Strabismus pp 153-192 | Cite as

Strabismus Surgery

  • Burton J. Kushner


We usually straighten eyes by shortening (recessing) muscles, which is thought to weaken them, or stretching (resecting, plicating, tucking, etc.) muscles, which is thought to tighten or strengthen them. When muscles are recessed, there are two different effects. An acutely shortened muscle should be weaker because of Starling’s law on muscle contraction, which states that the more a muscle is stretched, the greater its force of contraction.


Accommodative convergence/accommodation (AC/A) ratio High Adjustable faden Adjustable suture Anterior segment ischemia (ASI) Botulinum toxin (BTX) Bupivacaine Chemodenervation Elongated scars Faden—see posterior fixation Forced ductions Torsional Exaggerated Foster augmentation Hang-back (see suspension) Heavy eye syndrome Induced effects Insertion Jenson procedure Knapp procedure Magnetic resonance image (MRI) Dynamic Marginal myotomy Mexican tuck Plication Posterior fixation Psychosocial benefits Pulley fixation Sagging eye syndrome Scott’s adjustable faden—see adjustable faden Semi-adjustable Slipped muscles Spring-back test Stretched scars Surgery principles Suspension Transposition Vessel sparing Yokoyama procedure 


  1. 1.
    Kushner BJ. Multiple mechanisms of extraocular muscle “overaction”. Arch Ophthalmol. 2006;124:680–8.CrossRefGoogle Scholar
  2. 2.
    Scott AB. Change of eye muscle sarcomeres according to eye position. J Pediatr Ophthalmol Strabismus. 1994;31:85–8.PubMedGoogle Scholar
  3. 3.
    Apt L, Call NB. An anatomical reevaluation of rectus muscle insertions. Ophthalmic Surg. 1982;13:108–12.PubMedGoogle Scholar
  4. 4.
    Helveston EM, Ellis FD, Schott J, et al. Surgical treatment of congenital esotropia. Am J Ophthalmol. 1983;96:218–28.CrossRefGoogle Scholar
  5. 5.
    Kushner B, Lucchese N, GV M. Should recessions of the medial recti be graded from the limbus or insertion. Arch Ophthalmol. 1989;107:1755–8.CrossRefGoogle Scholar
  6. 6.
    Kushner B, Preslan M, Vrabec M. Artifacts of measuring during strabismus surgery. J Pediatr Ophthalmol Strabismus. 1987;24:159–64.PubMedGoogle Scholar
  7. 7.
    Bloom JN, Parks MM. The etiology, treatment and prevention of the “slipped muscle”. J Pediatr Ophthalmol Strabismus. 1981;18:6–11.PubMedGoogle Scholar
  8. 8.
    Ludwig IH, Chow AY. Scar remodeling after strabismus surgery. J AAPOS. 2000;4:326–33.CrossRefGoogle Scholar
  9. 9.
    Jung JH, Leske DA, Holmes JM. Classifying medial rectus muscle attachment in consecutive exotropia. J AAPOS. 2016;20:197–200.CrossRefGoogle Scholar
  10. 10.
    Kushner BJ. Evaluation of the posterior fixation plus recession operation with saccadic velocities. J Pediatr Ophthalmol Strabismus. 1983;20:202–9.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Scott AB. The faden operation: mechanical effects. Am Orthopt J. 1977;27:44–7.CrossRefGoogle Scholar
  12. 12.
    Millicent M, Peterseim W, Buckley EG. Medial rectus faden operation for esotropia only at near fixation. J AAPOS. 1997;1:129–33.CrossRefGoogle Scholar
  13. 13.
    Kushner BJ, Preslan MW, Morton GV. Treatment of partly accommodative esotropia with a high accommodative convergence-accommodation ratio. Arch Ophthalmol. 1987;105:815–8.CrossRefGoogle Scholar
  14. 14.
    Scott A. Posterior fixation: adjustable and without posterior sutures. In: Lennerstrand G, editor. Clinical strabismus management. Boca Raton: WB Saunders; 1994. p. 399.Google Scholar
  15. 15.
    Bock CJ Jr, Buckley EG, Freedman SF. Combined resection and recession of a single rectus muscle for the treatment of incomitant strabismus. J AAPOS. 1999;3:263–8.CrossRefGoogle Scholar
  16. 16.
    Thacker NM, Velez FG, Rosenbaum AL. Combined adjustable rectus muscle resection--recession for incomitant strabismus. J AAPOS. 2005;9:137–40.CrossRefGoogle Scholar
  17. 17.
    Christiansen SP, Antunes-Foschini RS, McLoon LK. Effects of recession versus tenotomy surgery without recession in adult rabbit extraocular muscle. Invest Ophthalmol Vis Sci. 2010;51:5646–56.CrossRefGoogle Scholar
  18. 18.
    Apt L, Isenberg S. Eye position of strabismic patients under general anesthesia. Am J Ophthalmol. 1977;84:574–9.CrossRefGoogle Scholar
  19. 19.
    Lingua RW, Azen SP, Walonker F, Levin L, Baker S. A comparison of the succinylcholine induced ocular position and the postoperative alignment in strabismus. J Pediatr Ophthalmol Strabismus. 1986;23:69–73.PubMedGoogle Scholar
  20. 20.
    Lingua RW, Levin L, Azen SP, Baker S, Walonker F. Comparison of the succinylcholine induced ocular position and the postoperative alignment in strabismus. J Ophthalmic Nurs Technol. 1987;6:7–13.PubMedGoogle Scholar
  21. 21.
    Romano P, Gabriel L, Bennett W, Snyder B. Stage I intraoperative adjustment of eye muscle surgery under general anesthesia: consideration of graduated adjustment. Graefes Arch Ophthalmol. 1988;226:235–40.CrossRefGoogle Scholar
  22. 22.
    Romano PE. Stage III intraoperative adjustment of eye muscle surgery (under general anesthesia) for neuroparalytic and mechanical (restrictive) incomitant strabismus: Report of results in a series: outcomes in 20 eye muscle surgeries in twelve patients. Binocul Vis Strabolog Q Simms Romano. 2012;27:46–50.PubMedGoogle Scholar
  23. 23.
    Jampolsky A. Spring-back balance test in strabismus. Transactions of the New Orleans Academy of Opththalmology. St Louis: Mosby; 1978. p. 104–11.Google Scholar
  24. 24.
    Guyton DL. Exaggerated traction test for the oblique muscles. Ophthalmology. 1981;88:1035–40.CrossRefGoogle Scholar
  25. 25.
    Kushner BJ. Superior oblique tendon incarceration syndrome. Arch Ophthalmol. 2007;125:1070–6.CrossRefGoogle Scholar
  26. 26.
    McKeown C, Lambert H, Shore J. Preservation of the anterior ciliary vessels during extraocular muscle surgery. Ophthalmology. 1989;96:498–506.CrossRefGoogle Scholar
  27. 27.
    Repka MX, Fishman PJ, Guyton DL. The site of reattachment of the extraocular muscle following hang-back recession. J Pediatr Ophthalmol Strabismus. 1990;27:286–90.Google Scholar
  28. 28.
    Spielmann A. Association of fixed suspensions of the capsulo-palpebral head of the inferior rectus with semi-adjustable recession of the inferior rectus muscle to minimize complications. In: Kaufmann H, editor. Transactions of the 21st meeting of the European Strabismological Association. Giessen: Gahmig Druck; 1993. p. 175–80.Google Scholar
  29. 29.
    Kushner BJ. An evaluation of the semiadjustable suture strabismus surgical procedure. J AAPOS. 2004;8:481–7.CrossRefGoogle Scholar
  30. 30.
    Foster RS. Vertical muscle transposition augmented with lateral fixation. J AAPOS. 1997;1:20–30.CrossRefGoogle Scholar
  31. 31.
    Iizuka M, Kushner B. Surgical implications of the superior oblique frenulum. J AAPOS. 2008;12:27–32.CrossRefGoogle Scholar
  32. 32.
    Knapp P. The surgical treatment of double-elevator palsy. Trans Am Ophthalmol Soc. 1969;67:304–23.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Mehendale RA, Dagi LR, Wu C, Ledoux D, Johnston S, Hunter DG. Superior rectus transposition and medial rectus recession for Duane syndrome and sixth nerve palsy. Arch Ophthalmol. 2012;130:195–201.CrossRefGoogle Scholar
  34. 34.
    Yang S, MacKinnon S, Dagi LR, Hunter DG. Superior rectus transposition vs medial rectus recession for treatment of esotropic Duane syndrome. JAMA Ophthalmol. 2014;132:669–75.CrossRefGoogle Scholar
  35. 35.
    Velez FG, Oltra E, Isenberg SJ, Pineles SL. Assessment of torsion after superior rectus transposition with or without medial rectus recession for Duane syndrome and abducens nerve palsy. J AAPOS. 2014;18:457–60.CrossRefGoogle Scholar
  36. 36.
    Oltra EZ, Pineles SL, Demer JL, Quan AV, Velez FG. The effect of rectus muscle recession, resection and plication on anterior segment circulation in humans. Br J Ophthalmol. 2015;99:556–60.CrossRefGoogle Scholar
  37. 37.
    Velez FG, Demer JL, Pihlblad MS, Pineles SL. Rectus muscle plication using an adjustable suture technique. J AAPOS. 2013;17:480–3.CrossRefGoogle Scholar
  38. 38.
    Leenheer RS, Wright KW. Mini-plication to treat small-angle strabismus: a minimally invasive procedure. J AAPOS. 2012;16:327–30.CrossRefGoogle Scholar
  39. 39.
    Clark RA, Isenberg SJ, Rosenbaum AL, Demer JL. Posterior fixation sutures: a revised mechanical explanation for the faden operation based on rectus extraocular muscle pulleys. Am J Ophthalmol. 1999;128:702–14.CrossRefGoogle Scholar
  40. 40.
    Clark RA, Ariyasu R, Demer JL. Medial rectus pulley posterior fixation: a novel technique to augment recession. J AAPOS. 2004;8:451–6.CrossRefGoogle Scholar
  41. 41.
    Velez FG, Thacker N, Britt MT, Alcorn D, Foster RS, Rosenbaum AL. Rectus muscle orbital wall fixation: a reversible profound weakening procedure. J AAPOS. 2004;8:473–80.CrossRefGoogle Scholar
  42. 42.
    Ela-Dalman N, Velez FG, Felius J, Stager DR Sr, Rosenbaum AL. Inferior oblique muscle fixation to the orbital wall: a profound weakening procedure. J AAPOS. 2007;11:17–22.CrossRefGoogle Scholar
  43. 43.
    Goldberg RA, Rosenbaum AL, Tong JT. Use of apically based periosteal flaps as globe tethers in severe paretic strabismus. Arch Ophthalmol. 2000;118:431–7.CrossRefGoogle Scholar
  44. 44.
    Underdahl JP, Demer JL, Goldberg RL, Rosenbaum AL. Orbital wall approach with preoperative orbital imaging for identification and retrieval of lost or transected extraocular muscles. J AAPOS. 2001;5:230–7.CrossRefGoogle Scholar
  45. 45.
    Kushner BJ. Torsion and pattern strabismus: potential conflicts in treatment. JAMA Ophthalmol. 2013;131:190–3.CrossRefGoogle Scholar
  46. 46.
    von Noorden GK, Jenkins RH, Chu MW. Horizontal transposition of the vertical rectus muscles for cyclotropia. Am J Ophthalmol. 1996;122:325–30.CrossRefGoogle Scholar
  47. 47.
    Scott AB. Graded rectus muscle tenotomy for small deviations. In: Proceedings of the Jampolsky festschrift. San Francisco: The Smith-Kettlewell Eye Research Institute; 2000. p. 215–6.Google Scholar
  48. 48.
    Scott A. Graded rectus muscle tenotomy. Arch Chil Oftal. 2006;63:127–8.Google Scholar
  49. 49.
    Wright KW. Mini-tenotomy procedure to correct diplopia associated with small-angle strabismus. Trans Am Ophthalmol Soc. 2009;107:97–102.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Chaudhuri Z, Demer JL. Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients. JAMA Ophthalmol. 2013;131:619–25.CrossRefGoogle Scholar
  51. 51.
    Tan RJ, Demer JL. Heavy eye syndrome versus sagging eye syndrome in high myopia. J AAPOS. 2015;19:500–6.CrossRefGoogle Scholar
  52. 52.
    Pineles SL. Divergence insufficiency esotropia: surgical treatment. Am Orthopt J. 2015;65:35–9.CrossRefGoogle Scholar
  53. 53.
    Kushner BJ. Vertical strabismus. In: Lambert SR, Lyons CJ, editors. Taylor & Hoyt’s pediatric ophthalmology and strabismus. 5th ed. London: Elsevier; 2017. p. 27–37.CrossRefGoogle Scholar
  54. 54.
    Clark RA. The role of extraocular muscle pulleys in incomitant non-paralytic strabismus. Middle East Afr J Ophthalmol. 2015;22:279–85.CrossRefGoogle Scholar
  55. 55.
    Krzizoh TH, Kaufmann H, Traupe H. Elucidation of restrictive motility in high myopia by magnetic resonance imaging. Arch Ophthalmol. 1997;115:1019–27.CrossRefGoogle Scholar
  56. 56.
    Yamaguchi M, Yokoyama T, Shiraki K. Surgical procedure for correcting globe dislocation in highly myopic strabismus. Am J Ophthalmol. 2010;149:341–6.CrossRefGoogle Scholar
  57. 57.
    Scott AB. Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. J Pediatr Ophthalmol Strabismus. 1980;17:21–5.PubMedGoogle Scholar
  58. 58.
    Scott AB. Botulinum toxin injection of eye muscles to correct strabismus. Trans Am Ophthalmol Soc. 1981;79:734–70.Google Scholar
  59. 59.
    Scott AB. Botulinum treatment of strabismus following retinal detachment surgery. Arch Ophthalmol. 1990;108:509–10.CrossRefGoogle Scholar
  60. 60.
    Scott AB, Magoon EH, McNeer KW, Stager DR. Botulinum treatment of childhood strabismus. Ophthalmology. 1990;97:1434–8.CrossRefGoogle Scholar
  61. 61.
    Scott AB. Development of botulinum toxin therapy. Dermatol Clin. 2004;22:131–3, vCrossRefGoogle Scholar
  62. 62.
    Scott AB, Kraft SP. Botulinum toxin injection in the management of lateral rectus paresis. Ophthalmology. 1985;92:676–83.CrossRefGoogle Scholar
  63. 63.
    Scott AB, Magoon EH, McNeer KW, Stager DR. Botulinum treatment of strabismus in children. Trans Am Ophthalmol Soc. 1989;87:174–80; discussion 80–4PubMedPubMedCentralGoogle Scholar
  64. 64.
    Scott AB, Miller JM, Shieh KR. Treating strabismus by injecting the agonist muscle with bupivacaine and the antagonist with botulinum toxin. Trans Am Ophthalmol Soc. 2009;107:104–9.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Phillips PH, Guyton DL, Hunter DG. Superior oblique overaction from local anesthesia for cataract surgery. J AAPOS. 2001;5:329–32.CrossRefGoogle Scholar
  66. 66.
    Kushner BJ, Vrabec M. Theoretical effects of surgery on length tension relationships in extraocular muscles. J Pediatr Ophthalmol Strabismus. 1987;24:126–31.PubMedGoogle Scholar
  67. 67.
    Kushner BJ, Morton GV. Postoperative binocularity in adults with longstanding strabismus. Ophthalmology. 1992;99:316–9.CrossRefGoogle Scholar
  68. 68.
    Kushner BJ. Binocular field expansion in adults after surgery for esotropia. Arch Ophthalmol. 1994;112:639–43.CrossRefGoogle Scholar
  69. 69.
    Johnson CA, Keltner JL. Incidence of visual field loss in 20,000 eyes and its relationship to driving performance. Arch Ophthalmol. 1983;101:371–5.CrossRefGoogle Scholar
  70. 70.
    Keltner JL, Johnson CA. Visual function, driving safety, and the elderly. Ophthalmology. 1987;94:1180–8.CrossRefGoogle Scholar
  71. 71.
    Keltner JL, Johnson CA. Visual function and driving safety. Arch Ophthalmol. 1992;110:1697–8.CrossRefGoogle Scholar
  72. 72.
    Kraft SP. Adult strabismus surgery: more than just cosmetic. Can J Ophthalmol. 2008;43:9–12.CrossRefGoogle Scholar
  73. 73.
    Rogers GL, Chazan S, Fellows R, Tsou BH. Strabismus surgery and its effect upon infant development in congenital esotropia. Ophthalmology. 1982;89:479–83.CrossRefGoogle Scholar
  74. 74.
    Pineles SL, Birch EE, Talman LS, et al. One eye or two: a comparison of binocular and monocular low-contrast acuity testing in multiple sclerosis. Am J Ophthalmol. 2011;152:133–40.CrossRefGoogle Scholar
  75. 75.
    Pineles SL, Demer JL, Isenberg SJ, Birch EE, Velez FG. Improvement in binocular summation after strabismus surgery. JAMA Ophthalmol. 2015;133:326–32.CrossRefGoogle Scholar
  76. 76.
    Pineles SL, Velez FG, Isenberg SJ, et al. Functional burden of strabismus: decreased binocular summation and binocular inhibition. JAMA Ophthalmol. 2013;131:1413–9.CrossRefGoogle Scholar
  77. 77.
    Pineles SL, Velez FG, Yu F, Demer JL, Birch E. Normative reference ranges for binocular summation as a function of age for low contrast letter charts. Strabismus. 2014;22:167–75.CrossRefGoogle Scholar
  78. 78.
    Tandon AK, Velez FG, Isenberg SJ, Demer JL, Pineles SL. Binocular inhibition in strabismic patients is associated with diminished quality of life. J AAPOS. 2014;18:423–6.CrossRefGoogle Scholar
  79. 79.
    Hengstler LK. The eye of the beholder. J Pediatr Ophthalmol Strabismus. 1991;28:301.PubMedGoogle Scholar
  80. 80.
    Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol. 1993;111:1100–5.CrossRefGoogle Scholar
  81. 81.
    Burke JP, Leach CM, Davis H. Psychosocial implications of strabismus surgery in adults. J Pediatr Ophthalmol Strabismus. 1997;34:159–64.PubMedGoogle Scholar
  82. 82.
    Jackson S, Harrad RA, Morris M, Rumsey N. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol. 2006;90:883–8.CrossRefGoogle Scholar
  83. 83.
    Hatt SR, Leske DA, Kirgis PA, Bradley EA, Holmes JM. The effects of strabismus on quality of life in adults. Am J Ophthalmol. 2007;144:643–7.CrossRefGoogle Scholar
  84. 84.
    Nelson BA, Gunton KB, Lasker JN, Nelson LB, Drohan LA. The psychosocial aspects of strabismus in teenagers and adults and the impact of surgical correction. J AAPOS. 2008;12:72–6, e1CrossRefGoogle Scholar
  85. 85.
    Olitsky SE, Sudesh S, Graziano A, Hamblen J, Brooks SE, Shaha SH. The negative psychosocial impact of strabismus in adults. J AAPOS. 1999;3:209–11.CrossRefGoogle Scholar
  86. 86.
    Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large angle horizontal strabismus on ability to obtain employment. Ophthalmology. 2000;107:402–5.CrossRefGoogle Scholar
  87. 87.
    Goff MJ, Suhr AW, Ward JA, Croley JK, O’Hara MA. Effect of adult strabismus on ratings of official U.S. Army photographs. J AAPOS. 2006;10:400–3.CrossRefGoogle Scholar
  88. 88.
    Mojon-Azzi SM, Potnik W, Mojon DS. Opinions of dating agents about strabismic subjects’ ability to find a partner. Br J Ophthalmol. 2008;92:765–9.CrossRefGoogle Scholar
  89. 89.
    Berberat J, Jaggi GP, Wang FM, Remonda L, Killer HE. Changes in the amygdala produced by viewing strabismic eyes. Ophthalmology. 2013;120:2125–9.CrossRefGoogle Scholar
  90. 90.
    Beauchamp GR, Felius J, Stager DR, Beauchamp CL. The utility of strabismus in adults. Trans Am Ophthalmol Soc. 2005;103:164–71; discussion 71–2PubMedPubMedCentralGoogle Scholar
  91. 91.
    Hatt SR, Leske DA, Liebermann L, Holmes JM. Changes in health-related quality of life 1 year following strabismus surgery. Am J Ophthalmol. 2012;153:614–9.CrossRefGoogle Scholar
  92. 92.
    Kishimoto F, Ohtsuki H. Comparison of VF-14 scores among different ophthalmic surgical interventions. Acta Med Okayama. 2012;66:101–10.PubMedGoogle Scholar
  93. 93.
    Hatt SR, Leske DA, Liebermann L, Holmes JM. Comparing outcome criteria performance in adult strabismus surgery. Ophthalmology. 2012;119:1930–6.CrossRefGoogle Scholar
  94. 94.
    Hunter DG. Benefits of strabismus surgery in patients with one blind eye. Arch Ophthalmol. 1995;113:404.CrossRefGoogle Scholar
  95. 95.
    Rosenbaum AL. The goal of adult strabismus surgery is not cosmetic. Arch Ophthalmol. 1999;117:250.CrossRefGoogle Scholar
  96. 96.
    Kushner BJ, Fisher M. Is alignment within 8 prism diopters of orthotropia a successful outcome for infantile esotropia surgery? Arch Ophthalmol. 1996;114:176–80.CrossRefGoogle Scholar
  97. 97.
    Parks MM. The monofixation syndrome. Trans Am Ophthalmol Soc. 1969;67:609–57.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Burton J. Kushner
    • 1
  1. 1.Department of Ophthalmology and Visual SciencesUniversity of Wisconsin-MadisonMadisonUSA

Personalised recommendations