Bilateral medial rectus muscle recession and lateral rectus muscle resection in the treatment of congenital esotropia

Botulinum toxin augmented surgery versus conventional surgery in the management of large-angle concomitant esotropia: A randomized clinical trial

BACKGROUND

The surgical management of large-angle concomitant esotropia is challenging with high reoperation rates. This study aims to assess the effectiveness and safety of intraoperative botulinum toxin A (BTA) augmentation compared to surgery alone in large angle concomitant esotropia.

MATERIALS AND METHODS

This is a prospective randomized interventional study. Patients with large angle concomitant esotropia (≥55 prism diopter [PD]) were randomly allocated to either surgery only (Group I) or BTA augmented surgery (Group II). The surgical effect in PD/mm was calculated and compared between the study groups at all follow up intervals. Treatment was considered successful if the patients had orthotropia ± 10 PD at their final examinations.

RESULTS

A total of 23 patients were included in the study, 11 in Group I and 12 in group II. The surgical effect was significantly greater in Group II compared to Group I at all follow up durations. The 1-year surgical effect was 32.5% greater in Group II compared to Group I (5.99 ± 0.69 vs. 4.52 ± 0.91 PD/mm, respectively, P = 0.001). The success rate was greater for Group II compared to Group I (75% vs. 63.64%, respectively), but this difference was not statistically significant (P = 0.901).

CONCLUSION

Botulinum toxin augmented surgery is a good alternative to surgery alone in the treatment of large angle concomitant esotropia. BTA injection exerts a significant augmentation effect on medial rectus muscle recessions.

Large bilateral medial rectus recession versus three-to-four horizontal muscle surgery for large-angle esodeviations

PURPOSE

The best surgical approach to correcting large angle esodeviations is still debated. Options for correcting large esodeviations include recessing both medial rectus (BMR) muscles more than 5.5 mm or performing surgery on three or four horizontal rectus muscles. There remains no consensus on which surgery has better survival outcomes. In this research, we are interested in determining the survival rates and long-term outcomes of both surgeries locally in the Philippines.

RESULTS

A total of 74 medical records were retrospectively reviewed. The mean age at onset of deviation was 2  ±  2.9 years old, and the mean age at surgery was 14  ±  12.5 years, with a mean of 12  ±  12.1 years from onset to surgery. The mean follow-up period was 9.9 months (range 6-24) . The mean preoperative deviation at near was 59.3  ±  13.6 PD (range: 35-95) while at distance was 58.5  ±  13.6 PD (range 10-95). The most common type of esotropia (ET) was infantile ET (45%), followed by basic ET. Majority of the esodeviations did not have associated vertical strabismus (67.6%, n  =  50). Overall success rate was 48.1% for BMR recessions and 54.5% for 3-4 muscles surgery. Survival analysis revealed the decreasing trends of survival but plateauing of outcomes after 6 months.

CONCLUSION

We reported the outcomes for both surgeries. Neither had shown superiority over the other. After a mean follow up of 9.9 months, the overall success was relatively good: 50% were successful, 39.2% overall recurrence and 13.8% overcorrections. Survival plots showed a plateauing of results after 6 months.

[Three-muscle surgery for large angle esotropia]

BACKGROUND

Bilateral medial rectus muscle recession with or without Cüppers' posterior fixation suture and recess and resect surgery are used to correct for large angle esotropia. There are only few reports on three muscle surgery (3MS). We analyzed the results of 3MS.

PATIENTS AND METHODS

Between June 2016 and May 2020, 61 patients received 3MS for esotropia ≥ 27° (50 PD) together with oblique muscle surgery, if needed. Angles of strabismus were measured by simultaneous prism and cover testing (SPCT) and alternating prism and cover testing (APCT) at 5 m and 0.3 m. Grading was around 0.51 mm/degree (at 5 m). Medium-term results of 57 patients were available.

RESULTS

Medians and ranges (min-max) were: age, 6 years (3-56 years). Preoperative APCT, far 34° (27-45°), near 36° (27-50°). Amount of surgery, 17 mm (15-21 mm), oblique muscle recession in 21 cases. The APCT after 5 months (3-24 months), far 2° (-10-18), near 2° (-8-18). Success rates (absolute deviation ≤ 6° [10 PD]), APCT far 68%, near 67%, SPCT far 79%, near 74%. Exotropia > 6° occurred in 4 cases (7%) at far and 3 (5%) at near, esotropia > 6° in 14 cases (25%) at far and 16 (28%) at near.

CONCLUSION

The use of 3MS is a suitable first step procedure to correct for large angle esotropia.

Long-term Surgical Outcomes for Large-angle Infantile Esotropia

PURPOSE

To report the long-term surgical outcomes for a cohort of children with large-angle infantile esotropia.

DESIGN

Multicenter, nonrandomized clinical study.

METHODS

Setting: Two tertiary-care pediatric hospitals.

STUDY POPULATION

Children with large-angle (≥55 prism diopters) infantile esotropia.

INTERVENTION

Surgical treatment of infantile esotropia.

MAIN OUTCOME MEASURE

Success rate at final follow-up (postoperative deviation ≤ 10 prism diopters and no need for retreatment).

RESULTS

A total of 88 patients with large-angle infantile esotropia were treated during the 13-year study period. Treatment was bilateral medial rectus muscle recessions in 70 patients, botulinum toxin-augmented surgery in 15 patients, and 3-muscle surgery in 3 patients. After a mean follow-up of 40 months, 20 patients (23%) had a successful outcome compared to 68 treatment failures (77%). Of the 68 treatment failures, 59 had residual or recurrent esotropia and 9 had sequential exotropia. On multivariate logistic regression, treatment modality was the only factor significantly associated with a successful outcome. Specifically, patients treated with botulinum toxin-augmented surgery were more likely to have a successful outcome compared to patients treated with bilateral medial rectus muscle recessions. For the 26 patients (30%) who underwent retreatment, the mean number of procedures was 2.1, and 7 (27%) had a deviation of ≤10 prism diopters at final follow-up.

CONCLUSIONS

The overall success rate for treatment of large-angle infantile esotropia was poor in this cohort, with most failures owing to recurrent or residual esotropia. Botulinum toxin-augmented surgery was associated with a higher success rate at final follow-up.

Retrospective review of ocular alignment after large-angle congenital esotropia surgery

Objective: The study’s aims were to evaluate the success of bimedial rectus recession as a primary surgical procedure for patients with congenital esotropia; describe the demographic data of the study group; and compare surgical success with patient age at the time of surgery.Method: A retrospective review of 52 patients with congenital esotropia ≥ 50∆ (prism dioptres) was conducted. All patients underwent bimedial rectus recession and were followed-up postoperatively for a minimum of 6 months.Results: The study period was from January 1992 to September 2003. Fifty-two patients were included in the study group. The pre-operative angle of deviation ranged from 50∆–85∆. Patient ages ranged from 15 months to 22 years, with a mean of 5.3 years and a median of 4 years. The gender distribution was 42% male (n = 20) and 58% female (n = 28). Surgery was successful (within 10∆ of orthophoria) in 77% (n = 40), a partial success (10∆–20∆ from orthophoria) in 17% (n = 9) and a failure (> 20∆ from orthophoria) in 6% (n = 3). No statistically significant relationship was found between surgical success and patient age at the time of surgery.Conclusion: The study confirmed that bilateral medial rectus recession, performed as a primary procedure for patients with large-angle (> 50∆) congenital esotropia, has a high success rate. This finding corresponds with the outcomes of similar international studies.

Medium-term outcomes of three horizontal muscle surgery in large-angle infantile esotropia

PURPOSE

To evaluate the medium-term motor outcomes of three horizontal muscle surgery in patients with large-angle infantile esotropia.

METHODS

The charts of 18 patients with large-angle (> 55 prism diopters [PD]) infantile esotropia who underwent bilateral medial rectus muscle recession and one lateral rectus muscle resection were retrospectively reviewed. Preoperative and postoperative deviations at last examination, overcorrections and undercorrections, necessity of additional horizontal surgery, and follow-up durations were recorded.

RESULTS

The median age of patients at surgery was 22 months (range: 10 to 168 months). Orthotropia to within 10 PD or less was achieved in 14 of 18 patients (78%) in a median follow-up of 32 months (range: 5 to 63 months). The mean preoperative deviation of 68.8 ± 9.54 PD decreased to a median of 1 PD (range: esotropia 30 to exophoria 4 PD) postoperatively (P < .005). Marked residual esotropia necessitating additional surgery occurred in 4 patients, but significant overcorrection was not observed.

CONCLUSIONS

The success rate of the three horizontal muscle surgeries appears to be high enough in medium-term follow-up in patients with large-angle infantile esotropia. Overcorrection that necessitates additional horizontal muscle surgery does not seem to be significant in the medium term, according to this study.

Long-term results of botulinum toxin-augmented medial rectus recessions for large-angle infantile esotropia

PURPOSE

To evaluate the long-term results of medial rectus recessions augmented by botulinum toxin injection for treating infants with large-angle (> 60 prism diopters [PD]) infantile esotropia.

DESIGN

Interventional case series.

METHODS

SETTINGS

Hospital-based clinical practice.

PATIENT POPULATION

Twenty-three patients with large-angle infantile esotropia who were followed for at least 2 years postoperatively.

INTERVENTION

Surgical treatment with botulinum toxin in addition to bilateral medial rectus muscle recessions. The preoperative findings, treatment, and outcomes were reviewed.

MAIN OUTCOME MEASURES

Surgery was considered successful if the patients did not require additional horizontal strabismus surgery and had less than 10 PD of horizontal deviation.

RESULTS

The age at surgery ranged from 4 to 36 months (mean 14.5 months) and the angle of esotropia ranged from 65 to 100 PD (mean 72 PD). Treatment was successful in 17 of 23 patients (74%), with follow-up of 2 to 13 years (mean 6.6 years).

CONCLUSION

Botulinum toxin-augmented medial rectus recession is an effective treatment for large-angle infantile esotropia, with stable results over time.

Three horizontal muscle surgery for large-angle infantile esotropia: validation of a table of amounts of surgery

PURPOSE

To validate a table of amounts of three horizontal muscle surgery in patients with large-angle infantile esotropia (≥60 prism dioptres, PD).

METHODS

A prospective interventional case series reporting the postoperative alignment of 51 patients (27 male, 24 female) over a 15-year period was conducted. Surgery amounts were according to a published table developed on a previous patient cohort (n=49), using bilateral medial rectus recession with graded unilateral lateral rectus resection. Kaplan-Meier life-table survival curves were formulated for success to orthotropia (±10 PD) after one and subsequent horizontal muscle surgeries for up to 8 years follow-up.

RESULTS

The median preoperative deviation was 65 PD (range 60-80 PD) and median age at surgery was 11.8 months (range 5.1 months-3.6 years). Surgical success to orthotropia (±10 PD) after one surgery was 100% at 2 months, 95.7% at 6 months, 91.3% at 12 months, 77.8% at 4 years, and 73.6% at 8 years. Postoperative failure requiring further horizontal surgery occurred in 17.6% (residual esotropia 4, consecutive exotropia 5).

CONCLUSIONS

Our second cohort has reproduced the success rate of the previous cohort (77.8% vs 77.1% at 4 years). If the published table of surgical amounts is used, three horizontal muscle surgery in large-angle infantile esotropia (≥60 PD) appears to have a good long-term success rate, and does not lead to the high rates of either residual esotropia or consecutive exotropia reported by others in the literature.

Results of monocular surgery under peribulbar anesthesia for large-angle horizontal strabismus

OBJECTIVE

To evaluate the results of monocular surgery under peribulbar anesthesia for large-angle horizontal strabismus.

INTRODUCTION

Monocular surgery may preserve some muscles if a repeat operation is required, may help to avoid the exposure of the dominant eye to the inherent risks of a surgical procedure and may reduce surgical time.

METHODS

We evaluated ninety-two consecutive patients who underwent monocular surgery under peribulbar anesthesia for large-angle horizontal strabismus (angle of 40 prism diopters or greater). Patients were divided into group 1- esotropia and group 2 -exotropia. The postoperative follow-up was at 6 months, when the residual deviation was evaluated. In cases of residual deviations of over 15 PD (prism diopter), a second procedure was indicated.

RESULTS

In all patients with preoperative deviations up to 60 PD, residual deviations were under 15 PD. Some patients with preoperative deviations of 65 PD (two in group 1 and four in group 2) and all patients with deviations over 65 PD had residual deviations over 15 PD. The 13 patients who underwent a second procedure experienced successful outcomes. Our ROC curve analysis showed that the cutoff point for obtaining a successful surgical result was 62.5 PD. No patient presented with a major limitation in respect of ocular movement.

CONCLUSIONS

Monocular surgery under peribulbar anesthesia can be an alternative for horizontal large-angle strabismus given deviations of up to 60 PD. Monocular surgery did not result in successful outcomes for deviations of over 65 PD.

Three-muscle surgery for infantile esotropia in children younger than age 2 years

PURPOSE

To review the long-term outcome of infants undergoing three-muscle surgery for infantile esotropia.

PATIENTS AND METHODS

Surgical records of 10 patients with esotropia > or = 55 prism diopters (PD) who underwent three-muscle surgery for large-angle infantile esotropia were reviewed. Outcome measures included over- or undercorrection, need for additional surgery, and amount of deviation at last follow-up.

RESULTS

Mean age at initial surgery was 13 months. Mean preoperative deviation was 62.5 PD of esotropia. A single surgery was associated with satisfactory horizontal alignment in only three (30%) patients at last follow-up (mean, 37.1 months; range, 8-70 months). Esotropia was undercorrected in one (10%) and overcorrected in six (60%) patients, all of whom required additional surgery. One patient with satisfactory horizontal alignment required an additional procedure to correct a right hypertropia causing a left face turn.

CONCLUSIONS

In contrast to older children and adults, three-muscle surgery may be inappropriate for infants with large-angle esotropia due to a large overcorrection rate. This controversy may benefit from a prospective study.

Three horizontal muscle squint surgery for large angle infantile esotropia

BACKGROUND

To report the long-term outcome of a series of 49 patients who underwent three horizontal muscle squint surgery for large angle infantile esotropia. METHODS; The patient records were retrospectively reviewed of 49 (24 girls [49%], 25 boys) consecutive patients with infantile esotropia of angle > or =60 Delta, who had undergone three horizontal muscle surgery performed by one surgeon (author GG). Surgery consisted of bilateral medial rectus recession combined with graded unilateral lateral rectus resection. Surgeries were carried out over a 6-year period with a mean follow-up period of 32.9 months (3.7-71.8 months).

RESULTS

Using Kaplan-Meier life-table analysis, cumulative surgical success (orthotropia +/-10 Delta) was 93.9% at 1 week, 91.8% at 2 and 6 months, 87.7% at 12 and 18 months, 79.9% at 2 years, 77.1% at 3, 4 and 5 years, and 70.6% at 6 years. The mean preoperative deviation was 68.7 Delta. The mean age at surgery was 12.9 months. The failure rate was independent of preoperative deviation. Prevalence of residual esotropia (>10 Delta) varied from 2.0% at 1 week to 17.0% at 6 years. Similarly the prevalence of consecutive exotropia (>10 Delta) varied from 4.0% at 1 week to 12.4% at 6 years. CONCLUSION; Operating in a graded fashion on three horizontal muscles in children with large angle infantile esotropia has a high success rate, even over long-term follow up. Based on the study's results, amounts of surgery for a given angle of strabismus are proposed.

Two-muscle surgery for congenital esotropia: rate of reoperation in patients with small versus large angles of deviation

INTRODUCTION

Standard surgical treatment of congenital esotropia (CET) in patients with preoperative angles of deviation measuring </=50 PD is well defined. However, there is controversy over the management of larger angles of esotropia. Some surgeons prefer to operate on 3 or 4 horizontal rectus muscles, while others prefer to perform large recessions of the medial rectus muscles alone. The purpose of this study was to compare the rate of reoperation after bilateral medial rectus muscle recession of smaller angle (< or =50 PD) CET with the rate of reoperation after surgery for larger angle (>50 PD) CET.

METHODS

Medical records of 102 patients who underwent bilateral medial rectus muscle recessions between January 1991 and December 1997 were reviewed. Patients were excluded if neurologic abnormalities or developmental delays were documented before the operation, if major structural abnormalities of the eye were present, or if less than 1-month follow-up after surgery was documented. The remaining 56 patients were assigned to either the larger angle (>50 PD) or smaller angle (< or =50 PD) group, based on the magnitude of their preoperative esotropia. Rates of reoperation for residual CET, for consecutive exotropia or dissociated horizontal deviation, or for dissociated vertical deviation with or without oblique muscle dysfunction were determined for each group.

RESULTS

Forty of 56 patients (71%) were assigned to the smaller angle group and 16 of 56 patients (29%) to the larger angle group. In the larger angle group, 4 patients (25%) underwent surgery for residual esotropia. In the smaller angle group, 8 patients (19%) underwent surgery for residual esotropia, 8 (19%) underwent surgery for consecutive exotropia or dissociated horizontal deviation, and 8 (19%) underwent surgery for dissociated vertical deviation or oblique muscle dysfunction.

CONCLUSION

The success rate for ocular realignment in patients with CET by using bilateral medial rectus muscle recession did not appear to diminish when applied to deviations greater than 50 PD as compared with smaller angle deviations. Surgery on 3 or 4 horizontal rectus muscles may be unnecessary in the treatment of patients with very large angles of CET.

Results of classical and augmented bimedial rectus recession in infantile esotropia

PURPOSE

To compare the success rates of augmented bimedial rectus recession and the standard recession.

MATERIALS AND METHODS

Ninety patients were included in the study. The patients were evaluated in two groups according to the amount of recession. Group 1, the standard surgery group, received 5 mm or less of recession; Group 2, the augmented surgery group, received 6 mm of recession or more. The mean postoperative follow-up was 29 months (6-60 months) in Group 1, and 20 months (6-58 months) in Group 2.

RESULTS

The mean age at the time of surgery was 4.61 years in Group 1 and 4.58 years in Group 2. The 56 patients in Group 1 underwent bilateral rectus recession varying from a minimum of 3 mm to a maximum of 5 mm; the 34 patients in Group 2 had recessions varying from a minimum of 6 mm to a maximum of 8 mm. The mean preoperative angle size was 39.64 +/- 8.93 SD (range 20-50 PD) in the standard surgery group, and 59.70 +/- 10. 04 SD (range 51-85 PD) in the augmented surgery group. The average postoperative deviation was 13.37 +/- 11.87 SD (range 0-45) in Group 1 and 9.02 +/- 10.02 (range 0-45) in Group 2. A good surgical result was achieved with one operation in 29 of 56 patients (51.8%) in Group 1 and 24 of 34 patients (70.58%) in Group 2.

DISCUSSION

The optimal surgical technique for the correction of large-angle esotropia is still controversial; it appears that the augmented bilateral medial rectus recession is an effective and reasonable alternative to three- or four-muscle procedures as the initial surgical treatment.

Long-term results of bimedial rectus recessions in infantile esotropia

BACKGROUND

Congenital esotropia has a deviation of 50 or more prism diopters (delta). Generally, surgical alignment of the eyes is the accepted treatment but surgical techniques differ.

METHODS

A total of 54 patients were evaluated. Surgery was done at a mean age of 28 months. Bimedial rectus recessions up to 8 mm were performed.

RESULTS

The mean preoperative deviation was 70 delta of esotropia. Our success rate with a uniform approach was 66.6%.

CONCLUSIONS

Contrary to the selective approach for large angle congenital esotropia, we do not consider initial surgery on three or more muscles. Our method is quicker, simpler, less traumatic, and leaves the lateral rectus muscles unoperated for patients requiring a second surgery.

8 mm bimedial rectus recession in infantile esotropia of 80-90 prism dioptres

Sixteen patients with large angle infantile esotropia with deviations of 80-90 prism dioptres were operated at the age of about 2 years. All patients underwent 8 mm bilateral medial rectus recessions. At the last follow up examination, 6 to 48 months postoperatively (average 16.3 months), successful horizontal alignment was achieved in 12 patients (75%). Four patients (25%) were undercorrected. Clinically significant limitation of adduction or convergence was not observed postoperatively in any of the patients. Consecutive exotropia was not encountered in this series but a longer follow up is probably needed in order to assess its delayed appearance. These results suggest that 8 mm recession of the medial recti is an effective procedure for the correction of large angle infantile esotropia of 80-90 prism dioptres and can be considered as an acceptable alternative to operations on three or four muscles.

Seven-millimeter bilateral medial rectus recessions in infantile esotropia

Thirty-six patients with large angle infantile esotropia averaging 74 prism diopters underwent 7-mm bilateral medial rectus recessions by the cul-de-sac approach. Successful horizontal alignment with the initial procedure when measured at the most recent follow-up examination (average 18.2 months postoperatively) was achieved in 27 patients (75%). Five patients (14%) were undercorrected and four patients (11%) were over-corrected. The advantages of the method, as opposed to three or four muscle procedures, are that it is quicker, simpler, and a less traumatic procedure which leaves the lateral rectus muscles unoperated for future surgeries if necessary. This is effective even in very large angle congenital esotropia.

Congenital esotropia

Congenital esotropia represents the most common type of strabismus. Its pathogenesis, however, remains uncertain. It is typically characterized as a large angle, constant esotropia with onset during the first six months of life. Associated clinical findings include normal refractive errors for age, amblyopia, dissociated vertical deviation, inferior oblique muscle overaction and nystagmus. It must be distinguished from Duane's retraction syndrome, Moebius syndrome, nystagmus blockage syndrome, and early onset accommodative esotropia, as well as other causes of esotropia in infancy. The surgical management may involve recession of both medial recti muscles, unilateral recession of a medial rectus muscle and a resection of a lateral rectus muscle or three or four muscle surgery.

Surgical management of large angle congenital esotropia

Ninety-seven patients with congenital esotropia with deviations of 50 prism dioptres or greater underwent large (6 and 7 mm) bimedial rectus recessions. The overall success rate with one operation was 83.5%. Judgment of final alignment was made at the last follow-up examination, six to 61 months (average 23.4 months) postoperatively. Large bimedial rectus recessions for congenital esotropia are an effective surgical treatment which does not significantly alter adduction.

Large bimedial rectus recessions in congenital esotropia

The success rate of large (6 and 7 mm) bimedial rectus recessions in 45 congenital esotropes with deviations of 50 prism dioptres or greater was found to be 91%. Judgment of final alignment was made six weeks postoperatively, with an average follow-up of 13 months. Large bimedial rectus recessions are an effective surgical treatment for congenital esotropia. This procedure does not significantly alter adduction, and leaves other muscles available should further surgery be necessary. These findings show that initial surgery on three or more muscles is unnecessary in congenital esotropia.