Surgery in infantile strabismus syndrome: Surgery should be postponed until after amblyopia has been successfully treated (see previous section). It is also advisable to wait until the patient has reached a certain age. Adequate follow-up includes precise measurement of visual acuity at regular intervals in tests that require the patient's cooperation, and such cooperation is difficult to ensure in young patients below the age of four. Surgical correction in a very young patient prior to successful treatment of amblyopia involves a risk that a decrease in visual acuity in one eye may go unnoticed after the strabismus has been corrected. However, the child should undergo surgery prior to entering school so as to avoid the social stigma of strabismus. In such a case, surgery achieves only a cosmetic correction of strabismus.
Surgery in late strabismus with normal sensory development: In this case, surgery should be performed as early as possible because the primary goal is to preserve binocular vision, which is necessarily absent in infantile strabismus syndrome.
Procedure: The effect of surgery is less to alter the pull of the extraocular muscles than to alter the position of the eyes at rest. Esotropia is corrected by a combined procedure involving a medial rectus recession and a lateral rectus resection. The medial rectus is released because its pull is "too strong" (see Fig. 17.1), whereas the lateral rectus is shorted to increase its pull. The degree of correction depends on the angle of deviation. Primary oblique muscle dysfunction is corrected by inferior oblique recession and if necessary by doubling the superior oblique to reinforce it. Exotropia is corrected by posteriorly a lateral rectus recession in combination with a medial rectus resection.
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