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Finding the ‘Just Right’ in Restrictive Strabismus Care

In ophthalmology, one should always bear (ba dum tss!) in mind the story of Goldilocks and the Three Bears as it provides remarkable value as an educational tool. Indeed, ophthalmologists strive for treatment that meets the “just right” zone, neither too strong (and over-corrected), nor too weak (and under-corrected).

Applying this model to an incident involving an actual bear attack, however, wasn’t what we were literally expecting. This admittedly unlikely — but entirely real — scenario was shared during the All India Ophthalmology Society (AIOS) International Ophthalmic Conclave 2022. During the meeting, we heard from Dr. Manjushree Bhate, an associate ophthalmologist at the LV Prasad Eye Institute Hyderabad, and it was her presentation, entitled Restrictive Strabismus, that featured the aforementioned ursine assault.

Strabismus is, of course, a condition where the eyes don’t properly align with one another when looking directly at an object. Restrictive strabismus usually occurs after the introduction of a “mechanical” element that causes the eyes to deviate. According to Dr. Bhate, common subdivisions of restrictive strabismus include post-orbital wall fractures, thyroid strabismus, the effect of post-glaucoma drainage decisions, post-scleral buckle surgery, and unusual congenital and acquired restrictions.

Somebody’s Been Sleeping On My Surgical Table

So, on to our very own Goldilocks, a young Indian girl (age unknown) who was bitten in the face by a bear and suffered disfigurement, specifically a naso-orbito-ethmoid fracture. This resulted in strabismus causing a full restriction of mobility in her right eye and a significant reduction in mobility in the left eye. After undergoing an MRI scan, the doctors responsible for Goldilocks observed normal architecture of ocular musculature and soft tissue hyperintensity in the anterior chamber.

According to Dr. Bhate, after undergoing bilateral lateral rectus recession our Goldilocks regained much of the mobility in her eyes and the patient was described as being “almost just right.” She then contrasted this case with her own research into strabismus caused by fractures with a study she co-authored titled Clinical Profiles and Surgical Outcomes of Strabismus Following Orbital Wall Structures: A Large Cohort From a Tertiary Eye Care Center. The study examined 347 cases of strabismus after orbital wall fractures over a six-year period.

She reported that the overwhelming majority of patients who experienced strabismus caused by fractures were male (87%) and that orbital floor fractures were the most common form of injury (72%). Medial wall fractures also occurred in 44% of patients studied, exotropia in 25% of cases, and among this group, hypotropia occurred at a rate of 19%. Out of the total 347 patients, strabismus surgery was only performed in 10% of cases — this is the particular group where Dr. Bhate focused her study.*

Aiming for ‘Just Right’

She reported that of the patients who underwent strabismus surgery, their specificities could be broken down as follows: Restrictive strabismus (41%), paralytics strabismus (35%), and paralytics plus restrictive strabismus (23%). Preoperative diplopia occurred in 79% of cases, however, this only occurred postoperatively in 15%. The floor wall was most commonly involved in these cases, and the least commonly encountered wall was in the lateral and roof direction.

Dr. Bhate’s presentation didn’t just cover strabismus caused by fractures, and while that was certainly the main thrust of her presentation (you could even say that it was “just right”), she covered other aspects of strabismus, too. One section you should definitely watch is on thyroid strabismus, which she characterized as having asymmetrical involvement with an “un-cosmetic appearance.” In such cases, the surgeon should aim to achieve reasonable good cosmetic outcomes and a comfortable field of baseline vision.

In her concluding remarks (accompanied by an adorable representation of Goldilocks herself), Dr. Bhate said that restrictive strabismus was challenging and that an individualized approach and management was key. Surgery should be focused on relieving restrictions, as well as improving baseline vision. And finally — yes, everything involved in the process should be “just right!”

*Bhate M, Deshmukh A, Bothra N, et al. Clinical Profiles and Surgical Outcomes of Strabismus Following Orbital Wall Structures: A Large Cohort From a Tertiary Eye Care Center. J Pediatr Ophthalmol Strabismus. 2021;1-8. [Online ahead of print]

Editor’s Note: The All India Ophthalmology Society’s 2nd International Ophthalmic Conclave (AIOS IOC 2022) was held virtually from February 18-20, 2022. Reporting for this story took place during the event. 

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