Medial Rectus Recession Research Articles

Medium-Term Outcomes of Three Horizontal Muscle Surgery in Large-Angle Infantile Esotropia

To evaluate the medium-term motor outcomes of three horizontal muscle surgery in patients with large-angle infantile esotropia. The charts of 18 patients with large-angle (> 55 prism diopters [PD]) infantile esotropia who underwent bilateral medial rectus muscle recession and one lateral rectus muscle resection were retrospectively reviewed. Preoperative and postoperative deviations at last examination, overcorrections and undercorrections, necessity of additional horizontal surgery, and follow-up durations were recorded. The median age of patients at surgery was 22 months (range: 10 to 168 months). Orthotropia to within 10 PD or less was achieved in 14 of 18 patients (78%) in a median follow-up of 32 months (range: 5 to 63 months). The mean preoperative deviation of 68.8 ± 9.54 PD decreased to a median of 1 PD (range: esotropia 30 to exophoria 4 PD) postoperatively (P < .005). Marked residual esotropia necessitating additional surgery occurred in 4 patients, but significant overcorrection was not observed. The success rate of the three horizontal muscle surgeries appears to be high enough in medium-term follow-up in patients with large-angle infantile esotropia. Overcorrection that necessitates additional horizontal muscle surgery does not seem to be significant in the medium term, according to this study.

Surgically Induced Astigmatism Following Medial Rectus Recession: Short-Term and Long-Term Outcomes

The current study aimed to investigate short- and long-term postoperative ocular refractive effects of medial rectus recession on the involved eye and to describe the detectable effects in detail by the results of vector analysis. Data of patients in whom medial rectus recession was performed between 2010 and 2012 were retrospectively evaluated. The study included 52 eyes of 32 patients. Patients with a history of previous ocular surgery, congenital or progressive corneal disease, familial or acquired posterior segment disease, glaucoma, a history of ocular trauma, or any neurological or systemic disease were excluded. Best-corrected and uncorrected visual acuities and refraction examination findings of the patients were recorded before the surgery and at the postoperative first month and first year. A vector analysis program was used to analyze surgically induced astigmatism. Significant myopic shift and astigmatic change were determined in the spherical equivalent refraction in the early postoperative period (first month); however, these changes disappeared in the long term (at the postoperative first year). A positive correlation was not observed between the amount of surgical recession and the results of ophthalmic examination at the postoperative first month and first year. Only postoperative first month spherical equivalent showed a positive correlation with the amount of surgical recession; however, this correlation disappeared at the postoperative first year.

Muscle belly union associated with simultaneous medial rectus recession for treatment of myopic myopathy: results in 33 eyes

To describe the results achieved using muscle belly union associated with the recession of the ipsilateral medial rectus muscle to treat myopic myopathy and restore the normal anatomical relationship of superior and lateral rectus (LR). A retrospective, nonrandomized study performed on 33 eyes of 26 patients who underwent muscle belly union between January 2004 and October 2012. We preoperatively and postoperatively recorded: best-corrected visual acuity; refraction; intraocular pressure; complete orthoptic assessment, including the angle of deviation and maximal abduction measured using the Goldmann perimeter. Pictures of the eyes in all gaze directions were taken before and after the surgical treatment. Anatomical relationships between muscle cone and eye globe were preoperatively analyzed using magnetic resonance imaging (MRI). Surgical complications were noted. The follow-up period was 6 months. Preoperative mean BVCA was 0.97 ± 0.96 logMAR (ranging from 0.1 to 3 logMAR) and no changes were detected during postoperative controls. Preoperative mean hypotropia and esotropia were, respectively, 10.2 ± 3.9 prism diopters (PD) and 46.2 ± 15.5 PD. Postoperative mean hypotropia was 2.48 ± 2.00 PD (P<0.001) and mean esotropia was 7.36 ± 9.09 PD (P<0.001). A statistical incrementation of mean maximal abduction (P<0.001) was also noticed. Muscle belly union-coupled with the recession of the ipsilateral medial rectus muscle when considered convenient-is the elective surgical technique in myopic myopathy, when a downward displacement of LR muscle is shown on MRI with coronal sections.

Accommodative esotropia decompensated to cyclic esotropia in a 6-year-old boy

Cyclic esotropia, characterized by alternating intervals of esotropia and orthotropia, is associated with decreased vision, trauma, strabismus surgery, or central nervous system disease. We report a 6-year-old boy who developed cyclic esotropia after 3 years of successful control of accommodative esotropia with full hyperopic correction. After bilateral medial rectus recession, he remained esophoric with good binocular function and stereoacuity. To our knowledge, this is the first report of accommodative esotropia decompensating into a cyclic esotropia.

Ocular Complications of Strabismus Surgery

Background: To evaluate ocular complications of strabismus surgery at the Department of Strabismus and Neuroophthalmology in our clinic. Methods: The medical records of patients who underwent strabismus surgery between March 1999 and February 2013 were retrospectively reviewed. Patients with minor ocular complications such as wound irregularities, conjunctivitis, subconjunctival hemorrhage, and less than six-month follow-up periods were excluded from the study. Employed strabismus surgeries included recessions, resections, muscle advancements, inferior oblique myectomies, and muscle transpositions. Results: Our case series are comprised of 1468 patients who underwent strabismus surgery. The ages of the patients ranged from 6 to 80 years. Recognized primary ocular complications were noted in eight patients (0.5%). Scleral perforation with retinal break was observed in one myopic patient during retrobulbar anesthesia. Medial rectus rupture occurred during medial rectus recession in one patient with chronic complete sixth nerve palsy. Conjunctival cyst occured postoperatively in one patient with partially refractive accommodative esotropia who had bilateral medial rectus recession. Corneal dellen developed postoperatively in five patients with exotropia. Conclusion: Ocular complications of strabismus surgery are usually treatable. Damage to ocular structures can be prevented by meticulous surgical approach. Close postoperative follow-up is required in all cases.

Traumatic 6 th Nerve Palsy Managed with Medial Rectus Recession with Hangback Sutures and Hummelsheim Procedure

Traumatic paralytic esotropia due to 6 th nerve palsy is not uncommon but difficult to manage. We reported a case of 38-year-old male who sustained head injury in road traffic accident 15 years ago and inward deviation of his left eye. His vision in right eye was 20/20 and counting fingers at one foot in the left eye. He had >70 prism diopters esotropia in the left eye with restriction of movements in all directions of gaze except adduction. His forced duction test was positive. Examinations of the anterior and posterior segments of both eyes were within normal limits. Magnetic resonance imaging suggested old traumatic insult in the left eye. Diagnosis of left eye traumatic 6 th nerve palsy with medial rectus contracture was made. Left medial rectus recession with hangback sutures and Hummelsheim procedure were performed. Postoperatively, the patient's vision in the left eye had improved to 20/80 the esotropia had reduced to 15 prism diopters (delta).

Presumed Acute Adenoviral Dacryoadenitis Associated with Epidemic Keratoconjunctivitis: A Case Report

Traumatic paralytic esotropia due to 6th nerve palsy is not uncommon but difficult to manage. We reported a case of 38‑year‑old male who sustained head injury in road traffic accident 15 years ago and inward deviation of his left eye. His vision in right eye was 20/20 and counting fingers at one foot in the left eye. He had >70 prism diopters esotropia in the left eye with restriction of movements in all directions of gaze except adduction. His forced duction test was positive. Examinations of the anterior and posterior segments of both eyes were within normal limits. Magnetic resonance imaging suggested old traumatic insult in the left eye. Diagnosis of left eye traumatic 6th nerve palsy with medial rectus contracture was made. Left medial rectus recession with hangback sutures and Hummelsheim procedure were performed. Postoperatively, the patient's vision in the left eye had improved to 20/80 the esotropia had reduced to 15 prism diopters (delta).

両眼内直筋後転術を施行したMöbius症候群の一例

両眼内直筋後転術を施行したMöbius症候群の一例

Surgical Procedure Joining the Lateral Rectus and Superior Rectus Muscles With or Without Medial Rectus Recession for the Treatment of Strabismus Associated With High Myopia

To evaluate the outcomes of a surgical procedure involving the muscle union of the superior rectus (SR) and lateral rectus (LR) muscles with or without medial rectus (MR) recession for the treatment of strabismus associated with high myopia and the anatomic changes from before and after surgery. Thirty-five eyes of 20 patients who had undergone a muscle union of the SR and LR muscles with or without MR recession for treatment of acquired strabismus associated with an inferior displacement of the LR and nasal displacement of the SR in magnetic resonance imaging of the orbit due to axial high myopia were observed prospectively. Main outcome measures were the angles of the dislocation of the globe, angles of horizontal or vertical deviations, abductions, and supraductions. The angles of the dislocation of the globe were analyzed using magnetic resonance imaging (1.5 Tesla Magnet; Siemens Symphonia, Munich, Germany). The axial lengths ranged from 26 to 36 mm (mean: 30.6 ± 2.8 mm). The angle of dislocation of the globe changed from 178º ± 10º to 101º ± 6º, the angle of esotropia changed from 58.6 ± 2.5 to 6.8 ± 1.4 prism diopters (PD); and the angle of hypotropia changed from 12.5 ± 1.3 to 3.3 ± 1.1 PD postoperatively. Abduction and supraduction improved significantly after surgery. At the 4-year follow-up, the postoperative outcomes were stable. In the treatment of strabismus caused by high myopia, the surgical procedure involving the muscle union of the SR and LR muscles with or without MR recession was effective on both the restoration of the dislocated globe into the muscle cone and the improvement of ocular motility.

A case of cyclic esotropia with menstrual cycle

Cyclic esotropia, alternatively called ‘day squint’, is an intermittent disorder. It usually occurs in repeated cycles of every 48 hr (Hutcheson & Lambert 1998). The fusion and binocularity are usually defective on the strabismic days; in contrast, it remains normal during the straight days. Many studies have tried to clarify the pathophysiology of this rare condition, but exact mechanisms remain unknown (Metz & Searl 1984). We present a monthly cycle of these squints with misalignment associated with the days of the menstrual period that has never been reported yet. A 46-year-old female was referred for ocular pain. She had already been diagnosed with orbital pseudotumor at another clinic and took oral steroids for this condition. She was noted to have 45PD esotropia with diplopia. Six months later, her esotropia had improved without diplopia. We could not see her again until 4 years later when she presented to our clinic for a history of a squint, which was worse during her menstrual period. It typically lasted for 2 weeks each month. At that time, her ocular examination showed orthotropia and no diplopia, and visual acuity was 20/20. Two weeks later, she was noticed to have 35PD esotropia, but no change of visual acuity or refraction error was seen (Fig. 1). Her ocular motility was normal, but binocularity did not evaluated. We suggested a self-diary should be started, so she recorded daily whether she had straight eyes or a manifest squint. The diary clearly showed that the manifest deviation did predictably present during her menstrual periods. The cycle started on the first day of menstrual period, and it terminated at the end of menstrual period. Cyclic fluctuation usually occurred over one-month time frame. For evaluating the recurrence of orbital pseudotumor, she received CT scans, but we did not find any abnormalities on the CT scans (Fig. 1). The cycle had lasted for 4 months, and the strabismic period became more prolonged as time went on, and at last, her esotropia has lasted for 1 month. Finally, the periodic squint became a constant 40PD esotropia. The patient underwent bilateral medial rectus muscle recession (right, 5.5 mm; left, 5.0 mm). Following the surgery, she has remained orthotropic and free of diplopia during her menstrual period. Cyclic esotropia can be idiopathic or consecutive and also occur with defects of the central nervous system (CNS) (Pillai & Dhand 1987). The proposed mechanism of cyclic esotropia is a disruption of the innate biological clock associated with the CNS (Hutcheson & Lambert 1998). Some authors have suggested that a lesion of the suprachiasmatic nucleus of the hypothalamus could disrupt the biological clock and lead to cyclic esotropia (Pillai & Dhand 1987). Our case supports this possible mechanism in that the suprachiasmatic nucleus plays an important role in the course of menstruation (Norman et al. 1976). Several authors proposed that patients with cyclic esotropia have a basically strabismic condition with appended ‘bursts of orthophoria’ (Hutcheson & Lambert 1998). After visual maturity, late-onset cyclic esotropia could develop from conditions that disrupt fusion or cause diplopia (Hutcheson & Lambert 1998). The trigger event could be ocular surgery or CNS problems (Pillai & Dhand 1987). In this case, we could propose that constant esotropia by orbital pseudotumor might disrupt fusion. It is hypothesized that underlying this strabismic condition, our patient had entire days except her menstrual period where she experienced an orthotropic burst; therefore, a trigger factor to suppress orthotropic burst condition might also exist. The trigger factor could be menstrual hormones or unknown endogenous CNS transmitters stimulated by menstrual hormones. In conclusion, we present the first unique case of periodic esotropia with a monthly cycle and onset along with the menstrual period. In our patient, the development of cyclic esotropia could be related to the disruption of an innate biological clock, and the cycle was probably the result of some interacting factors related to the suprachiasmatic nucleus of the hypothalamus.

Clinical effect of super quantity of medial rectus recession in treating large angle esotropia

Clinical effect of super quantity of medial rectus recession in treating large angle esotropia

Three Horizontal Muscle Surgery for Large-Angle Infantile or Presumed Infantile Esotropia

Bilateral medial rectus muscle recession and one lateral rectus muscle resection surgery for the correction of large-angle infantile esotropia may be associated with a favorable long-term motor outcome. A consecutive exotropic drift was encountered more commonly than a recurrent esotropic drift in the long run, especially in the smaller (50-69 prism diopters [Δ]) range of preoperative esodeviation. To outline the short- and long-term motor outcomes of graded bilateral medial rectus muscle recession and one lateral rectus muscle resection for the correction of large-angle esotropia (≥50Δ). Retrospective analysis. Strabismus service, tertiary care university referral center. A total of 194 consecutive patients with infantile or presumed infantile esotropia. All patients underwent bilateral medial rectus recession and a lateral rectus resection in the nondominant eye by the same surgeon. Short-term (8 weeks) and long-term rates of postoperative successful alignment (±10Δ), undercorrection, and overcorrection. The median age of patients at surgery was 2.7 years (range, 20 months-36 years). The median follow-up time was 4.5 years (range, 6 weeks-25 years). The mean preoperative deviation was 68.2Δ. Of the 194 patients, 121 (62.4%) were successfully aligned at the last follow-up visit or prior to reoperation, and 154 (79.4%) were successfully aligned at the 8-week postoperative evaluation. A comparison of early vs late outcomes revealed a higher rate of late overcorrections (5.15% vs 24.1%, respectively; P = .001) but the same rate of undercorrections (15.4% vs 15.1%; P = .85). The outcome of surgery was not associated with the presence of amblyopia, high hyperopia, or the total amount of millimeters of surgery but was adversely influenced by the presence of inferior oblique overaction and the magnitude of the preoperative esodeviation. Delayed consecutive exotropia was more prevalent in the 50Δ to 69Δ range of preoperative esodeviation. Three horizontal muscle surgery for the correction of large-angle esotropia is associated with a high success rate. Long-term follow-up indicated that an exotropic drift may be expected 3 times more often than an esotropic drift.

Surgical Results of a Muscle Transposition Procedure for Abducens Palsy Without Tenotomy and Muscle Splitting

To report a simple muscle transposition procedure without tenotomy or muscle splitting to treat abducens palsy. Retrospective, interventional, consecutive case series. Nine patients with esotropia resulting from abducens palsy whose eyes could not abduct beyond the midline underwent this muscle transposition procedure, in which a suture was inserted through the temporal margin of each vertical rectus muscle. The same monofilament suture also was inserted into each inferotemporal or superotemporal sclera. The lateral margin of each vertical rectus muscle was transposed superotemporally or inferotemporally and was sutured onto the sclera. All 9 patients underwent unilateral muscle transposition, and 6 of the 9 underwent a medial rectus muscle recession combined with muscle transposition in the same eye. The surgical correction by muscle transposition alone ranged from 24 to 36 prism diopters, and that by muscle transposition and recession of the medial rectus muscle ranged from 50 to 62 prism diopters. The mean correction was 46.3 ± 13.1 prism diopters per eye. All paretic eyes could abduct beyond the midline. No major vertical ductional disturbances developed. Anterior segment ischemia did not occur in any patients. This procedure, which achieved the same corrective results as other popular procedures, is simple to perform because it requires only a suture from the muscle to sclera. Tenotomy or splitting of the transposed muscles is unnecessary.

Treatment of consecutive exotropia by bimedial rectus advancement in comparison with bilateral lateral rectus recession

Introduction Consecutive exotropia has been reported in 20–27% of patients following surgical correction of esotropia. However, higher rates have been reported with longer durations of follow-up. Surgical options for correction of consecutive exotropia include medial rectus advancement, medial rectus resection and advancement, lateral rectus recession, and a combination of these methods. Purpose The aim of this study was to compare the effectiveness of both bilateral medial rectus advancement and bilateral lateral rectus recession in the management of consecutive exotropia. Patients and methods This study included 20 patients with consecutive exotropia. Patients presenting with exotropia of at least 20 prism diopter (PD), with a history of bilateral medial rectus recession, were included. Ten patients underwent bimedial rectus advancement and 10 patients underwent bilateral lateral rectus recession. They were followed up for 1 year. Results The mean age of the patients was 6.7±3.2 (range 3–10 years). Mean preoperative exotropia was 28.8±5.3 PD. Successful alignment was achieved in 70% of cases treated by bimedial rectus advancement and 80% of cases treated by bilateral lateral rectus recession. Conclusion There was no significant difference between bilateral medial rectus advancement and bilateral lateral rectus recession in the treatment of consecutive exotropia.

Inferior oblique myectomy for upshoots mimicking inferior oblique overaction in Duane retraction syndrome

To evaluate the results of inferior oblique myectomy in selected patients with Duane retraction syndrome with upshoot on adduction. This was a prospective, interventional study of consecutive patients with types 1, 2, or 3 Duane syndrome with isolated upshoot in adduction operated on from January 2007 to December 2011. Patients underwent inferior oblique myectomy on the side of the upshooting eye. Only patients with gradual elevation of the eye in adduction in a pattern similar to inferior oblique overaction or patients with hypertropia in the primary position were included. All patients were followed for at least 6 months. Ductions, versions, degree of upshoot, degree of fundus torsion, and pattern of strabismus were analyzed in all patients before and after surgery. A total of 11 patients were included in the study. Mean patient age at time of surgery was 6.4 ± 5.2 years (range, 3-22 years). Two patients had bilateral inferior oblique myectomy and 4 had simultaneous bilateral medial rectus muscle recession to correct horizontal misalignment. Mean duration of follow-up was 8.6 months (range, 6-36 months). Of the 11 patients, 10 (91%) had complete disappearance of the upshoot at last follow-up. None of the patients developed inferior oblique underaction postoperatively. There was a statistically significant improvement of V pattern after surgery (P < 0.01). Mean vertical misalignment in primary position was 5(Δ) before surgery and 1(Δ) after (P = 0.02). Most patients had no significant fundus torsion before or after surgery. Inferior oblique muscle weakening can improve upshoot in selected patients with Duane retraction syndrome without inducing inferior oblique muscle underaction.

Surgical results after one-muscle recession for correction of horizontal sensory strabismus in children

To report the success rates in children after one-muscle recession for sensory strabismus. The medical records of consecutive patients ≤18 years of age who underwent primary unilateral horizontal surgery for sensory strabismus measuring ≤30(Δ) from 2004 to 2010 were retrospectively reviewed. Data collected included age at surgery, sex, length of follow-up, procedure performed, pre- and postoperative deviation, and treatment of associated vertical strabismus. Success was defined as a final deviation within 10(Δ) of orthotropia. A total of 33 patients (16 males) were included. Mean age at surgery was 5.2 years (range, 6 months to 17 years) and mean follow-up was 36 months (range, 6 months-7.4 years). Age at surgery (P = 0.37) and follow-up (P = 0.79) were comparable in patients with esotropia (n = 12) and exotropia (n = 21). Mean preoperative deviation was 23.7(Δ) in the esotropia group and 24(Δ) in the exotropia group (P = 0.875). Successful postoperative alignment was achieved in 76% of esotropic patients and 92% of exotropic patients (P = 0.379). Lateral rectus recessions resulted in a mean correction of 2.8(Δ)/mm of recession compared to 3.0(Δ)/mm for medial rectus recessions (P = 0.71). Advantages of one-muscle recession include a high success rate, few over-corrections, relatively short duration of surgery, and an intact muscle should reoperation be indicated.

Muscle Union Procedure With Medial Rectus Recession for Unilateral Abducens Palsy

Five patients underwent a muscle union procedure with medial rectus recession. The mean preoperative esotropia in the primary position was 51.0 ± 20.1 prism diopters [PD] (range: 20 to 75 PD). The mean follow-up period was 6.2 ± 2.1 months (range: 3 to 8 months). The mean decrease in esotropia in the primary position was 49.0 ± 18.0 PD (range: 18 PD to 63 PD). The mean postoperative angle in the primary position was 1.6 ± 5.9 PD esotropia (range: 2 PD exotropia to 12 PD esotropia). There was no change in vertical deviation. Satisfactory ocular alignment was achieved using the loop muscle union procedure with weakening of the antagonist muscle. This could be considered an option for a transposition procedures in patients with abducens palsy who have a large-angle esotropia or significant residual deviation after conventional surgery.

Oculoplastic Approach to Congenital Cutis Laxa Syndrome

Cutis laxa is a rare congenital or acquired disorder of elastic tissue, characterized by loose skin with folds and multiple internal organ involvement, which may cause life-threatening complications. We present a patient with cutis laxa syndrome who had cross eyelids with esotropia. Bilateral lateral canthal tendon repositioning and bilateral medial rectus recession procedures were performed in a single session. The patient had acceptable eyelid and globe cosmesis after the procedure. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Comparison of the efficacy of medial rectus recession and lateral rectus resection for treatment of divergence insufficiency

Purpose Surgical approaches for divergence insufficiency esotropia include medial rectus recession and lateral rectus resection. A retrospective chart review compared the efficacy of each. Methods Eighteen patients older than 50 years with divergence insufficiency esotropia who were operated on between 2005 and 2012 by two surgeons were reviewed. Results Nine patients underwent medial rectus recession and nine underwent lateral rectus resection. The average distance esotropia decreased from 19.75 to 3.2 prism diopters in the medial rectus recession group (P = .001) and from 17.7 to 2.6 prism diopters in the lateral rectus resection group (P = .0002). The disparity between distance and near alignment decreased from 7.3 to 3.4 in the medial rectus recession group (P = .019) and from 9 to 5.4 prism diopters in the lateral rectus resection group (P = .004). Conclusions Both medial rectus recession and lateral rectus resection are effective treatment for divergence insufficiency, with both decreasing distance-near disparity.

Conjugate surgery versus recession-resection for lateral incomitance in sixth nerve paresis

To compare ipsilateral lateral rectus resection and contralateral medial rectus recession (conjugate surgery) to an ipsilateral recession-resection procedure for the treatment of 6th nerve paresis to reduce incomitance between right and left gaze. This is a retrospective medical record review of patients with sixth nerve paresis treated with either conjugate surgery or an ipsilateral recession-resection procedure. Patients with preoperative deviation difference between right and left gaze (lateral incomitance) of at least 15Δ were included. Nine patients who underwent conjugate surgery and fifteen patients who underwent ipsilateral recession-resection procedures were evaluated. Pre- and postoperative alignment in primary gaze and lateral incomitance were compared. The mean preoperative primary gaze esotropia was 25Δ in the conjugate surgery group and 26Δ in the recession-resection group. The mean lateral incomitance was 31Δ in the conjugate surgery group and 24Δ in the recession-resection group. The mean postoperative deviation in primary position was 0 in the conjugate surgery group and 1Δ in the recession-resection group. The mean postoperative lateral incomitance was 9Δ in the conjugate surgery group and 16Δ in the recession-resection group; this is a statistically significant difference in an ANCOVA model adjusting for preoperative incomitance (P = 0.03). Both procedures achieve excellent postoperative primary position alignment and reduce lateral incomitance. Conjugate surgery results in significantly greater reduction of lateral incomitance. Conjugate surgery may be preferable to a recession-resection procedure in patients with sixth nerve paresis and more than 15Δ of lateral incomitance.