Subsequent strabismus surgeries in patients with no prior medical records

To investigate subsequent strabismus surgeries in patients with no prior medical record and to evaluate discrepancies between surgical findings and preoperative presumptions made based on patient self-reporting and clinical findings.

The medical records of patients who underwent a subsequent strabismus surgery between January 1992 and October 2017 were retrospectively reviewed. Patients with no available medical records were included in analyses. Discrepancies between preoperative presumptions and surgical findings were investigated. Original ocular alignment and previous surgical details were presumed using alternative methods, including patient self-reporting, review old photographs of patient, and checking conjunctival scarring.

Eleven consecutive patients (4 females, 7 males) met the inclusion criteria. The mean age at subsequent surgery was 47.7 years (range, 23-69). Seven patients had exotropia and four patients had esotropia before the subsequent surgery. Seven patients reported originally having exotropia and four patients reported originally having esotropia. However, findings from surgical exploration did not agree with preoperative presumptions from patient self-reporting in 7 of 11 patients (7/11, 63.6%). These discrepancies included errors in the original type of strabismus (7/11, 63.6%), which eye was previously operated on (1/11, 9.1%), and number of prior surgeries (1/11, 9.1%).

When planning a subsequent strabismus surgery in patients with no prior medical record, information obtained from the patient should be used with caution. This includes the original type of strabismus and previous surgical details.