Outcomes of Strabismus Procedures in Children with Perinatal Brain Injury

To evaluate the long-term success rates of strabismus procedures in children with a history of perinatal intracranial injuries compared to matched controls.

Retrospective clinical cohort study.

108 patients with strabismus (84 esotropia, 24 exotropia) and perinatal brain injury. Controls (108 without brain injuries) were matched 1:1 by horizontal deviation type, age at intervention, and preoperative deviation magnitude.

Patients underwent incisional surgery, botulinum toxin injection, or botulinum toxin-augmented surgery with at least two years of follow-up.

Two-year motor success (horizontal deviation ≤10 prism diopters) and general motor-sensory success (motor success or fine stereopsis ≤100 arcseconds), without requiring retreatment.

At 3-6 months, success did not differ significantly (52.9% vs 67.3%; P=.098). At 2 years, motor success was lower in the brain-injury cohort overall (43.5% vs 65.7%; OR=0.31, 95% CI, 0.16-0.62; P=.0005) and the esotropia subgroup (45.2% vs 66.7%; OR=0.36, 95% CI, 0.17-0.74; P=.005). General motor-sensory success was likewise lower overall (47.2% vs 69.4%; OR=0.33, 95% CI, 0.17-0.64; P=.0007) and in esotropia (47.6% vs 70.2%; OR=0.34, 95% CI, 0.17-0.71; P=.0034). Postoperative drift was greater in the brain-injury cohort (P=.037), and failures were predominantly under-corrections. Among 60 matched esotropia pairs undergoing incisional surgery alone, surgical dosing was comparable (95.9% vs 96.6% of standard; P=.68). In the primary multiple-variable model, larger preoperative deviation was associated with lower general motor-sensory success in the combined cohort (OR=0.963 per prism diopter, 95% CI, 0.934-0.994; P=.019) and esotropia subgroup (OR=0.950, 95% CI, 0.912-0.989; P=.012). Treatment with botulinum toxin was not independently associated with success in a sensitivity model (adjusted OR=0.18; P=.126). Male sex was associated with motor failure in exotropia (OR=0.03; P=.015).

Children with perinatal brain injury had lower long-term strabismus treatment success, predominantly from undercorrection, despite comparable normalized surgical dosing. Larger preoperative deviation was associated with lower success, particularly among patients with esotropia. These findings support tailored preoperative counseling regarding secondary interventions and warrant prospective studies evaluating adjusted treatment dosing in this population.