Strabismus Surgery in Hemophilia: A Novel Surgical Technique and Guideline Recommendations

Abstract

Hemophilia is a serious X-linked inheritance coagulation factor deficiency. Clinically, prolonged bleeding or delayed clotting in any area of vascular disturbance is the main manifestation of all hemophilia. We presented a 23-year-old male with a history of left sensory esotropia since the age of three. The patient had not undergone any previous eye surgery and refused to wear glasses. Hematologic studies confirmed a diagnosis of hemophilia A. Upon ophthalmologic examination, the patient's visual acuity was 20/20 in the right eye and 20/120 in the left eye, with deep amblyopia. The patient exhibited left inferior oblique overaction and a V pattern. The ophthalmologic examination otherwise revealed no abnormalities. Preoperative correction of factor VIII was deemed necessary, and the recommended dose was administered to raise the factor VIII level to 52%. The patient underwent bilateral medial rectus recession, left lateral rectus plication, and left inferior oblique myectomy. A new technique utilizing viscodissection with subconjunctival injection of a viscoelastic solution was employed to minimize intraoperative bleeding, resulting in reduced bleeding compared to standard strabismus surgery. No unusual bleeding occurred during the procedure. No postoperative bleeding was observed. The patient was discharged on the fourth postoperative day, having achieved satisfactory cosmetic alignment in the primary position with no complications related to hemophilia. In conclusion, strabismus surgery can be performed safely in strabismic patients with hemophilia. Viscodissection is a helpful novel surgical technique to decrease the risk of bleeding during surgery, and we recommend using this technique in patients using anticoagulants. A multidisciplinary team approach and strict post-operative monitoring are essential in order to achieve optimal results.

Keywords: haemophilia; novel technique; strabismus; subconjunctival; surgery.

Figure 1. The preoperative presentation of a patient with hemophilia A showed esotropia.

Figure 2. Photos showed the postoperative appearance of the conjunctiva.