Preoperative Esotropia Research Articles

Determinants of postoperative alignment in patients of infantile esotropia

Abstract Purpose: The purpose of this article is to study the factors affecting postoperative alignment in patients of infantile esotropia with deviation more than or equal to 30 prism diopter (PD) after 12 weeks of follow-up. Materials and Methods: A total of 23 patients with infantile esotropia were included in this study over a period of 18 months. All the patients were assessed preoperatively and postoperatively at day 1, 3rd week, 6th week, and 12th week. The patients underwent horizontal muscle surgery alone or vertical combined with horizontal muscle surgery wherever required. All surgeries were planned and performed according to W.E. Scott table by a limbus-based approach. Results: Mean age of our study population was 13.36 ± 8.0 years (1.5–30 years). Fifteen (65.2%) patients were hypermetropic, 5 (21.7%) patients were emmetropic and 3 (13.1%) were myopic. Among the study participants, amblyopia was present in 13 patients (56.6%). The mean preoperative horizontal deviation was 48.04 PD ± 13.3 PD (range = 30–70 PD). Eleven patients had preoperative esotropia of >50 PD and 12 had <50 PD. The mean postoperative horizontal deviation was 5.1 ± 3.1 PD (range = 2–14 PD). Twenty-one (91.30%) patients had orthophoria, 2 (8.70%) patients had residual esotropia and none had overcorrection. Conclusion: The postoperative alignment was not influenced by age at the time of surgery (P = 0.67) and magnitude of preoperative deviation (P = 0.67) Further, the postoperative outcome was independent of the laterality of surgery (unilateral vs. bilateral, P = 0.6) and extraocular muscles operated (horizontal vs. combined horizontal and vertical, P = 0.537).

Sandwich (Amnion/Conjunctival-Limbal Autograft/Amnion) Transplantation for Recurrent Pterygium with Restrictive Strabismus

(1) Background: This study aimed to evaluate the clinical outcome of Sandwich (Amnion/Conjunctival-Limbal Autograft/Amnion) transplantation for recurrent pterygium with restrictive strabismus. (2) Methods: This retrospective study included 11 eyes in 11 patients diagnosed with recurrent pterygium with restrictive strabismus who received sandwich transplantation. The outcomes were measured by pterygium recurrence, best-corrected visual acuity, esotropia (prism diopters), and treatment complications. (3) Results: Eleven patients (six males, five females) had a mean age of 60.5 (range 36-80) years. The previously received pterygium excision surgery number was 1.8 ± 1.02 (range 1-4). The mean follow-up period was 19.9 ± 8.41 (range 12-36) months. All patients had a restriction of abduction in the previously operated eye, causing esotropia in the primary position. Pre-operative esotropia was 17.2 (range 10-30) prims diopter (PD). Five eyes (45.5%) had symblepharon before surgery. All patients were orthotropic until the last follow-up. Symblepharon was released in all eyes. Free ocular motility was present in all eyes. No donor site scar formation, scleral melt, or corneal ulcer was noted. (4) Conclusions: Sandwich transplantation for recurrent pterygium with restrictive strabismus is safe and effective.

Clinical Profile, Neuroimaging Characteristics, and Surgical Outcomes of Patients With Acute Acquired Non-accommodative Comitant Esotropia.

To report the clinical presentations, neuroimaging findings, and surgical outcomes in patients with acute acquired non-accommodative comitant esotropia (AACE). A retrospective review of records of all patients diagnosed as having AACE between January 2011 and December 2019 across three tertiary eye care centers was done. Cases with AACE onset after age 1 year were included. Patients were divided into two groups based on age of onset of esotropia: childhood (16 years or younger) and adult (older than 16 years). Surgical success was defined as postoperative horizontal deviation of 8 prism diopters (PD) or less at the last follow-up visit. A total of 338 patients (220 males and 119 females; mean age at presentation: 12.60 ± 9.8 years) met the study criteria. The mean age at onset of esotropia in the childhood and adult onset groups was 3.61 ± 1.1 and 26.6 ± 8.7 years, respectively. There were significantly more individuals with myopia (30%) in the adult onset group compared to the childhood onset group (6%) (P = .004). Thirty-seven (16%) had positive neuroimaging findings (16.4% adult onset vs 9.4% childhood onset). A total of 148 (44%) patients underwent surgery for esotropia, and the overall success rate was 73%. Mean preoperative esotropia was comparable in either group (P = .20), but surgical success was better in the adult onset group (75.6% vs 66.3% in the childhood onset group). Mean duration of follow-up postoperatively was 13.6 ± 12 months. Two-thirds of the patients had childhood onset of AACE. Intracranial pathology was found in 1 of 6 patients. Surgical success was better in the adult onset group, which was not influenced by preoperative esotropia, neuroimaging findings, or refractive status, but was dependent on age at onset of esotropia and duration between onset and intervention. [J Pediatr Ophthalmol Strabismus. 2023;60(3):218-225.].

Impact of Adding Augmented Superior Rectus Transpositions to Medial Rectus Muscle Recessions When Treating Esotropic Moebius Syndrome

To describe outcomes after treatment of Moebius syndrome (MBS) esotropia by adjustable bilateral medial rectus recession (BMR) with and without augmented superior rectus transposition (SRT). Retrospective case series. Patients meeting 2014 diagnostic criteria for MBS and treated at Boston Children's Hospital between 2003 and 2019 were identified via billing records and chart review. Visual acuity, sensorimotor evaluations, strabismus procedures, and other clinical features were recorded. Surgical outcomes for patients treated with strabismus surgery (excluding those with prior surgery elsewhere) were evaluated. The primary outcome measure was postoperative alignment comparing treatment by adjustable BMR vs adjustable BMR+SRT. A total of 20 patients had MBS, and 12 of these (60%) were male. Fifteen patients (75%) had primary position esotropia, and all had bilateral abduction deficit. Eight of 20 patients met inclusion criteria for primary strabismus surgery outcome. Five had undergone adjustable BMR ranging from 4.5 to 6.5 mm. Three had undergone adjustable BMR+SRT, all with 4-mm medial rectus muscle recessions. Mean preoperative esotropia before treatment by BMR was 39.5 PD (± 15 PD) with mean postoperative esotropia 9 PD (± 7.9 PD) at 6 months. Mean preoperative esotropia before treatment by BMR+SRT was 70.8 PD (± 5.9 PD) with mean postoperative esotropia 2.5 PD (± 3.5 PD) at 6 months. Significantly greater reduction in esotropia resulted from BMR+SRT than from BMR (P=.036). BMR proved sufficient to treat esotropia <50 PD and BMR+SRT for greater esotropia in patients with MBS-associated abduction limitation.

Yokoyama procedure for esotropia associated with high myopia: real-world data from a large-scale multicentre analysis.

High myopic patients may develop strabismus due to globe dislocation out of the normal extraocular muscle cone. Surgical correction of this strabismus type is possible by joining the superior and lateral rectus muscles without the need for a scleral suture called the Yokoyama procedure. Data from large patient samples and the evaluation of a potential effect of an additional medial rectus recession (MRR) have been lacking so far. We pooled retrospective patient data of 14 departments of ophthalmology in Germany and Switzerland and analysed determinants of postoperative results using multivariable regression models. We included 133 patients (mean age: 59.7 ± 13.4 years, surgery between 2008 and 2017) with a mean preoperative esotropia (both Yokoyama with and without MRR) of 23.8°±4.6°. The angle of preoperative esotropia increased with age. The postoperative esotropia was 8.7° ± 9.9°, and six patients were overcorrected. While preoperative esotropia was highly associated with postoperative results, we found no association of additional MRR with any of our postoperative outcome measures. The Yokoyama procedure had a higher absolute effect in patients with higher preoperative esotropia. Our study confirms the positive effect of the Yokoyama procedure on strabismus due to high myopia in large-scale real-world data. In some cases, MRR may be needed because of muscle contracture, although additional MRR statistically did not affect the postoperative outcome. In patients with bilateral high myopic strabismus, correction of both eyes seems beneficial. The effect size of the Yokoyama procedure appears to be mainly driven by preoperative esotropia.

Outcomes of modified vertical rectus belly transposition versus augmented superior rectus transposition for chronic abducens nerve palsy

To compare the surgical outcomes of modified vertical rectus belly transposition (mVRBT) and medial rectus recession (MRc) versus augmented superior rectus transposition (aSRT) and MRc in Chinese patients with chronic abducens nerve palsy. The medical records of patients with chronic abducens nerve palsy who underwent mVRBT/MRc or aSRT/MRc were retrospectively reviewed. Pre- and postoperative deviation in primary position, pre- and postoperative abduction limitation, and complications were recorded. Follow-up was at least 6months. A total of 26 patients (mean age, 37.9±19.6years; 16 males [62%]) were included. Fourteen patients underwent mVRBT/MRc (mVRBT group) and 12 underwent aSRT/MRc (aSRT group). Both groups had similar amounts of recession (t=0.27; P=0.79). After surgery, statistically significant changes of abduction limitation and esotropia were observed (both P<0.05). However, the difference in abduction improvement between groups was not statistically significant (mVRBT vs aSRT, 2.3±0.91 vs 2.3±0.97; t=0.10, P=0.92). Of the 19 patients who underwent unilateral surgery, preoperative esotropia was similar in both groups (t=1.3; P=0.21), but more esotropia was corrected in the mVRBT group than in the aSRT group (mVRBT vs aSRT, 57.8Δ±14.3Δ vs 44.6Δ±9.8Δ; t=2.1; P=0.047). There was no symptomatic vertical or torsional deviation. In our patient cohort, mVRBT/MRc showed a better effect in correcting esotropia and a similar effect in improving abduction limitation compared with aSRT/MRc.

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES:To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves’ orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities.METHODS:Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964.RESULTS:Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002).CONCLUSIONS:IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Augmented bimedial rectus muscles recession in acute acquired concomitant esotropia associated with myopia

ObjectiveTo review the clinical features of acute acquired concomitant esotropia in myopia and the results of augmented bilateral symmetrical medial rectus recession. MethodsThe medical charts of 50 patients diagnosed with acute acquired concomitant esotropia associated with myopia between 2013 and 2018 were reviewed. The dose-response was calculated, and the relationship of sex, age, refraction, best-corrected visual acuity (BCVA), preoperative deviation angle, and stereopsis with surgical results were analysed. ResultsForty-six patients (mean age 40.1 ± 18.1 years) were included in the study. Preoperative esotropia angle at near and distance were, respectively, 26.0 ± 7.5 PD and 25.2 ± 7.9 PD. Surgery amount was 12.1 ± 1.8 mm of recession, and surgical success was achieved in 38 patients (82.6%). No overcorrections were recorded. At 1-year follow-up, the mean deviation angle at distance and at near was 1.9 ± 2.4 and 1.7 ± 2.1 PD, and no recurrences were observed. The average dose-response was 1.8 ± 0.6 PD/mm and was positively correlated with preoperative angle of deviation (R2 = 0.799, p < 0.001) and negatively correlated with age (R2 = −0.365, p = 0.013). Conversely, there were no significant associations between dose-response and sex, refractive error, BCVA, or stereopsis (all p > 0.05). Factors associated with surgical failure were a lower amount of recession and absence of stereopsis. ConclusionsAugmented bilateral medial rectus recession allows good motor and sensory results in patients with acute acquired concomitant esotropia associated with myopia.

Outcomes of symmetric bilateral medial rectus recession in large-angle esotropic Duane syndrome.

To evaluate the efficacy of symmetric bilateral medial rectus recession in large-angle esotropic Duane retraction syndrome (DRS) with moderate to severe globe retraction. In a retrospective study, medical reports of 30 patients with esotropia of equal or more than 20 prism diopters (pd) and moderate to serve globe retraction due to unilateral DRS who underwent symmetric bilateral medial rectus recession were reviewed. Age, gender, laterality, amblyopia, length of follow-up, pre- and postoperative measurements of primary position deviation, ocular ductions and severity of globe retraction and abnormal head posture were evaluated. A successful result was defined as decreasing esotropia to equal or less than 8 pd or equal or less than 8 pd of consecutive exotropia. The mean age of patients at surgery was 13.7 ± 8.5 years old (range: 3-38). The mean preoperative esotropia measured 28.9 ± 9.1 pd in distance and 25.7 ± 7.2 pd in near, which decreased to 4.9 ± 6.1 pd in distance and 3.9 ± 8.8 pd in near postoperatively. The mean bilateral medial rectus recession was 4.9 ± 0.9 mm (range: 3-6 mm). The mean abnormal head posture improved from 19.1 ± 6.9 degrees (range: 10-30 degrees) to 3.3 ± 4.7 degrees (range: 0-15 degrees) postoperatively. At the last follow-up visit, 23 patients (76.7%) had a successful outcome. In the large-angle esotropic DRS patients with moderate to severe globe retraction, symmetric bilateral medial rectus recession, can be conducted to successfully resolve primary position deviation and abnormal head posture.

Muscle belly union surgery with or without medial rectus recession for the treatment of high myopic strabismus fixus

To evaluate the results of surgery involving the union of the superior rectus muscle and the lateral rectus muscle with or without medial rectus recession (MRc) for the treatment of high myopic strabismus fixus over a 20-year period. The medical records of patients who underwent muscle belly union for the treatment of high myopic strabismus fixus were reviewed retrospectively. Patients were classified according to the timing of MRc. In group 1, MRc was performed before muscle union surgery; in group 2, MRc was performed concurrent with muscle union surgery; in group 3, MRc was not performed; in group 4, MRc was performed after muscle union surgery. A total of 50 eyes of 40 patients were included. Mean esotropia decreased from 57.27Δ ± 25.45Δ (range, 8Δ-100Δ) before surgery to 11.67Δ±13.85Δ (range, -18Δ to 45Δ) after (P<0.001); mean hypotropia, from 6.05Δ±9.13Δ (range, 0Δ-13Δ) before to 1.20Δ±3.03Δ (range, 0Δ-10Δ) after (P<0.001). Mean abduction improved from -2.82±1.17 (range, -4 to 0) before to -0.75±0.92 (range, -3 to 0) after (P<0.001); mean elevation, from -1.62±1.62 (range, -4 to 0) before to -0.57±0.90 (range, -3 to 0) after (P<0.001). Preoperative esotropia and postoperative limitation in abduction were significantly lower in group 3 (P=0.03; P=0.01). Muscle union surgery successfully corrected the restrictive esotropia and hypotropia. MRc in addition to muscle union surgery was not necessary for some patients, for whom preoperative esotropia was lower.

Changes in horizontal strabismus after inferior rectus muscle recession with or without nasal transposition in thyroid eye disease: A retrospective, observational study.

Since the inferior rectus muscle (IRM) is a secondary adductor, it is expected to commonly observe esotropia in thyroid-associated inferior rectus myopathy, but this can be improved after the IRM recession. However, variable outcomes regarding the changes in horizontal strabismus after IRM recession ± IRM nasal transposition have been encountered in patients with thyroid eye disease (TED). We, therefore, examined the changes in 62 patients with TED in this retrospective, observational, comparative study. The patients were classified into 3 groups based on the results of postoperative changes in horizontal strabismus: Groups A (reduced esotropia), B (unchanged esotropia), and C (increased esotropia). Consequently, Groups A, B, and C included 23 (38.7%), 11 (17.7%), and 27 (43.5%) patients, respectively. In the multivariate linear regression analysis, the angle of preoperative esotropia (P < 0.001) and the amount of IRM nasal transposition (P = 0.049) were significant predictors of postoperative changes in horizontal strabismus. The results of our study will be helpful to ophthalmologists for formulating an effective preoperative surgical plan.

Long-term surgical outcomes of preoperative prism adaptation in patients with partially accommodative esotropia.

To determine the long-term surgical outcomes of preoperative prism adaptation test (PAT) in patients with partially accommodative esotropia. PAT was performed for the remaining esotropia after full correction of hyperopia. Prism adaptation (PA) responders were defined as patients with stable esodeviation between 0 and 8 prism diopters (PD) while developing sensory fusion throughout the prism adaptation period. Surgical success was defined as a deviation within 8 PD of both the far and near deviation angles at the last follow-up examination. Of the 102 patients, 43 (42.2%) were PA responders, and 59 were PA non-responders (57.8%). After a mean follow-up duration of 6 years after surgery, the surgical success rate was significantly higher in PA responders (76.7% vs. 54.2%, p = 0.023). By multivariate analysis, good stereoacuity at near before surgery significantly correlated with successful outcomes after surgery (p = 0.001, β = 4.466). The risk factors of undercorrection were preoperative esotropia >35 PD (OR 3.067, p = 0.041), and preoperative hyperopia >+5.25 diopters (OR 3.099, p = 0.049). Among undercorrected patients, the annual decrease of esodeviation was significantly greater in PA responders (p = 0.043). PA responders showed a better long-term success rate than in PA nonresponders. Patients with high hyperopia and large esotropia had a higher risk of undercorrection. Undercorrected patients eventually achieved good motor outcome with postoperative prism correction if they were PA responders before surgery.

"Yokoyama procedure" efficacy on non-highly myopic patients with acquired esotropia and hypotropia.

To assess the efficacy of "Yokoyama Procedure," on non-highly myopic patients with acquired esotropia and hypotropia. The study involved 10 eyes of 5 patients with eso-hypotropia. Inclusion criteria were acquired esotropic-hypotropic strabismus with lateral rectus inferior displacement and superior rectus nasal displacement confirmed by magnetic resonance imaging, refractive errors between ±6 D, and axial length < 27 mm. Range of full duction movements and maximum angles of abduction-sursumduction was measured in each eye before and after surgery. All patients underwent T1- and T2-weighted magnetic resonance imaging. The surgery was aimed at creating a junction between the muscle bellies of the superior and lateral rectus muscles. This junction was made approximately 14 mm behind the insertions using a non-absorbable mersilene 5/0 suture (Yokoyama procedure). Mean patient age was 64.8 ± 4.8 years. The mean globe axial length was 25.4 ± 0.76 mm and a mean corresponding spherical equivalent refraction of -3.7 ± 1.7 D was observed. Eight eyes on 10 had mild limitation in abduction, while the remaining 2 had no limitation. Three out of 10 eyes showed a moderate limited sursumduction, 5 eyes were categorized as mild, and the remaining 2 had no limitation. No evident post-operative limitation was present in any eye, in both abduction and sursumduction (p < 0.01). Pre-operative esotropia and hypotropia were, respectively, 32 ± 11 prismatic diopters and 25 ± 5 prismatic diopters, and they were significantly reduced after surgery as 9 ± 1.7 prismatic diopters and 6 ±1 prismatic diopters (p = 0.043), respectively. Yokoyama procedure is an effective, fast, reversible procedure to face eso-hypotropic acquired strabismus, even in patients with a clear magnetic resonance imaging displacement of superior and lateral rectus muscles, and absence of globe dislocation and of elevated myopia.

Long-term outcomes of strabismus surgery in Mobius sequence

ABSTRACTPurpose: Mobius sequence is a rare disorder that results from underdevelopment of the sixth and seventh cranial nerves, with subsequent facial weakness and impairment of ocular abduction. Approximately half of the affected patients have esotropia with limitation of extraocular movements. This study retrospectively reviews the long-term outcome of strabismus surgery for such patients.Methods: The long-term follow-up results in five children with Mobius sequence, who were observed after strabismus surgery for congenital esotropia, were analyzed.Results: All patients had a limitation of abduction in both eyes. Preoperative esotropia ranged from 20 to 30 prism diopters (PD) (mean 27 PD). Patient age at surgery ranged from 4.5 to 14 months. Bilateral medial rectus muscle recession was performed in all cases, ranging from 4.0 to 6.5 mm. Inferior transposition of the medial rectus muscles was performed in two patients for treatment of V-pattern, and two patients also had surgery for vertical strabismus. Follow-up ranged from 4 to 19.5 years (mean 11.7 years). The final horizontal alignment was <8 PD in all patients, and all demonstrated some binocularity.Conclusion: Bilateral medial rectus muscle recession is an effective treatment for esotropia associated with Mobius sequence, with good long-term stability.

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.

Decompensated Esophoria as a Benign Cause of Acquired Esotropia

To determine informative clinical and magnetic resonance imaging (MRI) characteristics of patients with symptomatic adult acquired, comitant esotropia due to decompensated esophoria. Retrospective, interventional case series. Setting: Institutional. Patients with decompensated esophoria who developed acute acquired comitant esotropia. Ophthalmic examination, stereopsis, and strabismus measurements at distance and near using prism cover tests in diagnostic gaze positions were performed. Patients underwent high-resolution surface coil MRI of extraocular muscles with target fixation, and MRI of the brain. Strabismus surgery was performed under topical anesthesia with adjustable sutures wherever possible. Paired t testing was used to evaluate postoperative changes with 0.05 considered significant. Clinical and MRI characteristics, and surgical outcome of patients with decompensated esophoria. Eight cases were identified involving subjects of mean age 29 ± 9.4 (range: 20-48) years having gradually progressive intermittent horizontal, binocular diplopia for 10months to 3 years. Mean preoperative esotropia was 31 ± 12 Δ at distance and 29 ± 12 Δ at near, although this was intermittent in 5 patients who exhibited enhanced fusional divergence. Neurologic evaluation and MRI of brain, orbits, and extraocular muscles were unremarkable in all cases. Orthotropia was successfully restored in all by standard or enhanced doses of bimedial rectus muscle recession surgery, improving mean stereoacuity from 535 to 68 arc seconds, although 5 patients exhibited 2-14 Δ asymptomatic residual esophoria. Decompensated esophoria is a benign clinical entity causing acute, acquired, comitant esotropia treatable with enhanced medial rectus recession.

Long-term Surgical Outcomes in the Sagging Eye Syndrome

ABSTRACTBackground/aims: Strabismus due to sagging eye syndrome (SES) caused by age-related connective tissue involution is now an established cause of diplopia in older people. High suspicion of the condition results in early recognition, often obviating extensive neurological investigations and enabling surgical correction of the strabismus.Methods:This retrospective study reviewed surgical results in 93 patients (40 males) of average age 68 ± 12 years, who had small-angle strabismus due to SES, during the 20-year period 1994–2014.Results: In central gaze, mean distance pre-operative esotropia was 4.2 ± 7.5Δ (mean, SD), while mean hypertropia was 4.7 ± 5.9Δ. Surgeries comprised medial rectus (MR) recession; lateral rectus (LR) resection; plication, imbrication, and superior transposition of the LR to the superior rectus (SR) for esotropia; and graded vertical rectus tenotomy (GVRT) or vertical muscle recession for hypertropia. Mean post-operative immediate and long-term deviation after 316 ± 265 months average follow-up was 0.2 ± 1.2Δ and 1.1 ± 2.7Δ esotropia (both distance), respectively, and 0.00Δ and 1.1 ± 2.7Δ, respectively, for hypertropia. Strabismus recurred in 19 cases.Conclusions: Progressive connective tissue involution in SES may occasionally result in symptomatic recurrences of the small-angle strabismus in about 20% of patients, irrespective of surgical procedures performed, possibly because of progressive involutional changes. This risk should be disclosed pre-operatively.

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.

Augmented superior rectus transposition with medial rectus recession in patients with abducens nerve palsy

To evaluate the surgical outcome of augmented superior rectus transposition (SRT) and medial rectus recession (MRc) in patients with abducens nerve palsy. The medical records of consecutive patients with abducens nerve palsy who underwent unilateral or bilateral simultaneous SRT with MRc from January 2012 to December 2014 were analyzed. Patients with previous strabismus surgery or botulinum toxin injection were excluded. Primary outcome measures were esotropia in primary position and abduction deficit. Data collected included age, sex, etiology, pre- and postoperative deviation, pre- and postoperative abduction deficit, anomalous head posture, induced vertical or torsional deviations postoperatively, reoperations, and details of other complications. Success was defined as postoperative alignment within 10Δ of orthotropia; failure, as residual esotropia of ≥20Δ. A total of 15 eyes of 13 patients were included. The most common cause of abducens nerve palsy was trauma (10 patients). The mean preoperative esotropia was 55.4Δ ± 24Δ, which improved postoperatively to 9.9Δ ±10Δ (P=0.0000). The mean preoperative abduction deficit was -5 units, decreasing postoperatively to -3.1 (P=0.000). Nine patients (69%) achieved success; 2 were classified as failures. One patient each developed postoperative hypotropia and intorsion; however, these were transient and did not require additional procedures. No patients developed anterior segment ischemia. Augmented SRT with MRc is effective in the management of abducens nerve palsy; however, its success in large deviations remains variable. Long-term follow-up is essential to determine the incidence of vertical and torsional deviations.

Effectiveness of Bilateral Lateral Rectus Resection for Residual Esotropia in Dysthyroid Ophthalmopathy

To report one surgeon's experiences with bilateral lateral rectus resections in dysthyroid ophthalmopathy patients with residual esotropia after initial bilateral medial rectus recession. Retrospective interventional case series evaluating outcomes. Medical records for patients with dysthyroid ophthalmopathy who underwent bilateral lateral rectus resections for persistent esotropia by a single surgeon from June 2012 to June 2015 were retrospectively reviewed. All patients had residual esodeviations following initial bilateral medial rectus recession. The goal of surgery was to obtain fusion in primary gaze and the reading position without prism, with a postoperative deviation equal to or less than 8Δ at distance and a phoria at near without diplopia. Seven of the 9 patients were successful in achieving this goal. Preoperative esotropia before resection ranged from 12Δ to 30Δ (23.1Δ ± 10.3Δ) at distance and-2Δ to 40Δ (14.9Δ ± 12.3Δ) at near. No exodeviation was created at near by the resections, but 1 patient had an asymptomatic exophoria both pre- and postoperatively. Patients with large horizontal misalignment may have residual esodeviations that are too large for correction with recession alone. Given our findings, we believe resection may be an effective tool in resolving esotropia in certain patients with restrictive strabismus.