A modified vertical muscle transposition for the treatment of large-angle esotropia due to sixth nerve palsy

Introduction: Multiple different procedures have been proposed to address complete sixth nerve palsy with severe abduction limitation. In this study, we report a modification of the Hummelsheim’s procedure. It is in fact muscle pulley transposition that obviates the need for tenotomy or muscle splitting. For the first time, Muraki and Nishida proposed this technique.

Materials and Methods: Patients with large angle esotropia and abduction limitation of minus four or greater were enrolled. The surgery involved insertion of a polyester monofilament fiber suture through the temporal muscular margin of each vertical rectus muscle at approximately one-third of the width from the edge at 10 mm behind the muscle insertion. We tried to insert sutures away from the vessels of vertical muscles. Then, the vertical muscles were transposed without any tenotomy or splitting and the sutures were secured to the sclera 16 mm from the limbus in supratemporal and infratemporal quadrants. In all of the patients, this transposition was combined with medial rectus recession.

Results: A total of 10 patients were included; all of them had an esotropia with profound abduction deficit (?4 or more). The mean age of patients was 44.2 ± 9.2 years (mean ± standard deviation) (range: 28–57). The mean preoperative deviation was 49.5 ± 9 PD prism diopters (PD) (range: 40–65 PD). The mean preoperative abduction limitation was ?4.8 ± 0.8. The patients were followed for at least 6 months. Postoperative deviation ranged from orthotropia to 12 PD of esotropia and all the patients obtained abduction at least beyond the midline. No vertical ductional disturbances or deviations were developed. The adduction was not compromised in any patient. Anterior segment ischemia did not occur in any patients.

Conclusion: This procedure is comparable to traditional procedures with the advantages of no need to tenotomy or splitting and can be a good alternative to conventional Hummelsheim’s procedure.     

硅胶带部分直肌肌腹联结术治疗重度高度近视眼固定性内下斜视的疗效

目的：观察硅胶带部分直肌肌腹联结术同时联合内直肌后退术治疗重度高度近视眼固定性内下斜视 （MSF）的安全性和有效性。方法：回顾性系列病例研究。收集2017年3月至2021年4月在空军军医 大学西京医院眼科行单眼或双眼硅胶带联结上直肌颞侧1/2 和外直肌上1/2 部分肌腹且同时联合内 直肌后退术的重度MSF患者8例（12眼）。年龄30~80（53.8±15.6）岁；等效球镜度为-26.00~-13.50 （-20.41±4.12）D；B超测量眼轴长度26.34~35.30（30.16±2.51）mm。术后随访时间6个月~3年。对 比分析患者手术前后内斜视、下斜视、眼球外转和上转受限程度改变，以及眼球脱位角度(AGD)的 改变。采用配对样本t检验以及Wilcoxon符号秩和检验进行数据处理。结果：8例（12眼）患者内斜度 由术前（+101±13）PD减为术后的（+3±5）PD，下斜视度由术前30（25，34）PD减为术后的0（0，0） PD，外转受限由术前的-5（-5，-5）降为术后的-2（-3，-1），上转受限由术前-5（-5，-5）降 为术后的-2（-2，-2），差异均有统计学意义（均P<0.01）。手术前后影像学资料完整的5例（8眼）， AGD由术前的（185±28）°减为术后（121±19）°，差异有统计学意义（t=8.96，P<0.001）。术前有代 偿头位患者3例，术后头位均明显改善或消失。术后有3例患者术眼有异物感，3周后消失。结论： 硅胶带上直肌和外直肌部分肌腹联结术联合内直肌后退术治疗重度MSF安全有效，可以显著矫正重 度内下斜视和改善眼球运动。     

Clinical features and surgery for acquired progressive esotropia associated with severe myopia

PURPOSE: The purpose of this study was to evaluate the clinical and physiological findings and to determine the most appropriate surgical procedure for acquired progressive esotropia with severe myopia. METHODS: Thirty-eight cases of acquired progressive esotropia with severe myopia were examined to evaluate their clinical and physiological findings. All cases were divided into four groups according to the limitation of their abduction. The eyeball in group IV is fixed in an extremely adducting position. Thirty-one cases underwent strabismus surgery; medial rectus muscle recession and lateral rectus muscle resection in 23 cases, transposition of superior and inferior rectus muscles (modified Jensen procedure included) in eight cases. RESULTS: The medial rectus muscle recession with the lateral rectus muscle resection procedure was effective in the early stage of acquired progressive esotropia patients. Transposition procedure was effective in the severe abducting limited patients. CONCLUSIONS: As the recession & resection procedure is easier than the transposition procedure, we recommend performing surgery in the earlier stage of the abducting disorder before the eyeball is fixed in an extremely adducting position.     

继发性内斜视的手术治疗

目的 探讨手术治疗继发性内斜的效果.方法 回顾分析近3年诊治的13例继发性内斜患者,均有外斜手术矫正病史,术后继发内斜持续均大于6个月.3例患者正前方内斜小于等于+20PD,外转不受限,行内直肌后徙手术;5例患者正前方小于等于+35PD,外转不同程度受限,行外转受限眼的外直肌复位手术;5例患者正前方内斜大于等于+50PD,外转不同程度受限,行外直肌复位联合内直肌后徙手术.术后随访超过6个月.结果 13例患者术后无复视及代偿头位,平均眼位为(-2.0±6.0)PD,术后远期(大于6个月)随访眼位平均为(-2.8±4.4)PD,远期随访眼位的变化为(-0.8±4.2)PD.内斜矫正手术后手术成功率为84.62%(11/13),远期随访眼位矫正成功率为84.62%(11/13).所有患者均对术后眼位满意,未行再次手术.结论 继发性内斜的手术治疗有效,对于大角度的继发内斜视,外直肌复位联合内直肌后徙手术可取得较好的疗效,并且远期随访患者满意度较高.

Abstract：

Objective To evaluate the surgical management of consecutive esotropia.Methods In 13 patients with consecutive esotropia which persisted over 6 months after exotropia surgery were observed.Three patients less than +20PD in primary position without limited abduction were treated with recession of medial rectus; 5 patients less than +35PD in primary position with abduction impairment were treated with advancement at insertion of lateral rectus muscle; 5 patients with large angle esotropia in primary position were treated with advancement of lateral rectus combined with recession of medial rectus.The patients were followed up for more than 6 months.Results Postoperatively, 13 patients were orthophoria without diplopia or abnormal head position, mean deviation was -2.0± 6.0PD, -2.8± 4.4PD as long term follow up.The success rate was 84.62% (11/13) both immediately after surgery and for long term follow up.All patients were satisfied with the surgical correction and no one needed more surgery.Conclusions Surgical management is effective for consecutive esotropia.For large angle consecutive esotropia, advancement of lateral rectus muscle combined with recession of medial rectus is an effective choice with high level satisfactory from follow up.     

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

ABSTRACT

Aim: 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.     

上直肌转位联合内直肌后徙术治疗外展神经麻痹性内斜视的临床疗效

目的　探讨上直肌转位（SRT）联合内直肌后徙术（MRC）治疗外展神经麻痹性内斜视的临床疗效。方法　回顾性系列病例研究。收集2017年9月至2020年3月郑州大学第一附属医院斜视与小儿眼科专业组收治的应用SRT联合MRC治疗的38例（50眼）外展神经麻痹性内斜视患者的临床资料。采用三棱镜角膜映光法测量所有患者第一眼位斜视度,第一眼位时应用角膜映光法评估眼球外转受限程度;Titmus立体图评估近立体视,同视机随机点图片评估远立体视。随访时间为6~14个月。采用配对样本t检验比较手术前后第一眼位的斜视度和外转受限程度,配对卡方检验比较手术前后立体视变化情况。结果　38例（50眼）患者的第一眼位斜视度由术前的(75.53±13.17)PD降至术后6个月的(5.93±2.46)PD（t=12.49,P=0.00）,外转受限程度由术前的-4.50±0.68改善至术后6个月的-1.87±0.55（t=-13.00,P=0.00）。术后20例患者近立体视恢复,17例患者远立体视恢复。2例患者术后仍残余小角度内斜视,配戴压贴三棱镜后复视消除。所有患者术后均未发生垂直斜视和旋转斜视。结论　SRT联合MRC可有效矫正外展神经麻痹性内斜视,减少手术累及眼外肌的数目,且术后未发生明显垂直斜视和旋转斜视。     

直肌联结术与改良部分直肌转位术治疗完全性麻痹性内斜视的疗效比较

目的:比较直肌联结术与改良部分直肌转位术治疗完全性麻痹性内斜视的疗效。方法:回顾分析我院2016-10/2020-10确诊完全性麻痹性内斜视患者35例44眼,其中15例21眼行直肌联结联合拮抗肌后徙术(联结组),20例23眼行改良部分直肌转位联合拮抗肌后徙术(转位组)。观察两组患者手术时长、手术前后原在位斜视度、外展麻痹程度、内直肌后退量及治愈率等。结果:两组患者一般资料及手术时长均无差异(P>0.05)。术后末次随访联结组患者斜视度由102.33±41.70PD降为3.93±4.82PD(P<0.001),外展麻痹由-4.81±0.40改善至-1.57±0.51(P<0.001);转位组患者斜视度由94.75±33.03PD降为2.85±5.96PD(P<0.001),外展麻痹由-4.91±0.29改善至-1.22±0.42(P<0.001)。术后两组间斜视度比较无差异(P>0.05),转位组较联结组外展麻痹改善佳(P<0.05)。联结组与转位组内直肌后退量分别为7.16±2.07和6.37±2.34mm(P>0.05)。术后末次随访：...     

An Unexpected Outcome of Blunt Ocular Trauma: Rupture of Three Muscles

Introduction: Traumatic strabismus due to isolated extraocular muscle rupture is uncommon. Treatment usually depends on the severity of both the subjective and objective findings. Methods: We report a male patient with restricted abduction and supraduction in the right eye follow ing a blunt ocular trauma. The exploration revealed the rupture of superior rectus, superior oblique, and lateral rectus muscles. Only lateral rectus muscle could be sutured to the proximal segment. Superior rectus and superior oblique muscles were severed brutally, so that repairing was not possible.

Results: On the day after exploration and primary suturation, there was 25 prism diopters (PD) hypotropia and 15 PD esotropia in his right eye with severe limited supraduction and abduction. His major complaint was a large vertical diplopia which resolved partially with the prismatic glasses prescribed. After 6 months follow-up, medial rectus and inferior rectus recession was performed in the right eye. The patient had a limited but improved abduction after the operation. He was orthotropic and had a single binocular vision in the primary position.

Discussion: In suspected extraocular muscle ruptures, orbital imaging methods and surgical exploration should be considered promptly. MRI may be mandatory to demonstrate the severed muscles in cases with persistent diplopia and normal CT. Prognosis is usually better in patients having partial extraocular muscle damage and treatment options should be evaluated on patient basis.     

Treatment of congenital esotropia with botulinum toxin type A

Purpose: To examine the effect of botulinum toxin type A injections given transconjunctivally into the medial recti muscles in patients with congenital esotropia. Methods: Eighty‐two patients with congenital esotropia were treated with botulinum toxin type A transconjunctival injections into the medial recti muscles. Results: A Kaplan–Meier curve shows a 24‐month success rate of 87% (n = 53) with alignment within 20 prism dioptres (PD) of the 80 patients who were seen at least 1 year following the last injection. Seven of the 80 patients underwent standard monocular surgery with recession of the medial rectus and resection of the lateral rectus muscle. Two patients were lost during follow‐up. Conclusion: Botulinum toxin type A injections into the medial recti muscles are a valuable alternative to conventional strabismus surgery.     

Unilateral recession and resection in Duane syndrome.

PURPOSE: To assess the efficacy of lateral rectus resection with medial rectus recession in the affected eye of patients with Duane retraction syndrome (DRS) with esotropia and limited abduction, compared with bilateral medial rectus recessions. METHODS: The charts of 9 patients with DRS who underwent a recession-resection procedure and 10 patients with DRS who underwent bilateral medial rectus recessions were reviewed. Ocular ductions (graded from 0 = full duction to -4 = total deficit), severity of retraction, alignment, head position, and binocular single vision field (for study group only) were recorded before and after surgery. RESULTS: Before surgery, the study and control groups did not differ in mean primary position esotropia (16.9 and 18.8 PD, respectively), face turn (16.5 degrees and 15.0 degrees, respectively), average limitation of abduction (-3.9 and -3.7, respectively), or adduction (-0.1 and -0.3, respectively). After surgery, both groups had similar mean face turns (3.9 degrees and 1.0 degrees ), esotropia (3.3 PD and 1.0 PD), and abduction limitation in the affected eye (-2.4 and -2.6). However, mean adduction was significantly worse in the control group than in the study group (-1.5 vs -0.6, P = .02). Globe retraction improved in all control subjects. It worsened in 5 study subjects and did not improve in the other 4. In the study group, 1 patient required reoperation for undercorrection and another was overcorrected. CONCLUSION: Seven of 9 patients with DRS, selected on the basis of esotropia, limited abduction, and mild retraction, benefited from a recession-resection procedure. Abduction improved to the same degree as seen after bilateral medial rectus recessions, with less tendency to limit adduction.     

Muscle Belly Union for Treatment of Myopic Strabismus Fixus

Purpose: To evaluate the surgical results of the medial rectus (MR) muscle recession associated with longitudinal splitting of the lateral rectus (LR) and superior rectus (SR) muscles and surgical union of their corresponding midpoints in highly myopic patients with severe esotropia and hypotropia and restricted abduction and elevation. Methods: Six cases of severe high myopic strabismus fixus were considered with more than 90Δ esotropia and 25Δ to 30Δ hypotropia. The nasally deviated SR muscle and inferiorly shifted LR muscle were confirmed by MRI or CT scan. Supratemporal herniation of the globe from the muscle cone was also found by imaging. The LR and SR muscles were split in half from the insertion to past the equator. The lateral half of the SR muscle was united to the superior half of the LR muscle. Medial rectus muscle was recessed also. Results: Motility gradually improved and by 8 weeks in four cases there was 5Δ to 15Δ residual esotropia and no hypotropia and mild limitation in abduction and elevation. In two cases due to marked residual esotropia, we performed a second operation, and 2 months later residual esotropia was mild. Conclusion: In highly myopic patients, if the deviant paths of the LR and SR muscles are demonstrated by MRI or CT scan, the surgical method described is effective and recommended.     

甲状腺相关眼病眼眶减压术后继发内斜视伴复视的手术疗效观察

目的探讨甲状腺相关眼病(TAO)眼眶减压术后继发内斜视伴复视的斜视矫正手术治疗效果。方法回顾性系列病例研究。选取2016年3月至2018年10月在天津市眼科医院因TAO行眼眶减压术后继发内斜视伴复视行斜视矫正手术治疗的11例患者资料。斜视矫正手术前、后检查患者斜视度数、眼球运动,观察复视情况。手术均在监护下麻醉联合局部麻醉下进行,术中采用被动牵拉试验结合调整缝线方法,调整至第一眼位复视消失。术后定期随访。结果11例患者中男性1例,女性10例;年龄26~42岁;均为单纯内斜视伴复视;内斜视度数10~98三棱镜度;眼眶CT提示患者内直肌不同程度增厚,外直肌增厚程度较内直肌轻。2例患者行单眼内直肌后徙术,2例行双眼内直肌后徙术,2例行单眼内直肌后徙联合外直肌缩短术,另外5例行双眼内直肌后徙联合单眼外直肌缩短术。11例患者术中内直肌后徙量为3.5~7.5 mm,7例联合外直肌缩短术患者外直肌缩短量为2.0~6.0 mm。全部患者术后复视消除,第一眼位正位,均达到治愈标准。眼球运动术前外转受限分级为(-1.91±1.04)级,术后外转受限分级为(-0.64±0.81)级。11例患者均对手术结果满意,术后随访6~24个月,效果稳定,未发现远期过矫患者。结论应用术中调整缝线技术,斜视矫正手术可以有效治疗TAO眼眶减压术后继发的内斜视伴复视。     

Superior Oblique Tucks for Apparent Inferior Oblique Overaction and V-pattern Strabismus Associated with Craniosynostosis

Introduction: Apparent inferior oblique overaction and apparent superior oblique underaction are common in strabismus associated with craniosynostosis, and in many cases are likely due to excyclotorsion of the globes, with the rectus muscles acting with oblique vectors. We present a patient with craniosynostosis who underwent bilateral superior oblique tucks to specifically address the excyclotorsion of the globes.

Methods: A 16-year-old male with Saethre-Chotzen syndrome presented with apparent bilateral inferior oblique overaction and apparent bilateral superior oblique underaction. He had 30 prism diopter (PD) esotropia and 5 PD left hypertropia by simultaneous prism and cover test (SPCT) at distance and near fixation. Fundus exam revealed marked excyclotorsion of both globes. The superior oblique tendons were tucked 10?mm bilaterally, using a 6-0 mersilene suture and the medial rectus muscles were recessed 5.5?mm on an adjustable suture with a 10-mm inferior displacement. Surgical results were reviewed at 6 weeks and 2 years postoperatively.

Results: At 6 weeks and 2 years postoperatively, apparent inferior oblique overaction, apparent superior oblique underaction, and V-pattern esotropia were markedly improved. At 2 years, SPCT measurements were 8 PD esotropia in primary position at distance and 4 PD esotropia and 3 PD left dissociated vertical deviation at near.

Conclusions: Bilateral superior oblique tucks are useful in addressing the excyclotorsion that leads to apparent inferior oblique overaction and V-pattern strabismus associated with craniosynostosis.     

The use of one muscle recession for horizontal strabismus

Purpose

To evaluate the outcomes of one muscle recession for horizontal comitant strabismus at a major referral hospital in the Middle East.

Surgical outcome of a new modification to muscle belly union surgery in heavy eye syndrome

ABSTRACT

Objectives: 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.     

Vertical rectus muscle transposition for bilateral Duane syndrome.

BACKGROUND: Augmented transposition of the superior and inferior rectus muscles to the lateral rectus muscle is effective surgical treatment for esotropia in unilateral Duane syndrome. Medial rectus muscle recession in bilateral Duane syndrome may increase the risk of consecutive exotropia and cause limitation to adduction postoperatively. Vertical rectus muscle transposition may be useful in bilateral Duane syndrome with esotropia. METHODS: We undertook a retrospective review of 11 patients with bilateral Duane syndrome and esotropia in primary position. All patients had vertical rectus muscle transpositions. Six patients had unilateral vertical rectus transpositions (2 eyes with and 4 without suture augmentation). Twelve eyes from 7 children (2 unilateral and 5 bilateral) had transpositions augmented with posterior fixation sutures. Posterior fixation suture were added to large deviations in patients without prior medial rectus recessions. RESULTS: The preoperative esotropia at distance was 22.8 +/- 6.3 prism diopters (PD). It reduced to 2.0 +/- 6.7 PD postoperatively. (P < 0.001) Esotropia at near changed from 21.0 +/- 5.8 PD preoperatively to 1.2 +/- 8.1 PD postoperatively. (P < 0.001) One patient with a 10-degree face turn had complete resolution postoperatively. One patient had a small undercorrection and developed a vertical deviation requiring additional surgery. All patients had improvement in abduction. Nine of 11 patients did not develop any limitation to adduction. One patient developed a -1 adduction deficit 5 years later. Three patients achieved fusion with a mean stereovision of 67 seconds of arc (range, 80-40 seconds.). Follow-up averaged 22.2 months (range, 1-100 months). CONCLUSION: Vertical rectus muscle transposition in patients with bilateral Duane syndrome and esotropia is an effective procedure to improve ocular alignment and motility while preserving adduction.     

Effect of bimedial rectus recession with a loop on the deviation in essential infantile esotropia

Thirty-two patients with essential infantile esotropia were treated by using a 2.5 millimeter loop, added to a 4 millimeter medial recti recession bilaterally. Objective deviation was more than 45 prism diopters (PD) in all of the patients preoperatively. After surgery the deviation ranged between -10 PD and +IO PD in 26 (81.2%) patients, and limitation of abduction disappeared in all of the cases. A slight limitation of adduction was encountered in two (6.2%) patients. The authors concluded that bimedial rectus recession with a loop is an effective method as an early surgical procedure in patients with infantile esotropia with a large deviation.     

Bupivacaine injection combined with recession of antagonist rectus muscle to treat sensory strabismus

Purpose: This study aims to evaluate the effect of bupivacaine injection at 1.5% combined with recession of the antagonist rectus muscle to treat sensory strabismus in adult patients.

Methods: Nine patients with a horizontal deviation, visual acuity of <20/60 in the worst-seeing eye, and no previous strabismus surgery were selected. Patients with vertical strabismus were excluded. Lateral rectus (LR) recession was performed in patients with exotropia and medial rectus (MR) recession in patients with esotropia according to Park’s Table, as modified by Wright. Bupivacaine 1.5 mL at 1.5% was injected in the antagonist of the recessed muscle. The patients were evaluated after 1, 7, 30, 60, 90, and 180 days of the procedure. Successful motor alignment was defined as within 10 prism diopters (PD) of orthophoria. Dose-response was considered as the total amount of correction, divided by recession performed in millimeters, associated with bupivacaine injection in the antagonist muscle.

Results: Of the patients, 44% (4/9) had a successful motor alignment. The mean correction for exotropia (n = 5) with a preoperative horizontal deviation of 50 ± 6.12 PD was 23 ± 14.4 PD with a dose-response of 2.6 PD/mm. For esotropia (n = 4), the mean correction of 21.25 ± 4.8 PD was achieved with a preoperative deviation of 28.7 ± 14.9 PD with a final dose-response of 5 PD/mm. All unsuccessful patients had a preoperative deviation of ≥45 PD.

Conclusion: Bupivacaine injection in the antagonist of a recessed extraocular muscle (EOM) appears to add an effect to the standard dose-response of a muscle recession. For patients with esotropia (<25 PD), a single MR recession combined with bupivacaine in the LR can produce a successful motor alignment. For patients with large horizontal strabismus (>45 PD), larger bupivacaine doses (volume and concentration) combined to larger recessions may be needed.     

Long-Term Results of Bilateral Medial Rectus Muscle Recession in Children with Developmental Delay

Purpose: To assess the long-term results of a reduced amount of medial rectus recession in children with esotropia and developmental delay.

Methods: A retrospective chart analysis of 42 children with developmental delay who had undergone surgery for esotropia during a 20-year period in a large referral center was performed. The pre- and postoperative angle of deviation was calculated for each subject as the mean of distant and near angles measured by a cover test or the Krimsky measurement. Surgical success was categorized as esotropia or exotropia of ≤10 prism diopters (PD). The main outcome measure was a stable surgical result after several years of follow-up.

Results: The chart review identified 42 children who met inclusion criteria, with a mean age of 2.9 years (range, 0.8-10 years). The mean angle of esotropia prior to surgery was 44.29 ± 13.9 PD (range 20-80 PD). All patients had bilateral medial rectus muscle recessions, with a mean surgical dosage of 5.04 ± 0.62 mm per muscle, on average 0.66 mm less than the standard amount. The average postoperative follow-up was 4.6 years (median 3.67 years, range 8 months-15 years). Twenty-four children (57%) achieved surgical success, 13 (31%) were undercorrected, and 5 (12%) were overcorrected. Ten of the 18 with an unsuccessful surgical outcome underwent a second procedure. The overall surgical success rate for all patients after all procedures was 71%.

Conclusions: The main reason for surgical failure after bilateral medial rectus muscle recession (BMR) in developmentally delayed children remains residual esotropia. However, with time, more patients demonstrated consecutive exotropia. Although it is difficult to achieve a stable long-term ocular alignment in children with developmental delay, satisfactory results may be achieved with additional surgical procedures. The optimal amount of primary recession and whether to perform the surgical schedules according to the Parks tables or to reduce the amount of the recession when operating on children with developmental delay is still debatable.     

共同性水平斜视的再次手术

目的 探讨共同性水平斜视手术后施行再次斜视手术的临床特点及手术处理的特殊性.方法 共同性水平斜视手术后施行再次斜视手术的55例患者进行了回顾性临床分析,手术前后进行眼位检查、眼球运动,Titmus立体视检查双眼视觉功能.手术方法:手术前做全麻下或局麻下行牵拉试验.手术方式选择原则:依据视近和视远斜视角的不同,眼球运动受限制的受累肌肉和牵拉试验结果选择术式.术后追踪观察1～8年,平均2年.结果 (1)内斜视术后继发外斜视13例中,除即刻过矫3例在手术后48h内施行内直肌探查术外,其余施行原后徙内直肌完全复位或部分复位术,联合外直肌截除.治愈率76.9%.外斜视术后继发内斜视11例,施行原后徙外直肌完全复位或部分复位术,联合内直肌截除.治愈率81.8%.伴有V型斜视和垂直性斜视者联合水平直肌移位或斜肌减弱术.(2)内斜视欠矫15例中,8例施行内直肌边缘切开联合外直肌截除术;选择单纯在同一眼上外直肌截除术2例;伴有斜肌异常患者,则选择对侧眼内直肌后徙联合外直肌截除并下斜肌后徙5例.术后正位率86.7%.外斜视欠矫16例中:6例施行原外直肌后徙眼边缘切开联合内直肌截除术;2例Ⅴ型外斜视联合双下斜肌后徙,4例外直肌周围瘢痕松解术,4例联合调整缝线.术后正位率87.5%.结论 (1)水平斜视过矫伴有受累肌运动障碍,结合看近与看远斜视角的差别,选择内直肌或外直肌复位术.(2)调整术后缝线可将再次斜视手术的非预期结果降低到最小程度.