Dr. Avraham Shapirer Children and Vision Strabismus Surgery in Children and Adults

Dr. Avraham Shapirer - Director of the Children's and Strabismus Unit, Goldschlager Eye Institute - Sheba Medical Center, Tel HashomerStrabismus is defined as a condition in which the visual axes are not straight, and this is in the gaze of the eye. Fidel Sittbem and Arshi Yermir, binocular vision (for example: depth perception disorder) and sometimes double vision (diplopia). One of the complications caused by strabismus is the development of a lazy eye (amblyopia), which is caused by the suppression of vision in one eye. In addition, strabismus also causes aesthetic disturbance in the appearance of the face, and as a result, psychological disorders may occur. Accordingly, the goal of treatment is twofold: to enable binocular vision in those children in whom this potential exists and to prevent diplopia and the development of a lazy eye, as well as to correct the cosmetic deformation that exists in the eyes. Treatment methods are divided into: 1. Glasses or eye drops. 2. Extraocular muscle surgeries. In this review, we will discuss surgical treatment methods. In general, current surgical methods are relatively safe and do not require the child to be hospitalized, although the surgery is performed under general anesthesia. After surgery, the child's eyes are not covered, and he receives antibiotic eye drops for several days.
Surgical methods: The two most common forms of surgery are: weakening the muscle's pulling force or strengthening the muscle's strength. Weakening the muscle (RECESSION) is performed by detaching the muscle from its attachment point on the sclera (DISINSERTION)) and securing it posteriorly on the eyeball and suturing the muscle to the sclera in its new position. Moving the muscle posteriorly weakens its force of action, and the degree of muscle attachment is proportional to the extent required to weaken the muscle. Strengthening the muscle is achieved by shortening its length (RECESSION). During the surgery, the muscle is severed from the eyeball, a section of the muscle is cut, and the "new" end is attached to the sclera. One type of surgery can be performed during the surgery, or both types of surgery can be combined on different muscles. Muscle strengthening can also be achieved by moving the muscle forward (ADVANCEMENT). Another surgical method is to move the muscle to a different location on the sclera (TRANSPOSITION). In this surgery, the muscle is severed from its normal position and attached to the eye after being moved to the side in the horizontal plane, or moved up or down in the vertical plane. The goal of this treatment is to move the muscle's action vector to a new direction in which it did not act before the surgery. The sutures used to suture the muscles are dissolved after a few weeks, so there is no need to remove them after a while. In most cases, success is achieved after one surgery. Sometimes, repeated surgery(s) are necessary.Performing the surgery according to the type of strabismus Esotropia (deviation of the eyes towards the nose) This is the most common type of strabismus in children. Before surgery, the refraction of the eye must be checked and whether a lazy eye has already developed. These problems must be treated before surgery. The preferred age for surgery, in children who do not suffer from brain damage, is 6 years old. 12-months. At this age, the angle of the strabismus can be accurately assessed. The most common surgery to correct this type of strabismus is bilateral weakening of the medial rectus muscle. The greater the angle of the strabismus, the greater the need for muscle recession. If additional surgery is needed, bilateral shortening of the lateral rectus muscle is performed. Usually, several months are waited between surgery and reoperation. Some prefer to perform surgery on only one eye. This surgery is especially preferred if the eye is lazy. In this case, the lateral rectus muscle is weakened and the lateral rectus muscle is strengthened. If additional surgery is needed, the other eye is operated on. Often, the underlying strabismus, but also esotropia, is accompanied by overactivity of the inferior oblique muscle. In this case, the muscle must also be weakened by its RECESSION.
Exotropia (deviation of the eyes towards the ears). Here too, the refraction and visual acuity must be checked in each eye before surgery. The congenital form of strabismus must be treated at an early age. On the other hand, there are children in whom the strabismus developed later, so in these children the surgery can be postponed until the age of 5 years. The visual disturbances in this form of strabismus are more numerous than in esotropia strabismus. The surgery for this strabismus can be bilateral weakening of the external rectus muscle (LARETAL RECTUS). Another option is a combination of weakening of the external rectus muscle (LARETAL RECTUS) and strengthening of the internal rectus muscle (MEDIAL SUTCER) in the same eye. When the angle of strabismus is greater at a distance, the first method is preferred, while if the angle of strabismus is greater at a near angle, then the second surgical method is preferred. The second surgical method is also the preferred method in cases where vision is impaired in one eye - this The eye that we will operate on. Height strabismus. In these cases, an imbalance of the eyes in the vertical plane is created, with one eye higher than the other. The form of strabismus in which was described in a tangible way in the Talmud 2000 years ago: "Such as, one who sees the house and the ascent as one." In these cases, the vertical muscles must be operated on, namely the upper or lower rectus muscle, or the upper and lower oblique muscles. A or V strabismus. These are situations in which the angle of the strabismus is different when looking up or down. In these children, the strabismus is often accompanied by a pronounced head tilt, which causes additional disturbance. In these cases, the operated muscles must be shifted up or down depending on the form of the deviation. This deviation causes the muscle to weaken in the direction of its deviation, and on the other hand, to strengthen the muscle in the opposite direction of its deviation. Sometimes these conditions arise from overactivity of the inferior oblique muscle (INFERIOR OBLIQUE) or from overactivity of the superior oblique muscle (SUPERIOR OBLIQUE). In this case, these muscles must be weakened by their RECESSION or even their complete cutting (TENOTOMY). Rotational strabismus. These are conditions caused by weakness or paralysis or, conversely, overactivity of the muscles responsible for the rotational movements of the eye, i.e. the inferior oblique muscle (INFERIOR OBLIQUE) or the superior oblique muscle (SUPERIOR OBLIQUE). When the disorder arises from the activation of