Types of strabismus and strabismus surgery after retinal detachment repair: a health registry database analysis.

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Published in final edited form as: J AAPOS. 2025 May 10;29(3):104216. doi: 10.1016/j.jaapos.2025.104216 Types of strabismus and strabismus surgery after retinal detachment repair: a health registry database analysis Brian T Soetikno a , Elaine M Tran a , Karen M Wai a , Prithvi Mruthyunjaya a , Ehsan Rahimy a, b , Euna B Koo a Author information Article notes Copyright and License information a Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California b Department of Ophthalmology, Palo Alto Medical Foundation, Palo Alto, California ✉ Correspondence: Euna Koo, MD, Department of Ophthalmology, Byers Eye Institute at Stanford University, 2452 Watson Court Palo Alto, CA 94303 ( eunakoo@stanford.edu ). Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12185234  NIHMSID: NIHMS2081801  PMID: 40355074 The publisher's version of this article is available at J AAPOS Abstract Purpose To examine the rate of diplopia, strabismus, and interventions for strabismus after pneumatic retinopexy, scleral buckle, and pars plana vitrectomy with and without scleral buckle for primary repair of rhegmatogenous retinal detachment (RRD). Methods This retrospective cohort study draws on deidentified EHR data of over 126 million patients in the TriNetX Analytics platform, a federated health research network. Subjects were assigned to three cohorts: pneumatic retinopexy (PR) alone, scleral buckle (SB) alone, or pars plana vitrectomy with or without scleral buckle (PPV+/−SB). Univariate analyses and propensity score matching (PSM) sensitivity analyses were conducted. Main outcomes were the risk of diplopia, strabismus, sensorimotor examination, or strabismus interventions, including chemodenervation or surgery. Kaplan-Meier analysis was performed. Results A total of 25,169 subjects were identified: PR (n = 1,646), SB (n = 3,658), and PPV+/−SB (n = 19,865). SB had the highest rates of diplopia (2.73%) and strabismus (1.79%), followed by PPV+/−SB (diplopia, 2.28%; strabismus, 1.46%) and PR (diplopia, 1.54%; strabismus, 0.612%). SB and PPV+/−SB had a significantly higher risk of diplopia ( P < 0.01) and strabismus ( P < 0.001) compared to PR. No significant differences were observed between PPV+/−SB and SB ( P = 0.106 and P = 0.139). Kaplan-Meier analysis indicated SB had the highest hazard during the first year after surgery. Strabismus interventions were rare, with surgery in ≤0.27% of the SB cohort, 0.22% of the PPV+/−SB cohort, and ≤0.61% of the PR cohort. No subjects underwent chemodenervation. Conclusions The risk of diplopia and strabismus after RRD treatments is low. SB carries the highest risk, followed by PPV+/−SB and PR. These findings support informed decision making in selecting RRD repair techniques. Diplopia and strabismus are potential, recognized complications after rhegmatogenous retinal detachment (RRD) repair, particularly when scleral buckling (SB) is used either alone or in conjunction with pars plana vitrectomy (PPV). 1 The effects of postoperative strabismus can significantly impact a patient’s functional quality of life, including visual disorientation, loss of depth perception, difficulty performing activities of daily living, and psychosocial distress related to the cosmetic appearance. 2 Characterizing these complications after RRD repair is critical to appropriately counseling patients on the risks of surgery and optimizing improving functional outcomes of RRD repair techniques. SB use is often cited as a primary risk for resultant strabismus after RRD repair surgery, because the technique requires manipulation of the extraocular muscles. In addition, SB elements, either encircling, segmental or radial, may alter the contact of the muscle with the sclera and change the vector of action of the extraocular muscles, providing an obvious mechanism for diplopia and strabismus. 3 Although the buckle is likely a significant factor, other factors for strabismus after RRD repair have been recognized. Mechanical factors, such as restrictive adhesions, fat adherence syndrome, iatrogenic muscle injury, and anesthetic-induced myotoxicity, may contribute to post-RRD strabismus. 3 Sensory factors, including reduced visual acuity and metamorphopsia from macular pathology as well as aniseikonia due to silicone oil or axial length changes, can disrupt sensory fusion, causing diplopia. Prolonged sensory deprivation may reveal latent phoria or tropia, and subtle macular displacement in macula-involving RRDs can lead to cyclovertical strabismus. 3 – 6 Thus, although the mechanical influence of the SB is a significant mechanism for strabismus, it is possible that RRD repair employing techniques such as pneumatic retinopexy (PR) and PPV may also induce diplopia. Up to 50% of patients may experience transient strabismus after RRD repair, which usually resolves in 3–6 months. 3 However, depending on the cited source, persistent strabismus and diplopia have been variably described in 5%-25% of cases. 7 Although postoperative diplopia and strabismus have been studied in small retrospective studies, the findings are often variable because of the limited sample sizes studied and the rarity of the complications. 8 , 9 In the current study, we used a large, federated health research network of deidentified electronic health record (EHR) data from over 126 million patients to investigate the rates of diplopia, strabismus, and corrective procedures after different RRD repair techniques. Methods This retrospective cohort study used the TriNetX Health Research Network (TriNetX, LLC, Cambridge, MA), a platform that consolidates deidentified EHR data from over 80 healthcare organizations globally, including 56 organizations within the United States. Although the TriNetX network contains data from healthcare systems in multiple countries, this study analyzed only data from United States–based patients from 43 healthcare organizations. By focusing exclusively on US data, we ensured that the ICD-10 and CPT coding reflects standardized US practices and that the findings are relevant to US regional and national practice patterns. TriNetX adheres to regulations of the US Health Insurance Portability and Accountability Act of 1996 and holds certification under the ISO 27001:2013 standard. Data from the TriNetX platform are presented in an aggregated, deidentified manner, and hence this study was exempt from institutional review board approval. The most updated data utilized for this study was collected on July 13, 2024. At the time of data querying, the TriNetX research database included records from 126,087,186 subjects. Our research followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cohort studies. 10 Inclusion Criteria and Outcome Definitions Three cohorts were extracted from the database to represent subjects that underwent primary repair for RRD: PR, SB alone, and PPV with or without SB (PPV+/−SB). Each cohort included patients identified by the International Classification of Diseases, Tenth Revision (ICD-10) code for retinal detachment with retinal break (H33.0) paired together with the corresponding Current Procedural Terminology (CPT) codes for primary repair: PR (67110), SB (67107), and PPV+/−SB (67108). The prerequisite requirements for each of the three cohorts are provided in Supplement 1 (available at jaapos.org ), eTables 1 – 3 , respectively. For each cohort, the corresponding CPT code was required to be mutually exclusive at the index date of inclusion. For example, for the PR group, subjects with the CPT codes 67107 and 61708 were excluded, thus limiting patients to having only one type of repair. For each cohort, codes 67112 (removed from the 2016 version of CPT) and 67113 were excluded to limit subjects from having had prior retinal detachment repair and complex retinal detachment repair surgery, respectively. Subjects were excluded with a history of amblyopia ex anopsia (H53.0), thyroid eye disease (E05.00), or with any prior history of strabismus or diplopia coding. Age was restricted to >18 years of age for each cohort. All subjects with the RRD repair code within 20 years before the analysis were included (ie, January 1, 2004, through July 13, 2024). We investigated the rates of diplopia and strabismus after RRD repair, the rate of workup, and the rate of interventions. We defined five primary outcomes: diplopia, strabismus, sensorimotor exam, chemodenervation, and strabismus surgery ( Supplement 1 , eTable 4 ). Diplopia was denoted by its respective ICD-10 classification code (H53.2). Strabismus was defined as any ocular misalignment and thus included ICD-10 codes for esotropia (H50.0), exotropia (H50.1), vertical strabismus (H50.2), mechanical strabismus (H50.6), and cyclotropia (H50.41). Workup for strabismus was inferred from the sensorimotor examination (CPT 92060). Interventions included chemodenervation (eg, perimuscular botulinum toxin injection) of an extraocular muscle (67345) and strabismus surgery. Strabismus surgery included CPT codes for superior oblique surgery (67318), vertical muscle surgery (67314, 67316), horizontal muscle surgery (67311, 67312), and other CPT codes that could represent strabismus surgery after a retinal detachment repair (see Supplement 1 , eTable 4 ). Subtypes of diplopia and strabismus surgery and their respective ICD-10 and CPT codes were also investigated ( Supplement 1 , eTable 5 ). Statistical Analysis In the primary analysis, we explored associations between the primary outcomes and the three RRD repair cohorts. Primary outcomes were analyzed up to 5 years after the RRD repair code. All subjects with the primary outcome before the RRD repair were excluded from the analyses. In other words, patients with existing diplopia or strabismus before the retina detachment and repair codes were excluded from the analysis. Measures of association analysis were calculated directly on the interactive TriNetX research platform. Univariate analyses were conducted between PR vs SB, PR vs PPV, and SB vs PPV for each outcome. P values of <0.05 were considered significant. The TrinetX platform obfuscates counts under 10 to protect subject privacy. 11 , 12 When the actual patient count is between 1 and 10, the count reported by TrinetX is rounded to 10. We reported the count as “[1,10]” in our tables when this occurred. In some situations, this range strengthens the statistical hypothesis testing, but in others it makes testing inconclusive. Whenever obfuscation was encountered, we performed statistical testing for a count of 1 and 10, testing the upper and lower range of the obfuscated data. If the statistical conclusion remained the same regardless of the count, the significance for the count of 10 was reported, the same as the P value reported by the TrinetX platform. If the statistical conclusion differed, the testing was deemed inconclusive due to the obfuscation of the actual count, and this was denoted by a † in our tables. To support our primary analysis and reduce the effect of possible bias from confounders, propensity score matching (PSM) was performed as a secondary sensitivity analysis, controlling for age, sex, race, and ethnicity, and ICD-10 codes for myopia and degenerative myopia. PSM was conducted using the TriNetX analysis platform (1:1 matching by nearest neighbor greedy matching algorithm with a caliper of 0.25 standard deviations). Finally, we conducted a survival analysis with Kaplan-Meier curves on the TriNetX research platform for each primary outcome. The log-rank test and hazard ratio for the survival curves were calculated. Results We identified 1,646 subjects for the PR cohort, 3,658 subjects for the SB cohort, and 19,865 subjects for the PPV+/−SB cohort that matched our inclusion and exclusion criteria ( Table 1 ). In our primary analysis, the SB cohort had a statistically significant higher risk of diplopia within five years of the initial repair (2.73%) compared with PR (1.54% [ P < 0.01]), but this was not statistically significant compared to PPV+/−SB (2.28% [ P = 0.106]) ( Table 2 ). The SB cohort had a statistically significant higher rate of new-onset coded diagnosis of strabismus (1.79%) compared with the PR (0.61% [ P = 0.0009]), but it did not differ significantly from PPV+/−SB (1.46% [ P = 0.139]). PPV+/−SB likewise had a greater risk of strabismus than PR (1.46% vs 0.61%; P = 0.005). We found no statistically significant difference in the risk of requiring sensorimotor examination evaluation for PR vs SB (0.80% vs 1.29% [ P = 0.119]) and PR vs PPV+/−SB (0.80% vs 0.93% [ P = 0.59]). SB had a statistically significantly higher rate of sensorimotor examination than PPV+/−SB (1.29% vs 0.93% [ P = 0.0436]). Table 1. Demographic characteristics of the RRD repair cohorts Characteristic PR SB PPV+/−SB Age at Index, years 59.6 ± 11.9 45.7 ± 17.5 59.5 ± 13.5 Male 953 57.90% 2083 56.94% 12267 61.75% Female 680 41.31% 1486 40.62% 6486 32.65% Unknown sex 13 0.79% 89 2.43% 1112 5.60% Hispanic or Latino 120 7.29% 356 9.73% 1556 7.83% Not Hispanic or Latino 1231 74.79% 2569 70.23% 13953 70.24% Unknown ethnicity 295 17.92% 733 20.04% 4356 21.93% White 1283 77.95% 2580 70.53% 14204 71.50% Black or African American 60 3.65% 296 8.09% 1280 6.44% Asian 57 3.46% 176 4.81% 516 2.60% American Indian or Alaska Native 10 0.61% 12 0.33% 49 0.25% Native Hawaiian or Other Pacific Islander 10 0.61% 10 0.27% 70 0.35% Other race 54 3.28% 130 3.55% 748 3.77% Unknown race 183 11.12% 461 12.60% 2998 15.09% Degenerative myopia, bilateral 10 0.61% 88 2.41% 43 0.22% Myopia 10 0.61% 20 0.55% 228 1.15% Total 1646 3658 19865 Open in a new tab PPV+/−SB, pars plana vitrectomy with or without scleral buckle; PR, pneumatic retinopexy; SB, scleral buckle alone. Table 2. Primary outcomes after rhegmatogenous retinal detachment repair Outcome PR SB P value PPV +/− SB P value PR vs SB PR vs PPV SB vs PPV Diplopia Number (risk) 25 (1.54%) 99 (2.73%) 0.00868 449 (2.28%) 0.05 0.106 Risk difference (vs PR) 1.19% (0.389%, 1.99%) 0.746% (0.112%, 1.38%) Risk ratio (vs PR) 1.77 (1.15, 2.74) 1.48 (0.996, 2.21) Risk difference (vs SB) −0.443% (−1.01%, 0.127%) Risk ratio (vs SB) 0.838 (0.676, 1.04) Strabismus Number (risk) [1,10] [0.06%, 0.612%] 65 (1.79%) 0.000871 288 (1.46%) 0.005 0.139 Risk difference (vs PR) 1.17% (0.601%, 1.75%) 0.848% (0.435%, 1.26%) Risk ratio (vs PR) 2.92 (1.5, 5.66) 2.39 (1.27, 4.47) Risk difference (vs SB) −0.326% (−0.787%, 0.136%) Risk ratio (vs SB) 0.818 (0.626, 1.07) Sensorimotor exam Number (risk) 13 (0.797%) 47 (1.29%) 0.119 184 (0.929%) 0.59 0.0436 Risk difference (vs PR) 0.491% (−0.0741%, 1.06%) 0.132% (−0.319%, 0.584%) Risk ratio (vs PR) 1.62 (0.877, 2.98) 1.17 (0.666, 2.04) Risk difference (vs SB) −0.359% (−0.749%, 0.0304%) Risk ratio (vs SB) 0.721 (0.525, 0.992) Strabismus surgery Number (risk) [1,10] [0.06%, 0.612%] [1,10] (0.274%) Not 45 (0.227%) Not Not Risk difference (vs PR) −0.335% (−0.747%, 0.0776%) reported a −0.381% (−0.763%, 0.000189%) reported a reported a Risk ratio (vs PR) 0.45 (0.188, 1.08) 0.373 (0.188, 0.739) Risk difference (vs SB) −0.0468% (−0.229%, 0.135%) Risk ratio (vs SB) 0.829 (0.418, 1.64) Open in a new tab PPV+/−SB, pars plana vitrectomy with or without scleral buckle; PR, pneumatic retinopexy; SB, scleral buckle alone. a Not reported because of obfuscated counts and inconclusive statistical testing; TrinetX obfuscates counts between 1 and 10 to protect patient privacy. No subjects in any of the three cohorts received chemodenervation procedures for strabismus. For strabismus surgery, 0.27% of subjects in the SB group underwent surgery after RRD; however, due to the TrinetX platform’s data privacy practices, the count was reported as a range ([1,10]), making the possible percentage as low as 0.027%. Similarly, in the PR cohort, 0.61% had strabismus surgery, but the count was also reported in single digits ([1,10]); thus, the percentage could be as low as 0.06%. In the PPV+/−SB cohort, 0.23% of subjects underwent surgery. The uncertainty in the counts of these outcomes due to single digit reporting by TrinetX made statistical testing between PR vs SB, PR vs PPV+/−SB, and SB vs PPV+/−SB inconclusive. We carried out PSM in a secondary sensitivity analysis, which matches the size of the patient cohorts in each comparison as well as the patient characteristics. After PSM, the cohorts showed nearly equivalent patient characteristics for each comparison between the three cohorts ( Supplement 1 , eTables 7 – 9 ). After PSM, PPV+/−SB did show a significant difference compared with PR for the diplopia outcome (2.82% vs 1.54% [ P = 0.012]). For the strabismus outcomes, the statistical conclusions in our sensitivity analysis with PSM remained similar to our primary analysis ( Supplement 1 , eTable 9 – 11 ). With PSM, the risk of sensorimotor examination for PR vs SB was statistically significant (0.71% vs 1.56% [ P = 0.0339]), whereas PR vs PPV+/−SB remained not significant (0.80% vs 1.1% [ P = 0.372]). After PSM, the rate of sensorimotor examination of SB compared with PPV+/−SB was no longer significant (1.31% vs 1.02%; P = 0.264). The rates of subtypes of strabismus were investigated as secondary outcomes ( eTable 6 ). Horizontal tropias were the most common (1.23%), followed by vertical tropias (0.88%), mechanical strabismus (0.27%), and then cyclotropia (0%). A similar trend was also observed in the PPV+/−SB group, with horizontal tropia being most common (1.00%), followed by vertical tropia (0.727%), mechanical strabismus (0.055%), and cyclotropia (0.050%). These secondary outcomes in the PR group were rare with single-digit counts ([1,10]). The subtypes of strabismus surgery in the PR and SB groups were all rare, with single-digit counts ([1,10]) for horizontal muscle surgery, vertical muscle surgery, and superior oblique muscle surgery ( Supplement 1 , eTable 6 ). In the PPV+/−SB group, the most common strabismus surgery was horizontal muscle surgery (0.16); vertical muscle surgery (0.11%) and superior oblique surgery (0.05%) were rarer. Kaplan-Meier curves for the diplopia outcome showed an early divergence between the three groups by one year, sustained throughout the observation period ( Figure 1A ). The log-rank test confirms statistically significant differences in the diplopia survival curves for PR versus PPV+/−SB ( P = 0.0120) and PR versus SB ( P = 0.001). However, the difference between SB and PPV+/−SB was not statistically significant ( P = 0.080). PPV+/−SB had a greater hazard for diplopia compared with PR (hazard ratio: 1.7, 95% confidence interval: 1.1, 2.5; P = 0.0191). Similarly, SB had a higher hazard than PR (hazard ratio: 2.0, 95% confidence interval 1.3, 3.1; P = 0.033). PPV+/−SB had a smaller hazard ratio when compared with SB, but this was not statistically significant (hazard ratio: 0.8, 95% CI, 0.7–1.0 [ P = 0.297]). The diplopia survival probabilities at the end of the observation window were 97.5%, 95.7%, and 96.4% for the PR, SB, and PPV+/−SB cohorts, respectively. FIG 1. Open in a new tab Kaplan-Meier survival analysis for the diplopia (A) and strabismus outcomes (B) for the three RRD repair cohorts. The highest hazard is observed during the first year after RRD repair with stabilization of the curves after 1 year. Curves demonstrate a gradation effect with scleral buckle (SB) having the highest risk, followed by pars plana vitrectomy with or without scleral buckle (PPV+/−SB) and pneumatic retinopexy (PR). For the strabismus outcome ( Figure 1B ), the log-rank test confirms statistically significant differences in the survival curves between PR vs PPV+/−SB ( P = 0.001) and PR versus SB ( P< 0.001) but not between SB versus PPV+/−SB ( P = 0.111). The hazard ratio is largest for the SB cohort during the first year but becomes similar between the groups beyond year one. None of the hazard ratios for strabismus were statistically significant (PR vs PPV+/−SB hazard ratio, 3.0, and 95% CI, 1.5–5.8 [ P = 0.491]; PR vs SB hazard ratio, 3.7, and 95% CI 1.8–7.4 [ P = 0.297]; SB vs PPV hazard ratio, 0.8, and 95% CI, 0.6–1.1 [ P = 0.115]). The survival probability at the end of the observation window was 99.2%, 97.2%, and 97.6% for the PR, SB, and PPV+/−SB cohorts, respectively. Kaplan-Meier analysis was also performed for the sensorimotor examination and the strabismus surgery outcomes ( Supplement 1 , eFigures 1 – 2 ), which showed similar gradation effects between the three groups. Discussion Strabismus can significantly impact functional vision and quality of life after RRD repair. Our analysis of a large EMR database showed that diplopia and strabismus rates were highest following SB (2.73% and 1.79%, resp.), followed by PPV+/−SB, with PR having the lowest incidence (1.54% for diplopia and 0.61% for strabismus). PSM analyses and Kaplan-Meier analyses confirmed these findings, with SB showing the highest hazard within the first year post-RRD repair. Horizontal tropias were the most common strabismus type, consistent with previous studies. 13 These findings suggest that patients undergoing SB repair have an overall low rate of diplopia and strabismus but higher than patients treated with PR or PPV, warranting preoperative counseling on these complications. PPV alone presents a theoretically lower risk than SB due to the absence of muscle manipulation. Prior studies have indicated PPV’s superiority over SB in terms of diplopia rates. 14 Although utilizing real-world CPT codes for PPV+/−SB was not granular enough to distinguish subjects who had a PPV with SB from those without SB, potentially obscuring more pronounced differences between techniques, we could still observe a trend that matched the theoretical mechanisms as PPV+/−SB had an intermediate risk of diplopia (1.79%) and strabismus (1.46%) between SB and PR. Kaplan-Meier analysis for diplopia and strabismus also demonstrated curves between the PR and SB groups, further confirming a gradation effect ( Figure 1 ). In addition to the lack of a SB, the lower incidence of diplopia and strabismus in PR may reflect shorter monocular occlusion times. Specifically, there is usually a smaller gas fill compared with that of PPV+/−SB, which may reduce the risk of decompensating pre-existing phorias or microtropias. Additionally, PR patients are less likely to receive a retrobulbar block, which may further minimize the risk of postoperative strabismus. Strabismus surgery after RRD repair was uncommon, with low rates across all groups (0.27% for SB, 0.23% for PPV+/−SB, and 0.61% for PR). For comparison, a recent retrospective study from a single retina practice reported a similar 0.17% incidence of strabismus surgery (7 cases of 4,176 retinal detachment repairs). 15 Notably, only 2 of these cases involved scleral buckle placement, underscoring the multifactorial causes of strabismus following retinal detachment repair. Literature consensus indicates that most post-SB strabismus cases are conservatively managed, with surgery reserved for complex deviations. 13 , 16 Our findings also suggest that workup for strabismus post-RRD repair using the sensorimotor examination might be underutilized. Botulinum toxin injection into an extraocular muscle (chemodenervation) is another method for temporarily treating strabismus for minor, intermittent deviations; however, in our study, no individuals underwent this procedure. Limitations of this study include inability to separate PPV from SB because of the real-world use of CPT codes and lack of laterality data, which limits confirmation of direct correlations between the primary procedure and strabismus interventions. Additionally, the absence of detailed operative reports prevents deeper analyses of factors such as preoperative visual acuity, fovea-involvement status, or specific surgical techniques, including the type of buckling elements used. Visual acuity data, which was unavailable, could have helped distinguish sensory from nonsensory patterns of strabismus and provided context for the possibly higher rates of strabismus surgery observed following PR, because patients with better postoperative vision may be more likely to pursue surgical intervention for symptomatic diplopia. Furthermore, without access to patient records and sensorimotor examinations prior to retinal surgery, we are unable to distinguish monocular refractive shifts and decompensated preexisting phorias, or microtropias, from true newly acquired tropias. High myopia, controlled for in our study, could be a contributing factor if not recorded. Undetected prior history of strabismus or previous strabismus surgeries could also be factors. However, we mitigated this by excluding subjects with previous diplopia, strabismus, amblyopia, and thyroid eye disease from the analysis. Our study relies heavily on the accuracy of coding by healthcare providers. Although combining ICD-10 and CPT codes enhances our data’s reliability, coding inaccuracies could still affect our findings. The ICD-10 codes for diplopia do not distinguish between monocular and binocular diplopia. As such, cases of nonstrabismic origin may have been misclassified, mainly if patients were referred for evaluation based on symptoms without a formal sensorimotor examination. A key limitation of this study is the reliance on data from a single health repository, which may only encompass some healthcare encounters for individual patients. For instance, strabismus surgeries performed outside the participating systems or uncaptured in follow-up records may not be included, potentially leading to an underestimation of incidence. Finally, the TriNetX platform does not support three-cohort propensity score matching, thus limiting this technique to a secondary analysis. The strengths of this study include its large sample size, which involves multiple healthcare organizations from large healthcare systems representing a heterogeneous patient population, both geographically and racially. The number of patients included in our study exceeds cited sources in the literature based on meta-analyses or small retrospective studies. Notably, TriNetX is a live real-world database with new patient data being added daily, allowing for observations and trends to be captured in real-time without delays. The present study represents the largest aggregate group of EMR records examining this study question to date while enforcing strict inclusion and exclusionary criteria and well-matched cohorts to account for patient and disease-specific differences. We were also able to examine longer-term outcomes (up to 5 years) while maintaining a robust study size. In conclusion, this study has defined the risk of diplopia and strabismus in a large study cohort, which can be utilized in preoperative counseling. SB carries a higher risk of diplopia and strabismus compared to other techniques. The risk of subsequent strabismus surgery post-RRD repair is extremely rare. Patients with strabismus may benefit from appropriate strabismus evaluation including a full sensorimotor examination to consider both surgical and nonsurgical options to reduce symptomatic diplopia. Supplementary Material 1 NIHMS2081801-supplement-1.pdf (215.4KB, pdf) Disclosures: PM is a consultant for Aura Biosciences, Castle Biosciences, Alcon, Amgen, Immunogen, and Genentech; receives grant support from Genentech; and is a lecturer for Alcon. EK is a consultant for Verana Health. ER is a consultant for Allergan/Abbvie, Apellis, Genentech, Iveric Bio, Regeneron, and Zeiss; a speaker for Allergan/Abbvie, Apellis, Genentech, Iveric Bio, Regeneron. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. References 1. Regillo CD, Benson WE. Retinal detachment: diagnosis and management. Philadelphia: Lippincott-Raven; 1998. [ Google Scholar ] 2. McBain HB, Au CK, Hancox J, et al. The impact of strabismus on quality of life in adults with and without diplopia: a systematic review. Surv Ophthalmol 2014;59:185–91. [ DOI ] [ PubMed ] [ Google Scholar ] 3. Guo S, Wagner R, Gewirtz M, et al. Diplopia and strabismus following ocular surgeries. Surv Ophthalmol 2010;55:335–58. 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