Medial Rectus Recession Research Articles

Wright central plication of lateral rectus versus standard medial rectus recession in adult divergence insufficiency esotropia

Wright central plication is a new minimally invasive tightening procedure. We compare outcomes of lateral rectus central plication (LRCP) to standard medial rectus recession (MRR) in the treatment of diplopia associated with adult divergence insufficiency esotropia (ADIE).

Lateral rectus muscle resection following maximal recession of the medial rectus muscle in thyroid eye disease

Rectus muscle restriction is a common finding in thyroid eye disease (TED). Typically, restricted muscles are recessed to address strabismus and diplopia. However, some patients have residual strabismus following maximal recession of a restricted muscle. The purpose of this study was to report outcomes following resection of the lateral rectus muscle after maximal recession of the medial rectus muscle in patients with TED. The medical records of patients with TED who underwent lateral rectus resection between 1998 and 2015 were reviewed retrospectively. Information regarding thyroid disease history and surgical treatment, including history of orbital decompressions, rectus muscle recessions, rectus muscle resections, and pre- and postoperative alignment was collected. Adjustable suture was used in all cases. Success was defined as a postoperative orthotropia with ≤2Δ of phoria at distance and a phoria at near. A total of 11 patients were included. Of these, 10 (91%) required postoperative adjustment. A successful outcome was achieved in 10 cases (91%). Lateral rectus muscle resection to address residual esotropia and diplopia was effective at reducing residual esotropia following medial rectus recession in our study cohort.

Advances in research of divergence insufficiency

Divergence insufficiency is acquired esotropia at distance fixation with symptomatic uncrossed diplopia but fusion at near. It can be divided into two forms: primary isolated form and secondary form associated with neurologic abnormalities, also called divergence palsy. The clinical features of divergence insufficiency include small esotropia only at distance but orthotropia or small esophoria at near, comitant deviation at lateral gaze, reduced divergence fusion, full abduction and normal saccadic velocities in abduction. Primary divergence insufficiency is a benign condition predominantly occurring in adults older than 50 years. Recently, studies on the etiology of age-related distance esotropia, also called sagging eye syndrome, have demonstrated that the degenerative changes of orbital tissue could induce the inferior displacement of the inferior rectus pulley, different from the neurological etiology in abducens nerve palsy and secondary divergence insufficiency. The treatment goal is to relieve diplopia. Both prism and regular surgeries including medial rectus recession and lateral rectus resection are effective. Some unusual surgeries have been applied in divergence insufficiency, but further investigations with large samples are needed. The recent research advances in the etiology, diagnosis, differential diagnosis and treatment of divergence insufficiency are reviewed in this article. (Chin J Ophthalmol, 2017, 53: 552-556).

Superior and Lateral Rectus Myopexy for Acquired Adult Distance Esotropia: A “One Size Fits All” Surgery

ABSTRACTAim: To evaluate the results of bilateral lateral rectus to superior rectus myopexy for the treatment of acquired adult distance esotropia.Methods: The charts of all adult patients who were operated for esotropia by the first author at the Department of Ophthalmology, Assaf Harofeh Medical Center, Tel Aviv University, Zrifin, Israel, between the years 2010-2015 were analyzed. Patients with the following inclusion criteria were included: acquired esotropia (not present during childhood); deviation greater for distance than near by at least 4 prism diopters (PD); slight abduction deficit in one or both eyes and/or displacement of the lateral rectus downwards as evident by CT/MRI with or without superior rectus nasal shift and no neurologic abnormalities such as cranial nerve palsies or other.Results: Eighteen patients were identified (age 31–80 years, mean 49.6 years, 77.7% females). Pre-operative esodeviation averaged 24.3 PD (range 14–35 PD) for distance and 15.7 PD (range 8-25 PD) for near. Thirteen patients (72%) had diplopia. All patients were myopic (average -5.54 diopters, range -2.00 to -13.00). All patients underwent bilateral superior rectus–lateral rectus myopexy. Seven patients needed additional single medial rectus recession of between 2–6 mm, and two had additional inferior rectus recession. After a follow-up period of 3–52 months (average 16 months), 16/18 patients (88%) had a deviation less than 5 PD. No overcorrections were noted.Conclusion: Lateral to superior rectus myopexy is a safe and effective treatment for patients with distance esotropia in which displacement of these muscles is identified. Additional single medial rectus and/or inferior rectus recession may be needed in some patients.

Postoperative full abduction in a patient of Duane retraction syndrome without an abducens nerve: a case report

BackgroundDuane retraction syndrome (DRS) consists of abduction deficit, globe retraction and upshoots or downshoots with adduction. The abducens nerve on the affected side is absent in type 1 DRS. After bilateral medial rectus muscle recession in unilateral type 1 DRS may improve the abduction limitation, but still more than −3 limitation remains.Case presentationA 6-month-old boy presented with esotropia which had been noticed in early infancy. He showed limited abduction, fissure narrowing on attempted adduction and a small upshoot OS. Left abducens nerve was not identified on magnetic resonance imaging compatible with Duane retraction syndrome type 1. He showed full abduction after bilateral medial rectus recession of 6.0 mm at the age of 9 months, and remained orthotropia with full abduction OU 2 years postoperatively. He is my only patient with Duane retraction syndrome who showed full abduction after bilateral medial rectus recession.ConclusionsA patient with the type 1 Duane retraction syndrome rarely may show full abduction after bilateral medial rectus recession mimicking infantile esotropia.

Modified loop myopexy technique for severe high myopic strabismus fixus.

This study introduces a modified loop myopexy technique for severe high myopic strabismus fixus. This study aims to evaluate the surgical results of loop myopexy with or without medial rectus recession for the treatment of patients with myopic strabismus fixus. This is a retrospective study in a Chinese teaching hospital. Data was collected from 25 myopic strabismus fixus patients (33 eyes) with restriction in both abduction and sursumduction. First, the loop myopexy technique was performed. Following the loop myopexy technique, a medial rectus recession was performed if esotropia remained. If esotropia and/or hypotropia still persisted, second-stage surgery of the contralateral eye was performed. The main outcome measures were ocular deviations, eye movements and the angles of dislocation of the globe. At the last follow-up, mean deviation of esotropia was significantly improved (10 vs. 92 PD; p=0.000), while mean deviation of hypotropia was improved (6 vs. 32 PD; p=0.008). Mean abduction limitation was improved (-2.7 vs. -5.0; p=0.000); mean elevation limitation improved (-3.2 vs. -5.0; p=0.000). The angle of dislocation of the globe was significantly decreased (103.0 vs. 235.3 D; p=0.002). Modified Yokoyama's surgery effectively corrected the restrictive esotropia and hypotropia, restored the dislocated globe back into the muscle cone and improved the eye movement in severe myopic strabismus fixus.

Unilateral Recession-Resection Surgery for Infantile Esotropia: Survival of Motor Outcomes and Postoperative Drifts

ABSTRACTPurpose: To outline the short- and long-term motor outcomes of unilateral medial rectus muscle recession and lateral rectus muscle resection for the correction of moderate angle infantile esotropia. Methods: A retrospective study of 109 consecutive patients with moderate angle infantile esotropia treated with graded unilateral recession-resection surgery. Criteria for successful motor outcome included alignment ±10Δ from orthophoria. Outcome evaluation was a comparison of successful alignment versus an overcorrection or undercorrection at eight weeks postoperatively as well as on the final follow-up examination. Results: The mean preoperative deviation was 35.5 prism diopters (Δ) and mean follow-up time was 4.9 years. At the eight-week postoperative examination, 99 patients (89.9%) were successfully aligned, as opposed to 75 of 95 patients (78.9%) at the final postoperative visit (P=0.041). There was no statistically significant difference between the rate of early versus late undercorrections (7.3% versus 12.5%, P=0.267) or overcorrections (2.7% versus 8.3%, P=0.125). Ten patients had an esotropic drift over time and 10 patients had an exotropic drift. Recurrent esotropia was associated with high hyperopia and presumed infantile esotropia diagnostic entity. The Kaplan-Meier estimate of survivorship of a successful motor outcome was 75.5% at five years and 71% at 15 years postoperatively. The mean response to surgery was 2.9Δ per mm of muscle recessed and resected and was positively related to the preoperative angle of deviation (R=0.615). Conclusions: The unilateral recession-resection procedure for the correction of infantile esotropia is shown to be associated with a favorable survival of motor outcomes and a relatively balanced rate of undercorrections versus overcorrections tending to be maintained through the follow-up period.

Complications of augmented superior rectus transposition in Duane syndrome

Abstract Clinical case A patient diagnosed with Duane syndrome underwent an augmented superior rectus transposition (SRT) to lateral rectus (LR) and medial rectus (MR) recession. Vertical, torsional deviation and diplopia were observed post-operatively. Removal of the Foster suture and superior rectus recession resolved the symptoms. Discussion SRT to LR is proposed in Duane syndrome with a favorable outcome. The benefit of SRT is open to debate. It could be an alternative for the vertical rectus transposition when MR recession has to be operated on in the same procedure, or in the immediate post-operative period, in order to decrease the risk of anterior segment ischemia.

Wright central plication of lateral rectus versus standard medial rectus recession in adult divergence insufficiency esotropia

Wright central plication is a minimally invasive tightening procedure described for the first time by Wright and colleagues in 2012. We compare outcomes of lateral rectus central plication (LRCP) to medial rectus recession (MRR) in the treatment of adult divergence insufficiency esotropia (ADIE). A retrospective chart review of 30 consecutive patients with ADIE, who underwent either LRCP or MRR between 2010 and 2015 was performed. age ≥45years, LRCP or MRR surgery fixed suture technique, esotropia (ET) at least 10Δ greater at distance than at near, subjective diplopia at distance, fusion at near fixation, follow-up of at least 6months. Primary outcome was postoperative single binocular vision. Secondary outcome was postoperative deviation of <5Δ. A total of 28 patients (15 females) met inclusion criteria: 15 had LRCP and 13 MRR. Primary outcome of no diplopia was not significantly different between LRCP and MRR group having a success rate of 93.3% versus 92.3%, respectively (P≤0.01). Secondary outcome of a deviation of ≤5Δ at distance was better in the LRCP group than the MRR group (15/15 vs 11/13 [P≥0.01]). One patient in LRCP group had an early overcorrection corrected by in-office suture lysis. Both procedures had excellent primary outcomes eliminating diplopia in over 90% of cases. The LRCP group had statistically better postoperative alignment of <5Δ. The Wright LRCP has the advantage of being minimally invasive, semi-reversible, vessel sparing, and can be done with topical anesthesia.

Outcomes After Superior Rectus Transposition and Medial Rectus Recession Versus Vertical Recti Transposition for Sixth Nerve Palsy

To compare the effectiveness of superior rectus transposition and medial rectus recession (SRT/MRc) vs inferior and superior rectus transposition (VRT) for acquired sixth nerve palsy. Consecutive, interventional case series. The medical records of a consecutive series of patients with acquired sixth nerve palsy who underwent VRT or SRT/MRc by a single surgeon were reviewed. The preoperative and postoperative findings were compared between the 2 groups. Eight patients (mean age, 46.8 years) underwent SRT/MRc and 8 patients underwent VRT (mean age, 51.1 years). Lateral fixation was performed on all but 4 patients in the VRT group. Preoperative esotropia in primary position and abduction deficit were similar in both groups (SRT/MRc, 41.9 prism diopter [PD],-4.6; VRT, 55.6 PD,-4.5; P= .195, 1.0). The SRT/MRc group underwent a mean MR recession of 6 (range, 5-7) mm. Four patients in the VRT later underwent MR recession (mean 5.3mm, range 5-6mm). In addition, 5 patients in the VRT group had 1 or more botulinum toxin injections in the medial rectus muscle. No additional procedures were performed in the SRT/MR group. Fewer additional procedures were performed with SRT/MR (SRT/MR, 0; VRT, 1.8 ± 1.2; P < .010). At last follow-up, residual esotropia (SRT/MRc, 7.1 PD; VRT, 10.3 PD; P= .442) was similar in both groups, but abduction was better in the SRT/MRc group (SRT/MR,-3.0 ± 0.7; VRT,-3.8 ± 0.4; P= .038). There were no new persistent vertical deviations or torsional diplopia. Final outcomes were similar with SRT/MRc vs VRT. However, fewer additional surgical procedures were needed with SRT/MR.

Medial rectus pulley posterior fixation for esotropia with a high AC/A ratio

Many different surgical approaches have been advocated for the treatment of esotropia with a high ratio of accommodative convergence to accommodation, most involving increasing the magnitude of medial rectus recessions over than the amount recommended for the distance esotropia to either partially or fully correct the larger near esotropia. Maximal medial rectus recessions are relatively successful in correcting the excess near esotropia without overcorrecting the distance esotropia, but the expected loss of excess convergence over time raises the possibility of late overcorrections. Posterior fixation sutures have been shown to reduce the excess near esotropia without utilizing very large medial rectus recessions. The pulley posterior fixation technique takes advantage of an improved understanding of the biomechanics underlying the surgical effects of posterior fixation sutures. Because posterior fixation creates its effect through the creation of a collision between the suture and muscle pulley, not through the loss of the arc of contact between muscle belly and globe, the suture can be placed through the pulley tissue itself instead of the posterior sclera. This technique has been shown to be very effective in reducing the excess near esotropia without overcorrecting the distance esotropia.

Anterior Segment Ischemia after Strabismus Surgery.

A 46-year-old male patient was referred to our clinic with complaints of diplopia and esotropia in his right eye that developed after a car accident. The patient had right esotropia in primary position and abduction of the right eye was totally limited. Primary deviation was over 40 prism diopters at near and distance. The patient was diagnosed with sixth nerve palsy and 18 months after trauma, he underwent right medial rectus muscle recession. Ten months after the first operation, full-thickness tendon transposition of the superior and inferior rectus muscles (with Foster suture) was performed. On the first postoperative day, slit-lamp examination revealed corneal edema, 3+ cells in the anterior chamber and an irregular pupil. According to these findings, the diagnosis was anterior segment ischemia. Treatment with 0.1/5 mL topical dexamethasone drops (16 times/day), cyclopentolate hydrochloride drops (3 times/day) and 20 mg oral fluocortolone (3 times/day) was initiated. After 1 week of treatment, corneal edema regressed and the anterior chamber was clean. Topical and systemic steroid treatment was gradually discontinued. At postoperative 1 month, the patient was orthophoric and there were no pathologic symptoms besides the irregular pupil. Anterior segment ischemia is one of the most serious complications of strabismus surgery. Despite the fact that in most cases the only remaining sequel is an irregular pupil, serious circulation deficits could lead to phthisis bulbi. Clinical properties of anterior segment ischemia should be well recognized and in especially risky cases, preventative measures should be taken.

Adult divergence insufficiency esotropia: a comparison of lateral rectus resection, medial rectus recession, and miniplication of lateral rectus

Purpose The aim of this study was to compare the outcomes and efficacy of three surgical procedures for correction of adult divergence insufficiency esotropia: lateral rectus resection (LRR), medial rectus recession (MRR), and Wright lateral rectus miniplication (LRMP). Patients and methods A retrospective study was conducted on 22 patients with adult divergence insufficiency esotropia who were operated between 2012 and 2016; eight of them underwent LRR, six underwent MRR, and eight underwent LRMP. Their age ranged from 45 to 68 years. Esotropia was at least 10Δ greater at distance than at near. All patients did not have significant esotropia at near [0–6 prism diopter (PD)] with fusion at near; all of them complained of diplopia for far with no underlying neurological diseases. The mean follow-up period was 24 (12–40) months. Achieving single vision at far and postoperative deviation of up to 5 PD was considered a successful result. Results Age at presentation was 45–68 years, with mean age of 56.8±7.7 years. All the cases underwent bilateral surgeries. In group LRR, the preoperative angle of deviation at far was 20.5±5.8 prism diopter(PD) and for near was 2.9±2.4 PD. In group MRR, the preoperative angle of deviation at far was 21.7±6.1 PD and for near was 3.5±2.8 PD. In group LRMP, the preoperative angle of deviation at far was 21.4±8.5 PD and for near was 3.1±2.7 PD. Postoperative, no cases of diplopia were reported along the follow-up period in groups MRR and LRMP, whereas one case of the eight cases of group LRR showed diplopia. The postoperative angles for far in LRR, MRR, and LRMP groups were 2.38±2.1, 2.5±2.3, and 2.25±1.8 PD, respectively. Conclusion The three procedures had excellent outcomes in eliminating diplopia and postoperative alignment, but LRMP has the advantage to be vessel sparing, less invasive, reversible, and being able to be done with topical anesthesia.

A Valid Indication and the Effect of Bilateral Inferior Oblique Transposition on Recurrent or Consecutive Horizontal Deviation in Infantile Strabismus.

PurposeTo evaluate the effects of bilateral inferior oblique transposition (BIOT) on horizontal deviation from primary position among patients with bilateral dissociated vertical deviation (DVD) associated with inferior oblique overaction (IOOA) in infantile strabismus.MethodsRetrospective chart review was conducted among 19 patients with infantile strabismus. All patients had DVD and IOOA with consecutive or recurrent horizontal deviation and underwent modified BIOT surgery. Patients were divided into three subgroups: patients who underwent BIOT (BIOT group, n = 9) alone, BIOT with medial rectus recession or lateral rectus resection simultaneously (ET BIOT group, n = 6), or BIOT with lateral rectus recession or medial rectus resection simultaneously (XT BIOT group, n = 4). Postoperative angle of horizontal deviation (prism diopter, PD) and corrected magnitude of horizontal deviation (PD) at final visit after surgery were analyzed in each group.ResultsThe mean age was 55.11 ± 21.05 months (range, 32 to 115). The mean follow-up period was 8.68 ± 2.87 months (range, 6 to 18). Preoperative horizontal deviation was 4.23 ± 5.99 PD (range, 0 to 16) in BIOT, −17.33 ± 6.76 PD (range, −30 to −10) in ET BIOT, and 17.50 ± 2.52 PD (range, 14 to 20) in XT BIOT. Esodeviation is represented by negative values. DVD and IOOA were reduced less than +1 in all patients. The corrected amount of horizontal deviation was 3.56 ± 5.18 PD (range, 0 to 16) in BIOT surgery alone and larger in XT BIOT (18.50 ± 3.41 PD) than in ET BIOT (12.33 ± 5.57 PD, p = 0.004).ConclusionsMinimal exodeviation was corrected by BIOT alone. In addition, secondary eso- or exodeviation at great magnitudes should be corrected with proper horizontal muscle surgery along with BIOT.

Y-splitting with recession of lateral rectus versus lateral rectus recession in correcting upshoot in Duane retraction syndrome.

PURPOSE:To report the surgical effect in upshoot of Duane retraction syndrome (DRS) with corecession of horizontal rectus muscles with or without Y-splitting.PATIENTS AND METHODS:A retrospective chart review of six patients of DRS received muscle surgeries for upshoot in adducted position was performed.RESULTS:From 1994 to 2010, six Duane patients received muscle surgeries for upshoots of lesion eye in adduction. Their age of receiving surgery ranged from 5 to 41 years. Four of the patients were male, and five had their left eye involved. Three underwent recession of ipsilateral medial and lateral rectus (LR) muscles, and the other three also received Y-splitting of LR muscle when recession. One of the patients that received Y-splitting showed mild hypertropia at down gaze postoperatively, and another one had little improvement of exotropia at the primary position. All patients showed improvement of their upshoots and lid fissure narrowing in adduction as well as face turn.CONCLUSION:Postoperative improvements in abnormal head posture and upshoots were achieved with corecession of horizontal muscles with or without Y-splitting. Although Y-splitting of the LR muscle is an effective surgery, it might cause undesired complications.

Refractive error changes after bilateral medial rectus muscle recession surgery in congenital esotropia

Purpose The aim of this study was to evaluate the changes in refractive errors after bilateral medial rectus muscle recession surgery in children with congenital esotropia. Patients and methods Medical reports of 75 children with congenital esotropia were retrospectively reviewed. All included patients attended the Ain Shams University hospitals for undergoing bilateral medial rectus muscle recession surgery from January 2013 till January 2016. Cycloplegic refraction was done preoperatively and 3 months and 1 year postoperatively. Spherical equivalent (SE) was calculated to determine the amount of change in refractive error especially astigmatism and its axis. Patients were excluded if neurological abnormalities or developmental delays were documented and if structural eye abnormalities were present. Results Significant myopic shift and astigmatic change were determined in the SE refraction in the early postoperative period (3 months); however, these changes disappeared in the long term (at the postoperative first year). Conclusion Only the early postoperative period showed significant change in the SE value with myopic shift that necessitates early postoperative visual rehabilitation for fear of recurrence of the deviation or development of amblyopia.

Early Onset Sixth-Nerve Palsy with Eccentric Fixation

ABSTRACTPurpose: To report four cases of early onset sixth-nerve palsy all of whom had eccentric fixation.Methods: A retrospective case note review was undertaken of all cases presenting to the senior author's private and NHS practice with early onset sixth palsy between 2006 and 2012. As well as demographic information, details of ophthalmic, orthoptic, electrophysiological examinations, and radiological investigations that were extracted from the records.Results: Four children with unilateral or asymmetric early onset sixth-nerve palsy were identified, of which three were congenital. All four had MRI and only one had a normal MRI. Age at presentation ranged from 14–42 months, but all four had marked esotropia and poor visual acuities in the worst affected eye with eccentric fixation, which became more easily or only noticeable after surgical correction. Three patients with congenital sixth-nerve palsy underwent vertical muscle transposition with Botulinum Toxin A(BTXA) to the ipsilateral medial rectus, and two of these patients also had Foster sutures to the transposed vertical muscles. The fourth patient had unilateral medial rectus recession and lateral rectus resection. The mean preoperative measurement was 55Δ ET (range 50–60Δ), and the mean postoperative measurement was 11Δ ET (range 16XT-25ET) at near, and 2Δ XT (range 15XT-14ET) at distance.Conclusions: We speculate that early onset paralytic strabismus due to congenital sixth-nerve palsy results in an inability to cross fixate which results in the development of eccentric fixation. Attempts to use reverse occlusion to negate the eccentric fixation failed. We therefore recommend early surgery for this condition to avoid this sequelae.

Long-Term Changes in Refractive Error and Clinical Evaluation in Partially Accommodative Esotropia after Surgery.

We investigate the changes in refractive error and clinical evaluation in partially accommodative esotropia(PAET) after surgery. A total of 68 patients PAET who received at least 2 years of follow-up after surgery were enrolled in this study. We performed a retrospective study in patients who underwent unilateral or bilateral medial rectus recession for a non-accommodative component of PAET between January 2005 and March 2013. Patients were divided into groups according to the presence of dominancy (dominant, non-dominant, alternative eye), and presence of amblyopia (amblyopic, fellow, normal eye). Changes and changing pattern in SE refractive error were analyzed in all patients and compared between groups. Patients were divided into two groups, those weaned off of hyperopic glasses and those who continued using them, then factors that significantly influenced the continued use of glasses were analyzed. The changes and changing pattern in SE refractive error according to time after operation and presence of amblyopia or dominancy. The mean length of follow-up was 4.89±1.74 years after surgery and the mean change in SE refractive error rate per year was -0.284±0.411 diopters (D). The pattern of changes in the mean SE refractive error for those with dominant, non-dominant, and alternative eyes was not significantly different (p = 0.292). The pattern of changes in the mean SE refractive error for those with amblyopic, fellow, and normal eyes was significantly different (p = 0.0002). Patients were successfully weaned off of hyperopic glasses at an average age of 9.41±2.74 years. The average SE refractive error in the group weaned off of hyperopic glasses was significantly lower than that in the group maintained on hyperopic glasses (p = 0.0002). The change of SE refractive error in amblyopic eyes decreased less than that in fellow or normal eyes, which may be correlated with the presence of amblyopia. Patients with a smaller esodeviated angle without hyperopic correction, a lower degree of hyperopia, and who were older at the time of disease onset were discontinued from hyperopic glasses sooner after surgery.

Surgical correction of persistent adult-onset cyclic strabismus

A 24-year-old man developed cyclic esotropia following vitreoretinal surgery for retinal detachment in his right eye. He underwent right eye medial rectus recession (6mm) and lateral rectus resection (8.5mm) under local anesthesia for the correction of cyclic esotropia. Following surgery, he developed a unique pattern of cyclic strabismus that involved alternation between esotropia and exotropia every 24hours. To treat this condition, the patient underwent lateral rectus recession (8.5mm) and medial rectus posterior fixation of medial rectus in the right eye. Following surgery, he was corrected for heterotropia on both esotropic and exotropic days.

Age-related distance esotropia: Clinical features and therapeutic outcomes

Abstract Objective To describe the clinical characteristics and surgical outcomes of a group of patients with age-related distance esotropia (ARDE). Methods A retrospective study was conducted on a consecutive case series of 16 adult patients diagnosed with ARDE between 2008 and 2015. The clinical features evaluated included mean age and gender, primary position deviations at distance and near, measured in prism dioptres (pd), treatment offered in each case, and post-surgical deviations. Ductions and versions were full, with no evidence of lateral rectus paresis. None of these patients had any obvious underlying neurological disorder, such as, high myopia or thyroid disease. A good result is considered to be the disappearance of diplopia in all positions of gaze. Results A total of 16 patients (11 females [68.8%]) were identified. The mean age at diagnosis was 78.19 ± 6.77 years. The mean initial esodeviation was 2.25 ± 3.08 pd at near (−4 to +8 pd) and 9.5 ± 4.18 pd at distance (2–18 pd). Treatment was not necessary in 5 cases because the symptoms were intermittent or well-tolerated. Of the 11 patients with symptoms, one was corrected with an external base therapeutic prism. Botulinum toxin was administered in another patient, without satisfactory results. Unilateral medial rectus muscle recession was performed on one patient, and unilateral lateral rectus plication on 7 patients, indicating prisms before surgery. One patient refused surgery despite continuous diplopia in far vision. After a mean follow-up of 16.5 months, all operated patients were asymptomatic. Conclusions Not all patients with ARDE require treatment, as the tolerance to diplopia varies from one subject to another. Both medial rectus weakening and lateral rectus strengthening provides excellent results.