Use of neuromuscular blocking drugs in strabismus surgery: systematic review of literature and ophthalmology survey study.

OBJECTIVE Nondepolarizing neuromuscular blocking drugs have been advocated for accurate forced duction testing (FDT) during strabismus surgery. The purpose of this study was to evaluate the literature on use of muscle relaxants (MRs) in strabismus surgery and to evaluate the current practice of pediatric ophthalmologists. DESIGN Systematic review and survey study. PARTICIPANTS Seventy-seven pediatric ophthalmologists. METHODS MEDLINE, EMBASE, CENTRAL, Web of Science, and OpenGrey were searched to August 2019. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Primary studies on depolarizing or nondepolarizing MRs in patients undergoing strabismus surgery were included. Primary outcomes included indications and prevalence of use. A 23-question survey was emailed to pediatric ophthalmologists worldwide to collect practice pattern information involving MRs in strabismus surgery. RESULTS Three studies were included in the systematic review. MRs were used in 34%-45% of patients undergoing strabismus surgery in one 1999 study for FDT. No evidence exists to support the use of MRs for facilitating FDT. Seven of 77 (9.1%) pediatric ophthalmologists requested MRs for FDT. Those who use MRs were more likely to be practicing outside the United States (p < 0.05) and in academic hospitals or private centres rather than in community settings. Drawbacks appeared to outweigh benefits, with the biggest drawback identified as increased turnover time between surgical cases (44%). CONCLUSIONS Inadequate evidence exists in the literature to support the use of nondepolarizing MRs to maintain paralysis of extraocular muscles during strabismus surgery, and this is an uncommon practice among pediatric ophthalmologists.