Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android


Strabismus has a prevalence of 3%–5% in the general population and affects both genders equally with a 1:1 ratio. It is a condition where lack of coordination of the extraocular muscles (EOMs) prevents the eyes from aligning on a single focal point. The muscle groups that comprise the EOM are the four rectus muscles (medial, lateral, superior, and inferior) and the two oblique muscles (superior and inferior). Strabismus can be congenital, acquired, or secondary to another condition. Most cases are idiopathic; however, strabismus has been linked to chromosomal defect, metabolic disorders, congenital abnormalities, and cardiac diseases (Table 149-1).

TABLE 149-1Conditions Associated with Strabismus

The surgical correction aims to correct the misalignment of the divergent visual axes by removing and reattaching the affected EOM to the globe. Surgical approach varies, but consists of at least one of the following strategies:

  • Weakening muscles (resection, marginal myotomy, or inserting a spacer);

  • Strengthening muscles (shortening the length, moving the insertion toward the limbus, or tightening the muscle’s fibers (plication or tuck);

  • Transposing the muscles.


As with any patient undergoing surgery, a thorough preoperative assessment is essential. A detailed history should be obtained from their patient or patient guardian and include birth history, history of prematurity, central nervous system (CNS) disorders, syndromic associations, and any cardiopulmonary history. There has been reported a higher incidence of malignant hyperthermia with strabismus but direct association to malignant hyperthermia has been disproven. Any child requiring anesthesia for ophthalmologic surgery should be questioned about a personal or family history of reactions or complications with anesthesia.

Despite the short nature of this corrective surgery, there are numerous approaches to providing a safe and quality anesthetic. The same considerations as with any other anesthetic should be applied when choosing whether to premedicate the child with midazolam. Keep in mind that struggling and anxiety during induction do not have the same negative effects with strabismus patients like open globe patients. Numerous methods of anesthesia have been successfully reported, such as general anesthesia, retrobulbar, peribulbar, subtenon, and subconjunctival regional blockade. General anesthesia, however, remains the most common method of anesthetizing patients with strabismus.

Standard American Society of Anesthesiologists (ASA) monitors (pulse oximetry, noninvasive blood pressure, electrocardiography, and end-tidal capnography) are sufficient to safely care for these patients unless the patient’s comorbidities dictate more invasive monitoring. Endotracheal intubation is not essential, but is often chosen for ease of management with the airway rotated away from the anesthesia provider. Access to the endotracheal tube and circuit should remain accessible throughout surgery without compromising the operative field. Paralysis may be needed to ensure ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.