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.     

Comparison of Surgical Outcomes Between Bilateral Medial Rectus Recession and Unilateral Recess-Resect for Infantile Esotropia

Purpose: To compare surgical outcomes between bilateral medial rectus recession (BMR) and unilateral medial rectus recession-lateral rectus resection (RR) for infantile esotropia. Methods: In this retrospective study, BMR was performed on 57 patients (BMR group) and RR on 23 (RR group) for treatment of infantile esotropia with the postoperative follow-up period of 6 months or more. The main outcome measures were angle of esodeviation, rate of surgical success, rate of reoperation, rate of postoperative development of DVD, and postoperative sensory status. Surgical success was defined as esotropia or exotropia of 10 PD or less.

Results: The mean preoperative esodeviation at near was 44.1 prism diopters (PD) in BMR, and 40.2 PD in RR (p = 0.161). There was no statistically significant difference in angles of deviation between BMR and RR from postoperative day 1 to final follow-up, respectively (p > 0.05). Whereas until postoperative month 6 the surgical success rate did not significantly differ, from postoperative year 1 to final follow-up it was significantly higher in BMR than in RR (p < 0.05). The final success rates were 80.70% and 56.52% for BMR and RR, respectively (p = 0.047). The reoperation rate, correspondingly, was significantly lower for BMR (17.54%) than for RR (60.78%) (p = 0.000).

Conclusion: There was no significant difference in the mean postoperative angle of deviation between BMR and RR for infantile esotropia. However, the final success rate was higher (p = 0.047) and the reoperation rate was lower for BMR than for RR (p = 0.000).     

Surgical Outcomes of Medial Rectus Recession and Lateral Rectus Resection for Large-angle Deviations of Acute Acquired Concomitant Esotropia

PurposeThis study aimed to evaluate the surgical outcomes of unilateral medial rectus recession and lateral rectus resection (R&R) for patients with large-angle deviations of acute acquired concomitant esotropia (AACE) without a neurological disease. Further, we have also suggested the surgical dosage of R&R for large-angle deviations of AACE.MethodsThis was a retrospective study of patients with AACE who underwent surgery and followed up after surgery for at least 6 months between September 2016 and March 2020. Among them, patients with ocular deviations of ≥30 prism diopters (PD) who underwent unilateral R&R were included.ResultsSeventeen patients with AACE were enrolled in this study (mean age, 23.5 years; four females). The mean amount of deviation was 40.00 PD at distance and near (range, 30–55 PD). Fifteen patients (88.2%) had myopia. The mean interval between the initial visit and surgery was 7.7 months (range, 4–20 months). All included patients had resolved diplopia after the surgery. Most patients with decreased stereoacuity displayed stereoacuity recovery after surgical treatment. At the final visit (mean follow-up period, 12.8 months), the mean angle of esodeviation was 0.82 PD (range, 6–0 PD) at distance and 0.47 PD (range, 4–0 PD) near. No patient displayed over-correction or adduction limitations in the operated eye.ConclusionsThe unilateral R&R procedure presented favorable surgical outcomes for patients with large-angle deviations of AACE. These results and proposed surgical dosage guidelines may be useful for surgeons in planning the surgical treatment of large-angle deviations of AACE.     

Short-Term Motor and Sensory Outcomes in Acquired Nonaccommodative Esotropia of Childhood

Information on the management of acquired nonaccommodative esotropia (ANAET) of childhood is incomplete. Most prior reports combine the results of patients with both accommodative and nonaccommodative esodeviations. The primary objective of this study was to describe the early postoperative motor and sensory results of children with acquired nonaccommodative esotropia.

The medical records of 72 consecutive children with ANAET who underwent surgical correction at East Tennessee State University College of Medicine from August 1, 1995 through October 1, 2001 were retrospectively reviewed.

The median age at surgery for the 72 study patients was 43.8 months with a median angle of deviation of 30 prism diopters (PD) at both distance and near. Ten patients (13.9%) required a second surgical procedure while one patient (1.4%) required a third. The cumulative probability of a second surgery within two years of the first procedure was 24% (95% CI 4–43%). During a median postoperative follow-up period of 7.1 months, 64 (88.9%) patients were within 8 PD of orthotropia on the last postoperative examination. Normal postoperative stereoacuity was achieved in several children whose deviation began after 30 months of age, as well as in one child who was misaligned for at least two years prior to surgery.

Although the postoperative follow-up on these patients with acquired nonaccommodative esotropia managed without prism adaptation is short, the motor results are similar to other studies on patients with acquired esotropia, with sensory outcomes superior to those obtained in children with congenital esotropia.     

Evaluation and Management of Acute Acquired Comitant Esotropia in Children

ABSTRACT

Acute acquired comitant esotropia (AACE) is characterized by a sudden-onset eye misalignment with an equal angle of deviation in all fields of gaze. This form of esotropia is distinct from common forms of childhood esotropia, such as infantile esotropia and accommodative esotropia, in the rapid tempo and typically later timing of onset; further, AACE is distinct from restrictive or paretic strabismus, which usually results in an incomitant angle of deviation that varies with the direction of gaze. The underlying etiologies for AACE are broad but, in some cases, it may be associated with significant neurologic disease. Therefore, the purpose of this article is to examine and summarize the current literature on AACE to provide a framework for the evaluation and management of this form of acquired strabismus.     

Long-Term Outcome of Medial Rectus Recession and Pulley Posterior Fixation in Esotropia With High AC/A Ratio

Purpose: Medial rectus (MR) recession with pulley posterior fixation (PF) can be used to treatesotropia (ET) with a high accommodative convergence to accommodation (AC/A) ratio as effectively in the short term as MR recession with scleral PF. This study provides a novel examination of the long-term results of MR recession with pulley PF (PPF). Methods: In 21 children we performed bilateral MR recession and pulley PF for ET greater at near than distance (high AC/A). Mean follow-up was 3.5?±?2.5 (standard deviation [SD]) years. Results: Mean age at presentation was 2.7?±?1.8 and at surgery 4.3?±?1.6 years. Fourteen (67%) children had amblyopia. Distance and near pre-operative ET averaged 19.6Δ ± 10.5Δ and 36.9Δ ±18.9Δ, respectively. Mean near-distance (N-D) disparity was 16.4Δ ± 12.3Δ. The MR recession averaged 4.4?±?0.9?mm. Early mean postoperative ET was 1.3?±?3.3Δ at distance and 2.8Δ ± 5.2Δ at near. Mean late postoperative ET was 0.1Δ ± 5.8Δ and 1.0Δ ± 6.2Δ at distance and near, respectively. At the final postoperative examination, mean N-D disparity was reduced to 0.9Δ ± 3.6Δ. Discussion: MR recession with PPF has a high long-term effectiveness, even in patients with amblyopia and autism. Since no posterior scleral suturing is required, it minimizes the perforation risk associated with scleral PF. Conclusion: MR recession with PPF is a safe and highly effective long-term treatment for ET with high AC/A ratio. Long-term results may surpass those of alternate procedures.     

Divergence Excess Intermittent Exotropia: Long-Term Effect of Augmented Bilateral Lateral Rectus Recession

Purpose: To investigate the long-term (10 years) effects of augmented bilateral lateral rectus (aBLR) recession in patients affected by divergence excess intermittent exotropia (deIXT). Methods: Data of 58 patients affected by deIXT who underwent aBLR muscle recession were retrospectively analyzed. All patients were treated with 8.0 to 9.5 mm (mean 8.6 ± 0.5 mm) recession of BLR.Results: Our result showed a significant decreasing of both distance and near residual deviation during follow-up. The percentage of patients with successful surgical outcome (defined as a residual deviation ranging from 10pd intermittent exotropia to 5pd esotropia) increased during follow-up (from 51.7% to 81% at last follow-up). Stereopsis increased in 39.7% of patients at last follow-up. Moreover, there was a significant correlation between age at surgery and short/mid-term residual deviation. Conclusions: Our long-term results suggest that aBLR recession surgery is a very effective approach in patients affected by deIXT.     

Comparison of Postoperative Exodrift after First Unilateral and Second Contralateral Lateral Rectus Recession in Recurrent Exotropia

Purpose

To compare postoperative exodrift of the first unilateral lateral rectus (ULR) muscle recession with the exodrift of the second contralateral ULR muscle recession in patients with recurrent small-angle exotropia (XT).

Methods

We evaluated the results of a second ULR muscle recession in 19 patients with recurrent XT with deviation angles under 25 prism diopter (PD), following a first procedure of ULR muscle recession for small-angle XT. Recession of the lateral rectus muscle ranged from 8 to 9 mm. The postoperative motor alignment and degree of exodrift were investigated after the first ULR muscle recession and the second ULR muscle recession in the same patients.

Results

Observed differences in postoperative ocular alignment between the first ULR muscle recession and the second ULR muscle recession were statistically significant at follow-up periods of six months (7.84 ± 4.43 vs. 3.89 ± 3.47 PD), one year (9.58 ± 4.97 vs. 5.21 ± 4.94 PD), and at a final follow-up (21.11 ± 2.98 vs. 7.52 ± 4.06 PD) after surgery (p = 0.006, 0.013, and 0.000). Postoperative exodrift was statistically different between the first and second ULR muscle recessions at three to six months (2.89 ±3.75 vs. 0.63 ± 3.45 PD) and one year to final follow-up (11.52 ± 5.50 vs. 2.32 ± 3.53 PD) (p = 0.034 and 0.000). All of the first ULR muscle recession patients showed XT with deviation angles of more than 15 PD at the final follow-up. Regardless, the surgical success rate (<8 PD) after the second ULR recession was 63.16% (12 patients) among the total amount of patients with recurrent XT.

Conclusions

This study shows that changes in exodrift after a second ULR muscle recession are less than changes after the first URL muscle recession among patients with recurrent XT. A second ULR muscle recession may be a useful surgery for small-angle XT patients with deviation angles of 25 PD or less after a first ULR muscle recession.     

Vertical Muscle Transposition with Augmentation for Treatment of Exotropia Caused by Iatrogenic Lost Medial Rectus Muscle

Purpose: To evaluate the results of vertical muscle transposition with augmentation in cases of exotropia caused by iatrogenic lost medial rectus muscle.

Methods: This is a retrospective review of 5 cases of lost medial rectus with exotropia and marked limitation of adduction that underwent surgery. All cases had a history of strabismus surgery on the medial rectus and failed attempt at retrieval of the lost muscle.

Results: Five patients fulfilled the criteria. Full tendon vertical muscle transposition with augmentation sutures was done for all cases. Surgery led to a significant reduction of the angle of exotropia 25.8±13.6 ?D (P=0.027) and improvement in adduction of 7.5±3.8 degrees (P=0.034). There were no complications.

Conclusions: Isolated vertical muscle transposition with augmentation is a useful option to improve the exotropia and adduction deficit in patients with iatrogenic lost medial rectus muscle.     

A Case of Corneoscleral Dellen after Medial Rectus Recession Combined with Pterygium Resection in Right Eye

 Purpose: A case of corneoscleral dellen after medial rectus recession combined with pterygium resection was reported. Methods: Case report Results: A male patient aged 48 years had ghost for 1 year after acoustic neuroma resection. The patient was diagnosed with rectus paresis in the right eye. He successfully underwent medial rectus recession combined with pterygium resection. A corneoscleral dellen with a size of 2×2 mm was observed at 20 d postoperatively. The thinnest cornea was 147um, diagnosed as corneoscleral dellen, which was cured after undergoing corneal limbal stem cell transplantation with conjunctival flap. Conclusion: Corneoscleral dellen is non-infectious corneoscleral ulcer caused by complex reasons. Most cases recovered by using artificial tears, antibiotic ointment and eye wrap, and other patients required corneal limbal stem cell transplantation with conjunctival flap, even keratoplasty. It is recommended that the patients with strabismus combined with pterygium underwent conjunctival flap transplantation at early stage to prevent the incidence of surgical complications.     

双眼外直肌倾斜后徙术治疗儿童集合不足型外斜视

目的：:评价双眼外直肌倾斜后徙术（S-BLRc）治疗儿童集合不足型间歇性外斜视（CI-IXT）的有效性和安全性。方法：:回顾性病例对照研究。收集2019年8月至2020年7月于天津市眼科医院收治的集合不足型外斜视儿童患者58例,年龄4~10岁。根据S-BLRc外直肌上、下缘止点后徙量的差异分为3组：A组（1 mm,22...     

肌腹下眶-球硅管连接术治疗固定性斜视

目的探讨在麻痹肌肌腹下行眶-球硅管连接术治疗固定性斜视的疗效。方法收集23例（23只眼）固定性斜视患者,其中内斜视22例,外斜视1例;11例为全固定性斜视,12例为亚固定性斜视（9例斜视眼可转动,但无法达到正视位,3例斜视眼转动可达到正视位）。行拮抗肌后退术后,用直径为1mm的硅管经麻痹肌腹下连接眦部眶骨膜和麻痹肌止端前巩膜。术后随访12～36个月,观察眼位和眼球运动情况。结果23例患者术后眼位均恢复至正视位。术眼可向麻痹肌侧转动达25％、50％及75％正常幅度者分别为5例、2例及3例。结论肌腹下眶-球硅管连接术借用硅胶的弹性,起到被动牵拉作用以矫正斜视,是治疗固定性斜视的可行方法,同时该手术具有硅胶不外露的优点。（中华眼科杂志,2005,41：817-820）     

双鼻侧遮盖法辅助治疗儿童共同性内斜视的效果

目的：观察双鼻侧遮盖法辅助治疗儿童共同性内斜视的效果。方法：前瞻性临床研究。纳入2019年 1─7月期间在厦门市儿童医院经阿托品眼膏散瞳验光连续配戴远视全矫眼镜6～9个月后仍有+20△ 以上内斜视的3～10岁非调节性内斜视或部分调节性内斜视患儿21例。给予双鼻侧遮盖辅助治疗。 每个月定期复查观察患儿视力及斜视度的矫正情况。数据采用重复测量方差分析进行分析。结果： 遮盖前斜视度为（+33±13）△;遮盖3个月后斜视度为（+21±15）△,其中矫正显效3例,有效11例, 无效7例;遮盖6个月后斜视度为（+18±12）△,其中矫正显效5例,有效13例,无效3例。3个时间点 斜视度比较,总体差异有统计学意义（F=8.316,P=0.001）。结论：双鼻侧遮盖法可以有效地辅助治 疗儿童共同性内斜视。     

Effect of Binasal Occlusion in Children with Concomitant Esotropia

Objective: To investigate the effect of binasal occlusion in the treatment of children with concomitant esotropia. Methods: In this propective clinical study, 21 children aged 3 to 10 years with nonaccommodative esotropia or partly accommodative esotropia who had more than +20△ esotropia after full refraction correction for 6 to 9 months at Xiamen Children's Hospital from January 2019 to July 2019 were examined. All the children were given binasal occlusion. Vision function and strabismic degree were re-examined every month. Data were analyzed by single factor analysis of variance. Results: The average strabismus was +33△±13△ before binasal occlusion. After binasal occlusion for 3 months, average strabismus was +21△±15△. Three cases were markedly corrected, 11 cases were effectively corrected, 7 cases were invalid. After binasal occlusion for 6 months, average strabismus was +18△±12△. Five cases were markedly corrected, 13 cases were effectively corrected, 3 cases were invalid. The difference was statistically significant (F=8.316, P=0.001). Conclusions: Binasal occlusion can effectively assist the treatment of concomitant esotropia in children.     

Comparison of Surgical Success for Infantile Esotropia and Strabismus Associated with Neurological Impairment

Purpose: Surgery for strabismus associated with neurological impairment is assumed to have unsatisfactory results in comparison with other strabismus cases. The aim of this study is to compare the surgical success rates of infantile esotropia (IE) and strabismus associated with neurological impairment.

Methods: The records of 103 patients that received operations for IE and strabismus associated with neurological impairment between January 1994 and May 2014 were reviewed retrospectively. The angles of deviation and surgical success rates were evaluated at preoperative, 1-month postoperative, and 24-month postoperative visits.

Results: Forty-five patients received operations for strabismus associated with neurological impairment (25 patients with esotropia and 20 patients with exotropia) and 58 patients for IE. Mean preoperative angles of deviation in cases with neurological impairment were 42 prism diopters (PD) for esotropia, 44.7 PD for exotropia, and 44.4 PD for IE. One patient from each group had consecutive deviation at first visit, and at last visit, 3 patients with neurological impairment and 5 patients with IE had consecutive deviations. Surgical success rates at the end of the second year were 52% for esotropia and 50% for exotropia in patients with neurological impairment and 56.8% for IE cases.

Conclusion: This study was unable to find the differences between surgical success rates in IE and strabismus associated with neurological impairment.     

甲状腺相关眼病患者斜视手术量效关系分析

目的探讨甲状腺相关眼病（TAO）患者斜视手术量与矫正效果的关系。方法回顾分析作者在中山大学中山眼科中心自1999年1月至2006年3月期间诊治的甲状腺相关眼病患者行斜视矫正手术的全部病例。结果TAO患者因斜视需要手术矫正者共30例（32只眼）,其中男性19例,女性11例;平均年龄49．4岁;左眼21只,右眼11只。32只患眼中,10只眼行下直肌后徙术,10只眼行上直肌后徙术,6只眼行内直肌后徙术,3只眼行上直肌断腱术,2只眼行下直肌后徙联合内直肌后徙术,1只眼行上直肌后徙联合内直肌后徙术。32只眼中眼位完全矫正30只眼,术后正位率为93．75％。以29只眼行直肌后徙术后正位的28只眼计算每毫米矫正量,平均为（3．93±1．67）°／mm。上直肌矫正量最小为（2．63±0．83）°／mm,内直肌矫正量最大为（5．33±1．46）°／mm,下直肌矫正量为（4．11±1．55）°／mm;斜视度数≤15°者,矫正量为（2．30±1．09）°／mm;斜视度数16°-30°者,矫正量为（3．56±0．79）°／mm;斜视度数〉30°者,矫正量为（6．02±1．01）°／mm。结论TAO斜视患者单位手术矫正量均大于其他类型斜视的单位手术矫正量;随着斜视度数的增加,每毫米矫正量增大。但其手术定量性仍较差,手术效果预测较为困难。（中华眼科杂志,2007,43：982-986）     

The Effect of Prism Adaptation on the Angle of Deviation in Convergence Excess Esotropia and Possible Consequences for Surgical Planning

Convergence excess esotropia describes a heterophoria with binocular single vision (BSV) on distance viewing that becomes esotropic on accommodation upon near fixation. Prism adaptation test (PAT) is a procedure routinely used to reveal the maximum angle of deviation preoperatively for many types of strabismus and has been shown to improve surgical outcomes; however, it is not conventionally used for convergence excess esotropia.

Aim: This study compares the angle of deviation at 1/3 m and 6 m before and after prism adaptation in subjects with convergence excess esotropia to determine if a masked distance angle of deviation can be demonstrated similar to the masked near angle of deviation in some intermittent exotropes. Surgical results are reported.

Results: Fifty-eight children with convergence excess esotropia were prescribed prism adaptation prior to strabismus surgery and 49 met the inclusion criteria. A median increase in the angle of deviation of 20 prism dioptres (PD) was seen at both 1/3 m and 6 m following PAT. These changes were statistically significant (p < 0.001) at both distances. Following one surgical procedure, 83.6% were fully binocular postoperatively.

Conclusion: Prism adaptation frequently reveals an otherwise masked large distance angle of deviation in convergence excess esotropia. Convergence excess esotropia can be subdivided into two categories: true and simulated. Those with true convergence excess exhibit a manifest convergent strabismus when viewing a close object and a small, well-controlled latent strabismus upon fixation of a distant object. Those with simulated convergence excess have a comparable near deviation to those with true convergence excess but can be shown to have a distance deviation that approaches the size of the near strabismus once the normal fusional mechanisms are disrupted by a period of prism adaptation.