Strabismus Repair (Pediatric)
Patient phenotype
Children 1-10 years usually. Otherwise healthy. Some with associated syndromes (cerebral palsy, Duane's, congenital fibrosis). Outpatient.
Procedure
EOM resection/recession to correct ocular misalignment. ~30-90 min. Supine. Local conjunctival incision; muscles isolated, repositioned.
Anesthetic plan
GETA with LMA usually (no need for paralysis). Standard induction (sevo mask + IV after asleep, or IV if cooperative). Avoid ketamine (nystagmus interferes with measurement).
Setup
- ·Standard monitors
- ·Pediatric LMA (or ETT if reflux/aspiration risk)
- ·Pediatric circuit
- ·Forced air warmer (Bair Hugger pediatric)
- ·Atropine drawn (oculocardiac reflex)
Biggest concerns by phase
MH risk — strabismus has higher historical association
Strabismus (especially with myopathy or family history) has HIGHER background MH risk than general pediatric surgery. Have dantrolene readily available. Avoid succinylcholine + volatile if MH-susceptible.
Inhalational induction (children) — standard mask
Sevoflurane 8% + N₂O if no contraindication. PIV after asleep. Avoid IM ketamine (nystagmus + delayed wakeup interferes with measurement).
Oculocardiac reflex — frequent + significant
Strongest with medial rectus traction. 20-90% incidence. Treatment: stop traction, deepen anesthesia. Persistent: atropine 10 mcg/kg or glyco 5 mcg/kg. Pretreatment debated (atropine routine?). Always have atropine ready.
PONV — high baseline rate (40-90%)
Strabismus is the highest-PONV pediatric surgery. Multimodal: dex 0.15 mg/kg + ondansetron 0.1 mg/kg + avoid N₂O + avoid opioid (use ketorolac or local). Hydration generous.
Smooth emergence
LMA pulled with patient awake (or fully deep — both work). Children + emergence delirium = consider dex 0.5 mcg/kg before emergence.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
5-yo otherwise healthy F for strabismus repair (medial rectus recession). Mom mentions her brother had a 'high temperature' during anesthesia 20 years ago. Plan?
What an examiner probes for
- ▹MH-susceptible until proven otherwise
- ▹TIVA (propofol + remi) + nondepolarizing if needed
- ▹Avoid sux + volatile
- ▹Dantrolene + cooling at hand
- ▹OCR + PONV management
Sources
- Miller's Ch 65 + 79
- MHAUS Guidelines
Anatomy reference
Sourced reference images. 4 matches for "eye orbital muscle".
