Second cluster of strabismus cases after periocular anesthesia without hyaluronidase

We describe a second cluster of cases of iatrogenic strabismus that occurred in clinical practices following cataract surgeries that occurred in 2000 when hyaluronidase was once again unavailable for use in periocular anesthetic regimens. Twelve cases of transient or permanent strabismus were referred by 4 anterior segment surgeons who had no previous cases of postcataract strabismus when performing periocular injections with hyaluronidase. The charts of the patients were reviewed retrospectively. Recurrence of an increase in postoperative strabismus when hyaluronidase became unavailable for a second time supports the concept that this enzyme may be more important than previously suspected in preventing damage to the extraocular muscles after periocular anesthetic injections.