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Abstract: An 8-year-old boy with crossed eyes since childhood had a physical examination suggesting the presence of internal strabismus and poor visual acuity in the left eye. The diagnosis of internal strabismus was established after a complete examination, and an extraocular muscle operation was performed under general anesthesia to correct the strabismus. After the surgery, the child felt good results and could see much easier, and the internal strabismus disappeared. After the surgery, he was trained in amblyopia and binocular vision, and all visual function indicators were normal at the time of review.
Basic information】Male, 8 years old
Disease Type】Internal strabismus, left eye amblyopia
Hospital】The First Affiliated Hospital of Zhengzhou University
Date of Consultation】April 2021
Treatment plan】Covering treatment + amblyopia training + extraocular muscle surgery
[Treatment Period] 10 months for amblyopia correction with masking, 5 days of inpatient treatment for extraocular muscle surgery, 3 weeks and 2 months of postoperative review
Treatment effect】corrected visual acuity restored, eye position orthostasis
I. Initial consultation
The parents complained that the child had been suffering from double vision since childhood. Afterwards, he got used to seeing it and did not feel it was obvious. This time, the child came to the doctor because of a school physical examination, which revealed poor vision in the left eye.
The child was then given a physical examination: binocular position +20°, alternating masking: internal→medium, no significant abnormalities in eye movements. Visual acuity OD1.0, OS0.5. No significant abnormalities were seen in the anterior segment and fundus of both eyes. IOP R16mmHg, L15mmHg. dilated pupil optometry: OD +0.00DS/+0.25DCx12=1.0, OS+0.50DS/+0.50DCx8=0.6. synoptic machine: Ⅰ objective +26°, Ⅱ none, Ⅲ none, Worth four-point light: near 2 lights, far 2 lights. The preliminary diagnosis of the above examination results was: internal strabismus and amblyopia of the left eye.
II. Treatment history
The diagnosis of internal strabismus was clear based on the child’s eye position examination and the results of the simultaneous vision machine, combined with the characteristics of the onset of the disease since childhood. The right eye is the dominant eye and the left eye is the dominant strabismus eye, and there is no obvious refractive aberration, so the left eye has poor corrected visual acuity and amblyopia is the result of long-term internal strabismus. In order to ensure the accuracy of the examination and the stability of the postoperative eye position, it was planned to treat the amblyopia in the left eye first and then consider surgery to correct the strabismus after the visual acuity of both eyes was balanced. The child was asked to cover the right eye for 6-8 hours a day, while the left eye was trained for amblyopia and reviewed every 1-2 months.
After about 10 months of masking treatment and 40 minutes of amblyopia training per day in the left eye, the child’s visual acuity in the left eye had reached a level of 0.8+. However, no improvement of the internal strabismus was observed. Therefore, it was proposed to perform extraocular muscle surgery to correct the strabismus and improve the appearance while trying to restore part of the binocular visual function.
After hospitalization, the trigeminal + masking examination was completed, and the results showed that 33cm +60△ and 6m +45△, and the posterior migration of the internal rectus muscle of the left eye was performed 5 mm under general anesthesia, and the shortening of the external rectus muscle was 4.5 mm.
III. Treatment effect
Outpatient review 3 weeks after the operation: the patient’s eye position was orthotropic and there was no self-conscious discomfort. The left eye was examined for mild conjunctival congestion, and the conjunctival incision healed neatly. The corrected visual acuity was OD1.0, OS0.8, and both eyes were orthotropically positioned. Synoptic machine: I + 2°, II no, III no, Worth four-point light: near 2 or 5 lights, far 2 or 3 lights.
The examination indicated orthotropia and partial recovery of binocular visual function, but training was still needed to have promoted simultaneous vision and fusion. Therefore, amblyopia training combined with binocular visual function training was given. On review after 2 months of training, the binocular visual function improved significantly.
IV. Notes
We are pleased that the child’s internal strabismus has disappeared and his visual acuity has been restored after the surgery and training. Therefore, the post-operative binocular vision training must be given enough attention. In general, we should actively remind the child to do a good job in training, maintain the correct learning posture, and reduce the time spent looking at electronic products. In addition, you can wear sunglasses to reduce the stimulation of the sun on the eyes.
V. Personal insight
Parents should pay attention to their children’s behavior. If the internal strabismus affects binocular vision, it is recommended to seek surgery as soon as possible, as early treatment is more plastic and the recovery effect after surgery is better. This child was already older at the time of consultation and was less plastic than younger children, making treatment more difficult. After full communication with the child and his family, they understood the danger of strabismus and actively cooperated with the treatment, which effectively improved the cure rate and eliminated the internal strabismus.