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

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.

Infantile Esoropia: Management results and prognostic factors

BACKGROUND

Infantile esotropia is characterized by a significant deviation angle and a marked sensory perversion. Although the motor surgical results are satisfactory, the sensory results remain disappointing.

AIM

Our work aims to describe the methods of surgical management, its motor and sensory results as well as its prognostic factors.

METHODS

Retrospective study of 68 cases of infantile esotropia. All patients underwent a complete ophthalmologic examination and sensorimotor assessment. They were operated on, under general anesthesia, by the same surgeon. We assessed the motor and sensory results. The prognostic factors studied were age of onset, treatment delay, amblyopia severity, strabismus deviation angle, and presence of a vertical element.

RESULTS

The mean minimum angle of deflection was 38.6 ± 13.2D. Inferior oblique muscle hyper action was noted in 73.5% and a dissociated vertical deviation in 5.8%. Bilateral medial rectus muscle recession was the most performed surgery (60.2% of cases). The overall success rate was 94.11%. No patient acquired stereoscopic vision. Multivariate logistic regression analysis showed that preoperative nail (p = 0.007), immediate postoperative outcome (p <0.001) and surgical dosage (p = 0.009) were associated with long-term motor success.

CONCLUSION

The motor results of early esotropia surgery are generally satisfactory; the sensory results are often disappointing. Detecting poor prognostic factors improves operative results.

Outcome of large angle exotropia treated by single stage adjustable strabismus surgery with monitored conscious anesthesia

Purpose:

To evaluate the outcomes of large-angle exotropia by single-stage adjustable strabismus surgery (SSASS) under monitored conscious anesthesia.

Methods:

A prospective study was done in 33 patients above 14 years with ≥40 prism diopters (PD) of exotropia. All patients underwent SSASS under monitored conscious anesthesia (topical anesthesia plus intravenous sedation). For deviations of ≤55 PD, two horizontal rectus muscles, and for >55 PD, three rectus muscles were operated and a decision on adjustment/operating on an additional rectus muscle was taken after assessing the alignment. Monitored conscious anesthesia allowed us to check our results after surgery and plan further surgery/adjustment to achieve the desired alignment.

Results:

Mean preoperative deviation for distance was 52 ± 11.1 PD. The target alignment was achieved with the initial surgical plan in 10/21 patients with <55 PD exotropia and 4/12 patients with >55 PD exotropia, and one patient in each group needed adjustment. The remaining patients needed additional rectus muscle surgery. One patient with >55 PD exotropia needed both adjustment and additional rectus surgery. The success rate for distance correction was 85% at 6 months and 1 year. The overall success rate was 71% at 6 months. Percentage of patients with binocular single vision improved from 31% preoperatively to 78% by 6 months. Incidence of oculocardiac reflex was 6.1%.

Conclusion:

SSASS under monitored conscious anesthesia is a viable option for large-angle strabismus correction with good patient comfort and safety.

Horizontal rectus muscle transplantation for recurrent and residual strabismus

Purpose: To report outcomes of muscle transplantation for recurrent/residual strabismus. Retrospective, multicentric, observational study.  Methods: We retrospectively reviewed records of all patients operated at three institutes who underwent transplantation of the resected muscle for re-operations for residual/recurrent strabismus from January 1, 2018, to December 31, 2019. Data were collected regarding age, gender, visual acuity, type of strabismus, fixation preference, associated amblyopia, the surgical procedure performed, preoperative and postoperative primary position deviation, limitation of ductions, associated intra-operative and post-operative complications. Surgical success was defined as heterotropia less than or equal to 8 PD, and cosmetic success was defined as manifest deviation ≤12 PD (at 6 weeks follow up). Results: During this period, we identified records of seven patients (5 men: 2 women, median age: 24 years) who underwent muscle transplantation for residual/recurrent strabismus. Six patients underwent extraocular muscle surgery for residual/recurrent exotropia (XT) and one for residual esotropia (ET). In all the patients, median pre-operative primary position deviation reduced from 40 prism diopters (PD) (range: 30 to 55 PD) to 8 PD (range: 6 PD ET to 10 PD XT) at six-weeks follow-up. Four patients had residual exotropia (10-16PD), two had orthotropia and one patient had small-angle esotropia (6PD) at the last follow-up. Excluding two patients who underwent supramaximal re-recession of lateral rectus (≥11 mm from insertion) and re-resection of medial rectus, 3/5 (60%) patients achieved surgical success, and all (100%) achieved cosmetic success at six-weeks-follow-up. There was mild (up to -1) limitation of duction in all patients except one patient (-2 limitation of abduction) who underwent re-recession of lateral rectus to 11 mm from insertion along with medial rectus re-resection and muscle transplant procedure. No intra-operative or post-operative complications were encountered. No patient reported postoperative diplopia. Conclusions: This study describes the feasibility and successful use of muscle transplantation procedure to correct residual/recurrent strabismus, with or without re-recession, especially in patients planned for surgery in one eye. However, larger prospective studies with longer follow-ups will be needed to establish long-term outcomes and correction achieved from this procedure, and comparison with other approaches for reoperations.

Outcome of Esotropia Surgery in 2 Tertiary Hospitals in Cameroon

Purpose

To evaluate the ocular alignment following esotropia surgery in our setting.

Patients and Methods

We conducted a cross sectional descriptive study which spanned 19 years, from October 1999 to September 2018 at the Douala General Hospital and the Yaoundé Central Hospital. Complete medical records of patients who underwent surgery for esotropia during the study period were included. Data collected included age at diagnosis, sex, age of onset of esotropia, age at surgery, refractive error, type of surgery performed, pre and post-operative angle of deviation. The outcome was considered good when the postoperative angle was ≤10 prism diopters (PD).

Results

Four hundred and ninety patients with primary esotropia were seen during the study period. Only 155 returned for follow-up after wearing the full cycloplegic correction for a minimum period of 3 months. Accommodative esotropia was found in 32 cases (20.6%). Among the 123 cases requiring surgery, 63 cases underwent surgery (51.2%). Fifty-nine complete records were included (59.3% females and 40.7% males). The mean age at the time of diagnosis was 6.5 ± 6.1 years and the mean age at the time of surgery was 8.7 ± 6.1 years. The mean preoperative angle at distance was 42.8 ±10.8 PD. The outcome was good in 91.5% of cases. No factor influenced the outcome of surgery.

Conclusion

The outcome of esotropia surgery was good in this study. This could serve to increase patient motivation to accept surgery in our setting.

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.

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

PURPOSE

To investigate the development pattern and related factors of postoperative re-drift in infantile esotropia.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.].

Surgical success and lateral incomitance following three-muscle surgery for large-angle horizontal strabismus

PURPOSE

To evaluate motor alignment, motility, and sensorial outcomes of simultaneous three-muscle surgery for large-angle horizontal strabismus, with special attention to lateral incomitance and long-term success.

METHODS

The medical records of consecutive patients with large-angle deviations (≥30^Δ) who underwent simultaneous surgery on three horizontal muscles to correct esotropia or exotropia were reviewed retrospectively. Successful motor alignment was defined as residual deviation of ≤10^Δ and consecutive deviation in primary position of ≤4^Δ, with no induced lateral incomitance >5^Δ between lateral gazes. Sensory success was defined as an improvement in stereopsis of ≥2 octaves. Surgical procedures included a combination of recessions and resections/plications depending on surgeon preference. The majority of cases were two-muscle recessions combined with one-muscle resection or plication.

RESULTS

A total of 19 patients with exotropia and 9 patients with esotropia were included. In the esotropic group, the mean age at surgery was 48 ± 15 years and the mean preoperative deviation improved from 45.6^Δ ± 11.9^Δ to 1.5^Δ ± 1.6^Δ (P < 0.001); there was no undercorrection, recurrence or overcorrection. In the exotropic group, the mean age at surgery was 44 ± 25 years, and the mean preoperative deviation improved from 44.1^Δ ± 8.7^Δ to 5.8^Δ ± 9.6^Δ (P < 0.001), recurrence occurred in 2 (22%). Overall motor success at distance was 85%, with 1 (3.8%) unsuccessful patient due to induced incomitance. Sensory success was 44% for esotropia and 31% for exotropia. No patient lost stereopsis.

CONCLUSIONS

Patients undergoing three-muscle surgery for horizontal strabismus had good motor outcomes with low incidence of induced lateral incomitance. Motor and sensorial outcomes for esotropia were very stable.

Variability in Response to Bilateral Medial Rectus Recessions in Infantile Esotropia

PURPOSE

To evaluate factors associated with surgical success in bilateral medial rectus recessions in infantile esotropia.

METHODS

The results of 97 patients with infantile esotropia undergoing surgical correction from January 2010 through December 2013 at Children's Medical Center of Dallas were reviewed. Multivariate logistic regression analysis of risk factors for success and evaluation of the relationship of surgical responses to baseline characteristics were performed.

RESULTS

The authors achieved an overall success rate of 59% (57 of 97 patients) with one surgery. At the time of surgery, preoperative angle, refraction, amblyopia, and simultaneous inferior oblique surgery were not significantly related to success or failure. The mean dose response was 3.61 ± 1.45 prism diopters per millimeter of surgery and was modestly correlated only with the preoperative deviation (r(2) = 0.32). Failure was associated with variability in dose-response, not inadequate or inconsistent with surgical dosing.

CONCLUSIONS

Surgical success with bilateral medial rectus recessions in infantile esotropia is limited by the high variability in surgical dose-response. [J Pediatr Ophthalmol Strabismus. 2016;53(5):305-310.].

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.

Essential infantile esotropia: postoperative motor outcomes and inferential analysis of strabismus surgery

BACKGROUND

The aim of this retrospective study is a long-term evaluation of postoperative motor outcomes and the inferential analysis of strabismus surgery in infant eyes with essential infantile esotropia.

METHODS

576 patients were compatible with the criteria: confirmed EIE diagnosis, angle ≥ 30 pD, absence of associated ocular anomalies, onset by 6 months of age, absence of hyperopia > 3 Diopters, operation before age 4. Preoperative deviation classes (30-40 pD, 41-59 pD, ≥ 60 pD) were established, different types of surgery were performed. Follow-up was conducted for 5 years after surgery. Longitudinal data were analyzed using general linear mixed models stratified according to the class of pre-operative deviation. A random intercept and a random slope with time (in months) was assumed with an unstructured within subject correlation structure for repeated measurements.

RESULTS

In patients with preoperative angle ≤ 40 pD, a significant interaction effect for intervention by time (F5,155.9 = 3.56, p = 0.004) and a significant intervention effect (F5,226.1 = 6.41, p < 0.001) on residual deviation were observed; only the intervention 5 showed a residual deviation inside the limits of a partial success. In Class 41-59, a significant interaction effect for intervention by time (F4,166.7 = 5.16, p = 0.001), intervention (F4,178.1 = 2.48, p = 0.046) and time (F1,174.6 = 9.99, p = 0.002) on residual deviation were observed; intervention 7 had the highest degree of stability showing an outcome within the range of a partial success. In Class ≥ 60 pD no significant effect for intervention (F4,213.9 = 0.74, p = 0.567), time (F1,169.5 = 0.33, p = 0.569) or intervention by time (F4,160.9 = 1.08, p = 0.368) on residual deviation was observed; intervention 3,6 and 7 resulted in a residual deviation within the range of a partial success.

CONCLUSIONS

We suggest, where possible, a two-horizontal muscles approach in small angle EIE, while a multiple muscles surgery in large angle EIE.