Changes in Lateral Comitance After Asymmetric Horizontal Strabismus Surgery

Asymmetric horizontal strabismus surgery is often performed to correct primary gaze alignment without considering the symptoms that may result from misalignment in the patient's side gaze. Surgical choices influence alignment in side gaze and may contribute to functional and social deficits.

To identify the surgical procedures associated with changes of alignment in side gaze to help inform surgical planning for patients with horizontal strabismus.

The medical records of 1081 horizontal strabismus surgical procedures that were performed at Boston Children's Hospital during a 2-year period were retrospectively reviewed. Only records with strabismus measurements recorded in the right and left gaze before and after surgery were included. Data analysis was conducted from September 1, 2012, through June 7, 2015.

Change in comitance (CIC), determined by measuring the horizontal comitance (the difference between right- and left-gaze strabismus measurements) before and after surgery.

The review identified 569 patients who met the inclusion criteria. Of the 491 patients with comitant preoperative alignment, 59 developed postoperative incomitance, of whom 53 (89.9%) had asymmetric surgery. Of the 78 patients with incomitant preoperative alignment, 36 patients' (46.2%) deviation had improved to comitance after surgery; 32 (88.9%) of these patients had asymmetric surgery. Asymmetric 2-muscle surgery had a median CIC of 4.0 while symmetric 2-muscle surgery had a median CIC of 1.5 (difference in CIC, 2.5; 95% CI, 2.0-3.0; P < .001). A CIC of 25 prism diopters or more was observed in 6 patients who underwent asymmetric surgery (0 with symmetric surgery). New postoperative incomitance was symptomatic in at least 17 patients (28.8%).

Asymmetric strabismus surgery can treat incomitant deviations, but it can also create symptomatic incomitant deviations in patients who were previously comitant. Surgical planning should include consideration of the potential for CIC, including the potential for unsatisfactory appearance in side gaze. Patients with binocular vision will be sensitive to diplopia in any gaze direction; in such cases, the consequences of asymmetric surgery should be considered with particular care.