Strabismus surgery under local anaesthesia at a tertiary eye hospital: a 5-year case review

Strabismus surgery is traditionally performed under general anesthesia (GA), however this is not safe or suitable for many patients. There has been increasing interest in strabismus surgery under local anesthesia (LA), however large datasets comprehensively exploring what is feasible under LA are lacking.

We identified 440 operations performed under LA at a tertiary eye center over a 5-year period from 2020 to 2024 and performed a retrospective review of surgical notes for all cases. Further in-depth analysis of anaesthetic notes was performed for a subset of 153 LA cases and compared to 92 representative GA cases from the same time period.

This study provides an extensive patient cohort to show that even complex or re-do strabismus surgery can be safely and successfully performed under LA with appropriate sedation. The most common indications for LA were weekend scheduling constraints, patient preference, and co-morbidities. The widespread use of sedation permitted more complex surgery than has previously been reported with LA alone; this included vertical recti and re-do operations, as well as challenging strabismus procedures such as Yokoyama and Harada-Ito surgery. Only one case required conversion to GA due to pre-operative anxiety, with a very low incidence of other complications. LA with sedation significantly outperformed GA in several parameters including incidence of oculo-cardiac reflex (0% vs. 42.4%), post-operative opioid requirements (0.6% vs. 13.0%), post-operative anti-emetic requirements (7.2% vs 13.0%) and median hospital stay after surgery (119 vs. 174 minutes). The LA cohort also had a higher average age (54.7 vs. 41.9) and BMI (28.5 vs. 26.2).

Strabismus surgery under LA with sedation is a safe and well-tolerated option, including in patients at higher anaesthetic risk for GA. More widespread use may help to expand the eligible patient population, allowing access to corrective surgery for those who would otherwise only be eligible for botulinum toxin in an outpatient setting. We also demonstrate the potential to reduce intra- and post-operative complications and optimize theater efficiency and utilization of resources in a day case setting.