Changes call for innovation and innovation leads to progress
Dr. Meenakshi Swaminathan, MS
Department of Pediatric Ophthalmology
Sankara Nethralya, Chennai
Strabismus is an area that has continuously evolved over the last century. The evolution has been in areas of etiopathogenesis, imaging for strabismus, newer treatments, both surgical and non-surgical.
The etiology of many strabismus disorders remains an enigma. Genetic studies will play an important role in understanding conditions such as Duanes retraction syndrome and many forms of familial strabismus. Using imaging to understand central mechanisms of strabismus causation, especially the group of disorders called congenital cranial dysinnervation disorders (CCDD), will help plan better management of this complex group of disorders. Interest in extraocular muscle pulleys will continue to rise as evidence of their involvement in many disorders comes to light with better imaging. Functional imaging (fMRI) will also throw light on cortical mechanisms of amblyopia and responses to various treatments both monocular image degradation and binocular treatment. Greater insights into anatomical structures in the retina and choroid, as well as the optic nerve may be available with greater use of Optical coherence tomography (OCT). This in turn will help with our comprehension of the etiology of amblyopia.
Next ten years is also likely to see an increase in indications for use of Botulinum toxin, from its beginnings in treatment for paralytic strabismus to widespread use for several other situations. Pharmacological therapy for nystagmus which is now in its infancy will likely become routine practice thereby improving visual function for many patients. Newer drugs are likely to be introduced to improve the management of both amblyopia discovered in adults and refractory amblyopia. Dichoptic treatment of amblyopia will gain momentum as such treatment and availability
of tablet computers becomes more widespread and affordable.
As the search continues for surgical procedures with least chance of recurrence, there will be better techniques for adjustable suture strabismus surgery, more interest in augmentation for certain types of strabismus, more use of surgery on extraocular muscle pullies.
Surgical managment of patients with nystagmus, some with associated head posture and/or strabismus will find more takers as eye movement recordings become widely available, less expensive and as more people learn the interpretation and clinical significance of such recordings.
Patient comfort following strabismus surgery has always been a concern for the strabismologist as the vast majority are children. Minimally invasive surgery introduced in Switzerland may be one way to reduce comfort. Such surgeries have a learning curve. More training in this technique needs to be introduced through various forums to gain better acceptance. Other ways to minimize postoperative discomfort such as better pain management with injectable local anesthetics or safe non steroidal anti inflammatory agents will also become available. Other modalities of postoperative pain control with the least side effects may become the routine. Suture use for both anchoring the muscles and conjunctival closure may become obsolete.
Standardized assessment of surgical performance of strabismus surgeries will become routine as more rubric based assessments become available. These will be incorporated as routine practice into training programs for fellows and postgraduates. Models of extraocular muscles will be made available in many training programs. Trainee surgeons can make use of these models to practice and perfect surgical techniques before trying them out on patients.
Greater awareness of psychological impact of strabismus amongst public and practitioners will lead to earlier referral for strabismus surgeries. These surgeries will no longer be labelled as ‘cosmetic’ as functional benefits such as alleviation of diplopia and regaining or obtaining stereopsis will become a definite possibility. More health care insurance providers will accept this change and support reimbursement for strabismus surgeries.
Greater interaction between oculoplasty surgeons and strabismologists will pave way for better techniques for periosteal fixation for many complex strabismus. Vision screening through photoscreening will become the norm in many paediatrician offices thereby detecting refractive errors and strabismus earlier than before. Photoscreeners will also be used more in school screening projects. The increase in demand will bring down the cost. Just as it has always been in science, so it shall be in strabismus that progress will happen through timely innovation.