Types of Strabismus Surgery

Strabismus surgery, commonly known as “crossed eyes” or “wandering eyes,” affects millions of people worldwide. When the extraocular muscles controlling eye movement are not balanced, one eye may drift inward, outward, upward, or downward. While glasses, patching, and vision therapy often help in mild cases, surgical intervention—strabismus surgery—is sometimes essential for optimal alignment and binocular vision. Understanding the types of strabismus surgery empowers patients and caregivers to make informed decisions about treatment options and expected outcomes.

Why Strabismus Surgery Is Performed

Surgical correction of strabismus is indicated when non‑surgical treatments fail to achieve adequate alignment or binocular function. Key reasons include:

• Functional Improvement: Restoring proper eye alignment enhances depth perception and prevents amblyopia (“lazy eye”), especially in children.
• Cosmetic Enhancement: Misaligned eyes can impact self-esteem; surgery often yields significant cosmetic benefits.
• Symptom Relief: Patients with strabismus may suffer from double vision (diplopia), eye strain, or headaches. Surgery alleviates these symptoms by rebalancing the eye muscles.
• Long‑Term Stability: While vision therapy can train ocular muscles, surgery offers a more permanent mechanical solution when muscle imbalance is significant.

Surgeons tailor the approach based on patient age, type and severity of deviation, prior surgeries, and overall health. Let’s delve into the principal types of strabismus surgery and why each may be chosen.

1. Recession and Resection Procedures

What It Is

• Recession: The surgeon detaches an overacting muscle from its original insertion and reattaches it farther back on the eyeball, weakening its pull.
• Resection: The surgeon removes a segment of an underacting muscle and reattaches the shortened muscle to its original insertion, strengthening its action.

Why It’s Used

• Customizable Adjustment: Degrees of recession/resection can be precisely calculated (typically in millimeters) to correct specific amounts of eye turn.
• Versatility: Applicable to horizontal (esotropia/exotropia) and vertical deviations.
• Long‑Term Efficacy: Provides stable alignment for most patients, with low rates of under- or over-correction.

2. Adjustable Suture Technique

What It Is

During surgery, muscles are placed on “adjustable sutures.” After the patient awakens (usually within 24 hours), the surgeon fine‑tunes muscle positioning based on real‑time alignment and eye movement testing.

Why It’s Used

• Post‑operative Customization: Allows precise postoperative adjustments without a second full surgery.
• Ideal for Complex Cases: Beneficial in adults and those with unpredictable healing or large-angle strabismus.
• Higher Success Rates: Studies report improved surgical outcomes and reduced reoperation rates in select populations.

3. Botulinum Toxin (Botox) Injection

What It Is

Botulinum toxin is injected directly into an overactive extraocular muscle, temporarily weakening it. Effects typically last 3–4 months.

Why It’s Used

• Minimally Invasive: Avoids incisions; often performed under local anesthesia.
• Diagnostic Tool: Helps determine if a muscle is the primary cause of misalignment before committing to permanent surgery.
• Adjunctive Therapy: Used alongside other surgical procedures to optimize alignment in complex or recurrent strabismus.

4. Tendon Transposition

Four
For paralytic or restrictive strabismus (due to nerve palsy), normally functioning muscles are transposed to support the weakened muscle’s action. Common transpositions include the Hummelsheim and Jensen procedures.

Why It’s Used

• Targeted Correction: Redirects force from healthy muscles to compensate for a paralyzed muscle.
• Restores Motion: Especially useful in oculomotor (third cranial nerve) or abducens (sixth cranial nerve) palsies.
• In the: Aims to re-establish both primary gaze alignment and limited motility in the affected direction.

5. Myectomy and Myotomy

What It Is

• Myectomy: Removal of a small strip of muscle tissue to weaken an overacting muscle without reattaching the ends.
• Myoto: Partial cutting of muscle fibers to weaken an excessive pull.

Why It’s Used

• Simplicity: Faster than reattachment procedures; less dissection required.
• Effective in Specific Cases: Employed when only moderate weakening is needed, or scarring prevents standard recession.
• Reduced Cost and Time: Often quicker, with shorter operative times.

6. With

What It Is

Surgeons may combine multiple techniques (e.g., recession on one eye and resection on the fellow eye) or stage surgeries weeks to months apart.

Why It’s Used

• Complex Deviations: Large-angle strabismus often benefits from combined procedures for balanced correction.
• Minimized Overcorrection: Staging allows assessment of initial results before further intervention.
• Personalized Care: Tailored plan based on patient response and healing.

Recovery and Prognosis

Postoperative care typically includes:

• Antibiotic and Anti-inflammatories: To prevent infection and control swelling.
• Activity Restrictions: Avoid strenuous exercise and rubbing eyes for 1–2 weeks.
• Follow‑Up Visits: Monitor alignment and adjust treatments (e.g., patching, prism glasses).

Most patients experience mild discomfort, redness, and temporary double vision, which resolves as healing progresses. Success rates for first‑time surgeries range from 70% to 90%, with adjustable sutures and staged approaches offering higher precision in challenging cases.

Conclusion

Choosing the right type of strabismus surgery is a collaborative decision between patient and surgeon, guided by the nature of the eye deviation, patient age, and visual goals. From standard recession‑resection techniques to innovative adjustable sutures and minimally invasive Botox injections, each procedure offers unique advantages. Understanding these options ensures that patients receive personalized, effective care for optimal ocular alignment and visual function.

If you or a loved one is considering strabismus surgery, consult a board‑certified ophthalmologist who specializes in pediatric or adult strabismus. Early intervention can dramatically improve both functional vision and quality of life.