Medial Rectus Insertion Research Articles

Medial rectus insertion site in cases of acute acquired comitant esotropia associated with excessive digital device usage.

To compare the distance of the medial rectus muscle insertion to the limbus (DMIL) between patients with acute acquired comitant esotropia (AACE) associated with excessive digital device usage (EDDU) and exotropic patients. Retrospective study. The medical records of 72 eyes of 44 patients with EDDU were retrospectively analyzed. The DMIL was measured from the anterior part at the midpoint of the medial rectus muscle insertion into the anterior limbus using a caliper after dissecting the medial rectus muscle with two control sutures at 12 o'clock and 6 o'clock. The DMIL in the non-fixation eye was compared between 44 patients with AACE and 23 patients with exotropia. The mean daily EDDU was 6.5 ± 3.1h. The mean cycloplegic refractive errors (spherical equivalent: SE) were - 3.18 ± 2.52 diopters (D) OD and - 3.03 ± 2.42 D OS. The mean DMIL in the 72 eyes of 44 patients with AACE associated with EDDU was 4.30 ± 0.66mm. The difference in DMIL of non-fixation eyes between 44 AACE patients and 23 exotropic patients was significant (4.28 ± 0.65mm vs. 5.28 ± 0.50mm, p < 0.0001). However, the SE in 44 non-dominant eyes of AACE was - 3.08 ± 2.56 D, significantly stronger than - 1.22 ± 1.93 D in the 23 exotropic eyes (p = 0.008). DMIL in patients with AACE associated with EDDU was significantly shorter. This anatomical anomaly may be an etiology of AACE associated with EDDU.

Efforts to improve the surgical outcome for exotropia and investigation of the insertion locations of the extraocular muscles.

In our previous retrospective study, we found that using the strabismus surgery dosages established by western strabismus mentors tends to result in undercorrection of Taiwanese exotropia (XT) patients compared with those in western populations. We also discovered that the location of extraocular muscle (EOM) insertion could vary by ethnicity. In this study, using a generalized estimation equation model, we compared the XT surgery outcome between augmented and original strabismus surgery dosages in Taiwanese patients. We also conducted an observational study to investigate the horizontal EOM insertion location in a Taiwanese population and compared the data with Dr. Apt L.'s study. For Taiwanese XT patients, augmented surgical dosages resulted in significantly better outcome at 6 months and 1 year postoperatively compared with original surgical dosages (p = 0.003 and p < 0.001, respectively). The distance from the lateral recuts muscle (LR) insertion location to the limbus was significantly shorter in Taiwanese than in white Americans (6.5 vs. 6.9 mm, respectively, p = 0.0001). Furthermore, the medial rectus muscle and LR insertion locations differed significantly between males and females (p < 0.001 and p = 0.023, respectively). The patients' sex did not affect the surgery outcome. Augmented surgery doses modified from western strabismus mentors produce better surgery outcome for Taiwanese XT patients. Surgeons may require country-specific guidelines for strabismus surgery dosage. We also demonstrated a simple method for young ophthalmologists to establish their own normograms to improve their surgical success rate. Our study confirms that LR insertion locations differ between Taiwanese and White Americans.

Independent risk factors of type III acute acquired concomitant esotropia: A matched case-control study.

To investigate the risk factors and surgical design for type III acute acquired concomitant esotropia (AACE). In this retrospective, matched, case-control study, 51 patients developed type III AACE between March 2018 and September 2020, and the control group consisted of 60 patients matched by age and refractive power during the same period. A history of the duration of near work per day and the use of glasses were reviewed, and the refractive power of both eyes, deviation angles at both near and far vision, visual function, and treatment options were analyzed. Additionally, the distance from medial rectus insertion to the limbus was measured in surgical patients. The data were analyzed by logistic regression analysis. We found that 99.96% of the patients and 91.67% of the controls had myopia. Of these, 60.8% and 20.0%, respectively, did not wear glasses for near work. Twelve patients were treated with a prism and 39 were treated surgically. The average time devoted to near work per day was 7.24 and 3.7 h by the patients and controls, respectively. Univariate logistic regression analysis showed that increased hours of near work per day and near work without the use of spectacles were associated with the incidence of type III AACE. Multiple logistic regression analysis revealed that increased hours of near work per day and near work without the use of glasses were independent risk factors for AACE. Increased hours of near work per day and uncorrected myopia in near work are independent risk factors for type III AACE.

Medial rectus insertion site in surgical candidate children with esotropia

Medial rectus insertion site in surgical candidate children with esotropia

Advancement of the muscle insertion toward the limbus as an alternative or adjunct to resection

To describe the surgical outcomes of patients that underwent strabismus surgery involving advancement of the muscular insertion line toward the limbus. The medical records of patients who underwent rectus muscle advancement surgery between January 2009 and June 2019 and had at least 1 year of follow-up were reviewed retrospectively. Patients were classified into one of four types of deviation: (1) convergence insufficiency, without distance deviation; (2) small-angle distance esotropia, with diplopia; (3) residual strabismus after previous surgery; and (4) large-angle exotropia. The first group underwent 2 mm advancement of the medial rectus insertion bilaterally; the second, 2-3 mm advancement of the lateral rectus muscle bilaterally; the third, 2-3 mm advancement of the lateral or medial rectus muscle, with or without simultaneous resection; and the fourth, 3 mm advancement of the medial rectus with simultaneous resection, with or after maximum recession of the lateral rectus, bilaterally or unilaterally. A total of 25 patients were included (mean age, 28.76 ± 22.75 years): 4 with convergence insufficiency, 3 with small-angle distance esotropia and diplopia, 16 with residual strabismus, and 2 with large-angle exotropia. Mean postoperative follow-up was 4.76 ± 2.03 years. Surgery was successful in all patients at 1 year (residual deviation ≤10Δ), and all but 1 at 5 years; 1 patient required reoperation. Advancement of the muscle insertion proved successful as an alternative or adjunctive procedure to other forms of muscle tightening in the subtypes of patients evaluated in this study.

Nasal Transposition of the Split Lateral Rectus Muscle for Strabismus Associated With Bilateral 3rd-Nerve Palsy

To determine the success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating bilateral 3rd-nerve palsy. Retrospective, interventional case series. An international, multicenter registry was used for the study. The study population was all patients with bilateral 3rd-nerve palsy treated with NTSLR. Sensorimotor evaluations were conducted before and 6 months after unilateral or bilateral NTSLR. Outcome measures were postoperative horizontal alignment ≤15 prism diopters (PD), intraoperative technical difficulties, and vision-threatening complications. The association of patient demographics and surgical technique with each outcome was analyzed using multivariable logistic regression. A total of 34 patients were included, with a median age of 46 years (interquartile range [IQR]=25-54 years) at surgery. The most common etiologies were ischemic (29%), neoplastic (15%), and congenital (12%). NTSLR performed unilaterally with alternative surgery on the opposite eye (65%) resulted in a median postoperative exotropia of 18 PD (IQR=7-35 PD), and when performed bilaterally (35%) resulted in postoperative exotropia of 14 PD (IQR=5-35 PD). Success was achieved in 50% of cases, intraoperative technical difficulties were reported in 18%, and vision-threatening complications occurred in 21%. Attachment of the lateral rectus muscle ≥10 mm posterior to the medial rectus insertion was associated with increased vision-threatening complications (odds ratio=9.0; 95% CI=1.3-99). NTSLR can address the large-angle exotropia associated with bilateral 3rd-nerve palsy. Surgeons should be aware that posterior placement of the lateral rectus muscle may increase the risk of vision-threatening complications, particularly serous choroidal effusion.

Squint surgery in a case of osteogenesis imperfecta

Osteogenesis imperfecta (OI) is well known to be associated with blue sclera due to thinning along with skeletal deformities. Not all cases of OI have blue sclera despite having a thinner sclera than in normal individuals. We are presenting a case report of a 28-year-old girl with intermittent exotropia and OI with no evidence of blue sclera. On AS-OCT, scleral thinning was noted at the level of medial rectus muscle insertion. The patient underwent successful recession-resection surgery for the same. The thin sclera and OI need not deter the decision to operate on squint, and a successful squint surgery is possible in eyes with some amount of scleral thinning with careful suturing.

Periosteal fixation of the medial and lateral recti for large-angle incomitant exotropia.

To describe the evolution of a surgical technique for the correction of large-angle incomitant exodeviations. Retrospective review of an interventional case series from 2005 to 2019 in a single centre, with analysis of surgical procedure, prism diopter (PD) deviations and complications. Thirty-one patients underwent surgery at an average age of 42years (range 4-75years) for minimal medial rectus function, mostly from oculomotor nerve palsy (23/31; 74%). The mean pre-operative exodeviation was 75 PD (range 30-200PD). Sixteen patients (52%) had undergone previous strabismus surgery. Thirty-eight operations were performed in which the medial rectus insertion was anchored to the periosteum of the posterior lacrimal crest via a retrocaruncular transconjunctival approach. The ipsilateral lateral rectus (LR) was disinserted and fixed to lateral orbital tissue in 29/38 (76%) operations, injected with botulinum toxin in 5, recessed in 2 and had already undergone maximal LR recession in 2. In all but the first 8 operations, temporary limbal sutures were passed through the eyelids to maximally adduct the globe post-operatively. At last follow-up (mean 24months; range 2-130), the mean reduction in exodeviation was 49PD (range 10-80) and overall residual deviation was 26PD (range 80PD base-in to 14PD base-out). The 5 LR toxin procedures had a mean reduction of 22PD (range 10-40). Seven patients had persistent diplopia, one a transient corneal erosion and one caruncle suture exposure 4years after surgery. Large-angle exodeviations can be markedly improved by bi-rectus fixation. This approach is both safe and effective and can be performed in complex patients with multiple previous procedures.

Worldwide outcomes of nasal transposition of the split lateral rectus muscle for strabismus associated with 3rd-nerve palsy

Background/aimsTo determine success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating strabismus from 3rd-nerve palsy.MethodsAn international, multicentre, registry of patients with unilateral...

Evaluation of the insertion distance of the medial rectus in consecutive exotropia by means of intraoperative measure and optical coherence tomography.

To assess the agreement between the measurements of the distance from the medial rectus muscles insertion to the limbus measured by intra-operative spectral-domain optical coherence tomography (SD-OCT) in consecutive exotropia (cXT). An analysis was performed on total of 14 medial rectus (MR) muscles of 14 patients who underwent surgery for the treatment of cXT. The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper. The intraclass correlation coefficient (ICC) and Bland Altman plots were calculated to determine the agreement between the two methods, as well as the correlation. Mean age was 36.3±16.0 years (range 13-60), with 60% being women. Mean preoperative deviation was 38.7±16.9 prismatic dioptres (PD) (range 16-65), being +1.3±6.3 PD (range -12 to +10 PD) after surgery. Intraoperatively the MR insertion was found at 8.7±2.1mm (range 5.5-12.0) and by OCT at 7.7±1.2mm (range 5.3-10.0). The ICC showed a moderate to good agreement (0.659; 95% confidence interval: 0.157-0.885; p<0.001), with a correlation of R=0.792 (p=0.011). A better agreement was observed in those MR that were less retro-inserted. SD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on, showing moderate to good agreement with intraoperative measurements. However, the agreement was poor in muscles with a large retro-insertion.

Evaluación de la distancia al recto medio en la exotropía consecutiva mediante tomografía de coherencia óptica y medida intraoperatoria

PurposeTo assess the agreement between the intraoperative measurements of the distance from the medial rectus muscles insertion to the limbus and preoperative spectral-domain optical coherence tomography (SD-OCT) in consecutive exotropia (cXT). MethodsAn analysis was performed on total of 14 medial rectus (MR) muscles of 14 patients who underwent surgery for the treatment of cXT. The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper. The intraclass correlation coefficient (ICC) and Bland Altman plots were calculated to determine the agreement between the two methods, as well as the correlation. ResultsMean age was 36.3±16.0 years (range 13-60), with 60% being women. Mean preoperative deviation was 38.7±16.9 prismatic dioptres (PD) (range 16 to 65), being +1.3±6.3 PD (range -12 to +10 PD) after surgery. Intraoperatively the MR insertion was found at 8.7±2.1mm (range 5.5 - 12.0) and by OCT at 7.7±1.2mm (range 5.3 - 10.0). The ICC showed a moderate to good agreement (0.659; 95% confidence interval: 0.157-0.885; P<.001), with a correlation of R=0.792 (P=.011). A better agreement was observed in those MR that were less retro-inserted. ConclusionsSD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on, showing moderate to good agreement with intraoperative measurements. However, the agreement was poor in muscles with a large retro-insertion.

Correction of exotropia and improved adduction by fixation of the anterior encircling fascia to the medial rectus insertion site following myectomy of the four horizontal rectus muscles for infantile nystagmus

Myectomy of the four horizontal rectus muscles for infantile nystagmus syndrome without a null point may improve visual acuity and quality of life. Exotropia and adduction loss are complications of this procedure, although abduction is typically preserved. We investigated whether adduction loss may be rescued by reestablishing the attachment of the anterior intermuscular septum (AIMS) to the globe at the medial rectus insertion. We present 2 cases of exotropia and adduction loss following myectomy and transposition surgery, where the nasal AIMS and the medial rectus insertion site were joined with nonabsorbable polyester suture. Both patients experienced improvements in eye alignment and adduction. Based on radiologic observations of the posterior displacement of the pulley, or posterior intermuscular septum (PIMS), with medial rectus contraction, we hypothesize that adduction and alignment were improved by providing an anterior site of action for the posterior movement of the PIMS.

Horizontal Extraocular Muscle Insertion Site in Relation to Axial Length Using Swept-Source Anterior Segment OCT.

PurposeThe purpose of this study was to correlate between the axial length of the globe and the insertion site of horizontal extraocular muscles using swept-source anterior segment optical coherence tomography (SS-ASOCT), with posing an equation to calculate the muscle insertion site from the axial length.MethodsThe study design was observational and cross-sectional. It was performed on 157 eyes of 157 healthy subjects. The distance of the medial rectus (MR) and the lateral rectus (LR) insertion sites from the limbus were measured using SS-ASOCT. The insertion sites’ distances were correlated to the axial length (hypermetropes < 22.5 mm, myopes > 24.5). Correlation between numerical variables was done by Pearson’s correlation coefficient and confirmed by linear regression analysis and scatter diagrams.ResultsThe mean MR insertion site was 5.47 ± 0.19 mm in hypermetropes versus 5.68 ± 0.23 mm in myopes, whereas the mean LR insertion site was 6.81± 0.23 mm in hyperopes versus 7.08 ± 0.16 mm in myopes. The axial length showed a moderate positive, but significant, correlation to the insertional position for the medial and lateral rectus muscles (MR: r=0.417, p<0.001; LR: r=0.410, p<0.001).ConclusionComparing the horizontal extraocular muscle insertion site to axial length using SS-ASOCT showed a significant positive correlation. The model equation for MR insertion: MR (mm) = 4.522 + 0.045 (AXL in mm) with an R = 0.437, R2= 0.191, F=12.071, P<0.001. The model equation for LR insertion: LR (mm) = 5.72 + 0.048 (AXL in mm) with an R = 0.438, R2= 0.192, F=12.116, P<0.001.

Analysis of new attachment site in medial rectus resection with advancement using anterior segment optical coherence tomography

ObjectiveTo evaluate the surgical outcome of unilateral medial rectus resection with small advancement for recurrent exotropia, ≤30 prism diopters (PD), and verify new attachment site anatomically using anterior segment optical coherence tomography (ASOCT). MethodThis study is a retrospective chart review of patients who underwent 1.0 mm advancement of unilateral resected medial rectus from original medial rectus (OMR) insertion for recurrent exotropia since 2014. The age at operation, sex, preoperative angle of deviation, near stereopsis, and suppression were evaluated. Success was defined as ≤5 PD of esodeviation or ≤10 PD of exodeviation at the final visit. Preoperative scleral thickness was measured using ASOCT, 1.0 and 0.5 mm anterior to OMR insertion, and at the insertion. ResultsA total of 76 patients, including 30 males (40.2%), were reviewed retrospectively. Continuous values were presented as mean ± standard deviation. Age at operation was 11.6 ± 6.6 years. The preoperative deviation was 20.9 ± 3.6 PD, and the amount of resected unilateral medial rectus was 4.5 ± 0.6 mm. The minimum required follow-up period after operation was 12 months after surgery. The postoperative follow-up period was 21.3 ± 8.0 months. A total of 65 patients (87.8%) showed successful outcome at the final visit. Preoperative scleral thickness at 1.0 and 0.5 mm anterior to OMR insertion site, and at OMR insertion site were 0.52 ± 0.05, 0.52 ± 0.06, and 0.43 ± 0.04 mm, respectively. Scleral thickness at OMR insertion site was significantly less compared with 1.0 and 0.5 mm from the OMR insertion site (p = 0.03). ConclusionThe scleral thickness 1.0–0.5 mm anterior to OMR insertion site was thicker that than at the OMR insertion site. The new technique of medial rectus resection with small advancement may be safer and more effective than conventional technique.

Effects of Ocular Parameters on Medial Rectus Faden Operation with Recession for Esotropia

Background: In the treatment of infantile and accommodative esotopia medial rectus (MR) recession combined posterior fixation suture (Faden operation) can be used. But, there is very limited literature on effect of ocular parameters (axial length, medial rectus width and the distance of medial rectus insertion to limbus) to this operation. Objective: To evaluate effects of ocular parameters on medial rectus Faden operations with recession for esotropia. Material and Methods: In this retrospective study, 38 patients (57 eyes) who underwent Faden operation with unilateral or bilateral recession (4 - 4.5 mm) on medial rectus were divided into three groups according to axial length, medial rectus width and the distance of medial rectus insertion to limbus. Preoperative and postoperative deviations compared. Results: 11 cases were infantile esotropia, 46 cases were acquired esotropia. Female/male rate was 19/19. The mean preoperative amount of esotropia at near was 49.95 ± 17.36 prism diopters (PD) and postoperative 1 week 11.77 ± 11.14 PD, 1 month 12.02 ± 11.52 PD and 6 months 9.46 ± 10.19 PD. The mean preoperative amount of esotropia at distance was 38.84 ± 19.03 PD and postoperative 1 week 7.25 ± 11.29 PD, 1 month 6.54 ± 10.52 PD and 6 months 4.40 ± 9.08 PD. Due to axial length, in shorter eyes, the decrease in mean post-operative deviation was statistically significant. Due to medial rectus width and the distance of medial rectus insertion, there was no statistically significant difference. Conclusions: Axial length has an effect on medial rectus Faden operations with recession but medial rectus width and medial rectus insertion distance from limbus do not.

Medial and Lateral Rectus Muscle Insertion Distance and Width in Esotropia and Exotropia Patients

ABSTRACTPurpose: The hypothesis that the extraocular muscle insertion distance and muscle width may be associated with the type and size of deviation was tested.Methods: This was a prospective study of 129 patients who had surgery for horizontal strabismus or retinal detachment. The insertion distances and widths of the medial rectus (MR) and lateral rectus (LR) muscles were measured intraoperatively in esotropia, exotropia, and buckling surgery (control group) patients. Statistical analysis was performed to compare measured factors between the groups.Results: Median medial and lateral muscle insertions were 5.7 and 6.9 mm in esotropia (ET), 6.0 and 7.1 mm in exotropia (XT), and 5.5 and 6.7 mm in the control groups (p > 0.05). The widths of the medial and lateral muscles ranged from 7.0 to 13.0 mm in ET and XT groups and from 9.5 to 11.0 mm in the control group (p > 0.05). Muscle insertion distance and LR muscle width were not correlated with deviation size. Only the MR muscle width was positively correlated with the deviation size.Conclusions: Insertion distances of the medial and LR muscles are not statistically different in ET, XT, and control patients. Only MR muscle width was affected by the size of the deviation in ET patients.

Intraoperative Findings in Consecutive Exotropia with and without Adduction Deficit

Consecutive exotropia may be associated with limited adduction, which has been reported to be caused by 1 or more anatomic abnormalities of rectus muscles or their insertions. We studied the relative frequency of grades of adduction deficit and the relative frequency of abnormal anatomic findings. Retrospective cohort study. Patients undergoing surgery for consecutive exotropia. Preoperative duction deficits were graded on a-5 (severe limitation) to 0 (normal) scale. Operative reports were reviewed to classify intraoperative factors: (1) medial rectus muscle attachment type (normal, abnormal [slipped or stretched scar], attached to pulley, behind pulley, or mixed [a tenuous normal attachment, but with muscle fibers also attached to the pulley or behind the pulley]), (2) medial rectus muscle distal fiber location (millimeters from original insertion), and (3) lateral rectus muscle tightness (normal, mild restriction, moderate restriction). Relationship of grade of adduction deficit to each intraoperative factor. Of 143 eyes, 124 (87%) had an adduction deficit. Eyes with abnormal (n= 23), pulley (n= 9), behind pulley (n= 8), or mixed (n= 7) attachments had worse adduction deficits than normal attachments (n= 96; P<0.02). There was a significant correlation between distal medial rectus muscle fiber location (0-19.5 mm recessed) and grade of adduction deficit (P < 0.0001). Eyes with mild or moderate lateral rectus muscle tightness on forced duction testing (n= 48/143 eyes) had worse adduction deficits than eyes without tightness (P < 0.001). Nevertheless, despite overall correlation, there was considerable individual variability. For example, for-1 and-2 adduction deficits, medial rectus muscle attachment could be at the pulley, behind the pulley, or include the pulley (19/87 eyes [22%]), and the lateral rectus muscle was tight in 36 of 87 eyes (41%). Adduction deficits are common in patients with consecutive exotropia. Overall, more severe preoperative adduction deficits are associated with medial rectus muscle insertion abnormalities and abnormal forced ductions, but frequently there are exceptions. Severe medial rectus muscle insertion abnormalities, including lost muscles, may be found despite mild preoperative adduction deficits.

Ridge at the medial rectus muscle insertion: A new anatomical landmark.

Background and Aim:Rectus muscle insertions are usually linear or slight curved with the anterior convexity. While operating squint surgeries, we found a presence of ridge-like structure at the medial rectus insertion. None of the other rectus muscle insertions had such structure.Materials and Methods:Patients undergoing squint surgery were included in the study. All the patients had negative forced duction test for all the gazes and had comitant strabismus. The patients underwent surgery through the fornix route. All the squint surgeries were primary. None of the patients undergoing resurgery were included in the study. The ridge seen is actually an elevated curved structure and shows discontinuation of the actual medial rectus insertion. The measurements were taken from the superior and inferior end of the medial rectus muscle insertion.Results:In a total of 76 medial rectus surgery (for recession or resection), we found the ridge was present in 68 (89.5%) of cases. The ridge was located at an average distance of 6.33 ± 1.5 mm inferior and 3.82 ± 0.9 mm superior to the superior and inferior point of medial rectus insertion, respectively.Conclusion:We describe the presence, morphology, and measurements of a ridge as an anatomical landmark at medial rectus insertion.

Botulinum toxin in the management of acquired abducens nerve palsy: Prospective Interventional controlled trial

Aim: The aim of this study is to assess the effectiveness of botulinum toxin in patients presenting with isolated lateral rectus palsy. Materials and Methods: This prospective interventional controlled trial from March 2012 to March 2015. Inclusion criteria were acquired lateral rectus palsy, no other neurological defects, normal magnetic resonance imaging scan, and age >30 years. The cases were treated with 15–25 units of botulinum toxin depending on the angle of squint. The surgical field is prepared, the medial rectus insertion grasped firmly with forceps, and the eye rotated to the primary position. Botulinum toxin is injected 5 mm from the medial rectus insertion, inside the bulk of muscle through a 27-gauge needle (without electromyographic guide) under topical anesthesia. No peritomy is done. Controls were treated with intravenous steroids for 3 days changed to oral steroids on tapering doses. Cases and controls were followed up 10, 30, 60, 120, and 180 days after initiating treatment. Wilcoxon signed-rank test is used for paired samples; Mann–Whitney U-test is for independent samples; P Results: Ten cases (six female) were enrolled into the study. Ten age-matched controls (six female) were also enrolled. The baseline characteristics of cases and controls were comparable in terms of duration of symptoms, head posture, primary deviation in the primary position, and limitation of abduction. After 10 days of injection, 100% of cases attained primary deviation Conclusion: Botulinum toxin is effective in achieving early subsidence of diplopia in the primary position and early recovery of abduction in patients presenting with isolated lateral rectus palsy.

Abnormal medial rectus insertion presenting exotropia: a case report and review of the literature.

Abnormal medial rectus insertion presenting exotropia: a case report and review of the literature.