tolerates them better when placed in
the eye with hypotropia or on the eye that has lower vision. If the
deviation is very incomitant they may require different prisms to be
used in primary position for viewing and for reading; or we can place
a segment to influence only a gaze position. There are patients who
finally fail to fuse comfortably and close one eye at some activities.

Botulinum toxin (BT) was initially used in the acute phase of the
disease to decrease contracture. However, there are patients with long-
term deviations of evolution or in cases of recent decompensations
after OD that may also respond to the use of BT. It was seen that
diplopia was eliminated between 15 and 33% of cases,30 being
more effective in ET, in patients with deviations of up to 20 PD and
recent onset of the disease, in the rest of the patients the deviation
is reduced, which decreases the magnitude of required surgery. The
recommended dose of BT is higher than the one used in the treatment
of non-restrictive strabismus, advising to use between 5 – 15 and up to
50 Units of Botox.®31,32,33,34 It is also suggested to reinject BT to obtain
an additive effect depending on muscle thickening. Botulinum toxin
may also be useful for residual deviations after surgery.35

Surgery is performed following these “rules”36: 1. The hormonal status
must be controlled, 2. Orbital inflammation must be inactive; besides,
the deviation must be stable for a period of 6 months; exceptionally
in patients having an inactive GO this period may be reduced, 3. The
following surgical order will be followed: first orbital decompression
or fat surgery should be practiced if indicated since it can modify
ocular deviation; secondly, strabismus surgery will be performed
and finally eyelid surgery since the position of the eyelids can also

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be modified especially after recession of the IR. However, there are
references of patients operated on in active phase with good results.37

The objective of strabismus surgery will be to correct diplopia mainly
in the primary position of gaze and downgaze. It will also improve
pain secondary to ocular rotations, but the normality of versions will
not be fully recovered. It is necessary to warn the patient that it is
common to need more than one surgery, especially in the most severe
cases or to have to use prisms to correct residual defects. In a study
conducted by Mills,38 50% of patients required more than one surgery,
especially when the follow-up is prolonged as late overcorrections
may happen at long term39.

There are a few basic ideas in thyroid strabismus surgery:

1. Muscle recessions are primarily proposed to improve restrictions.
We try to avoid muscle resections of fibrotic muscles as they
may create restrictions (Figure 3) and reduce the BSV field or
aggravate inflammation, however sometimes we must do them
to treat residual deviations and when practiced they are of small
amount.

2. Fibrosis of the muscles is varied and although there are specific
dose response tables for TED, the muscles do not respond precisely,
and experience of the surgeon in restrictive cases is important40.
Recessions are also planned based on the resting position of the
muscle.41,42

3. It is necessary to foresee the possibility of an overorrection,
especially in the vertical component when the antagonist and yoke
muscles are also affected, so it is necessary to consider all the
muscles of the orbit. Surgery is planned with a margin of initial
under ocorrection after IR recession. The goal of the surgery is
to leave at the end of the procedure rotations as symmetrical as
possible in both eyes.

4. Weakening a vertical muscle can influence the horizontal
component and vice versa, so sequential analysis of the passive
ductions should be done after the release of each muscle.

5. When the muscle recession is of great magnitude, the muscle loses

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Treatment of Thyroid Related Strabismus

the arc of contact, especially the IR. To decrease this effect, it is
convenient to use an explant of tutopatch or lyophilized sclera.43,44

6. The conjunctiva can be retractable and cause some of the restriction.
Forced duction test should be repeated after conjunctival closure
and often must be recessed after muscle weakening.45,46 The
recession of the tenon is also associated with a greater effect on
correction of the deviation in primary position and improvement
on ocular rotations.47

7. To avoid overcorrection, it is advisable to use non-absorbable
sutures although these are associated with major risk of infection
and extrusion.

8. There is a controversy about the use of the adjustable suture in
these patients, since on the one hand it allows adjustment of the
deviation in the postoperative period, but on the other hand it is
associated with an increased risk of overcorrection especially
when performed on the IR. Spielman (1999) and Kushner (2004)48
advise the use of semi-adjustable sutures to decrease this risk. In
our center an important amount of TED surgery is performed with
topical anesthesia with intraoperative adjustment with which it
allows us to do sequential analysis of the patient and to leave the
position of the eye sutured with a permanent suture at the end of
the surgery.49,50

Horizontal Strabismus Surgery

The most common type of horizontal strabismus in TED is ET with
limitation of abduction due to fibrosis of the MR that may happen
in variable degrees. LR is usually affected in less intensity. When
the deviation manifests as an XT we must think of MG. In cases of
absence of eyelid retraction together with variable ptosis we also must
out rule MG, although ptosis in TED often not intense. Ptosis in TED
patients also could be due to inflammation, III nerve paresis, and other
associated myopathies.

Recession of one or two MR can be performed depending on the
restrictions in each eye and the magnitude of the deviation. We should
try to leave ductions as symmetrical as possible. For dosage we rely

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on the tension-free resting position of the muscle combining it with
the dose response tables. The dose effect in correcting deviation in PP
varies in literature. After unilateral MR recession varies from 2 to 3.5
PD / per mm of muscle recession, and after bilateral MR recession from
2.5 to 3.62 PD/mm7,40,51. Standard doses of recession used for comitant
strabismus tend to undercorrect the deviation in TED patients. Small
recessions have smaller effect than in comitant strabismus while large
recessions have an increase effect per mm. Surgical dose‐response is
significantly larger for patients with deviations ≥ 25 PD compared
to patients with deviation <25 PD51, when surgery is done in both
eyes and when it is associated to an IR recession that enhances the
horizontal effect. Recessions in patients that had an OD have smaller
effect per mm.

Recessions over 6-7 mm may result in adduction deficiency. Beyond
this, ductions reduce rapidly. When a larger recession is needed, we
prefer to use muscle elongation with tutopatch ® or freeze-dried sclera.
LR resection is generally avoided in TED patients as first surgery, but
it can be the best option for residual deviations after MR recession
unilateral or bilaterally.52,53

For large deviations BT injection can be used simultaneously with the
MR recession or the BT can be injected postoperatively to manage
residual esotropia after maximum MR muscle recession has been
done.

Large recessions of MR may affect convergence and interfere reading
and patients may need base in prisms.

Vertical Strabismus

The most common type of vertical strabismus in TED is hypotropia
with limitation of elevation due to fibrosis of the IR that may affect
differently in both eyes. Other vertical muscles can be simultaneously
affected which may conduce to many different types of deviation.
Patient may have diplopia in all fields of gaze, but a typical case is the
presence of diplopia in primary position that increases in upgaze and
reduced in downgaze. Some patients present with chin-up position to
avoid diplopia in PP.

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Treatment of Thyroid Related Strabismus

Some important aspects to operate vertical deviations in TED are:

1. Preoperative motility evaluation is full of details in TED patients.
Special care to ductions and ocular torsion is needed to evaluate
involvement of each muscle. Hess screen, passive ductions
and MRI enrich the preoperative examination. Intraoperative
staged evaluation after each muscle recession and changes in
intraoperative torsion marked with blue dots on the limbus is very
helpful to take intraoperative decisions54. (Figure 6). In patients
operated with topical anesthesia, torsion can also be subjectively
evaluated during surgery using the Maddox rod.

Figure 6: Ocular Incyclorotation drift after IR detatchment evaluated with blue dots
in limbus. A. Preoperative B Pulling from the IR with the hook we can see a large

excyclorotation of the eye C After IR muscle is detached marked Inclyclorotation is
produced.

2. Special care must be taken to consider the fibrosis of all 4
vertical muscles in both orbits to avoid overcorrections. This
may happen after release of the tension following a muscle
recession if the contralateral yoke muscle or ipsilateral antagonist
is also contracted. A small under-correction on the immediate
postoperative period can reduce the risk of over-correction
specially after IR recessions. Oblique muscles may also play an
important role in overcorrections55.

3. Angle of the deviation should be measured in the primary
position, up, and down-gaze to decide the muscle or couple
of muscles to be operated on. BSV field in restrictive patients
is of great value. In a case of chin-up position, evaluation after
occlusion of the hypotropic eye suggest the need of bilateral IR
Recession. Basic recommendations are:

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Treatment of Thyroid Related Strabismus

a. In case that hypotropia is similar in PP up and downgaze a
unilateral IR recession is suggested. If large deviation is
present IR recession can be reduced alongwith SR Recession
on the contralateral eye especially if elevation is preserved on
the hypertropic eye56.

b. When deviation is reduced in downgaze, bilateral IR and
contralateral SR tightness must be considered to propose
asymmetric IR recessions or IR recessions of the hypotropic
eye of smaller amount and a SR recession of the hypertropic
eye.

c. When deviation is reduced markedly in down-gaze to almost
0 PD, bilateral asymmetric IR surgery is suggested or an IR
recession in the hypotropic eye and contralateral IR faden
surgery.

4. Surgery consists of muscle recessions based on the relaxed muscle
positioning technique. Dose-response data on the effect of an IR
recession range in publications from 3.25 to 4.9 PD / mm, being of
a great effect in larger recessions. If an IR must be recessed more
than 6-7 mm, we tend to use explants in order not to lose the arc
of contact.

5. Specially for IR recessions we use fixed sutures and intraoperative
adjustment under topical anesthesia if possible. We place a central
stitch of a non reabsorbable suture to avoid stretched scars and
overcorrections.

6. To avoid posoperarative A pattern IR nasal transposition has
been proposed for IR recessions larger than 4 mm, but nasal
IR transposition increases the tendency for incyclotorsion.
This incyclotorsion movement is greater in TED patients than
in nonrestrictive cases57,58. If a patient preoperatively has less
excyclotorsion than expected proportional to the degree of
IR fibrosis, or there is an important incyclomovement after
IR detachment (limbal blue dot technique, Figure 6) nasal
transposition should be avoided. During surgery sequential passive
duction is useful, considering intraoperatively simultaneous SO or
SR surgery.

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Treatment of Thyroid Related Strabismus

7. Vertical deviation that increases in downgaze is less frequent to
observe as a primary deviation. Superior complex and ocular
torsion (incyclotorsion) have to be evaluated. Dose effect per
millimeter of SR recession is stated as 2.8 to 3 PD/mm.

8. Patients should be explained of the goal of the surgery and that
full recovery is not frequently obtained. The main objective
of the surgery is to eliminate diplopia in primary position and
downgaze, and that they may need postoperative prisms to avoid
diplopia.

9. Residual deviations should be evaluated as a new case and
fibrosis of all muscles must be considered. Contralateral SR
recession can be the surgery of choice if that muscle is contracted
or resections of ipsilateral SR if this muscle is not enlarged.59

10. In case of an overcorrection after IR, advancement of the
recessed IR usually bring lower success than a recession of
ipsilateral SR or contralateral IR recession or both. In case of
smaller deviations in PP and small limitation of the contralateral
eye authors have practiced partial temporal IR recessions with
good results and no overcorrection one year postoperatively.

11. Inferior oblique muscle is also used to manage ocular torsion
in TED strabismus. IO recession may be used for patients with
marked excyclotorsion, small vertical deviations and good
ductions with an effect of 0.5°/mm. It has been used to treat
overcorrections with diplopia in downgaze position recessing
the contralateral IO muscle. Lateral transposition of IO may
also play a role in management of symptomatic incyclotorsion.60

Combined ET and Hypotropia

In cases of large vertical and horizontal deviation we need to combine
MR and IR recessions. Dose response per mm of recession in combined
surgery has larger effect (2.2°/mm for inferior rectus recession and
1.8°/mm for medial rectus recession)61 IR recession influences the
horizontal deviation as also do MR recession specially if the bellies
of the MR are displaced after OD. We should plan an undercorrection,
as there is a greater postoperative drift toward overcorrection for both

202 CME on COMPLEX STRABISMUS

Treatment of Thyroid Related Strabismus

Figure 7: Posotperative drift after combined MR and IR recessions. First column
TED patient that had an ET of 30 PD and a LE hyOT of 35 PD. 2nd column 3 days
after LMR and LIR recession planned for an intended undercorrection. 3rd column 1

month 4th column 9 months after

procedures. (Figure 7) During surgery we begin with recession of the
larger component of the deviation. Sequential examination by steps,
topical anesthesia and intraoperative examination or staged surgery is
useful in that scenario.

A pattern and incyclotorsion

A pattern and incyclotorsion is often seen after large IR recessions,
especially if the muscles are nasally transposed and patient do not
have large excyclotorsion preoperatively. IR nasal transposition may
improve A pattern but increases the incyclotorsion that already is
reduced with the IR Recession and may be increased due to overaction
of the SO. Supraposition of MR and downshift of the SO after OD
also induce incyclotorsion. In cases of very large horizontal or vertical
deviation it may be difficult to evaluate overactions and ocular torsion
preoperatively.

During surgery it is of great use the placement on limbal blue dots to
observe intorsion changes after IR detachment and to evaluate passive
ductions of all 4 vertical muscles. SO muscles can be simultaneously
recessed and left on an adjustable suture for a later adjustment54,55.

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Treatment of Thyroid Related Strabismus

Surgery in cases of A pattern and incyclotorsion must be evaluated as
a new patient. IR advancement may be very complicated if the patient
had a large recession as the new insertion is difficult to dissect and
surgery is quite unpredictable. Depending on residual deviation in PP,
versions, ocular torsion and passive ductions different surgeries can
be proposed as recession, posterior tenectomy of the SO muscles, SR
recession associated to horizontal transposition and anterior lateral
transposition of the IO to induce incyclotorsion.

Complications of surgery

Overcorrections can be produced on the first operative days, slowly
on the first postoperative month when sutures are absorbed, they may
appear months to years after, due to contracture of antagonists, once
the tightness of the muscle is released62. Sometimes it takes time
until patient complains as progressive vertical fusion amplitudes are
developed. Horizontal overcorrections are less frequent and easier to
manage. Vertical overcorrection can be due to an IR slippage or creation
of a stretched scar. Therefore, adjustable sutures have higher risk of
overcorrection specially in IR recessions. We place a non-absorbable
central stitch on the IR to avoid stretching as much as possible. In
many cases, when the IR is checked, it is seen that it is not slipped
and it is because when the IR recession is greater than 6-7 mm, the
arc of contact decreases in functionality. The use of muscle elongation
through explants is recommended if large recessions are needed.
Contracture of antagonists and contralateral yoke muscles also play an
important role in overcorrection of the vertical deviation. Lockwood
scar to the IR may pull it anteriorly and diminish its functionality63.
Early surgery or reactivation of the disease can be also another factor.
Recently, we have had patients in whom the COVID-19 disease or the
vaccine has reactivated TED disease that was stable for years.

Lower lid retraction

Recession of the IR can cause eyelid retraction that is much more
severe if the recession is over 4 mm. (Figure 8) Sometimes retraction
is mild on the early postoperative period and becomes more apparent
after some weeks/ months. To prevent this complication, it is advisable
to dissect the muscle and to free it from Lockwood ligament and its

204 CME on COMPLEX STRABISMUS

Treatment of Thyroid Related Strabismus

Figure 8: Bilateral Postoperative retraction of the lower eyelid treated with scleral
explants

retractors, to advance it as well as the surrounding tenon. However,
this complication is frequent and can be resolved with an explant.64
Superior lid retraction can also be augmented after SR recession due
to connections between the superior rectus and the elevator complex
in the upper lid.

Surgery on TED patients with very tight muscles are more complicated.
Surgery may have increased bleeding and muscles may be more
difficult to access in the more severe cases. If brisk pulling with
the hook it can produce a muscle fracture (Pull in two syndrome).
Special attention must be taken with the pulling done by the assistant
and grooved muscle hooks (Kowal, Bishop or Wright Hook) may be
used to reduce excessive traction.

Other complications that may appear after surgery are anterior segment
ischemia and apical compression, especially when 2 adjacent muscles
(eg MR and IR) that are very thick are recessed, proptosis increasing
after release of the fibrotic muscles and refractive changes have also
been published.

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ophthalmopathy or congenital strabismus. Acta Ophthalmol. 2019 Feb;97(1):74-
79

45. Weldy E, Kerr NC. Lateral rectus muscle resection following maximal recession
of the medial rectus muscle in thyroid eye disease. JAAPOS. 2017;21(4):291–
294.

46. Scofield-Kaplan SM, Dunbar K et al. Improvement in Both Primary and Eccentric
Ocular Alignment After Thyroid Eye Disease-Strabismus Surgery With Tenon’s
Recession Ophthalmic Plast Reconstr Surg. 2018;34(4S Suppl 1):85-S89.

47. Scofield-Kaplan SM, Dunbar K et al. Improvement in Both Primary and
Eccentric Ocular Alignment After Thyroid Eye Disease-Strabismus Surgery
With Tenon’s Recession Ophthalmic Plast Reconstr Surg. 2018 Jul/Aug;34(4S
Suppl 1):S85-S89.

48. Kushner BJ. An evaluation of the semiadjustable suture strabismus surgical
procedure. J AAPOS. 2004 Oct;8(5):481-7.

49. Kalpadakis P, Rudolph G, Boergen KP. Adjustment of eye muscle surgery dosage
under drop anaesthesia in patients with Grave’s orbitopathy]. Ophthalmologe
2002;99:941–5.

50. Gomez de Liaño R. Topical Anesthesia in strabismus surgery. ESA Lecture.
Transactions of the 38 th Meeting of the European Strabismological Association.
Budapest.

51. Akbari MR, Mirmohammadsadeghi A, Mahmoudzadeh R, Veisi A. Management
of thyroid eye disease-related strabismus. J Curr Ophthalmol 2020;32:1-13.

52. Matlach J, Döllinger VKR et al. Ocular ductions after rectus muscle recession
and resection in thyroid eye disease. Strabismus 2019 Sep;27(3):143-148

53. Kim EY, Roper-Hall G, Cross OA. Effectiveness of bilateral lateral rectus
resection for residual esotropia in dysthyroid ophthalmopathy. Am J Ophthalmol.
2016;171:84–87.

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Treatment of Thyroid Related Strabismus

54. Holmes JM, Hatt SR, Leske DA. Intraoperative monitoring of torsion to prevent
vertical deviations during augmented vertical rectus transposition surgery. J
AAPOS. 2012;16(2):136e140.

55. Holmes JM, Hatt SR, Bradley EA. Identifying masked superior oblique
involvement in thyroid eye disease to avoid postoperative A-pattern exotropia
and intorsion. J AAPOS. 2012;16(3):280e285.

56. Schlüter S, Dekowksi D, Esser J et al. [Primäre und sekundäre Rücklagerung
des M. rectus superior bei Endokriner Orbitopathie]. Z prakt Augenheilk
2015;36:236–241.

57. Sato M. Can we correct torsion with IR surgery? In Gomez de Liaño R. Advances
in Strabismus. 13th Meeting of the International Strabismological Association.
Madrid, Spain 2018. 44-47

58. Okamoto M., Kimura A., Masuda A., Mimura O. Surgical effects of nasal
transposition of inferior rectus muscle - 135 cases of acquired superior oblique
palsy. Clin Ophthalmol. 2015;9:691–695.

59. Tacea F, Loane E, Grixti A et al Rectus Muscle Resection for Vertical Strabismus
in Thyroid Eye Disease. Strabismus. 2018 Jun;26(2):71-76.

60. Child CS, Mackenzie KA, Adams GW Inferior oblique advancement surgery
for thyroid eye disease and orbital blowout fracture patients with symptomatic
incyclotorsion. JAAPOS 2011; 16: E13

61. Eckstein A, Schulz S, Esser J. [Is combined surgical correction of horizontal and
vertical squint of value in graves’ ophthalmopathy?]. Klin Monbl Augenheilkd
2004;221:769–75

62. Sprunger DT, Helveston EM. Progressive overcorrection after inferior rectus
recession. J Pediatr Ophthalmol Strabismus. 1993;30:145–8.

63. Wright KW. Late overcorrection after inferior rectus recession. Ophthalmology
1996;103:1503–7.

64. Bernardini FP, Skippen B, Zambelli A et al. Simultaneous Aesthetic Eyelid
Surgery and Orbital Decompression for Rehabilitation of Thyroid Eye Disease:
The One-Stage Approach Aesthet Surg J. 2018 Sep 14;38(10):1052-1061

210 CME on COMPLEX STRABISMUS

14Post-traumatic Strabismus

Post-traumatic Strabismus

Dr. Shreya Shah, Dr. Mehul Shah

Drashti Netralaya, Dahod, Gujarat, India

Introduction

Post traumatic strabismus is a unique entity, which requires special
strategy to manage all aspects of it. Patients’ symptoms and signs can
vary widely that present challenges to the examiner. Proper diagnosis
of type and severity of injury, particularly differentiation between
mechanical and neurological damage is important in determining the
timing and type of intervention for each individual.1,2

In case of poly, trauma open globe injury repair is priority and orbital
trauma is dealt later. Coexistence with other head, neck and brain
injuries which may be life threatening, are a priority. Post traumatic
strabismus requires a detailed and careful recording of the history,
systematic and local examination which must be supported by ocular
and general examination. Examination includes general sensory,
motor and the cranial nerve examination. Investigations include
blood examination and radiological investigation of brain and orbit,
including X-ray, CT scan, and MRI scan. Ultra-sonography B Scan for
Orbit is also important for making diagnosis.3

Aetiologies: Multiple varied and combined aetiologies may be
responsible for strabismus in case of ocular, orbital and EOM trauma.
Each of this requires a unique management strategy.

1. Direct trauma to muscle-

• Mainly mechanical injury

• Almost always associated with other adnexal injuries

• Requires retrieval of distal end of muscle and repair

• There may be late strabismus because of adhesions that
requires treatment

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Post-traumatic Strabismus

Figure 1: Direct trauma to the muscle immediately recognized after trauma

Figure 2: Late presentation of strabismus after trauma

2. Orbital Fracture causing muscle entrapment
• There may be entrapment in case of roof, floor or wall fracture
• White eye blow out fracture needs immediate attention
• Forced duction test is a diagnostic test
• Surgical management and release of entrapped muscle will
help achieving normalcy

Figure 3: Entrapped Medial rectus inth left eye
212 CME on COMPLEX STRABISMUS

Post-traumatic Strabismus
Figure 4: Entrapped Inferior rectus producing diplopia in up as well as downgaze.

Figure 5: CT scan with left eye inferior rectus entrappment

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Post-traumatic Strabismus

Figure 6: Preoperative and postoperative picture of the patient

3. Orbital trauma causing cranial nerve damage
• There may be partial or total third nerve palsy
• Partial third nerve palsy can wait
• For all immediate injuries, medical treatment in form of
corticosteroids form the first line of management.
• On late presentation surgical management is required to
achieve orthophoria in primary position

Figure 7: An acute onset third nerve palsy in a patient can be managed
conservatively.

214 CME on COMPLEX STRABISMUS

Post-traumatic Strabismus
Figure 8: A case of traumatic fourth nerve palsy

Figure 9: A case of traumatic inferior rectus palsy

4. Restrictive strabismus because of mechanical causes
Strabismus can also be caused due to restrictive causes like

fibrosis, contracture and symblepharon.

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Post-traumatic Strabismus

Figure 10: Symblepharon causing strabismus

5. Cranial nerve palsies because of head injuries
This may be seen in patients with diplopia or difficulties with their

vision following a concussion or brain injury. Brain injuries can
come in many forms. Below are some common diagnoses:
• Concussion
• Post-Concussion or Postconcussive Syndrome (PCS)
• Post Traumatic Vision Syndrome
• Traumatic Brain Injury (TBI)
• Mild Acquired Brain Injury
• Mild Closed Head Injury
• Cervical Trauma Syndrome
• Stroke
• Cerebral Palsy
• Cerebral Vascular Accident

216 CME on COMPLEX STRABISMUS

Post-traumatic Strabismus

6. Strabismus because of vascular causes: out of which one of the
main cause is carotico cavernous fistula

Figure 11: Case of left sided carotico-cavernous fistula.

Surgical management for closure of fistula and correction of residual
strabismus is the treatment in such cases.
7. Sensory deprivation because of media opacity

• Open globe or closed globe injury causing corneal opacity can
lead to sensory deprivation strabismus.

• Neglected traumatic cataract
• Long standing untreated trauma may result in exotropia
• Management of cause in form of elimination of corneal opacity

and management of traumatic cataract followed by strabismus
surgery required.

Figure 12: Sensory strabismus after a case of post traumatic corneal opacity

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Post-traumatic Strabismus

Figure 13: Case of traumatic cataract leading to strabismus

8. Iatrogenic
• Lateral Rectus palsies after spinal analgesia
• Injury to medial rectus noted during endoscopic sinus surgeries

Trauma & strabismus

Immediate Late

Direct Indirect Local Remote

*Head injury Deprivation

Mechanical

Trauma to Pressure Neurological Concussion
muscle effect contusion
*Corneal scar *CCF Head
*PTSD *Traumatic *Hematoma injury

*Muscle *Orbital Direct cataract at upper
tear *Posterior level
oedema damage to segment
*Muscle *Haeman-
hematoma *Orbital 3,4 and/or trauma gioma
&conj-palpe-
*Muscle Cellulitis 6th nerve or bral adhesions popping up
entrapment
Orbital its branches

hemorrhage

Gaze palsy
Bil ateral abduction defect
Bilateral adduction defect

Figure 14: Flow chart summarising trauma related strabismus and its mechanisms.

The authors of this chapter conducted a study to find out epidemiology
and outcome of strabismus in cases of ocular trauma.

218 CME on COMPLEX STRABISMUS

Post-traumatic Strabismus

This retrospective study included 124 patients with strabismus following
ocular trauma who reported to the Department of Ophthalmology
of a tertiary care centre in Western Central India between 2007 and
2018. All data were exported from electronic medical records to
Excel sheets and analysed using SPSS 22 (no conflict of interest). The
investigations were performed using descriptive analyses and cross
tabulation, and p value < 0.05 was considered significant.

Results

Among the treated cases, ocular motility disorder 5.25% (124/2379)
was of traumatic aetiology. The current cohort consisted of 124
cases, out of which 29 (23.4%) were women and 95 (76.6%) were
men. The age of onset of the presentation was 23.76 ± 12.71 years.
Exotropia was found in 77/124 (62.1%) cases, and 43/124 (34.7%)
had esotropia (Table-1). Furthermore, 41/124 (33.1%) were paediatric
patients. On examination, exotropia was the most common type of
strabismus (Table-2). When we studied the post-treatment deviation,
post-operatively 96(77.4%) were orthophoric. When we compared the
deviations in distance and near vision, we found significant differences
for both (p = 0.000 and p =0.001, respectively).

Table-1 Age and sex distribution

Age Group Sex Total
FM 19
0 to 10 34
11 to 20 8 11 44
21 to 30 12 22 18
31 to 40 4
41 to 50 6 38 3
51 to 60
61 to 70 2 16 2
04
12 124

02
29 95

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Post-traumatic Strabismus

Table-2 Type of strabismus following ocular trauma

Deviation Frequency Percent
Esotropia 43 34.7
Exotropia 77 62.1
Hypertropia 3 2.4
Hypotropia 1 .8
Total 124 100.0

Table-3 Object of injury Frequency Percent

Objects 1 .8
Birth Injury 19 15.3
Blunt 1 .8
Chocolate 31 25.0
Fall 2 1.6
Fire Crackers 1 .8
Glass 1 .8
Iron Particle 3.2
Iron Wire 4 8.1
RTA 16.1
Stone 10 8.9
Unknown 20 18.5
Wooden Stick 100.0
Total 11

23
124

Table-4 Ocular Trauma related clinical findings

Ocular Menifestation Frequency Percent
Corneal Opacity 33 26.6
History of Surgery 32 25.8
Lateral Rectus Palsy 2 1.6
Ophthalmoplegia 1 .8
Optic Atrophy 4 3.2
Orbital Fracture 12 9.7
Ptosis 3 2.4
Traumatic Cataract 27 21.8
Total 124 100.0

220 CME on COMPLEX STRABISMUS

Post-traumatic Strabismus

Out of the total 124 patients, 119 (91.9%) were treated by surgical
intervention.

Comparison revealed significant differences in pre- and post-treatment
stereopsis (p = 0.000).

Falls and wooden stick were the most common causes of injury
(Table-3).

Sensory deprivation was the most common (60/124, 58.4%) cause for
the ocular trauma that led to strabismus (Table-4).

Discussion

The gender distribution of the current cohort was similar to that
described in the literature. The predominance of the male gender
could be attributed to the frequency of the traumatic causes
predominant in this sample.4 The mean age of the patients included in
the current study was less (23.76±12.71) than that reported in other
studies, which may be because of the predominance of the trauma in
the young population.

The most common aetiology was found to be sensory deprivation as
compared to other reports.1 This difference may be because of the
late presentation.5

Regarding paresis or acquired paralysis of cranial nerve III, 8.3%
was traumatic aetiology and 59.1% was due to undetermined
causes. Some studies6,7 have reported that 45.5% were congenital
cases. Another study8 found a high frequency of indeterminate cases
(23.7%), followed by vascular causes (19.8%). These differences
could be ascribed to the demographic characteristics of the
catchment area. The low occurrence of vascular aetiology (17.5%)
is probably due to the lack of diagnosis or referral of these patients
to our department.1

Literature analysis6 also revealed that trauma (25.7%) and vascular
injury (15.7%) were the most frequent aetiological factors, while
28.3% were undetermined causes. Another study10 observed 39.5%

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Post-traumatic Strabismus

congenital cases, 34.0% traumatic cases and 23.2% cases of
undetermined origin.

Moreover, studies have reported mid-face injuries causing strabismus.11
However, the current study did not encounter this type of presentation.

Orbital fracture has been documented to be an important cause of
traumatic strabismus by many studies.12-16

Laursen et al. noted the direct splitting of inferior rectus due to direct
trauma to the inferior rectus.17,18

We found significant differences in deviation and stereopsis when
compared with the pre- and post-treatment values, which may be due
to the management of both sensory deprivation and strabismus.

We are not aware of any other study that has covered such a large series
of strabismus cases following ocular trauma, with sensory deprivation
as the major cause.

We could find case reports on EOM damage during endoscopic sinus
surgeries and rectus palsy following spinal analgesia;18,19,20 however,
the current cohort did not include such cases.

Open globe injuries as the cause for strabismus has not been reported
widely in the literature. Nonetheless, in the current cohort, neglected
traumatic cataracts were identified to be a common cause.1

In the present study, majority of the cases (91.9%) were managed
surgically probably because of the high number of cases with ocular,
adnexal and orbital trauma.

Conclusion:Post-traumatic strabismus is a less common cause of
strabismus and has different aetiologies. Systematic evaluation
and appropriate management ensure good structural and functional
outcomes.

References

1. Murray AD. An Approach to Some Aspects of Strabismus from Ocular and
Orbital Trauma. Middle East Afr J Ophthalmol. 2015;22(3):312-319.

222 CME on COMPLEX STRABISMUS

Post-traumatic Strabismus

2. Subramanian PS, Birdsong RH. Surgical management of traumatic strabismus
after combat-related injury. Mil Med. 2008 Jul;173(7):693-6

3. Sharma P, Gaur N, Phuljhele S, Saxena R. What’s new for us in strabismus?
Indian J Ophthalmol. 2017 Mar;65(3):184-190

4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after
their management in the tribal areas of Western India: a historical cohort study.
Graefes Arch Clin Exp Ophthalmol. 2008 Feb;246(2):191-7

5. Shah MA, Shah SM, Shah SB, Patel UA. Effect of interval between time of
injury and timing of intervention on final visual outcome in cases of traumatic
cataract. Eur J Ophthalmol. 2011 Nov-Dec;21(6):760-5

6. Richard BW, Jones FR Jr, Younge BR. Causes and prognosis in 4,278 cases
of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J
Ophthalmol. 1992;113(5):489-96.

7. Prieto-Diaz J, Souza-Dias C. In: Estrabismo 3a ed. São Paulo: Roca; 1996;
p.377-442.

8. Avó DS, Gurgel DPA, Salomão SR. Estrabismo paralítico: Um estudo de 168
casos. Bol Bras Ortóp. 1986;12:28-34.

9. Von Noorden GK, Murray E, Wong SY. Superior oblique paralysis. A review of
270 cases. Arch Ophthalmol. 1986;104(12):1771-6.

10. Kühnel TS, Reichert TE. Trauma of the midface. GMS Curr Top Otorhinolaryngol
Head Neck Surg. 2015 Dec 22;14:Doc06.

11. David R, Davelman J, Mechoulam H, Cohen E, Karshai I, Anteby I. Strabismus
developing after unilateral and bilateral cataract surgery in children. Eye (Lond).
2016;30(9):1210-1214.

12. Lueder GT. Orbital Causes of Incomitant Strabismus. Middle East Afr J
Ophthalmol. 2015;22(3):286-291.

13. Hsu, CK., Hsieh, MW., Chang, HC. et al. Anatomic Factors Predicting
Postoperative Strabismus in Orbital Wall Fracture Repair. Sci Rep 9, 14785
(2019).

14. Loba P, Ordon AJ. Management of simultaneous ocular elevation and depression
deficit in patients after reconstruction surgery for orbital floor fracture. Graefes
Arch Clin Exp Ophthalmol. 2020 Jul;258(7):1443-1449.

15. Pineles SL, Repka MX, Yu F, Lum F, Coleman AL. Risk of musculoskeletal
injuries, fractures, and falls in medicare beneficiaries with disorders of
binocular vision. JAMA Ophthalmol. 2015;133(1):60-65. doi:10.1001/
jamaophthalmol.2014.3941

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16. Ludwig IH. Traumatic longitudinal splitting of the inferior rectus muscle. J

AAPOS. 2011 Oct;15(5):506; author reply 506-7
17. Shah SM, Shah MA, Shah PD, Patel KB. Successful repair of injury to the

eyelid, lacrimal passage, and extraocular muscle. GMS Ophthalmol Cases. 2016
Mar 17;6:Doc04.
18. Mukherjee B, Priyadarshini O, Ramasubramanian S, Agarkar S. Iatrogenic
Injury to Medial Rectus After Endoscopic Sinus Surgery. Indian J Otolaryngol
Head Neck Surg. 2015 Dec;67(4):394-402
19. Mukherjee B, Priyadarshini O, Ramasubramanian S, Agarkar S. Iatrogenic
Injury to Medial Rectus After Endoscopic Sinus Surgery. Indian J Otolaryngol
Head Neck Surg. 2015 Dec;67(4):394-402
20. Fairclough WA. Sixth-nerve Paralysis after Spinal Analgesia. Br Med J.
1945;2(4431):801-803.

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CME on COMPLEX STRABISMUS v

About Editors

Dr. (Prof). Subhash Dadeya did his MBBS from Medical College Rohtak.
He did his M.D. (Ophthalmology) from Dr. R. P. Center A.I.I.M.S. He
did his Senior Residency from Guru Nanak Eye Center, Maulana Azad
Medical College Delhi & after a brief period as pool officer at Safdarjung
hospital , subsequently he joined as Assistant Professor at GNEC,
MAMC & is currently working as Director - Professor of Ophthalmology.

Dr. (Prof). Subhash Dadeya He is active Member of Delhi Oph Society . He has been Executive
Member, Library officer , Secretary and Vice President of Delhi Oph
Society. Currently he is President of Delhi Ophthalmology Society.

He has been Executive Member, Joint Secretary and Secretary
of Strabismological Society of India. He has been Secretary , Vice President and President of
Strabismus and Pediatric Ophthalmology Society of India. He has been Chief Editor of Indian
Journal of Strabismology and pediatric ophthalmology.

He is a member of Asia Pacific society of strabismus and Pediatric Ophthalmology. He is also a
Member of the International Strabismus Association.

He is active member of AIOS & has written CME series on amblyopia.

He has around 100 publications to his credit in various regional, national and international journals.
He has been invited as a guest speaker at various regional, national and international conferences
in various capacities.

Dr Savleen Kaur did her MBBS from LHMC Delhi.

She did her MS from Guru Nanak Eye Centre Maulana azad medical
college Delhi in 2011. She is currently working as Assistant Professor
in Department of Ophthalmology (Advanced eye centre) PGIMER,
Chandigarh.

Dr. Savleen Kaur She is fellow of ICO,Visiting fellow Jules Stain Eye Institute California,
fellow all India collegiium of Ophthalmology in pediatric ophthalmology
and strabismus.

She has more than 70 indexed publications and over 30 invited speaker sessions.

She has many awards to her credit namely Woman Scientists award by Department of Science
and technology, Ministry of Health, Govt of India. Best Publication, paper and poster award by
Strabismus and Paediatric Ophthalmology Society of India. Best paper award by North Zone Oph
Society and Chandigarh Oph Society.

DELHI OPHTHALMOLOGICAL SOCIETY

Prof. (Dr.) Namrata Sharma

Secretary, Delhi Ophthalmological Society
DOS Secretariat

Room No. 479, 4th Floor, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
vi ACll MIndEiaoInnstCituOteMofPMLeEdXicaSlTSRciAenBceISs,MNeUwSDelhi-110029, India Tel: +91-11-2086371

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