Strabismus Surgery for Psychosocial Reasons-A Literature Review

Abstract

Introduction: Strabismus surgery may be undertaken for visual benefit, to improve or eliminate diplopia symptoms, or to restore or improve binocular single vision (BSV). In patients without visual symptoms or expected visual benefit, strabismus surgery may still be undertaken if the presence of strabismus causes the patient psychosocial symptoms. To evaluate strabismus surgery undertaken for psychosocial reasons, evidence of postoperative outcomes in this specific cohort is needed.

Methods: A systematic search of the literature was conducted (1946-2023) to identify evidence where postoperative outcomes were reported for adult patients (age 18 years and above) who had undergone strabismus surgery for psychosocial reasons.

Results: Sixty-nine papers were included in the literature review. Most sources of evidence included patients within heterogeneous cohorts of strabismus surgery outcomes, with a range of symptoms and differing surgical aims.

Discussion: In adults who underwent strabismus surgery for psychosocial reasons, improved postoperative ocular alignment and/or improved health related quality of life (HRQoL) were common. Strabismus surgery outcomes appeared to be measured satisfactorily at three months postoperatively. Additional surgical outcomes, including an expanded field of vision, unexpected BSV, improved binocular summation, improved task performance and improved eye movements have been reported, but not fully investigated. There was a lack of consensus on how postoperative success should be defined and measured. A core outcome set for strabismus has been suggested and there is potential to add to the available evidence by investigating which outcome measures are most relevant to those with strabismus and psychosocial symptoms. There is a growing need for robust evidence in this specific subgroup of patients due to a lack of evidence specifically reporting postoperative outcomes in adults with strabismus and psychosocial symptoms.

Keywords: health related quality of life; outcomes; psychosocial; quality of life; strabismus; strabismus surgery.

Figure 1

Flow chart illustrating the results of the literature search. * No automated tools were used, all records were excluded by GA. * Exclusions due to:

1. – Strabismus surgery planned for visual benefit (to gain BSV or to eliminate diplopia), or to investigate outcomes in patients with potential BSV (for example prism adaptation to restore BSV prior to strabismus surgery).

2. – Strabismus secondary to or associated with other aetiologies such as neurogenic palsy, mechanical condition (for example Duane syndrome), high myopia, retinal detachment, orbital fractures, congenital fibrosis of the extraocular muscles, age related distance ET (with diplopia).

3. – Other strabismus diagnoses reported only (for example acute acquired concomitant esotropia, DVD, double elevator palsy).

4. – Strabismus surgery outcomes in co-existing ocular pathology (for example glaucoma).

5. – Strabismus surgery anaesthetic techniques.

   - Strabismus surgery but without strabismus outcome data reported or where it was unclear which patients, within a larger cohort, had undergone surgery for psychosocial reasons.

6. – Strabismus surgery techniques and outcomes following specific vertical muscle procedures for a vertical or torsional deviation (for example Harada-lto procedure).

7. – Intermittent strabismus or heterophoria only.

8. – Paediatric patients only (with the following exceptions: childhood strabismus that had recurred in adulthood and childhood onset strabismus that had received the primary surgical treatment in adulthood).

9. – Other surgical outcomes (for example refractive surgery outcomes performed in patients with strabismus).

10. – Treatments for diplopia (with the exception of diplopia resulting from psychosocial strabismus surgery, which was included).

11. – Slipped extraocular muscles during surgery (for example, description of surgical technique but no reported strabismus outcome).

12. – Outcomes from Botulinum Toxin (BT) injections.

13. – Poster abstracts.

14. – Review papers reporting no original data.

15. – Editorial articles.

** Exclusions due to:

1. – Strabismus surgery outcomes reported in a heterogeneous cohort and not possible to extract outcomes in those undergoing strabismus surgeries for psychosocial reasons only.

2. – Insufficient evidence reported to be able to determine postoperative outcomes of strabismus surgery in those undergoing strabismus surgery for psychosocial reasons.

3. – Cohort already reported in an earlier study.