A challenging case of scleral buckle-related restricted strabismus with unexpected good postoperative outcomes: A case report

Strabismus surgery in a scleral buckle patient is a challenging task that requires precise planning and meticulous surgical skills to accomplish a successful outcome. We report a case of a 32-year-old male who presented with complaints of diminution of vision in the right eye (RE) for 23 years and outward deviation of RE for 5 years after blunt trauma with a ball. The patient was diagnosed with RE total retinal detachment (RD) with traumatic retinal dialysis. He underwent scleral buckling as RD surgery in 2004 followed by silicon oil removal 6 months later elsewhere. On ocular examination of the RE, the best corrected visual acuity was perception of light with accurate projection of rays in all four quadrants, there was grade III relative afferent pupillary defect with an exotropia of 20° on Hirschberg test. The prism bar reflex test revealed an exotropia of 50 prism diopters (PD) [Figure 1]. An anterior segment examination revealed posterior subcapsular and cortical cataracts. After taking a retina clinic opinion, the patient underwent uneventful RE cataract surgery with in-bag implantation of a foldable implant cataract surgery first, followed by strabismus surgery under a guarded visual prognosis. Clinically significant adhesion and the presence of the scleral buckle posed a magnificent challenge during the strabismus surgery. The plan was improvised to 8 mm lateral rectus recession with 4 mm hang loose recession irrespective of a large deviation under local anesthesia. To our surprise, a satisfactory primary position alignment within 10 PD (orthophoria) was achieved, which was maintained on subsequent follow-up visits. We report an interesting and challenging case of restrictive strabismus due to scleral buckle which emphasizes that surgical procedures and their outcomes may not always align with expectations. Therefore, it is necessary to adopt a flexible and customized approach to effectively manage such instances.