Recurrence of strabismus after eye muscle surgery

I suffer from hyperopia and astigmatism (OD +3.00 -4.00, OS +2.00
-3.00, no lazy eye), and recently had eye muscle surgery to correct the
partially accommodative esotropia I've had for over twenty years (since
the age of two).
In recent years I'd only worn glasses for driving, but the doctor who
operated on my eyes has warned me that if I don't go back to wearing
them full-time, the esotropia will return. I'd be happy to hear group
members' opinions on this - what are the odds of the esotropia
returning if I continue to only wear glasses for driving, how long will
it take, and is some sort of compromise possible (e.g. wearing glasses
only for the more "demanding" activities)?
Thanks in advance

 

The accommodative/convergence system wasn't changed by the surgery, and
the eyes will still be receiving the signal to "turn inward" when you
accommodate. The glasses will help prevent this. Also, without
adequate stimulus to fusion, your eyes will be free to wander. Clear
and equal vision in both eyes is a powerful stimulus to fusion.

How long will it take to degrade? Hmmmm, let me see, take the square
of the refractive error spherical equivalent devided by the amount of
strabismus in prism diopters to get the exact time in years....heck, I
don't know the answer to that question.

I would heed your surgeon.

DrG

 

Partially? It would be nice to know how much the accommodative
component was. To me it's surprising that they waited 20 years to do it,
or did you also have surgery at age 2?

With that refractive error, I'd wear them or get contacts.

I'd be happy to hear group

I can't understand why you'd only wear them for driving. I'd think that
reading and any other close work you might do might be even more
important to do with them on, especially if the angle of deviation is
greater at the near point, in which case bifocals or 2 different Rxs may
be in order. The esot will probably return temporarily when you go
without your glasses, but permanent damage is not likely regardless, in
the absence of amblyopia.

w.stacy, o.d.

 

This kind of surgery is normally done ONLY on the nonaccommodative part of
the angle - that is, the angle WITH the glasses on.

If you operate for the larger angle with the glasses off, you end up
over-operating, and are straight only when accommodating (focusing), which
you can't hold all the time. When not accommodating, the eyes will deviate
outwards. During changes in accommodation, the angle will be variable.

If you operate correctly for the angle with the glasses on, they will often
cross again when glasses are not worn regularly. They then end up crossing
more of the time, and the surgery is essentially wasted.

Occasionally, one can ove-operate a bit and get away with it, but that is
generally not the rule. Note that this depends also on the angle with and
without glasses, at distance as well as at near.

I, for one, do not over-operate in that fashion. I have seen enough unhappy
campers who tried that, and I won't go there.

BTW, you have enough astigmatism that you definitely should be wearing
glasses full-time, anyway. I would be surprised if you had good enough
vision for daily comfort without them.


David Robins, MD
Board certified Ophthalmologist
Pediatric and strabismus subspecialty
Member of AAPOS
(American Academy of Pediatric Ophthalmology and Strabismus)

 

Chronic angling in due to accommodation with cause the return of the
esotropia in many cases. True, it is not amblyopia, but there are more ways
to "damage" the system besides amblyopia. This is permanent damage, in that
you then need to repeat the surgery, which is detrimental.

 

Well your message got a little garbled, but I'm wondering what other
kinds of damage you're thinking about. Accommodative esotropia is
easily fixed by correcting the hyperopic/accommodative problem with
glasses or contacts. I don't think accommodative esotropia should ever
be "corrected" with surgery, except maybe refractive surgery.

w.stacy, o.d.

 

Sorry if I wasn't entirely clear. I sometimes don't read what I have written
and check for clarity.

What I'm saying is, is that IF you operate for the nonaccommodative
component, and then do not wear glasses, you get recurrent esotropiafrom the
accommodative component, which may remain permanent even if you later try to
go back to the glasses. The eyes can "take a set" at the esotropic angle,
and even though wearing the glasses may reduce it somewhat, the eyes often
"unwind" and remain esotropic even with the glasses on. Therefore, what was
only the accommodative component (and could have been handled only with
glasses) can again become a mixed accommodative and non-accommodative
process requiring glasses and yet another surgical intervention.

Therefore, the comment that not wearing glasses after surgery won't do any
permanent harm is not exactly true. I was supporting your statement that it
is not amblyogenic, but I was pointing out that there can be permanent harm
done (to the alignment) by not wearing the glasses.

I agree, wholeheartedly, that accommodative esotropia should normally not be
corrected by surgery . HOWEVER, in the case of a mildly high AC/A ration,
where the eyes cross mainly at near, it is a recognized procedure to operate
for the near angle. This is, in a sense, operating for accommodative
component to get a child out of bifocals. It is over-operating, and takes
advantage of fusion (if it is there) to handle the distance exo that is
created by operating for this near eso-deviation. I, for one, do not do this
- I feel it is more prudent to handle the AC/A issue with bifocals, rather
than surgery, because I have seen results from other surgeons where they do
end up exotropic (not exophoric) in the distance.

Hope this is more clear.

-Daid Robins, MD

 

David Robins, MD wrote:
HOWEVER, in the case of a mildly high AC/A ration,

Definitely, and I think we're more in agreement than disagreement.

Thanks

w.stacy, o.d.