Large-angle Esotropia Research Articles

Medial Rectus Disinsertion for the Management of Large-Angle Sensory Esotropia.

Background and Objectives: The aim of the report is to report the outcomes of the medial rectus (MR) disinsertion procedure for the management of large-angle esotropia (ET) patients. Materials and Methods: This is a retrospective case series of patients with large-angle ET who underwent an MR disinsertion procedure between March 2012 to April 2022. The procedure happened accidentally during muscle surgery. The demographic and clinical data, including sex, age, visual acuity, pre- and postoperative angle of strabismus, duction limitations, results of intraoperative forced duction tests, and follow-up duration were collected from medical records. Results: Five patients were enrolled in this study. The mean age was 62.2 ± 9.8 years, and the mean follow-up was 24.8 ± 8.7 months. The ET at the primary position of gaze was 92.0 ± 17.9 prism diopters (PD) before MR disinsertion and 38.0 ± 29.5 PD after MR disinsertion only. Abduction deficiency was -4 before after MR disinsertion, which improved to -1 at the last follow-up. Conclusions: The results of MR disinsertion were not as frustrating as anticipated. MR disinsertion may be considered in patients with large-angle sensory ET who refuse surgery on the opposite eye.

Extraocular muscle enlargement of indeterminate cause in pediatric patients: case series and literature review

To specify the clinical characteristics of enlarged extraocular muscles of indeterminate cause in pediatric patients based on a case series and literature review. The medical records of pediatric patients who presented between January 2019 and January 2022 with enlarged extraocular muscles, where the underlying cause could not be determined, were retrospectively reviewed. Four patients were included. The main reason for presentation was evaluation of abnormal head posture. Head tilt or turn with duction deficit was observed in all patients. The age of onset ranged from 6 months to 1 year. Two patients presented with esotropia and hypotropia; the other 2 patients, with large-angle esotropia. Orbital imaging was performed in all cases and revealed unilateral rectus muscle enlargement sparing the muscle tendon. All 4 patients were found to have enlarged medial rectus muscle. In the 2 patients with hypotropia, the inferior rectus muscle was also involved. No underlying systemic or orbital disease was found. There were no changes in the orbit or extraocular muscles on follow-up imaging test. The intraoperative forced duction test revealed severe restriction in the direction of gaze opposite to the primary field of action of the enlarged muscles. Enlargement of extraocular muscles should be considered in the differential diagnosis when large-angle incomitant vertical or horizontal misalignment and abnormal head posture are observed in infancy.

One-step triple surgery for large esotropia in Chinese patients with chronic sixth nerve palsy

The aim of this study is to evaluate the effect of a one-step triple surgery comprising inferior rectus belly transposition, augmented superior rectus transposition and medial rectus recession (IRBT-aSRT-MRc), in the management of large-angle esotropia in Chinese patients with chronic six nerve palsy.

Anchored versus conventional hang-back technique in large bimedial rectus recession

Purpose To compare surgical outcome of anchored hang-back technique (HBT) against conventional HBT in bimedial rectus-muscle recession (BMR) for large-angle esotropia. Design A retrospective nonrandomized comparative interventional study. Participants In total, 94 patients with esotropia and indicated for at least 6-mm BMR. Methods Patients were randomly assigned into two groups according to surgical technique of BMR: (a) anchored HBT and (b) conventional HBT. Postoperatively, angles of deviation were quantified for near and far. Alignment within 10-prism diopters (PD) of orthotropia was considered a successful result by the end of 6 months. Kaplan–Meier analysis was used to determine the cumulative survival in both groups. Results In total, 48 patients underwent conventional HBT and 46 patients in the anchored HBT. Preoperatively, mean angles of deviation for near and far were 61.6 and 60.1 PD in the conventional group, versus 62.2 and 60.4 PD in the anchored group, respectively (P>0.05). By the sixth postoperative month, the mean angles of deviation for near and far in the conventional group were -1.4 and -3.4 PD, versus 1.2 and 0.1 PD in the anchored group, respectively (P=0.03). Success rate was 76% in the conventional group, versus 87.5% in the anchored group (P=0.03). Kaplan–Meier survival analysis showed a significantly higher cumulative 6-month incidence of failure in the conventional HBT group than the anchored one (P=0.025, Log rank). Conclusion Anchored HBT showed a higher efficacy than conventional HBT in large BMR recession.

Three-muscle surgery for large-angle esotropia in chronic sixth nerve palsy: comparison of two approaches

AimsTo report the effect of two three-muscle surgeries, inferior rectus belly transposition plus augmented superior rectus transposition plus medial rectus recession (ISM) and modified vertical rectus belly transposition plus medial...

Response to botulinum neurotoxin injections in large-angle infantile esotropia: a post hoc analysis

To determine the anticipated reduction of baseline angle of esotropia and identify predictors of change following botulinum neurotoxin (BNT) injections in large-angle infantile esotropia. This was a prospective, longitudinal study of children <10 years of age diagnosed with infantile esotropia of >30Δ and given either 1, 2, or 3 BNT injections. Post-injection change from baseline deviation was recorded, and predictors of reduction were analyzed. For this study, children were further divided into subgroups based on initial deviation of ≤60Δ (group 1) and >60Δ (group 2). The outcomes of subsequent surgeries in failed cases were analyzed. A total of 117 children were included, 55 in group 1 and 62 in group 2. Mean age was 30.3 ± 18.8 months. Mean baseline deviation was 62.5Δ ± 13.1Δ: 51.4Δ ± 8.4Δ in group 1 and 73Δ± 7.5Δ in group 2. The mean number of injections was 2.2 ± 0.7. Success was achieved in 25.6% of patients (33.4% in group 1; 16.2% in group 2). The mean percentage reduction of deviation after BNT injection was 55.2% ± 26%, larger in group 1 than in group 2 (61.3% vs 51.1% [P = 0.001]). Five children reverted to baseline deviation. In multivariate analysis, adjusting for number of injections, younger age and larger baseline deviation were significant independent predictors of a larger absolute amount of reduction (P = 0.02, and 0.002, resp.). Thirty-two children had subsequent surgery; 22 were followed for a minimum of 6 months, and 20 were aligned within 10Δ of orthotropia. In large-angle esotropia there was a reduction of approximately 50% of baseline deviation, with greater relative reduction for smaller baseline deviations; the absolute change in angle was greater in younger children. Alignment after subsequent surgery appeared to remain stable and surgery required less recession than would have been needed for the original angle of esotropia.

Two Stage Surgical Correction for Bilateral Sixth Nerve Palsy with Large-angle Esotropia

Two Stage Surgical Correction for Bilateral Sixth Nerve Palsy with Large-angle Esotropia

Three-muscle surgery for large angle esotropia

HintergrundZur Korrektur großwinkliger Esotropie sind die kombinierte Konvergenzoperation und die beidseitige Medialisrücklagerung ohne und mit Myopexie verbreitet. Nur wenige Berichte liegen zu Dreimuskeleingriffen (3 ME) vor. Wir analysierten die Ergebnisse von 3 ME.Patienten und MethodenVon Juni 2016 bis Mai 2020 erhielten 61 Patienten einen 3 ME wegen Esotropie ≥ 27°. Schrägschielen wurde mitbehandelt. Die Schielwinkel wurden in 5 m und 0,3 m im simultanen (SPCT) und alternierenden Prismenabdecktest (APCT) gemessen. Die Dosierung betrug 0,51 mm/° (APCT, 5 m). Die Ergebnisse von 57 Patienten waren auswertbar.ErgebnisseDie Mediane und Streubreiten (min-max) betrugen: Alter: 6 Jahre (3–56). APCT präoperativ: fern 34° (27–45), nah 36° (27–50). Operationsdosis: 17 mm (15–21), 21 Fälle mit Obliquuschirurgie. APCT 5 Monate (3–24) postoperativ: fern 2° (−10–18), nah 2° (−8–18). Einen Restwinkel im Betrag ≤ 6° (≈ 10 PD) wiesen (APCT) fern 39 (68 %), nah 38 (67 %) und (SPCT) fern 45 (79 %), nah 42 Patienten (74 %) auf. Eine konsekutive Exotropie > 6° im APCT hatten fern 4 (7 %), nah 3 (5 %), eine Esotropie > 6° hatten 14 (25 %) bzw. 16 Patienten (28 %).SchlussfolgerungDie 3 ME ist als Ersteingriff bei großwinkliger Esotropie gut geeignet.

Surgical outcomes of acute acquired comitant esotropia of adulthood

BackgroundAcute acquired comitant esotropia (AACE) is a type of strabismus characterized by a sudden onset of large angle esotropia with diplopia, which often occurs in children after infancy, teenagers, and young adolescents. However, studies on the surgical outcomes of only adults are rare. The purpose of this article is to analyze the surgical outcomes for adult patients diagnosed with AACE.MethodsMedical records of 24 patients who had undergone surgery for AACE were retrospectively analyzed. The main outcome measures were the final motor and sensory success rate after surgery and factors affecting motor and sensory outcomes. Motor success was considered alignment within 8 prism diopter (PD) at both near and distance and sensory success was stereoacuity ≥ 60 sec/arc.ResultsThe preoperative mean esodeviation angles were 33.1 ± 10.4 PD at distance and 33.3 ± 11.2 PD at near. The mean period of postoperative follow up was 7.5 ± 4.5 months (range 1–8 months). The postoperative mean esodeviation angles at final follow-up time were 3.4 ± 6.1 PD at distance and 3.8 ± 6.7 PD at near. The surgical motor success rate at final follow-up was 79.2% (19/24). The sensory success rate at final follow-up was 50.0% (12/24). The factor affecting the motor outcome was the type of surgery (p < 0.05). The factor affecting sensory outcome was postoperative follow-up time (p < 0.05).ConclusionsSurgery type appears to affect surgical motor outcomes in adults with AACE. Although the sensory outcome was favorable, it seems that regaining bifoveal fixation takes time.

Craniosynostosis, osteopetrosis, and Arnold-Chiari malformation type 1 – Ophthalmic manifestations

We report an interesting rare case of a child with a constellation of craniosynostosis (CS), osteopetrosis (OP), and Arnold-Chiari malformation type 1 (ACM1), presenting with developmental delay and progressive vision loss since infancy with normal intellect. The ophthalmic examination revealed bilateral advanced visual loss, bilateral proptosis, optic atrophy, and large angle esotropia in primary gaze. A systemic examination revealed facial dysmorphism, abnormal shape of the head, malunion fracture of the right arm, and scoliosis. Neuroimaging revealed features suggestive of CS, OP, and ACM-1. Neurosurgical consultation was sought, and the ventriculoperitoneal shunt was advised.

Muscle Transplantation for Large Angle Horizontal Strabismus.

Large angle sensory strabismus in the form of esotropia and exotropia often calls for bilateral surgery to correct the primary angle deviation. However, considering patients' reluctance to have surgery on the good eye, such large deviations may be managed with true muscle transplantation. The authors present a case series of four patients with large angle esotropia and exotropia who underwent unilateral true muscle transplantation as a single-stage procedure. [J Pediatr Ophthalmol Strabismus. 2020;57:e59-e62.].

Three horizontal muscle surgery for large-angle esotropia: success rate and dose-effect ratio.

To evaluate the moderate-term success and calculate the mean dose-effect ratio in large-angle esotropic patients who underwent three muscle surgery. In a retrospective study, we reviewed the medical records of 37 patients with large-angle esotropia who underwent bilateral medial rectus recession and one lateral rectus resection. Sex, age at surgery time, amount of recessed or resected muscles in millimeter (mm), pre- and postoperative alignment in prism diopter (D), dose/response ratio, and presence of amblyopia and other associated vertical deviations were recorded. The mean age of subjects at surgery was 12.2±12.3y (range: 1-57). The mean preoperative deviation of 70.4±8.1 D (range: 60-85 D) decreased to a mean of 5.4±8.1 D (range: 0-30 D) postoperatively (P<0.005). Successful alignment was achieved in 30 of 37 patients (81%) at a mean follow-up of 15.7±20.1mo (range: 3-90). The mean amount of recession and resection was 17.59±1.29 mm, and a mean dose-response ratio of 3.79±81 (range: 2.83-4.66) was determined. Three-muscle surgery for large-angle esotropia results in good moderate-term outcomes without high rates of overcorrection or undercorrection.

Single eye surgery by hang-back recession vs muscle transplantation in large-angle esotropia

Background A two horizontal muscle surgery cannot treat a very large angle of esotropia of more than 80 prism diopters (pd). A single eye surgery would not correct such a large angle. Supramaximal recession and resection would lead to restriction of ocular motility. True muscle transplantations have been tried for this abnormally wide-angle esotropia. Purpose The aim was to compare monocular surgery by hang-back recession vs muscle transplantation, regarding the technique, the expected results, and the possibility of minimizing the risk of complications, such as scleral perforation and a lost or slipped muscle. Patients and methods The study is a prospective and nonrandomized study that was held at the Ophthalmology Department, Al-Azhar University Hospitals, Egypt, during the period between May 2016 and May 2018 on 30 patients presenting with esotropia. A total of 15 patients had undergone medial rectus recession using the hang-back technique and 15 patients had undergone medial rectus recession with muscle transplantation. Conjunctival recession was done at the end of surgery, and lateral rectus resection was done in both groups. Their ages ranged from 4 to 58 years. Overall, 19 patients were males and 11 were females. Results There were nonstatistically significant differences between the two groups in all the follow-up visits. Conclusion True muscle transplantation is a safe alternative option and as effective as hang-back technique for large-angle esotropia. The procedure is stable in the long term, with some motility limitation in maximum adduction.

Vertical rectus muscle union combined with lateral rectus plication for complete abducens nerve palsy.

The aim of this study was to report our postoperative results concerning the vertical rectus (VR) muscle union combined with lateral rectus (LR) plication for the treatment of large-angle esotropia (ET) in complete abducens nerve palsy. Medical records from 36 patients who had undergone the VR union procedure for ET treatment due to sixth-nerve palsy between July 2014 and July 2018 at Beyoglu Eye Research and Training Hospital were reviewed. One week before surgery, all patients underwent a 4-IU botulinum toxin A (btx) injection into the ipsilateral medial rectus (MR). All patients then underwent a VR muscle union procedure. A non-absorbable suture was inserted through the lateral muscular margin of each VR muscle at approximately 1/5 the width from the edge at 10mm distance from the VR insertion. Both sutures were then tied to each other above the LR. Plication of the LR muscle using a non-absorbable suture was performed in all cases. The study population consisted of 14 (38.9%) females and 22 (61.1%) males. The mean age was 36.31 ± 19.16years. The mean preoperative deviation angle in primary gaze into distance was 47.77 ± 18.48 prism diopter (PD). The mean deviation angle 1year after surgery was -1.0 ± 6.62 PD. Abduction improved from -4.27 ± 0.46 to -1.88 ± 0.96. The VR muscle union in combination with LR plication appears to be an effective treatment procedure for complete abducens nerve palsy patients.

Amplified esotropia syndrome: long-standing, large-angle esotropia causing laxity of the lateral rectus–superior rectus band leading to progressive esotropia

Lateral rectus–superior rectus (LR-SR) band laxity has been implicated in multiple forms of strabismus; we present chronic, large-angle esotropia as a novel cause of this LR-SR laxity.

Botulinum toxin–augmented surgery for large-angle esotropia

Botulinum toxin–augmented surgery for large-angle esotropia

Post-operative analysis of pediatric esotropia associated with high hypermetropia

BackgroundTo describe clinical features, evaluation, surgical management and outcomes in children with esotropia associated with high hypermetropia.MethodsMedical records of healthy children who received strabismus surgery for accommodative esotropia with hypermetropia larger than spherical equivalence of + 4.0 diopters from 2009 to 2015, were reviewed.ResultsA total of 47 patients were identified. The average age was 2.9 years old. The average spherical equivalence of cycloplegic refraction was + 6.0 diopters (D). All patients presented with large angle esotropia with spectacle correction. Average age of esotropia onset was 1.3 years. Average time between the onset of esotropia to spectacle correction was 7.2 months. Average duration between onset of constant esotropia to strabismus surgery was 28.1 months. Average duration between spectacle correction to strabismus surgery was 21.8 months. Post-operatively, 74.5% of patients achieved ocular alignment within 10 prism diopters (PD) of orthotropia. Overall, 66.0% patients developed sensory fusion. For patients who achieved surgical success, 71.4% developed sensory fusion, compared at 50.0% for patients who were over- or under-corrected (p = 0.18). For patients who received hyperopic spectacles within 6 months of esotropia onset, 92.3% developed sensory fusion, compared with 54.5% for patients who received hyperopic spectacles at 6 month or later after esotropia onset (p = 0.02).ConclusionsStrabismus surgery for esotropia with high hypermetropia has high rate of surgical success with low rate of under- or over-correction. There is a trend toward higher rate of sensory fusion for patients with surgical success. Shorter time interval between esotropia onset and receiving hyperopic spectacles is associated with higher rate of sensory fusion development.

The management of large-angle esotropia in Graves ophthalmopathy with combined medial rectus recession and lateral rectus resection

To describe surgical management and outcomes for large-angle esotropia of ≥50Δ secondary to Graves ophthalmopathy using combined initial nonadjustable medial rectus recessions and lateral rectus resections. The medical records of consecutive patients undergoing strabismus surgery for large-angle esotropia secondary to Graves ophthalmopathy from 1995 to 2012 by a single surgeon at each of two institutions was performed. Patient characteristics, surgical technique, and pre- and postoperative measurements of ocular alignment were analyzed. A modified Gorman diplopia scale was used to assess outcome. Of 38 patients, 36 had bilateral nonadjustable medial rectus recessions and lateral rectus resections as initial treatment for esotropia, and 6 patients underwent simultaneous vertical muscle surgery. Mean preoperative horizontal deviation was 60Δ and mean preoperative vertical deviation was 10Δ. Of the 38 patients, 19 (50%) reached the primary outcome, including 5 of 6 (85%) who had no preoperative vertical strabismus. The indications for reoperation were vertical strabismus in 13 of 21 patients (62%), residual esotropia in 7 of 21 (33%), and consecutive exotropia in 1 of 21 (5%). With a median follow-up of 13.2months after first surgery, 32 of 38 patients (84%) reached the secondary outcome. Combining nonadjustable medial rectus recessions with lateral rectus resections can be a beneficial primary treatment for large-angle esotropia in patients with Graves ophthalmopathy, especially in those patients with small or no associated vertical strabismus.

Surgical outcome of a new modification to muscle belly union surgery in heavy eye syndrome

ABSTRACTObjectives: To report the clinical outcomes of a new modification to muscle belly union surgery in heavy eye syndrome.Methods: Muscle belly union was performed in patients with large-angle esotropia and characteristic findings of heavy eye syndrome on orbital imaging. After isolation of superior and lateral rectus muscle and passing a single armed suture in each muscle belly, approximation was achieved via tying of both arms of separate sutures together. Medial rectus (MR) was also recessed considering the results of the intraoperative force duction test.Results: Surgery was conducted in 24 eyes of 16 patients. The mean preoperative esotropia was 93.71 ± 23.1 prism diopters (PD), which improved significantly after the operation (final esotropia: 11.53 ± 15.59 PD, P value = 0.001). Six patients also exhibited mild hypotropia preoperatively (9.33 ± 6.88 PD), which resolved completely after surgery in all cases. Evaluation of preoperative abduction limitation (minus 3.1 ± 1.83) showed a significant improvement postoperatively (minus 0.95 ± 0.68, P value = 0.000). Additionally, mild limitation of adduction (minus 1) was seen in nine patients due to large MR recession. However, none of the patients reported postoperative diplopia.Conclusion: Our new approach in muscle belly union surgery resulted in favorable outcomes compared with previous studies. It seems that the two-suture technique presented in this study yields more convenient approximation of muscle bellies and acts as a safety suture upon spontaneous loosening of the first applied suture.

A modified vertical muscle transposition for the treatment of large-angle esotropia due to sixth nerve palsy

ABSTRACTIntroduction: Multiple different procedures have been proposed to address complete sixth nerve palsy with severe abduction limitation. In this study, we report a modification of the Hummelsheim’s procedure. It is in fact muscle pulley transposition that obviates the need for tenotomy or muscle splitting. For the first time, Muraki and Nishida proposed this technique.Materials and Methods: Patients with large angle esotropia and abduction limitation of minus four or greater were enrolled. The surgery involved insertion of a polyester monofilament fiber suture through the temporal muscular margin of each vertical rectus muscle at approximately one-third of the width from the edge at 10 mm behind the muscle insertion. We tried to insert sutures away from the vessels of vertical muscles. Then, the vertical muscles were transposed without any tenotomy or splitting and the sutures were secured to the sclera 16 mm from the limbus in supratemporal and infratemporal quadrants. In all of the patients, this transposition was combined with medial rectus recession.Results: A total of 10 patients were included; all of them had an esotropia with profound abduction deficit (−4 or more). The mean age of patients was 44.2 ± 9.2 years (mean ± standard deviation) (range: 28–57). The mean preoperative deviation was 49.5 ± 9 PD prism diopters (PD) (range: 40–65 PD). The mean preoperative abduction limitation was −4.8 ± 0.8. The patients were followed for at least 6 months. Postoperative deviation ranged from orthotropia to 12 PD of esotropia and all the patients obtained abduction at least beyond the midline. No vertical ductional disturbances or deviations were developed. The adduction was not compromised in any patient. Anterior segment ischemia did not occur in any patients.Conclusion: This procedure is comparable to traditional procedures with the advantages of no need to tenotomy or splitting and can be a good alternative to conventional Hummelsheim’s procedure.