Nationwide Multicenter Survey of Severe Complications of Strabismus Surgery in Japan: Japanese Strabismus Surgery Study

Objective: The increasing incidence of esotropia, potentially associated with excessive smartphone use, highlights the importance of ensuring the safety of strabismus surgery. This nationwide questionnaire survey, conducted as the Japanese Strabismus Surgery (JASS) study, aimed to estimate the incidence of severe complications associated with strabismus surgery and to characterize perioperative management practices in Japan. Design: Nationwide, multicenter, questionnaire-based survey study. Participants: All strabismus specialists affiliated with the Japanese Association for Strabismus and Amblyopia. Methods: We conducted the survey between July and August 2025. We developed a structured questionnaire using Research Electronic Data Capture. Main Outcome Measures: Number of severe complications, including infectious endophthalmitis, orbital cellulitis, anterior segment ischemia (grade 3 or higher), and scleral perforation with retinal detachment, as well as perioperative management protocols. Results: Of 210 specialists, 99 completed the questionnaire (response rate, 47.1%). After excluding 2 nonsurgical respondents, we analyzed data from 97 active surgeons (mean experience, 28.7 ± 12.2 years) covering 108 623 strabismus surgeries. Incidence rates (per 100 000 surgeries) of severe complications were 0.92 (95% confidence interval [CI], 0.02-5.13) for infectious endophthalmitis, 1.84 (95% CI, 0.22-6.65) for orbital cellulitis, 8.29 (95% CI, 3.79-15.73) for anterior segment ischemia, and 3.68 (95% CI, 1.00-9.43) for scleral perforation with retinal detachment. For perioperative management, nearly all surgeons (91.8%) used povidone-iodine immediately before surgery, all (100%) prescribed postoperative antibiotics, and most (74.2%) used adhesive drapes. A large majority (87.6%) conducted the first postoperative follow-up examination on day 1. Conclusions: This JASS study demonstrates that severe complications associated with strabismus surgery are exceedingly rare in Japan. Stringent, standardized management protocols, particularly for infection control and early postoperative follow-up, may contribute to this high level of safety. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.