Outcomes of Strabismus Surgery in Pediatric Hydrocephalus: Does Shunting Influence Surgical Success?

Background/Objectives: The primary aim of this study was to evaluate the rate of strabismus and surgical outcomes in pediatric hydrocephalus (HC) patients, and compare the results in patients with and without ventriculoperitoneal (VP) shunt surgery. Methods: This study includes pediatric HC patients who were followed at the pediatric ophthalmology and strabismus unit of a tertiary hospital. Detailed ophthalmological examinations including deviation angle were performed. Preoperative measurements and surgeries were carried out by one strabismus expert. Postoperative deviation of ≤10 prism diopters (PD) was considered successful. Results: In total, 64 subjects were included in this study (29 female, 35 male), and 42 had a VP shunt (shunt+), while 22 were shunt-. The mean age of participants was 8.5 ± 4.6 years, and 50% (n = 32) of them had strabismus (22 esotropia, 10 exotropia). Both groups had similar refractive error and visual acuities (p > 0.05). Amblyopia rates were 21% (9/42) vs. 23% (5/22) in the shunt+ and shunt- groups. In 40% of shunt+ patients (17/42) there was strabismus, compared to 68% of shunt- patients (15/22). Among 22 patients with esotropia, 12 underwent strabismus surgery. Surgical success was achieved in nine patients (75%). In exotropic patients only one had surgery and it was successful. The operation rate in the strabismus group was 41% (13/32). Others mostly did not have surgery due to systemic comorbidities. Patients with strabismus had approximately 3.7 times higher odds of having epilepsy or spina bifida compared to those without strabismus (p = 0.049; OR = 3.69; 95% CI: 1.13-12.11). Conclusions: These findings suggest that children with hydrocephalus may benefit from regular pediatric ophthalmologic follow-up to detect strabismus, amblyopia, and refractive errors at an early stage. Although acceptable alignment outcomes were observed in selected operated patients, the small surgical cohort limits definitive conclusions regarding surgical success or the influence of VP shunting; therefore, treatment decisions should be individualized within a multidisciplinary framework.