Surgery For Infantile Esotropia Research Articles

Bilateral Medial Rectus Advancement versus Unilateral Medial Rectus Advancement with Lateral Rectus Recession for Surgical Management of Large Angle Consecutive Exotropia without Adduction Deficit.

PurposeTo compare the postoperative eye alignment in patients who underwent bilateral medial rectus advancement with those who underwent unilateral medial rectus advancement plus ipsilateral lateral rectus recession in the case of large angle consecutive exotropia without adduction deficit.MethodsThirty-four patients with large angle consecutive exotropia that developed after infantile esotropia surgery were included in this retrospective study. Nineteen patients underwent bilateral medial rectus muscle advancement (group I) and 15 underwent unilateral medial rectus muscle advancement with ipsilateral lateral rectus muscle recession (group II). The follow-up periods were at least 12 months. Postoperative eye alignment was assessed and orthotropia within 10 prism diopters was considered a successful result.ResultsThe mean age of patients was 9.45±2.71 years in group I and 9.93±2.05 years in group II. Sixty percent of patients were female in group II and 57.89% in group I. In group I, the mean preoperative angle of deviation was 56.26±3.78 PD at distance and 53.11±3.49 PD at near. In group II, patients had a mean preoperative angle of deviation of 56±3.38 and 52.47±2.77 PD at distance and near, respectively. At the end of the follow-up period, the success rate was 52.63% in group I and 73.33% in group II (p = 0.22). The mean of the dose-effect relationship in group I was 2.62±1.35 PD/mm while in group II it was 2.36±0.84 PD/mm (p = 0.52).ConclusionIn patients with large angle consecutive exotropia, unilateral medial rectus advancement combined with ipsilateral lateral rectus recession produced better postoperative eye alignment than bilateral medial rectus advancement. Group I had a higher dose-effect relationship than group II.

Timing of surgery in essential infantile esotropia - What more do we know since the turn of the century?

This review summarizes the results and interpretations of studies pertaining to the long-standing debate regarding the timing of surgery in infantile esotropia, more recently referred to as essential infantile esotropia. A systematic search of studies from the year 2000 onward pertaining to the timing of surgery in infantile esotropia as listed in PubMed, Google Scholar, and the Cochrane database was performed. Appropriate cross-references from the articles were also included. Data collected included demographics, presentation, time of surgery, complications, and outcomes. Very early surgery, that is, within 6 months of the onset of infantile esotropia, offers significant advantages in terms of the quality of stereopsis and binocular vision as well as promoting the development of cortical visual processing, thereby benefiting cortical development in human infants. However, the postoperative alignment was not found to be significantly different in the very early, early, or late surgery groups. The reduction in the incidence of manifest dissociated vertical deviation postoperatively in the very early surgery group also showed measurable benefits. The results of this recent literature review demonstrated that very early surgery, within 6 months of misalignment, showed demonstrable benefits in essential infantile esotropia.

Comparison of bilateral medial rectus recession vs recession-resection as surgery for infantile esotropia

Background: Infantile esotropia is misalignment of eyes from bifoveal fixation where surgical correction at an early age usually presents with good outcomes.
 Aims and Objective: To compare the surgical outcome between bilateral medial rectus recession (BMR) and recession- resection (RR) surgery in infantile esotropia.
 Materials and Methods: The study was conducted in Lumbini Eye Institute, Bhairahawa, from December 2017 to December 2018. Patients with infantile esotropia who underwent surgical correction were included in the study. Patients were examined pre operatively, and post operatively at day one and third month, where the angle of deviation was measured and the level of binocular single vision (BSV) was assessed. Data was entered and analyzed using the SPSS program.
 Results: Total 79 patients were included in the study out of which 33 underwent BMR and 46 underwent RR. The mean pre-operative angle by PBCT was 52.58 PD (SD ±15.468) in the BMR group and 47.83 PD (SD ±12.140) in the RR group. Post-operative deviation in the BMR group had angle <35 PD. In the RR group the post-operative deviation observed was <35 PD, whereas 1/46 patients had angle between 35-50 PD. All patients who had residual esotropia (ET) in either the BMR or RR group had a pre-operative angle above 50 PD. Pre-operatively 43% had fusion and rest of them had suppression. Post-operatively 40.5% had fusion, 15.2% had stereopsis and rest of them had suppression or BSV could not be assessed in them. Therefore, there was increase in BSV by 2.5% from fusion to stereopsis. Those who initially showed suppression or in whom the BSV could not be assessed pre-operatively now showed to have fusion or some stereopsis. In total there was 15.2% increase in stereopsis.
 Conclusion: Though cosmesis has been improved in most patients after strabismus surgery, BSV improvement was insignificant as most surgery was performed after attainment of visual maturity. No significant difference between BMR and RR was found in terms of improvement of angle of deviation and BSV.

Cost comparison between botulinum neurotoxin and surgery in the treatment of infantile esotropia in a tertiary public hospital

ObjectiveTo compare the cost implications of botulinum neurotoxin (BNT) injection to surgery in infantile esotropia (IE) in a public/government funded hospital.Methods and analysisA simple costing comparison was undertaken for a...

Long term motor and sensory outcome after surgery for infantile esotropia and risk factors for residual and consecutive deviations

ABSTRACTPurpose: To present long-term motor and sensory outcomes after surgery for infantile esotropia and assess risk factors for residual and consecutive deviations.Methods: Data of infantile esotropia patients operated between 2002 and 2016 with minimum follow-up of 2 years were retrospectively reviewed.Results: Among a total of 62 patients, 35 had a successful motor outcome (alignment within 10 PD from orthotropia) after one surgery (Group A), while 27 required horizontal reoperation (Group B). Patients with residual esotropia had larger preoperative angle of deviation (P = .005) and younger age at first surgery (P = .01), while consecutive exotropia was associated with longer follow-up (P = .03) and higher rate of DVD (P = .003) compared to patients in Group A. Stereopsis was present in 30.3% of patients in Group A and associated with younger age at first surgery (P = .03).Conclusions: Successful motor alignment may be obtained with single surgery in infantile esotropia; however, reoperations are common. Younger age at first surgery may be associated with both higher rate of stereopsis and risk of reoperation. Careful preoperative assessment and surgical timing, with long-term postoperative follow-up is required to achieve satisfactory outcome.

Objective ocular torsion outcomes after unilateral horizontal rectus surgery in infantile esotropia.

To analyse objective ocular torsion among patients with infantile esotropia and to determine the effects of unilateral horizontal rectus surgery. Sixty-eight patients (136 eyes) (range 4 to 16years) who underwent unilateral horizontal rectus surgery for infantile esotropia participated in this retrospective single-centre study. Objective ocular torsion using fundus photography was assessed before surgery and 1year later. We defined three groups of patients based on preoperative qualitative objective ocular torsion: physiological extorsion and pathological extorsion and intorsion. For each group, the disc-foveal angle was measured and analysed both before and after surgery. We looked for possible correlations between amount of esodeviation and disc-foveal angle size. Preoperatively, 28 (41%) patients had + 6.73 (± 2.66) degrees of physiological extorsion. Thirty-one (46%) patients had + 12.94 (± 3.67) degrees of pathological extorsion. Nine (13%) patients had - 1.99 (± 2.52) degrees of intorsion. After surgery, the number of subjects with physiological extorsion increased to 45 (66%). The number of patients with pathological extorsion decreased to 17 (25%) and the mean disc-foveal angle was significantly reduced by 1.80°. Six (9%) patients presented intorsion and the mean disc-foveal angle was significantly reduced by 2.28°. For the pathological extorsion group, the size of the disc-foveal angle before surgery was positively correlated to its reduction after surgery. Disc-foveal angle variation and distance esodeviation variation after surgery were positively correlated. These results highlight that pathological objective ocular torsion can be frequently found in infantile esotropia and is decreased after unilateral recession-plication surgery.

Time and Factors Affecting the Direction of Re-drift in Essential Infantile Esotropia.

To investigate the development pattern and related factors of postoperative re-drift in infantile esotropia. A total of 112 patients with infantile esotropia who underwent surgery before 3 years of age were included. Surgical outcomes were divided into (1) consecutive exotropia: more than 8 prism diopters (PD) of exodeviation; (2) recurrent esotropia: more than 8 PD of esodeviation; and (3) monofixation syndrome: maintenance of deviations within 8 PD. The occurrence rate, time of onset, and associated factors of the re-drift were evaluated. At a mean follow-up of 9.5 years, consecutive exotropia developed in 37 patients (33.0%) and recurrent esotropia in 43 patients (38.4%). Whereas 76.7% of total recurrent esotropia cases were identified within postoperative 1 year, consecutive exotropia occurred constantly over 10 years postoperatively. The mean time to consecutive exotropia development from surgery was 78.6 months, greater than that of recurrent esotropia development (8.9 months) (P < 0.001). In multinomial logistic regression using monofixation syndrome as the reference category, fixation preference before surgery (odds ratio [OR]: 6.64, 95% confidence interval [CI]: 2.07 to 21.32) and the rate of myopic progression (OR: 15.07 per -1.00 D/year, 95% CI: 1.23 to 184.86) were associated with consecutive exotropia, whereas increase in the angle of esodeviation on postoperative day 1 (OR: 1.15, 95% CI: 1.04 to 1.26) was correlated with recurrent esotropia. This study demonstrates a difference between the development pattern of exotropic and esotropic drift after infantile esotropia surgery. Detailed preoperative assessment and close postoperative observation of deviations and refractive status will help to determine surgical outcomes of infantile esotropia. [J Pediatr Ophthalmol Strabismus. 2018;55(2):128-134.].

Esotropia with an accommodative component after surgery for infantile esotropia compared to primary accommodative esotropia

To compare the clinical outcomes of patients with an esotropia with an accommodative component after infantile esotropia surgery and patients with primary refractive accommodative esotropia. The medical records of patients with postoperative (secondary group) and primary refractive accommodative esotropia (primary group) were reviewed retrospectively. Changes in ocular alignment, refractive error, weaning rate, decompensation rate over time, and sensory outcomes were compared. The overall change in ocular deviation with glasses correction was -0.5Δ/year in the secondary group and -0.2Δ/year in the primary group (P=0.010). The overall change in spherical equivalent refractive error was -0.2 D/year in the secondary group and -0.3 D/year in the primary group (P<0.001). The latest stereoacuity result was poorer in the secondary group than in the primary group (P=0.027). No significant differences in the decompensation or weaning rates were detected between groups. The changes in refractive error and the amount of esotropia over time were different between the secondary group and the primary group. Although refractive error was significantly lower and stereoacuity was poorer in the secondary group compared to the primary group, the majority of patients in the secondary group maintained good control of ocular alignment after hyperopic correction.

Outcome of early surgery in infantile esotropia: Our experience in tertiary care hospital

BackgroundInfantile esotropia is a convergent strabismus presenting before 6 months of age and is the most common strabismus disorder presenting in the ophthalmology OPD. The dilemma of whether to go for early surgery and how early has been a matter of research for the last 50 years. We describe our results of surgery in infantile esotropia at variable age groups, as well as with different reoperation rates and compare with the results in western literature. MethodsA prospective study was carried out through a review of 113 cases operated for infantile esotropia between February 2013 and August 2014. The variables studied were: age at surgery, type of fixation, refractive error, associated nystagmus, inferior oblique overaction or dissociated vertical deviation (DVD), type of surgery performed and pre- and postoperative deviation angles. ResultsThere were 67 male and 46 female cases of infantile esotropia. The age group of patients varied from 6 months to 12 years. Latent nystagmus was seen in 22 cases, inferior oblique overaction in 49 cases and DVD (mild) in 14 cases. Bimedial rectus recession was done in 78 cases and recession–resection in non-dominant eye in remaining 35 cases. The postoperative residual deviation was <10 PD in 102 cases, between 10 and 16 PD in 5 cases and more than 16 PD in 6 cases. Only 6 cases (5.3%) required reoperation for correction of residual deviation. ConclusionThe authors recommend surgery before 12 months in all cases of infantile esotropia. The reoperation rates in the current study were considerably low.

Management of a Case of Undercorrection Following Surgery for Infantile Esotropia.

Management of a Case of Undercorrection Following Surgery for Infantile Esotropia.

Essential Infantile Esotropia: Postoperative Sensory Outcomes of Strabismus Surgery

ABSTRACTBackground: The optimum age for Essential Infantile Esotropia surgery is a controversial subject. Sensory status was evaluated in patients who underwent surgery at different ages in a retrospective study. The setting of the study is the ophthalmology department of a teaching hospital. Methods: Different clinical characters were analyzed pre- and postoperatively; nine different surgeries were performed. A total of 188 patients presented valid postoperative sensorial data, divided in two groups: surgery at ≤2 years (n=69) or >2 years (n=119). Sensory status was dichotomized in binocular single vision (BSV) and exclusion. Univariate differences were assessed with the chi-square test (or Fisher exact test). To identify the independent role of factors associated with the sensory status, all variables showing in univariate analyses a significant association (p<0.05) with the outcome variable were entered into a multivariate logistic regression model. All statistical tests were two-sided. Results: Multivariate analysis confirmed that children operated >2 years were 0.4 times less likely to obtain BSV compared with children operated at ≤2 years (AOR. 0.38, 95% C.I. 0.17–0.89, p=0.025). Patients operated on by OO MR rec.+ OO LR res. + OO IO rec.-ap. (intervention type 6) were about 11 times more likely to have BSV than those by OO rec.MR + unilateral res. LR (operation type 2); AOR.: 10.67, 95% C.I.: 1.34 – 85.29, p=0.026). Twenty-nine patients (12.1%) operated at ≤2 years of age underwent a reoperation, compared to 33 (8.6%) who underwent surgery after two years (p>0.05). Conclusions: Our findings suggest to perform EIE surgery between age 1 and 2 and, when indicated, to prefer a six-muscle approach in order to achieve a better sensory function.

Long-term motor and sensory outcomes after surgery for infantile esotropia.

Infantile esotropia (ET), entitled as congenital ET, is defined as an alternating, cross-fixational ET that occurs within the first 6 months of life. The aim of this study was to determine the long-term motor and sensory outcomes after surgical correction of patients with infantile ET. Medical records of 108 consecutive children who had bimedial rectus recession (BMR) initially for ET were reviewed retrospectively. The patients were divided into 3 groups: the group I, surgery before one-year old; the group II, surgery between one and two-year old; the group III, surgery after two-year old. No significant differences were determined among the groups for preoperative mean angle of deviation and refractive error (p > 0.05, for both). Development rate of dissociated vertical deviation (DVD) was greater (40%) in the group I, and the relationship between the rate of DVD and the timing of the initial surgery was statistically significant (p = 0.03). Risk for additional surgery was significantly greater in patients with a younger mean age at initial surgery (p = 0.01). Although measurable stereopsis rate was higher in the group I (35%, 32.4%, 27.8%, respectively) the difference among the groups was insignificant (p = 0.80). Patients with ET have limited potential of high grade stereoacuity despite the early alignment of eyes. Early surgery also has potential effects for the development of both inferior oblique overaction and DVD earlier.

Factors influencing the development and severity of dissociated vertical deviation in patients with infantile esotropia

To investigate the factors associated with the development and the severity of dissociated vertical deviation (DVD) in patients who underwent surgery for infantile esotropia. The medical records of consecutive patients who underwent surgery from March 1998 to December 2011 for infantile esotropia were reviewed retrospectively. The development, severity, and onset of DVD were assessed. Patients were divided into three groups: spontaneous, latent, and no DVD. The age at the time of the initial surgery, the angle of deviation of esotropia, anisometropia, amblyopia, stereopsis measured at the final visit, and history of prematurity were compared. A total of 90 patients were included. DVD was detected in 52 (58%). Of these, 34 patients demonstrated spontaneous DVDs and 18 showed latent DVDs. In the spontaneous DVD group, 71% underwent surgery after 24 months and 50% had a large angle of esodeviation (>60(Δ)), compared to the latent DVD group, in which 22% underwent later surgery and 11% had large-angle esodeviations (P < 0.001 and P = 0.002, respectively), and the no DVD group, in which 16% underwent later surgery and 13% had large-angle esodeviations (P < 0.001 each). Multivariate logistic regression analysis between groups revealed that later surgery (OR = 8.23; P < 0.001) and large-angle esodeviation (OR = 6.32; P= 0.003) were associated that greater development of spontaneous DVD. Surgical correction for infantile esotropia prior to 24 months of age, especially in caseswitha large amount of esodeviation, decreased the incidence of spontaneous DVD.

The relationship of age when motor alignment is achieved and the subsequent development of stereopsis in infantile esotropia

To determine the oldest age beyond which the chance of developing stereopsis is not possible even with excellent motor alignment in patients with infantile esotropia. The medical records of children with infantile esotropia who underwent a single operation and had alignment within 10(Δ) of orthotropia at all follow-up examinations were retrospectively reviewed. Patients were assessed for stereopsis after the age of 48 months. A total of 38 children were included. There was a statistically significant inverse correlation between age at surgery and final stereopsis (r = 0.494, P = 0.002). There was a significant difference at mean age at surgery between patients having stereopsis better than 1000 arcsec and those having no stereopsis (P = 0.002). Post hoc power analysis revealed a value of 85%. Receiver operating characteristic curve analysis revealed that the optimum cut-off value of the age at surgery for predicting stereopsis was 16 months (Youden index = 0.474; area under ROC curve, 0.784; 95% CI: 0.62-0.90; P = 0.0002). Surgery for infantile esotropia is most likely to result in measureable stereopsis if patient age at alignment is not more than 16 months.

What to Predict Favorable Long-Term Sensory Outcome after Surgery for Infantile Esotropia?

What to Predict Favorable Long-Term Sensory Outcome after Surgery for Infantile Esotropia?

The advancement of the medial rectus muscle for consecutive exotropia

ObjectiveTo characterize the dose effect of the advancement of the medial rectus muscle (MR) for consecutive exotropia (XT) after corrective surgery for infantile esotropia (ET) and provide a guide for achieving orthotropia. DesignRetrospective cohort study. ParticipantsSeventy-seven patients with consecutive XT that developed after surgery for infantile ET. MethodsAll patients underwent advancement of the unilateral or bilateral MR and were followed up for at least 1 year. The angle of deviation and stereopsis were retrospectively reviewed from patient records. ResultsAt the time of surgery for infantile ET, the mean eso-angle was 52.2 ± 13.10 prism diopters (PD; mean age, 28.5 ± 16.97 months). The exo-angle of consecutive XT was 25.6 ± 8.47 PD (mean age at surgery, 132.7 ± 82.32 months). The mean deviation was 1.8 ± 10.40 PD XT at the final follow-up (47.0 ± 43.57 months). The corrective effect of the exo-angle for a 1-mm advancement of the MR was 3.1 PD at 1 year after surgery and 2.9 PD at the last follow-up. There was a significant positive relationship between the preoperative exo-angle and the corrective effect of the 1-mm advancement of the MR at the last follow-up (r = 0.367, p < 0.05). Postoperatively, orthotropia was present in 79.2% of patients, re-exodrift in 16.9%, and ET in 3.9%. Favourable stereopsis was achieved in 73.2%. ConclusionsMR advancement was effective for treating consecutive XT, followed by recession of the MR for infantile ET, achieving favourable stereopsis. The corrective value was 3 PD per 1-mm advancement of the MR.

Diplopia in teenagers and adults following early surgery for infantile esotropia

To review the records of patients with infantile esotropia who developed diplopia between ages 13 and 33 years of age.

Influence of timing of initial surgery for infantile esotropia on the severity of dissociated vertical deviation

The purpose of this study was to clarify whether the timing of initial surgery for infantile esotropia contributes to better sensory outcomes and to the severity of dissociated vertical deviation (DVD). This retrospective study examined 55 children, aged 8 years and younger, who underwent esotropia surgery. Based on age at the time of the surgery, patients were divided into the very early surgery group (birth to 8 months, N = 14), early surgery group (9-24 months, N = 23) and late surgery group (25 months and older, N = 18). Sensory and motor outcomes of the three groups were statistically evaluated. No significant differences in the incidences of DVD were noted among the three groups at the final visit. However, all DVDs of the very early surgery group were latent, whereas 38.9% of the DVDs for both near and distance of the late surgery group were manifest. Significant differences were found among the three groups for the proportion of patients with manifest DVD, latent DVD and without DVD, and for the incidence of additional surgery for manifest DVD (p < 0.05, G-test). Early surgery for infantile esotropia decreases the severity of DVD and lowers the need for an additional operation for DVD.

Trends in surgical correction of strabismus: A 20-year experience, 1990-2009

Recent reports and anecdotal observations suggest that strabismus surgery, particularly for infantile esotropia, may be in decline, although a recent population-based study found the incidence to be stable. We analyzed the surgical database of 4,494 primary pediatric strabismus procedures from 1990 through 2009 at Children's Medical Center of Dallas. Linear regression models were used to identify the relationship between the year and the proportion of each surgical category (infantile esotropia, all esotropia, exotropia, and other) using the least-squares approach. Surgery for infantile esotropia (mean age, 10 months) was performed on 374 patients (mean, 19; range, 11-27/year). Trend analysis demonstrated no significant change in the annual rate of surgery for infantile esotropia (R(2) = 0.004) during the 20-year study period. Additionally, when compared to the annual number of births in Dallas County, no significant change in the incidence of surgically corrected infantile esotropia was noted during the study period (P = 0.25); however, surgery for both infantile esotropia (P = 0.001) and for any esotropia (P = 0.002) declined, while surgery for exotropia increased (P = 0.002) as a proportion of all primary strabismus surgeries. The incidence of surgically corrected infantile esotropia has remained stable over a 20-year period. As a proportion of all primary strabismus procedures, surgery for all types of esotropia has decreased and for exotropia has increased.

Dissociated vertical deviation and its relationship with time and type of surgery in infantile esotropia

AimTo investigate the development of dissociated vertical deviation (DVD) in infantile esotropia and its relationship with the infant's age and the surgical intervention technique.Material and methodThe medical records of the...