Anaesthesia

Review Article and Intensive Care

Anaesthesia and Intensive Care
2020, Vol. 48(4) 277–288
Anaesthetic considerations for ! The Author(s) 2020
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strabismus surgery in children and adults sagepub.com/journals-permissions
DOI: 10.1177/0310057X20937710
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Alfred WY Chua1 , Matthew J Chua2, Harry Leung3 and

Peter CA Kam1,4

Abstract
Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4%
lifetime risk of developing strabismus. Current treatment options include pharmacological injection of botulinum
toxin or bupivacaine, conventional corrective surgery, adjustable suture surgery and minimally invasive surgery.
Repeated surgery is common as each operation has a 60%–80% chance of successful correction. The benefits of
early surgical correction in large-angle strabismus in children outweigh the risks of anaesthesia. General anaesthesia
is suitable for patients of all age groups, for complicated or repeated surgery, and bilateral eye procedures. Regional
ophthalmic block reduces the incidence of oculocardiac reflex and emergence agitation, and provides postoperative
analgesia, but requires a cooperative patient as many experience discomfort. Topical anaesthesia has been used in
pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery and some
adjustable suture strabismus surgery. Its use, however, is only limited to cooperative adult patients. Prophylactic
antiemesis with both ondansetron and dexamethasone is recommended, especially for children. A multimodal
analgesia approach, including paracetamol, intravenous non-steroidal anti-inflammatory drugs, topical local anaes-
thetic and minimal opioid usage, is recommended for postoperative analgesia, while a supplementary regional oph-
thalmic block is at the discretion of the team.

Keywords
Anaesthesia, strabismus

Introduction a brief background on both conventional and innova-

Strabismus occurs in 3%–5% of children worldwide,1 tive strabismus surgery, and discuss the anaesthetic
and its correction is the most common paediatric considerations associated with these procedures in
eye surgery. The lifetime risk of developing adult- both children and adults.
onset strabismus is approximately 4%, with a peak
incidence in the eighth decade.2 The current
treatment options include injection of certain drugs
into the affected extraocular muscles and
conventional corrective surgery. Recent innovative sur-
gical procedures include adjustable suture surgery and 1
Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney,
minimally invasive surgery such as minitenotomy and Australia
2
miniplication. These treatment options can be per- Department of Intensive Care Medicine, Nepean Hospital, Sydney,
Australia
formed with either regional anaesthesia or general 3
Department of Ophthalmology, Sydney Children’s Hospital, Sydney,
anaesthesia. Australia
The majority of the published anaesthetic literature 4
Faculty of Medicine and Health, University of Sydney, Sydney, Australia
focuses on paediatric patients. In addition, there is no
Corresponding author:
discussion of the newer surgical procedures for strabis- Alfred WY Chua, Department of Anaesthetics, Royal Prince Alfred
mus and their relevant anaesthetic techniques. Hospital, 50 Missenden Road, New South Wales 2050, Australia.
The aims of this narrative review article are to provide Email: [email protected]
278 Anaesthesia and Intensive Care 48(4)

Search strategy Background of strabismus surgery

A literature search was conducted in September 2019 relevant to anaesthetic practice
using MEDLINE (Ovid) with the aim of identifying
English language articles published between January
Anatomical aspects of the eye in corrective
1998 and September 2019. The search words used strabismus surgery
included ‘anaesthesia’ in combination with ‘strabis- The movement of the globe is controlled by six extra-
mus’. Five hundred and seventy-nine articles were ocular muscles. There are four rectus muscles (medial
retrieved. The authors examined the articles in term and lateral rectus muscles (horizontal movement),
of quality and relevance to anaesthesia for strabismus superior and inferior rectus muscles (vertical move-
surgery. Further related key articles were retrieved ment)) and two oblique muscles (superior and inferior
through their references. As a result, 95 articles related oblique muscles (torsional movement)). The rectus
to ocular anatomy and physiology, causes of strabis- muscles arise from the annulus of Zinn near the apex
mus, pharmacological and surgical treatment options of the orbit and insert onto the outer surface of the
and anaesthetic practices were included in this review. globe anterior to its equator forming an incomplete
cone. The superior rectus, medial rectus, inferior
rectus and inferior oblique muscles are innervated by
Strabismus the oculomotor nerve (cranial nerve III), superior obli-
que muscle by the trochlear nerve (IV) and lateral
Orthotropic alignment of the eyes (both eyes focused at rectus muscle by the abducens nerve (VI). The nasocili-
the same spot) occurs by one month of age.3 The brain ary nerves are the sensory nerves to the cornea and the
then combines the two images, one from each eye, into perilimbal and superonasal quadrant of the conjuncti-
a single, three-dimensional image and this enables bin- va. Sensation to the remainder of the conjunctiva is
ocular vision (stereopsis). Visual development, result- mediated by the lacrimal and frontal nerves that lie
ing in the brain learning to interpret signals from an outside the muscle cone.
eye, occurs during the first seven or eight years of life. Tenon’s capsule, a fascial sheath, surrounds the
Strabismus (misalignment of the eye/eyes) results globe and separates it from orbital fat. Anteriorly,
from an imbalance in extraocular muscle function. Tenon’s capsule merges with conjunctiva before insert-
Consequently, two different images, one from each ing to sclera 3–8 mm away from the limbus. Posteriorly
eye, are transmitted to the brain, resulting in loss of Tenon’s capsule fuses with meninges around the optic
visual depth. In children, the brain may suppress the nerve and sclera at the optic nerve exit. The tendons of
image from the weaker eye and this impairs visual these six extraocular muscles pierce the sheath as they
development and may result in amblyopia (decreased pass to their insertions on the globe.8
vision in a normal healthy eye). The prognosis is good
if correction of strabismus is performed as early as pos- Treatment options for strabismus
sible before the child reaches the age of eight years. Optical aids. Optical lenses (glasses) are indicated in cer-
However, if untreated, amblyopia may become perma- tain forms of strabismus, for example, accommodative
nent. In adults, strabismus may cause diplopia because esotropia. Prisms are useful to relieve diplopia especial-
the brain cannot suppress the overlapping images. ly in small-angle strabismus. Patching of the dominant
Strabismus may involve one or both eyes, resulting in eye often improves amblyopia; however, it does not
different presenting signs and symptoms. The affected correct the visual axis misalignment.
eye can be deviated outwards (exotropia), inwards (eso-
tropia), upwards (hypertropia) or downwards (hypotro- Injection of drugs into extraocular muscles. Injection of bot-
pia). The deviation may be intermittent or constant, large ulinum toxin or bupivacaine into affected extraocular
magnitude (large angle) or small magnitude (small angle). muscles is effective in the management of mild strabis-
Symptoms include diplopia, loss of stereopsis, headache, mus. Within two to four days of an injection of botu-
inability to read comfortably, fatigue when reading and linum toxin to the overactive extraocular muscle, the
amblyopia. It interferes with normal eye contact with muscle is paralysed and unopposed antagonist muscle
others, often resulting in psychosocial issues. (s) strengthen and pull the eye to the opposite direction,
Risk factors for strabismus include premature birth, often causing an overcorrection. The effect of botuli-
low birth weight, smoking throughout pregnancy, family num toxin lasts up to three months.9 Repeated injec-
history,4 Down syndrome (29%),5 cerebral palsy (53%)6 tions are often required.
and syndromes with craniofacial dysostosis (up to 90%).7 When bupivacaine was injected into animal muscles,
The causes of strabismus are summarised in Table 1. an immediate massive degeneration of the muscle fibres
Chua et al. 279

Table 1. Causes of strabismus.

Causes Pathology Examples

Congenital (onset of presentation 0–6 months of age)

Normal child Normal eye No specific cause (majority of cases)
Abnormal eye Congenital cataract
Associated with systemic problems Syndromes Apert, Down, Marfan
Developmental delay
Cerebral palsy
Acquired (onset of presentation >6 months of age)
Accommodative Extreme hyperopia Usually corrected by glasses
Ocular disease Tumour Retinoblastoma
Ocular trauma
Neurological Cranial nerve palsy Head trauma, space-occupying lesion,
infection, hydrocephalus
Myasthenia gravis
Cerebrovascular accident
Guillain–Barre syndrome
Diabetes Acquired paralytic strabismus
Multiple sclerosis
Myopathy (of extraocular muscles) Thyroid disease Hyperthyroid, hypothyroid
Orbital diseases Idiopathic ocular myositis
Chronic progressive external
ophthalmoplegia myopathy

occurred, but regeneration began within two days, and complex myopexy technique (posterior fixation of a
the muscle fibres returned to pre-injection size and suture through the muscle behind the equator without
strength by three weeks. Further regeneration contin- any surgical separation).13 The extent of surgical cor-
ued and resulted in muscle hypertrophy.10 Using this rection is influenced by the magnitude of deviation.
myotoxicity cycle, bupivacaine has been injected into
the weaker extraocular muscles to promote hypertro- Adjustable suture strabismus surgery. Adjustable suture
phy and strengthen the muscle. strabismus surgery that allows the surgeon to fine-
Botulinum toxin and bupivacaine can be used in tune the extraocular muscle position in the immediate
combination to weaken and strengthen the injected postoperative period has become more popular since
extraocular muscles, respectively, in the treatment of 1975. It is especially useful in complicated strabismus
strabismus.11 In cooperative adult patients, the injec- surgery, such as repeated surgery, trauma and thyroid
tion can be performed transconjunctivally with electro- eye disease.14 The surgery is commonly performed as a
myographic (EMG) guidance under topical two-stage procedure. Only cooperative adults and
anaesthesia10,12 while intravenous sedation is required selected teenagers are suitable for this procedure.
for anxious or younger patients.9 In children less than At the first stage, conventional strabismus surgery is
six years of age, open exposure and injection into the performed with an adjustable suture knot under gener-
muscle under direct visualisation is preferred by some al anaesthesia or regional ophthalmic block depending
surgeons. on the preference of the surgeon and the patient. The
Complications of botulinum toxin injection include second stage is delayed until the patient and the eyes
ptosis and iatrogenic strabismus (due to leakage of bot- have recovered from the effects of anaesthesia. In the
ulinum toxin to surrounding muscles). Serious sight- second stage, eye alignment is assessed and the muscle
threatening complications, such as scleral perforation, sutures are adjusted to achieve the desired outcome. It
retrobulbar haemorrhage and inadvertent intraocular is performed with the patient awake under topical
injection, can also occur.9 anaesthesia. Intraoperative suture adjustment is possi-
ble in a single stage if the procedure is performed under
Conventional strabismus surgery. Conventional strabismus topical anaesthesia, as the extraocular muscle functions
surgery attempts to realign the eyes by weakening are intact.15
(recession), strengthening (resection), or changing the
position of one or more of the extraocular muscles Minimally invasive procedures. Minitenotomy, a muscle-
(transposition). The Faden operation is a more weakening procedure, involves the detachment of the
280 Anaesthesia and Intensive Care 48(4)

central 3–4 mm of the rectus muscle tendon.15 As there is usually an underlying cause for adult-
Miniplication, a muscle-tightening procedure, is per- onset strabismus, a thorough evaluation should be per-
formed by advancing the central 3–4 mm of the formed with specific questions about thyroid function,
rectus muscle and suturing it to the sclera.16 These bleeding disorders and anticoagulants. These patients
are options for the correction of small-angle strabis- are often elderly and may be on antithrombotic drugs,
mus. As these procedures do not require hooking or particularly when the underlying cause is a cerebrovas-
complete resection of the rectus muscle, they can be cular accident. The risk of bleeding threatening vision
performed under topical anaesthesia without sedation in strabismus surgery is low even if antithrombotic
in cooperative adult patients. In addition, the effect of treatment is continued.29,30 Kemp et al. reported
the initial operation can be assessed immediately before three cases of strabismus surgery without any excessive
deciding whether a second procedure is required on bleeding in the perioperative period in patients taking
another muscle. warfarin.31
Strabismus surgery for thyroid eye disease should be
The ideal timing of strabismus surgery in delayed until the patient is euthyroid and eye disease is
stable for at least six months.32 Routine preoperative
very young children
investigations are not required in strabismus surgery.
Infantile esotropia (inward deviation of eye that begins However, specific investigations are indicated by
in the first six months of life), affecting one in every patient comorbidities. Echocardiography, for example,
100–500 people, commonly has large-angle deviation.17 may be required in syndromes associated with congen-
The main indication for surgery from a patient/parents’ ital cardiac anomalies. Magnetic resonance imaging
perspective is cosmetic appearance. may be required for some patients (e.g. atypical presen-
From a surgical perspective, early correction (10 tations, acute onset, swollen optic disc, neurological
months of age) has been advocated as there is growing causes such as cranial nerve VI palsy, etc.) to exclude
evidence that early surgery improves sensory and intracranial pathology.
ocular motor outcomes with no adverse long-term
effects.17 There are concerns of adverse neurological Malignant hyperthermia. Strabismus was considered as a
effects in children exposed to general anaesthesia. The risk factor for malignant hyperthermia. This is no
GAS study reported that slightly less than one hour’s longer considered valid. Halsall did not show any asso-
(54 minutes) exposure to general anaesthesia in early ciation with strabismus in a review of over 2500
infancy for inguinal herniorrhaphy did not alter neuro- patients tested for malignant hyperthermia susceptibil-
developmental outcomes at five years compared with ity.33 It is common practice to use volatile anaesthetic
awake regional anaesthesia.18 In addition, in a large agents in children having strabismus surgery and no
cohort study of over 10,000 siblings paired aged five increase in the incidence of malignant hyperthermia
to six years, children who had surgical procedures has been reported.34
under general anaesthesia were not found to be at
increased risk of adverse child development outcomes Pacemakers and automated implantable cardioverter
compared with their biological siblings who did not defibrillators. Bipolar electrocautery, used in strabismus
have surgery.19 As the duration of most strabismus surgery, carries a lower risk of electromagnetic inter-
surgery is one to two hours, the benefits of early surgi- ference associated with implantable cardiac devices
cal correction in large-angle (>20 prism dioptres) stra- compared with monopolar electrocautery. In a survey
bismus in children outweigh the risks of anaesthesia. of ophthalmic anaesthesiologists, 96% of the respond-
ents did not convert a pacemaker to asynchronous
Anaesthetic considerations mode and 86% did not inactivate an automated
implantable cardioverter defibrillator and no adverse
Preoperative considerations incidences were reported.35 However, modification to
these cardiac devices should be considered given
In children, specific enquiry about upper respiratory
the close proximity of the electrocautery to the
tract infections, prematurity and its associated compli-
cardiac device.
cations, developmental delay, cerebral palsy and con-
genital syndromes should be made. The clinical
features of strabismus-associated congenital syndromes Intraoperative considerations
are summarised in Table 2.20–28 Evaluation of the Topical vasoconstrictor. Application of a topical vasocon-
airway and cardiac status is essential because some strictor (e.g. apraclonidine, phenylephrine), preferred
syndromes are associated with craniofacial and cardiac by some surgeons, may cause adverse effects such as
anomalies. raised blood pressure, arrhythmia, pulmonary
Chua et al. 281

Table 2. Syndromes associated with strabismus and their clinical features.

Syndrome Clinical features

Apert syndrome20,95 Brachycephaly

Craniosynostosis
Midface hypoplasia
Cervical spinal fusion
Obstructive sleep apnoea
Multidigit hand and foot syndactyly
Congenital cardiac defects
Cri du chat syndrome21 Laryngeal abnormalities, micrognathia
Mental retardation
Hypotonia
Congenital cardiac defects
Prone to hypothermia
Crouzon syndrome Premature fusion of skull
Midface hypoplasia
C2–3 fusion
CVS abnormalities (patent ductus arteriosus, coarctation of aorta)
Down syndrome23 Congenital cardiac defects
Pulmonary hypertension
C1–2 subluxation
Subglottic stenosis
Intellectual impairment
Obesity
Goldenhar syndrome24 Hemifacial microsomia
Vertebral anomalies
CNS malformation
Congenital cardiac defects
Marfan syndrome25 High arched palate
C1–2 instability
Temporomandibular joint laxity
Spontaneous pneumothorax
Cardiovascular involvement (valvular disease, aortic dissection,
cardiac conduction defects)
Moebius syndrome26 Orofacial abnormalities
Skeletal hypotonia
Increased oral secretion
Gastrointestinal reflux
Congenital cardiac defects
Spinal anomalies
Stickler syndrome27 Midface hypoplasia
Micrognathia
Scoliosis
Turner syndrome28 Intellectual impairment
Small mandible
High arched palate
Congenital cardiac defects
CNS: central nervous system; CVS: cardiovascular system.

oedema36 and cerebrovascular accident. Caution accident. Furthermore, surgical incision in a pool of
should be exercised in patients with a history of hyper- eye drops containing a vasoconstrictor37 or direct
tension, ischaemic heart disease and cerebrovascular application of drops to the raw tissue surface of the
282 Anaesthesia and Intensive Care 48(4)

extraocular muscles36 should be avoided as the con- practices.43,54,55 However, with the cooperation of oph-
junctival membrane barrier is disrupted and this results thalmic surgeons and gentle traction on extraocular
in increased systemic absorption with a higher inci- muscles, this may not be necessary.
dence of systemic side-effects. There have been case The incidence of OCR is lower in adult strabismus
reports of severe hypertension and pulmonary patients (13%–22%).56 Adult patients undergoing stra-
oedema in children as a consequence.36,37 bismus surgery who received prophylactic atropine (10
Phenylephrine also dilates the pupil and may affect lg/kg) had a low risk of OCR and PONV, independent
adjustable suture strabismus surgery. of the general anaesthetic technique.56 There have been
conflicting reports on the association between OCR
Oculocardiac reflex. The oculocardiac reflex (OCR) is and PONV. Allen et al. reported that children with
defined as an over 20% decrease in heart rate from positive OCR were three times more likely to vomit
the baseline or the presence of arrhythmia induced by than those without the reflex,44 whereas Aly et al.
pressure on the globe or traction on extraocular found no association.57
muscles. OCR often results in sinus bradycardia, but
atrioventricular block, complete heart block, ventricu- Oculorespiratory reflex. The oculorespiratory reflex
lar ectopics, ventricular fibrillation, or even asystole (ORR), which results in bradypnoea with irregular
have been reported.38–41 Symptoms are generally mild and shadow breaths, hypercarbia and even respiratory
and transient in most patients.42 Immediate cessation arrest precipitated by traction on the extraocular
of muscle traction usually restores normal cardiac muscles has been observed in children during strabis-
rhythm. In severe cases, an anticholinergic agent (atro- mus correction.58 This is less frequent with general
pine 7 lg/kg or glycopyrrolate 1 lg/kg) may be anaesthesia with sevoflurane compared with halo-
required.43 thane.46 Atropine, glycopyrrolate or bilateral vagoto-
The incidence of OCR during strabismus surgery is my had no effect on ORR in animals while retrobulbar
reported to be as high as 86% in paediatric patients.38,44 block could completely abolish it.59
Risk factors include hypercarbia,40 hypoxaemia,42 light
anaesthesia (bispectral index >50)45 and the magnitude Forced duction test. The forced duction test, performed
and duration of the inciting stimulus.40 Acute traction on by gripping the limbus with forceps and moving the
the extraocular muscle is more reflexogenic than gradual globe in multiple directions, is employed by surgeons
traction. Generally OCR decreases with repeated stimu- to detect any restriction in eye movement.60 Resistance
lation (fatigue).40 The medial rectus muscle has shown to movement of the globe (positive result) indicates a
more resistance to fatigue; however, it was just as reflexo- ‘restrictive’ cause of strabismus while free movement
genic as the other extraocular muscles exposed to the without any resistance (negative result) indicates a
same stimulus.40 ‘neuropathic’ aetiology. The findings of the forced duc-
The choice of anaesthetic agent or technique also tion test will determine the type of corrective strabis-
affects the OCR. OCR occurred less frequently in gen- mus surgery required. It can be performed in
eral anaesthesia with sevoflurane than with halo- cooperative patients under topical anaesthesia as an
thane.46 There was no difference in the incidence of office-based procedure. Alternatively, it is performed
OCR between sevoflurane and desflurane.47 Although after induction of general anaesthesia and before com-
intraoperative ketamine (1.0–1.5 mg/kg) was more mencing surgery in children and uncooperative adults.
effective than atropine in decreasing the incidence of Suxamethonium causes a sustained contraction of
OCR,38,39 it was associated with increased incidence of the extraocular muscles for up to 20 minutes and there-
postoperative nausea and vomiting (PONV) and pro- fore interferes with the interpretation of the forced duc-
longed length of stay in the post-anaesthetic care tion test.61 The mechanism of this prolonged effect of
unit.39 Combined ophthalmic regional block and gen- suxamethonium on the extraocular muscles compared
eral anaesthesia reduced the incidence of OCR (from with other peripheral skeletal muscles is unclear. When
94% to 13%) in paediatric patients.48 General anaes- suxamethonium is used, the forced duction test should
thesia maintained with volatile anaesthetic agents be delayed for about 20 minutes after its injection so
decreased the incidence of OCR compared with propo- that its effects on the extraocular muscles have dissi-
fol (22% versus 49%) in paediatric strabismus sur- pated. Non-depolarising muscle relaxants do not inter-
gery.49 Intraoperative administration of a rapid acting fere with the forced duction test.61
opioid (such as fentanyl, sufentanil50 and remifenta-
nil)51 or dexmedetomidine52 potentiates OCR during Antibiotic prophylaxis. Routine administration of intrave-
strabismus surgery. nous antibiotic prophylaxis is not recommended
Prophylaxis with an anticholinergic for OCR is because ophthalmic procedures (except nasolacrimal
effective53,54 and has been used routinely in some duct surgery) are not associated with bacteraemia.
Chua et al. 283

Infection after strabismus surgery is rare, with an esti- accuracy in adjustable suture strabismus surgery.
mated incidence of one in 1100 to one in 1900.62 Furthermore, the globe occupies nearly 50% of the
orbital volume at birth, 33% at four years and only
The choice of anaesthetic technique 22% in adulthood. Consequently, the risks of compli-
General anaesthesia. General anaesthesia is the most cation from sharp needle block are potentially higher in
commonly used anaesthetic technique in strabismus children than in adults.75 Clinical conditions associated
surgery because it is suitable for: (a) patients of all with enophthalmos (e.g. traumatic orbital fracture,
ages; (b) complicated or repeated surgery; and metastatic carcinoma of the breast) are potentially
(c) bilateral eye procedures. Inhalational induction in associated with a higher risk of complications from
children with sevoflurane in oxygen with/without sharp needle block as the globe is displaced posteriorly
nitrous oxide is commonly used.63–66 into the orbit. It is best avoided in patients with thyroid
Sevoflurane, compared with halothane, is associated eye disease as the orbit is already congested with adi-
with a lower incidence of OCR, dysrhythmia and pose tissue and myofibroblasts.
airway irritability.46 However, it is associated with an
increased incidence of emergence agitation (sevoflurane Topical anaesthesia. Topical anaesthesia76–79 avoids
33% versus halothane 0%).67 Maintenance of anaes- the serious complications associated with general
thesia with propofol, compared with volatile anaesthet- anaesthesia and ophthalmic regional blockade. It is
ic agents, reduces emergence agitation68 and PONV69 suitable for a wide range of corrective treatment for
but increases the incidence of OCR49 in strabismus strabismus, including pharmacological injection, con-
surgery. ventional surgery, adjustable suture surgery and mini-
The airway can be secured with either a laryngeal mally invasive surgery.
mask airway63–65 or an endotracheal tube.70,71 Should Topical anaesthetic techniques include simple topi-
there be any concern with airway patency with a laryn- cal eye drops, gel and the application of sponges
geal mask airway, it should be changed to an endotra-
soaked with LA into the superior and inferior fornices
cheal tube before surgery commences because
for 10–15 minutes. The anaesthetic effect with gel or
manipulation or exchange of the airway device in the
soaked sponges is superior to that of topical drops.78,80
middle of the operation may contaminate the surgical
Topical anaesthesia is suitable for surgery on medial
field. Assisted or controlled ventilation is preferred
and lateral rectus muscles. It should be avoided in
over spontaneous breathing as hypercarbia and the
other extraocular muscle operations and revision stra-
additive effects of volatile anaesthetic agents and the
bismus surgery as these often involve difficulties in sur-
ORR increase the risk of an OCR. The non-
gical access resulting in patient discomfort.80 Pain and
depolarising muscle relaxants are the preferred neuro-
muscular blockers because they do not interfere with discomfort, especially during traction and detachment
the forced duction test. of the extraocular muscles, are common.78,81,82
Intravenous sedation is often required for patient com-
Regional anaesthesia. Ophthalmic regional block can fort. Careful selection of motivated and cooperative
be used as the primary anaesthetic technique for stra- patients is paramount to its success.
bismus surgery. However, while complete akinesia is
achieved, many patients still experience discomfort Complications of strabismus surgery and implications for
during muscle traction and conjunctival manipulation. anaesthesia. The complications of strabismus surgery
Consequently, many anaesthetists employ regional are summarised in Table 3. Globe perforation (inci-
anaesthesia only in medically unwell patients. dence of 0.08%),83 potentially leading to retinal detach-
Alternatively ophthalmic regional block can be used ment, may require conversion from topical anaesthesia
to supplement general anaesthesia, especially in chil- to ophthalmic regional block or general anaesthesia for
dren, and it is often performed by the surgeon during surgical repair. Precautions should be taken, similar to
surgery.72,73 an open globe injury, during the conversion to mini-
The advantages of ophthalmic regional blockade mise the risk of the extrusion of ocular content.
include a reduced incidence of OCR and emergence The incidence of slipped muscle (retraction of
agitation, postoperative analgesia and decreased detached extraocular muscle posteriorly within its
PONV.48,72,74 The contraindications include the pres- muscle capsule) and lost muscle (both muscle and its
ence of scars/adhesions from previous surgery, which capsule retract posteriorly into the orbit) is approxi-
can interfere with the spread of local anaesthetic (LA) mately 0.067% and 0.02%, respectively.83 These com-
solution and the insertion of a sub-Tenon’s block. plications may require conversion from topical or
Anatomical distortion, resulting from a large volume regional anaesthesia to general anaesthesia to facilitate
of injected LA solution, may interfere with the exploration of the globe.
284 Anaesthesia and Intensive Care 48(4)

Table 3. Complications of strabismus surgery. Droperidol is seldom used as the primary antiemetic
in children because of risks of extrapyramidal symp-
Intraoperative complications Postoperative complications
toms and drowsiness.87 It also received a controversial
Oculocardiac reflex Oculoemetic reflex ‘black box warning’ in 2001 from the US Food and
Oculorespiratory reflex Residual eye deviation Drug Administration because of its prolongation of
Globe perforation Double vision (diplopia) the QT interval and associated arrhythmia. A lower
Retinal detachment Slipped muscle dose of droperidol (25 lg/kg) has been supported as
Slipped muscle Lost muscle a second-line antiemetic in the 2016 guidelines by the
Lost muscle Anterior chamber ischaemia
Association of Paediatric Anaesthetists of Great
Orbital infection
Scleritis
Britain and Ireland.88
Retinal detachment The current recommendation is prophylactic ondan-
Endophthalmitis setron (150 lg/kg, maximum 4 mg) and dexamethasone
(150 lg/kg, maximum 8 mg) combination for strabis-
mus surgery in children.88 The same combination is
also often administered prophylactically in adults.86
Postoperative considerations
Postoperative nausea and vomiting. Early (six hours after Postoperative analgesia. Direct comparisons between
operation) and late (48 hours after operation) vomiting intravenous non-steroidal anti-inflammatory drugs
occurred in 54% (range 18%–88%) and 59% (range (NSAIDs) and intravenous opioids showed no differ-
43%–97%), respectively, in paediatric strabismus ence in postoperative pain scores or supplementary
patients who received no antiemetic prophylaxis.49 In analgesic requirements (diclofenac versus morphine;
adult patients, PONV was relatively less (30%), inde- ketorolac versus pethidine; ketorolac versus
pendent of the general anaesthetic technique used.56 fentanyl).89
The exact mechanism of the high incidence of PONV Topical NSAIDs (e.g. ketorolac) or topical LA (e.g.
following paediatric strabismus surgery is unclear. An amethocaine) alone provided inadequate analgesia in
oculo-emetic reflex, involving the ophthalmic division paediatric strabismus surgery.90 Pain scores were not
of the trigeminal nerve and the vomiting centre in the reduced by the use of topical NSAIDs compared with
medulla, has been proposed.84 placebo or topical LA.89,91 The efficacy of oral or rectal
Many anaesthetic-related factors influence PONV. paracetamol as part of multimodal analgesia has not
Ophthalmic regional blockade inhibits the sensory been compared with other agents in several studies.91
afferent pathway and reduces the incidence of Regional ophthalmic block reduces perioperative
PONV.48 Adequate hydration with intravenous crystal- analgesic requirements compared with place-
loid (15–30 ml/kg),85 maintenance of anaesthesia with bo.72,74,75,92,93 It reduces PONV, may improve periop-
propofol,69 use of topical LA48 and minimum opioid erative analgesia in comparison with opioids, but
usage,86 have also been reported to reduce the inci- provides no benefit over topical LA.89
In general, a multimodal analgesic approach should
dence of PONV.
be employed utilising paracetamol, intravenous
Surgical technique also influences the incidence of
NSAIDs, topical LA and minimal opioid usage. A sup-
PONV. Gentle surgical manipulation was associated
plementary regional ophthalmic block is at the discre-
with reduced PONV48 while the Faden operation was
tion of the team. As most patients experience pain for a
associated with increased PONV.13
median of three days (range one to nine days),94 regular
In a systematic review and meta-analysis, the addi-
analgesia should be prescribed for three days after
tion of a single antiemetic prophylaxis (ondansetron
surgery.
150 lg/kg or droperidol 75 lg/kg) to inhalational
anaesthesia appeared equally effective compared with
total intravenous anaesthesia in reducing the incidence Summary
of PONV in paediatric strabismus patients.87 However, General anaesthesia, the most commonly used tech-
the incidence of PONV was still unacceptably high (one nique, is suitable for patients of all ages, for complicat-
in three children) in both groups, indicating that mul- ed or repeated surgery and for bilateral eye procedures.
timodal antiemetic prophylactic measures should be The advantages of regional ophthalmic block include
employed. In addition, total intravenous anaesthesia reduced incidence of OCR and emergence agitation, as
is associated with increased bradycardia from OCR well as providing postoperative analgesia. However, it
compared with volatile anaesthesia.87 Hence, a volatile requires cooperative patients as many experience dis-
anaesthesia technique with prophylactic antiemetic comfort especially during traction of the extraocular
agents is often employed.39,57 muscle and manipulation of conjunctiva. Topical
Chua et al. 285

anaesthesia has been used in pharmacological injection, 6. Black P. Visual disorders associated with cerebral palsy.
minimally invasive surgery and uncomplicated conven- Br J Ophthalmol 1982; 66: 46–52.
tional strabismus surgery. Furthermore, it facilitates 7. Rosenberg JB, Tepper OM and Medow NB. Strabismus
the completion of adjustable suture strabismus surgery in craniosynostosis. J Pediatr Ophthalmol Strabismus
as a single-stage procedure. Its use, however, is only 2013; 50: 140–148.
8. Kumar CM. Anatomy of globe, orbit and its content. In:
limited to cooperative adult patients.
Jaichandran VV, Kumar CM and Jagadeesh V (eds)
Prophylactic antiemesis with ondansetron and dexa-
Principles and Practice of Ophthalmic Anaesthesia. New
methasone combination is recommended, especially for Delhi: Jaypee Brothers Medical Publishers, 2017,
children. A multimodal approach, including paraceta- pp. 3–14.
mol, intravenous NSAIDs, topical LA and minimal 9. Kowal L, Wong E and Yahalom C. Botulinum toxin in
opioid usage, is recommended for postoperative anal- the treatment of strabismus. A review of its use and
gesia. A supplementary regional ophthalmic block is at effects. Disabil Rehabil 2007; 29: 1823–1831.
the discretion of the team. 10. Scott AB, Alexander DE and Miller JM. Bupivacaine
injection of eye muscles to treat strabismus. Br J
Author contribution(s) Ophthalmol 2007; 91: 146–148.
Alfred WY Chua: Conceptualization; Methodology; 11. Scott AB, Miller JM and Shieh KR. Treating strabismus
Resources; Writing-original draft; Writing-review & editing. by injecting the agonist muscle with bupivacaine and the
antagonist with botulinum toxin. Trans Am Ophthalmol
Matthew J Chua: Conceptualization; Methodology; Soc 2009; 107: 104–109.
Resources; Writing-review & editing. 12. Granet DB, Hodgson N, Godfrey KJ, et al.
Harry Leung: Formal analysis; Writing-review & editing. Chemodenervation of extraocular muscles with botuli-
num toxin in thyroid eye disease. Graefes Arch Clin
Peter CA Kam: Formal analysis; Writing-review & editing. Exp Ophthalmol 2016; 254: 999–1003.
13. Saiah M, Borgeat A, Ruetsch YA, et al. Myopexy
Declaration of conflicting interests (Faden) results in more postoperative vomiting after stra-
bismus surgery in children. Acta Anaesthesiol Scand 2001;
The author(s) declared no potential conflicts of interest with
45: 59–64.
respect to the research, authorship, and/or publication of this
14. Nihalani BR and Hunter DG. Adjustable suture strabis-
article.
mus surgery. Eye (Lond) 2011; 25: 1262–1276.
15. Wright KW. Mini-tenotomy procedure to correct diplo-
Funding pia associated with small-angle strabismus. Trans Am
The author(s) received no financial support for the research, Ophthalmol Soc 2009; 107: 97–102.
authorship, and/or publication of this article. 16. Leenheer RS and Wright KW. Mini-plication to treat
small-angle strabismus: a minimally invasive procedure.
ORCID iD J AAPOS 2012; 16: 327–330.
17. Wong AM. Timing of surgery for infantile esotropia:
Alfred Wing Yan Chua https://orcid.org/0000-0003-2273- sensory and motor outcomes. Can J Ophthalmol 2008;
0752 43: 643–651.
18. McCann ME, de Graaff JC, Dorris L, et al.
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