Phased strabismus surgery under topical anesthesia.

PURPOSE: To evaluate the feasibility and outcomes of phased strabismus surgery under topical anesthesia, with intraoperative comparison of ocular alignment in supine and seated positions. METHODS: This retrospective clinical investigation analyzed the data of patients who underwent phased strabismus surgery with fixed sutures under topical anesthesia. The technique consisted of 2 phases, spaced out with an intraoperative alternate prism cover test (performed in supine and seated positions): (1) surgery on one or two muscles, as defined by a preoperative surgical plan; (2) if judged necessary, a further one-muscle surgery. Surgical success was defined as a residual angle of horizontal and vertical deviation ≤±8Δ and ≤5Δ, respectively, and the presence of single binocular vision in primary position in patients with preoperative diplopia. Follow-up visits were scheduled 1 day, 1 month, and 6 months after surgery. RESULTS: The review identified 38 patients (age range: 10-80 years). Surgery was well tolerated by all patients. Twelve (32%) required a second phase. No statistically significant differences were found for intraoperative angles of deviation in supine and seated positions. Surgical success was reached, respectively, in 88% and 87% of cases with horizontal and vertical deviation 6 months after surgery. No patients were reoperated during the follow-up period. CONCLUSIONS: Phased strabismus surgery is a feasible technique for various types of strabismus in adults and children. Secondly, intraoperative evaluation of ocular alignment can be performed either with the patient seated or supine, with the same accuracy in terms of surgical success.

Topical anaesthesia in strabismus surgery for Graves' orbitopathy: a comparative study of 111 patients.

PURPOSE: To evaluate the tolerability and usability of topical anaesthesia in single rectus muscle recession for strabismus caused by Graves' orbitopathy (GO). To compare the perioperative pain score and surgical outcome between GO patients and non-GO patients. METHODS: A retrospective comparative study of consecutive single rectus muscle recession performed under topical anaesthesia was carried out. All patients scheduled for one-stage single rectus muscle recession under topical anaesthesia were included. Numerical visual analogue pain score scale (NVAS) points, rates of motor success (horizontal deviation < 8 prism diopters (PD) and vertical deviation ≤ 6 PD) and sensory success (no diplopia without prisms), complications and postoperative adjustment frequencies were compared between GO and non-GO patients. RESULTS: A total of 111 patients were included. The mean perioperative pain scores were 2.3 (SD ± 1.3) in GO and 1.6 (SD ± 1.1) in non-GO patients (p = 0.06 adjusted for gender). The postoperative mean alignments in GO and non-GO patients were 2 versus 3 PD horizontally and 1 versus 1 PD vertically respectively. Both motor and sensory success rates were 98% in GO patients and 94% versus 93% in non-GO patients. Adjustments as a second procedure the day after surgery was performed in 10% of the GO patients and 15% of the non-GO patients. The oculocardiac reflex was not triggered in any of the GO patients. CONCLUSION: Topical anaesthesia in single muscle recession for GO is safe, well-tolerated and gives comparable surgical outcomes to those achieved in non-GO patients.

Outcome of large angle exotropia treated by single stage adjustable strabismus surgery with monitored conscious anesthesia.

PURPOSE: :To evaluate the outcomes of large-angle exotropia by single-stage adjustable strabismus surgery (SSASS) under monitored conscious anesthesia. METHODS: A prospective study was done in 33 patients above 14 years with ≥40 prism diopters (PD) of exotropia. All patients underwent SSASS under monitored conscious anesthesia (topical anesthesia plus intravenous sedation). For deviations of ≤55 PD, two horizontal rectus muscles, and for >55 PD, three rectus muscles were operated and a decision on adjustment/operating on an additional rectus muscle was taken after assessing the alignment. Monitored conscious anesthesia allowed us to check our results after surgery and plan further surgery/adjustment to achieve the desired alignment. RESULTS: Mean preoperative deviation for distance was 52 ± 11.1 PD. The target alignment was achieved with the initial surgical plan in 10/21 patients with <55 PD exotropia and 4/12 patients with >55 PD exotropia, and one patient in each group needed adjustment. The remaining patients needed additional rectus muscle surgery. One patient with >55 PD exotropia needed both adjustment and additional rectus surgery. The success rate for distance correction was 85% at 6 months and 1 year. The overall success rate was 71% at 6 months. Percentage of patients with binocular single vision improved from 31% preoperatively to 78% by 6 months. Incidence of oculocardiac reflex was 6.1%. CONCLUSION: SSASS under monitored conscious anesthesia is a viable option for large-angle strabismus correction with good patient comfort and safety.

Peribulbar anesthesia for strabismus surgery in adult patients.

PURPOSE: To evaluate the efficacy and safety of peribulbar anesthesia during strabismus surgery. METHODS: Medical records of patients undergoing strabismus surgery and peribulbar anesthesia were reviewed. The overall efficacy of peribulbar anesthesia was evaluated as requirement of supplemental peribulbar anesthesia, impossibility to perform eye muscles surgery due to inadequate efficacy of the block and peribulbar block complications that occurred up to 6 weeks postoperatively. Presence of oculocardiac reflex (OCR) and presence of decreased visual acuity and afferent pupillary defect postoperatively were reported. RESULTS: A total of 510 patients comprised our study group. The total amount of peribulbar injections was 717. Four patients (0.7%) required supplemental injection in the superonasal quadrant. Five of 510 (0.9%) required an anesthesiologic intervention with intravenous atropine. Eighty patients of 510 (15.6%) complained about transitory complete ptosis and/or amaurosis postoperatively. No complications were observed up to 6 weeks postoperatively. CONCLUSION: Peribulbar anesthesia was an effective and safe option during strabismus surgery in adult patients.

Evaluation of single stage adjustable strabismus surgery (SSASS) under topical anesthesia in patients with symptomatic diplopia.

We wish to assess effectiveness of using topical anesthesia without sedation in single-stage adjustable strabismus surgery (SSASS). Sixteen consecutive adults with diplopia and those willing to undergo SSASS, participated in a prospective study between September 2018-August 2019. They underwent detailed ophthalmic evaluation, ocular alignment measurement by prism cover test (PCT), and sensory evaluation. Subsequently they underwent SSASS under topical anesthesia (2% lidocaine gel). Surgery was performed using conventional technique; ocular alignment was then reassessed in sitting position by alternate cover test using prisms, for which with Snellen's chart was used as distance target and Lang's fixation stick as near target. Absence of diplopia was considered the end point of measurement. Any adjustment, if required, was performed intraoperatively, after recleaning the operative area with povidone iodine and redraping the eye. Participants were reassessed 1 day, 1 month, and 3-month after procedure, ocular deviation, and presence or absence of diplopia was documented. Fifteen males and one female patient participated in the study. Mean age of the study population was 31.29 years (range 19-65 years). Of these, 62.5% of patients required intraoperative modification of planned surgical dose. Patients with esotropia, vertical deviations, and combined deviations obtained surgical success, which remained stable till 3-month review. Patients with exotropia had initial surgical success rates of 100% immediately following surgery (day 1 postoperative evaluation), but it decreased to 83.33% and 66.67% during one and 3-months follow-up visits. In this study all patients tolerated the procedure well, without systemic adverse occurrence, including vasovagal reflex and without the need for additional anesthesia. SSASS is a good option in patients with diplopia and variable ocular deviations. Topical anesthesia allows intraoperative adjustment of surgical dosing, with aim of orthophoria or relief from diplopia, leading to satisfactory results. Postoperative drift may occur in exotropia. Case selection and preoperative counseling are necessary for cooperation during surgery, under topical anesthesia.

Postoperative Behaviour after Primary Strabismus Surgery in Children: Is There an Influence of Intraoperative Topical Anaesthesia? / Aufwachverhalten nach primärer Augenmuskeloperation im Kindesalter: Gibt es einen Einfluss einer intraoperativen Oberflächenanästhesie?

INTRODUCTION: The course of the recovery phase after general anaesthesia, during which consciousness and pain gradually return, is essentially determined by the choice of anaesthetic drug, and its total dose or duration of application. This phase is often complicated by more or less severe agitation, especially in children. In the present study we investigated whether the application of a topical anaesthetic to the conjunctiva at the end of a strabismus operation had a positive effect on the recovery behaviour of the child. PATIENTS/METHODS: This prospective, randomised, blinded study was conducted with 50 healthy, ASA class I or II children, aged 3 to 8 years undergoing their first strabismus operation. Following the surgeon's randomisation two drops of a 0,5% tetracaine-HCl ophthalmic solution were applied to the operated conjunctiva three times at 30-s intervals immediately following wound closure. The postoperative evaluation encompassed heart rate, as well as COMFORT and CHEOPS scores. The first assessment was directly postoperatively with repetitions at 15, 30, 45, 60, 75, 90 and 120 min, as well as on the day after surgery. RESULTS: The CHEOPS scores did not differ significantly between children with or without topical anaesthesia at any time during the observation period. The COMFORT scores revealed a slight, but non-significant analgesic effect at 15 and 30 min. The 60 min score showed the opposite effect, possibly indicating a slight disadvantage of the topical anaesthesia. There were no significant differences with regard to time to first request for additional systemic analgesia, to the total dose of systemic pain medication, or to when the patient was eligible for discharge to the ward. CONCLUSION: The application of topical tetracaine-HCl immediately after wound closure had no positive effects on the course of the postoperative recovery period after strabismus surgery in children. There was no evidence of an effect on pain or emergence agitation.

Single-stage superior oblique tendon recession with suture adjustment under topical anesthesia and sedation for A-pattern strabismus with superior oblique overaction.

PURPOSE: To assess the surgical effect of single-stage superior oblique recession with intraoperative suture adjustment under topical anesthesia and sedation in terms of A-pattern correction, vertical alignment, and superior oblique overaction. METHODS: The medical records of patients who underwent superior oblique weakening (recession with adjustable suture) for superior oblique overaction from 2015 to 2018 were reviewed retrospectively. Preoperative, pre- and postadjustment, and 6-week follow-up data were assessed and compared for A pattern, primary position hypertropia, superior oblique overaction scale and objective fundus torsion. RESULTS: A total of 29 patients (17-42 years of age) were included. Of 51 operated eyes, 37 underwent intraoperative adjustment (further recession of 1-4 mm) after superior oblique recession of 8 mm. Mean decrease in primary position hyperdeviation after adjustment was 3.6Δ ± 2.7Δ (range, 0Δ-8Δ); in A-pattern deviation, 5.5Δ ± 4.8Δ (range, 0Δ-16Δ). At 6 weeks' follow-up, A pattern had either resolved completely or became clinically insignificant (<10Δ) in 23 of 29 patients (79%); 24 (83%) patients had hyperdeviation in primary position of ≤5Δ. Of the 5 patients with preoperative primary position hyperdeviation of 15Δ-30Δ, 2 had residual primary position hyperdeviation of >10Δ. CONCLUSIONS: In our study cohort, single-stage, unilateral superior oblique tendon recession with adjustable suture under topical anesthesia and sedation was well tolerated and resulted in good postoperative outcomes at 6 weeks' follow-up, effectively correcting primary position vertical deviation of <15Δ.

Topical Anesthesia in Children With Intraoperative Adjustable Strabismus Surgery.

PURPOSE: To evaluate strabismus surgery with intraoperative adjustment of sutures under topical anesthesia in children. METHODS: Nineteen children with horizontal deviation underwent a one-stage surgical technique performed under topical anesthesia. Surgery consisted of unilateral or bilateral recession and/or resection of horizontal muscles or the medial or lateral rectus muscles, with intraoperative adjustment of sutures based on alternate prism cover test. Follow-up was done at 1 day and 1, 3, and 6 months postoperatively. RESULTS: Mean age at surgery was 12.68 ± 2.50 years (range: 8 to 16 years). Mean preoperative angle of deviation was 24.21 ± 11.20 prism diopters (PD) (range: -50 to +30 PD) at distance. Mean postoperative angle of deviation at 6 months was 4.11 ± 2.87 PD (range: -10 to +10 PD) at distance. In esotropic patients, the average angle of deviation decreased from +23.80 ± 5.89 PD preoperatively to +4.80 ± 3.35 PD at 6 months, whereas in exotropic patients it decreased from -24.36 ± 12.76 to -3.86 ± 2.77 PD. Seventeen of 19 patients (89%) remained comfortable during surgery, whereas 2 needed an intravenous injection of propofol. The success rate, defined by a postoperative residual angle of deviation of ±8 PD or less, was 89% at 6 months. CONCLUSIONS: Strabismus surgery with intraoperative suture adjustment under topical anesthesia in children is a tolerable procedure with encouraging outcomes, representing an alternative to general anesthesia in well-selected children. Clinical evaluation of children and parents is fundamental to predict a likely poor collaboration of the child during surgery, which, if present, would require surgery under general anesthesia. [J Pediatr Ophthalmol Strabismus. 2019;56(3):173-177.].

Reduction of oculocardiac reflex with Tetracaine eye drop in strabismus surgery.

INTRODUCTION: Recently, to reduce the incidence of oculocardiac reflex (OCR) in strabismus surgery, retrobulbar block and anticholinergic drugs or local anesthesia are also used. The present study evaluated the effects of Tetracaine eye drop as a topical nerve blocker on OCR during strabismus surgery. METHODS AND MATERIALS: In this randomized trial, 70 strabismus surgery candidates were randomly divided into placebo or synthetic teardrop (E) and Tetracaine eye drop (T) groups, so 3 drops of each solution were dropped in four directions of patients' eye immediately after applying anesthesia and before surgery. The incidence and severity of OCR during the stages of muscle release and incision (cutting), hemodynamic changes, the required time for OCR recovery and atropine dose were assessed. RESULTS: OCR was more seen in release phase compared to cutting phase. There were no significant differences between two group regarding the incidence and severity of OCR in the release phase (p > 0.05), but the incidence and severity of OCR in the cutting phase was more in group E than group T (p = 0.02, for both). The duration of OCR improvement (p-value = 0.74) and Atropine consumption (p-value = 0.92) did not differ between the groups. CONCLUSION: Tetracaine eye drop only reduces the incidence and severity of OCR during the incision stage of strabismus surgery.

Retrobulbar anaesthesia for adjustable strabismus surgery in adults: a prospective observational study.

OBJECTIVE: To characterize the ocular response to retrobulbar anaesthesia and to evaluate the efficacy of retrobulbar anaesthesia for adjustable strabismus surgery in adults. DESIGN: Prospective observational study. PARTICIPANTS: Adult patients undergoing adjustable strabismus surgery under retrobulbar anaesthesia. METHODS: Surgical success was defined by ocular alignment within 10 prism diopters (PD) of orthotropia for horizontal rectus surgery and within 5 PD for vertical rectus surgery. After retrobulbar injection of Xylocaine with epinephrine, the onset time and the degree of visual impairment, ocular akinesia, and analgesia were evaluated. Postoperative parameters included the restoration of vision, onset of pain, resolution of ptosis, normalization of pupil, resolution of extraocular motility deficits, and the timing of postoperative adjustment. Perioperative complications were also documented. RESULTS: A total of 33 patients were initially included in this study. Two patients experienced complications (perioperative retrobulbar hemorrhage, postoperative suprachoroidal hemorrhage) and were excluded from data analysis. Of the remaining 31 patients (mean age, 50.2 ± 14.8 years), surgical outcome was satisfactory in 30/31 (96.8%) patients at the first postoperative visit and in 15/19 (78.9%) cases at last follow-up (mean, 6.1 ± 1.6 months). Excellent intraoperative ocular akinesia and analgesia was achieved with retrobulbar anaesthesia. After retrobulbar injection, visual impairment was the first to resolve to preoperative levels within (mean ± SD) 3.7 ± 1.9 hours postinjection, followed by onset of pain at 4.1 ± 1.0 hours, resolution of ptosis at 4.3 ± 1.9 hours, and normalization of pupil reactivity at 6.1 ± 1.0 hours. The resolution of anaesthesia upon extraocular motility occurred within 5.7 ± 1.0 hours postinjection (range, 4.5-8.0 hours), allowing for subsequent same-day postoperative adjustment. CONCLUSIONS: Retrobulbar anaesthesia in the context of adult, adjustable strabismus surgery is a relatively safe and effective technique. It provides excellent intraoperative analgesia and akinesia. Retrobulbar anaesthesia enables for same-day suture adjustments to be reliably performed.

A novel surgical technique employing donor sclera in strabismus surgery.

We describe a novel surgical technique employing donor sclera as a spacer to solve the problem encountered in complicated cases of restrictive strabismus surgery when no more muscle or tendon is available for surgical extension of the eye muscle to correct the angle of deviation. This is often the case in patients who have previously undergone extensive surgery and in patients with mechanical restrictions, such as thyroid-associated orbitopathy (TAO).

Surgery option in the management of delayed diplopia after radiation therapy for nasopharyngeal carcinoma.

PURPOSE: Radiation therapy is a standard treatment for nasopharyngeal carcinoma. Diplopia due to radiation damage to the sixth nerve significantly erodes the patient's quality of life. This study investigated the effectiveness of extraocular surgery in the treatment of delayed diplopia caused by radiation therapy. METHODS: A retrospective case series of 16 patients (7 men and 9 women) with delayed diplopia after radiation therapy for nasopharyngeal carcinoma was enrolled in the study. Unilateral lateral rectus resection was performed under topical anesthesia. Follow-up time was more than 12 months. Outcome measures were prism diopter and self-reported symptoms. RESULTS: All patients diagnosed with sixth nerve palsy reported elimination of symptoms on postoperative day 1 without complications. One patient required a second procedure due to recurrence of symptoms. At 12-month follow-up, no patient reported recurrence of symptoms. The absolute horizontal deviation significantly decreased from a preoperative value of 16 prism diopter to a value of 1.5 prism diopter postoperatively (p < 0.001). CONCLUSION: These results suggest that unilateral lateral rectus resection under topical anesthesia is an effective treatment for delayed diplopia after radiation therapy for nasopharyngeal carcinoma. A large randomized prospective study to confirm these findings is warranted.

Combined lateral rectus augmented transposition and inferior rectus recession for monocular elevation deficiency.

We report the case of a 21-year-old woman who presented with a drooping right upper eyelid and smaller-appearing right eye, evident since birth. Her visual acuity was 20/30 in the right eye and 20/20 in the left eye. In primary gaze she had a hypotropia of 25Δ, with a marked elevation limitation and associated true upper lid ptosis of 3 mm. Under local anesthesia, the lateral rectus muscle was transposed to the superior rectus muscle and was augmented by a nonabsorbable suture attaching the superior rectus muscle and lateral rectus muscle 8 mm posterior to the insertion, accompanied by an inferior rectus recession. One year after surgery she was orthophoric in primary position and showed improvement in elevation. The surgical procedure can be performed at the same time as the inferior rectus recession and reduces the risk of anterior segment ischemia.

Adjustable Strabismus Surgery under Topical Anesthesia: Alignment in Supine vs Seated Position.

PURPOSE: To compare ocular deviation in the operating room depending on whether the patient is in supine decubitus or seated after single-stage adjustable strabismus surgery under topical anesthesia. MATERIAL AND METHOD: We performed a prospective observational study of 30 patients with horizontal and/or vertical strabismus who underwent single stage adjustable strabismus surgery under topical anesthesia. Both distance and near deviation were evaluated before surgery, during surgery in both positions (seated and supine), and at 1 day, 1 month, and 3 months after surgery. A final horizontal deviation <10 pd and a vertical deviation <5 pd without diplopia was considered to be a good outcome (3 months after surgery). RESULTS: The mean age of the sample was 55 years and 76.7% were women. Most had esotropia (70%). The most frequently used surgical combination was the medial rectus and lateral rectus (36.7%). Surgical adjustment was necessary in 40% of cases. Mean preoperative deviation was 21.9 ± 12.63 pd (distance) and 20.66 ± 4.76 (near). Deviation with the patient supine was 8 ± 8.25 pd (distance) and 7.26 ± 5.81 (near). Deviation with the patient seated was 8.13 pd±8.38 (distance) and 8.5 ± 7.41 (near). There was no significant difference between the positions. Outcome was favorable in 70% of patients; this percentage increased to 83.33% at 1 day, 1 month, and 3 months after surgery. CONCLUSIONS: No statistically significant differences were found between ocular deviations in the seated or supine position in the operating room. Outcome was favorable in most cases 3 months after surgery. Intraoperative ocular deviation was not a predictor of outcome.

Relationship between the phenylephrine test and eyelid droop after aponeurotic repair with the use of an epinephrine-containing local anaesthetic.

PurposeTo analyse the relationship between the results of the phenylephrine test and postoperative eyelid droop in transcutaneous aponeurotic repair using epinephrine-containing local anaesthetic for aponeurotic blepharoptosis.Patients and methodsWe retrospectively reviewed the medical records of 66 eyelids from 40 patients who underwent transcutaneous aponeurotic repair. A positive phenylephrine test result was defined as an increase in margin reflex distance-1 (MRD-1) ≥0.5 mm after application of phenylephrine eye drops. The patients were divided into a positive phenylephrine response group (Group A, 16 patients) and a negative phenylephrine response group (Group B, 24 patients). The ΔMRD-1 was calculated by subtracting the 3-month postoperative value from the intraoperative value. Patient age, sex, pre- and intraoperative MRD-1s, levator function, and phenylephrine response were investigated as factors potentially influencing the ΔMRD-1. The relationship between these factors and ΔMRD-1 was analysed using single and multiple regression analysis.ResultsThe ΔMRD-1 in Group A (0.68±0.52 mm) was significantly greater than that in Group B (0.17±0.56 mm; P=0.004). A moderate correlation was found between phenylephrine response and ΔMRD-1 in the total patient group (YΔMRD-1=0.441 Xphenylephrine+0.358; r=0.462; r2=0.213; P=0.002).ConclusionsAlthough the ΔMRD-1 in Group B was quite small, the ΔMRD-1 in Group A was considerable, and there was a moderate positive correlation between phenylephrine response and the ΔMRD-1 overall. This indicates that the degree of postoperative eyelid droop can be estimated by the phenylephrine test results in transcutaneous aponeurotic repair.

The accuracy of wide-field ultrasound biomicroscopy in localizing extraocular rectus muscle insertions in strabismus reoperations.

PURPOSE: To compare the accuracy of widefield ultrasound biomicroscopy (UBM) with mechanical intraoperative measurements of the distance between rectus muscle insertions and the corneal limbus in strabismus reoperations. METHODS: Subjects with a history of horizontal rectus muscle surgery who required further surgery on horizontal rectus muscle(s) were recruited prospectively. All widefield UBM measurements were carried out under topical anesthesia using a 50 MHz linear probe without immersion cup and external caliper. The insertion angle distance was measured using the caliper tool of the UBM device; the actual muscle insertion distance from the limbus was considered to be the measured distance plus 1 mm. The distance from muscle insertion to the limbus was also measured intraoperatively. The results of UBM and surgical measurements were compared. RESULTS: A total of 28 subjects were recruited, and 53 horizontal muscles (30 medial rectus, and 23 lateral rectus muscles) were included. The longest distance of the muscle insertion from limbus detectable on UBM was 13 mm for the medial rectus muscle and 15 mm for the lateral rectus muscle. In 38 muscles (71.7%) UBM and surgical measurements were within 1 mm of each other. Only in 1 muscle (1.9%) was the difference between measurements >2 mm (2.3 mm). The intraclass correlation coefficient was 0.87, demonstrating excellent agreement between measurements. Limit of agreement analysis demonstrated better agreement between measurements of medial rectus muscles and in consecutive exotropia cases. CONCLUSIONS: This study demonstrated good agreement between intraoperative and widefield UBM measurements of the muscle insertion-limbus distance in our patient cohort.

Lateral tarsal strip plus skin-muscle flap excision in the treatment of lower eyelid involutional entropion.

This article examines the effectiveness of skin-muscle flap excision in conjunction with a lateral tarsal strip for the treatment of involutional entropion. Ninety-six eyelids in 83 consecutive patients with involutional entropion were treated using a standardized surgical procedure. All patients underwent lower eyelid tightening with a lateral tarsal strip, dissection of a skin-muscle flap inferiorly through a subciliary incision and excision of redundant skin as well as orbicularis muscle. Follow-up data was obtained by retrospective chart review and telephone interviews. 80 patients were included in this study. The only exclusion criteria was failure to attend the 1 week follow-up appointment, n = 3. There was only one recurrence which was mild and revised under local anesthesia. Two patients had overcorrection with mild ectropion but did not require additional surgery. In those that completed their initial post-operative visit, the average time follow-up time was 502 days. Excision of a skin-muscle flap is a useful addition to lateral tarsal strip surgery in the treatment of involutional entropion and is a quick procedure producing excellent functional and cosmetic results. To our knowledge, this is the first cohort of patients to be reported using this technique where all patients had a standardized surgical approach. Additional studies are needed to compare long-term outcomes of this technique against other surgical treatments.

A double-masked randomized trial of postoperative local anesthetic for pain control in pediatric strabismus surgery.

PURPOSE: To determine to what extent local anesthetic reduces postoperative pain after pediatric strabismus surgery. METHODS: In this double-masked, randomized clinical trial of 50 children 13-91 months of age undergoing strabismus surgery, subjects were randomly assigned to one of three treatments given at the conclusion of surgery: topical lidocaine gel and sub-Tenon's (balanced salt solution) placebo (n = 16), topical placebo (hypromellose) and sub-Tenon's bupivacaine 0.75% (n = 17), or topical and sub-Tenon's placebo (n = 17). Pain was otherwise managed systemically in the usual fashion by the masked anesthesia team and assessed at regular postoperative intervals by a masked observer using an objective, validated pain scale. RESULTS: Average pain in the first 30 minutes was 6.57, 6.36, and 6.58 in the lidocaine, bupivacaine, and placebo groups, respectively, and was significantly lower (P = 0.016) for bupivacaine vs placebo. The bupivacaine group had significantly lower scores for pain after 30 minutes, total pain, and peak pain versus the lidocaine group. CONCLUSIONS: Sub-Tenon's bupivacaine may reduce postoperative pain in children undergoing strabismus surgery.

Surgically Induced Necrotizing Scleritis Following Strabismus Surgery Treated Successfully with Topical N-acetylcysteine in a Child with Congenital Fibrosis of Extraocular Muscles and Varadi Papp Syndrome.

INTRODUCTION: Surgically induced necrotizing scleritis (SINS) is a rare but serious disorder that can develop many years after strabismus surgery. It is generally treated with high-dose steroids or immunosuppression. CASE REPORT: We describe a patient with Varadi Papp syndrome and congenital fibrosis of the extraocular muscles, who developed surgically induced necrotizing scleritis a month after strabismus surgery and was successfully managed by oral vitamin C and topical N-acetylcysteine 10%. DISCUSSION: While SINS is conventionally treated with steroids/immunosuppression, a conservative approach may be tried in milder cases. The role of topical N-acetylcysteine in managing this complication needs to be explored.