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Outcomes following superior rectus transposition and medial rectus recession vs inferior and superior recti transposition for acquired sixth nerve palsy
e42 Methods: The medical records of a consecutive series of patients with symptomatic diplopia who underwent strabismus surgery after scleral buckling were reviewed. All patients had a segment of the scleral buckle removed intra-operatively. Pre- and postoperative ocular motility was compared. Outcomes were considered successful if residual horizontal deviations were \10D and/or vertical deviations \4D. Results: Twelve patients, mean age 51 years (range, 14-71 years), with a mean horizontal deviation of 16D (range, 2-40) and mean vertical deviation of 10D (range, 2-20) were studied (8 combined deviations, 3 horizontal only deviations, and 1 vertical only deviation). All patients underwent intraoperative removal of the segment of scleral buckle underlying a muscle being recessed at the time of strabismus surgery. Adjustable sutures were used in 86% of the surgeries. Surgical success and a subjective improvement in diplopia were achieved in all 12 patients after a mean of 1.25 surgeries and a mean follow-up of 12.4 months (range, 1-75 months). No patient had retinal redetachment. Discussion: Removal of the segment of the scleral buckle underneath a recessed muscle improves adherence of the muscle to the globe and facilitates postoperative adjustment. Conclusions: Partial scleral buckle removal at the time of strabismus surgery is associated with good outcomes without retinal redetachment. 139 Outcomes following superior rectus transposition and medial rectus recession vs inferior and superior recti transposition for acquired sixth nerve palsy. Scott R. Lambert, Yeon-Hee Lee Introduction: To compare effectiveness of superior rectus transposition/medial rectus recession (SRT/MR) vs. inferior and superior rectus transposition (VRT) for acquired sixth nerve palsy. Methods: The medical records of a case-control series of patients with acquired sixth nerve palsy who underwent VRT (1988-2005) or SRT/MR (2013-16) by a single surgeon were reviewed. The pre and postoperative findings were compared between the two groups. Results: Eight patients underwent SRT/MR and VRT. Lateral fixation was performed on all but 4 patients in VRT group. Median followup was 6 months in SRT/MR group and 17 months in VRT group. Preoperative esotropia in primary position and abduction deficit were similar in both groups (SRT/MR, 42D, 4.6; VRT, 56D, 4.5; P 5 0.195, P 5 1.0). SRT/MR group underwent a mean MR recession of 6.0 mm (range, 5-7). Four patients in VRT group underwent MR recession (mean 5.3 mm). In addition, 5 patients in the VRT group had 9 injection of BOTOX in the MR. No additional procedures were performed in SRT/MR group. Fewer additional procedures were performed with SRT/MR (SRT/MR, 0; VRT, 1.81.2; P \ 0.010). At last follow-up, residual esotropia (SRT/MR, 7D; VRT, 10D; P 5 0.442) was similar in both groups. But the abduction was better in the SRT/MRc group (SRT/MR, 3.0 0.7; VRT, 3.8 0.4; P 5 0.038). There were no new persistent vertical deviations or torsional diplopia. Discussion: Both SRT/MR and VRT procedures improved ocular alignment in primary position and abduction without creating persistent vertical deviations. Conclusions: Final outcomes were similar with SRT/MR versus VRT. However, fewer additional surgical procedures were needed with SRT/MR.
Volume 21 Number 4 / August 2017 140 Strabismus surgery after scleral buckle implantation: leaving the buckle in place. Orwa Nasser, Scott A. Larson Introduction: Debate exists about the best approach to correct strabismus that occurs after scleral buckle implantation. This patient series reports on outcomes of strabismus surgery while leaving the scleral buckle in place. Methods: Pre- and postoperative data of all patients operated on at one academic center between July 2013 and September 2016 for strabismus who also had a scleral buckle on the eye. Results: All patients (n 5 10) had strabismus surgery on the eye with the buckle. Average follow-up time was 6 months. Half of the patients underwent a recess/resect procedure. Three had a single muscle operated. Average preoperative horizontal deviation was 28D. Average postop horizontal deviation was 7D with average improvement of 86%. Seventy percent had both horizontal deviation \10D and vertical deviation \4D. Only 2 had diplopia postoperatively and required prism. Forty percent of cases were found to have muscles inserted more posterior than expected. One developed a conjunctival cyst over the buckle 1 year postoperatively. Discussion: Using alignment criteria (\10D horizontal and \4D vertical) our series had a 70% success rate. Surgical technique may require the use of permanent suture and suspending muscles over buckle elements. Muscle insertions were frequently more posterior especially in cases where the buckle was not found immediately behind the muscle insertion. Conclusions: Strabismus surgery after scleral buckle implantation can be successfully preformed while leaving the buckle in place. 141 Can medial and lateral rectus muscle status be predicted by severity of preoperative adduction deficit in consecutive exotropia? David A. Leske, Sarah R. Hatt, Jae Ho Jung, Jonathan M. Holmes Introduction: We investigated intraoperative medial rectus (MR) and lateral rectus (LR) muscle status across the spectrum of preoperative adduction deficits in patients with consecutive exotropia. Methods: In 143 eyes of 129 patients undergoing surgery for consecutive exotropia, preoperative adduction deficits were graded on a 5 (severe limitation, not to midline) to 0 (normal) scale. Operative data were reviewed to classify: (1) MR attachment type (normal, abnormal [stretched scar or slipped], attached to pulley, behind pulley, or mixed); (2) LR tightness based on forced duction testing (normal, mild, moderate); 3) distal MR fiber location (mm from original insertion). We analyzed the relationship of grade of adduction deficit to each intraoperative factor. Results: Eyes with abnormal (n 5 23), pulley (n 5 9), behind pulley (n 5 8), or mixed (n 5 7) attachments had worse adduction deficits than normal attachments (n 5 96, P # 0.02). Eyes with mild or moderate LR tightness (n 5 48) had worse adduction deficits than eyes without (n 5 95, P \ 0.001). There was a significant association between distal MR muscle fiber location (0–19.5 mm recessed) and grade of adduction deficit (P \ 0.0001). Nevertheless there was considerable individual variability. Surprisingly, for 1 and 2 adduction deficits, MR attachment could be at the pulley, behind the pulley, or include the pulley (19 [22%] of 86), and the LR was tight in 36 (42%). Discussion: In general, more severe preoperative adduction deficits are associated with MR insertion abnormalities and tight LRs, but there are frequent exceptions.
Journal of AAPOS
Volume 21 Number 4 / August 2017 140 Strabismus surgery after scleral buckle implantation: leaving the buckle in place. Orwa Nasser, Scott A. Larson Introduction: Debate exists about the best approach to correct strabismus that occurs after scleral buckle implantation. This patient series reports on outcomes of strabismus surgery while leaving the scleral buckle in place. Methods: Pre- and postoperative data of all patients operated on at one academic center between July 2013 and September 2016 for strabismus who also had a scleral buckle on the eye. Results: All patients (n 5 10) had strabismus surgery on the eye with the buckle. Average follow-up time was 6 months. Half of the patients underwent a recess/resect procedure. Three had a single muscle operated. Average preoperative horizontal deviation was 28D. Average postop horizontal deviation was 7D with average improvement of 86%. Seventy percent had both horizontal deviation \10D and vertical deviation \4D. Only 2 had diplopia postoperatively and required prism. Forty percent of cases were found to have muscles inserted more posterior than expected. One developed a conjunctival cyst over the buckle 1 year postoperatively. Discussion: Using alignment criteria (\10D horizontal and \4D vertical) our series had a 70% success rate. Surgical technique may require the use of permanent suture and suspending muscles over buckle elements. Muscle insertions were frequently more posterior especially in cases where the buckle was not found immediately behind the muscle insertion. Conclusions: Strabismus surgery after scleral buckle implantation can be successfully preformed while leaving the buckle in place. 141 Can medial and lateral rectus muscle status be predicted by severity of preoperative adduction deficit in consecutive exotropia? David A. Leske, Sarah R. Hatt, Jae Ho Jung, Jonathan M. Holmes Introduction: We investigated intraoperative medial rectus (MR) and lateral rectus (LR) muscle status across the spectrum of preoperative adduction deficits in patients with consecutive exotropia. Methods: In 143 eyes of 129 patients undergoing surgery for consecutive exotropia, preoperative adduction deficits were graded on a 5 (severe limitation, not to midline) to 0 (normal) scale. Operative data were reviewed to classify: (1) MR attachment type (normal, abnormal [stretched scar or slipped], attached to pulley, behind pulley, or mixed); (2) LR tightness based on forced duction testing (normal, mild, moderate); 3) distal MR fiber location (mm from original insertion). We analyzed the relationship of grade of adduction deficit to each intraoperative factor. Results: Eyes with abnormal (n 5 23), pulley (n 5 9), behind pulley (n 5 8), or mixed (n 5 7) attachments had worse adduction deficits than normal attachments (n 5 96, P # 0.02). Eyes with mild or moderate LR tightness (n 5 48) had worse adduction deficits than eyes without (n 5 95, P \ 0.001). There was a significant association between distal MR muscle fiber location (0–19.5 mm recessed) and grade of adduction deficit (P \ 0.0001). Nevertheless there was considerable individual variability. Surprisingly, for 1 and 2 adduction deficits, MR attachment could be at the pulley, behind the pulley, or include the pulley (19 [22%] of 86), and the LR was tight in 36 (42%). Discussion: In general, more severe preoperative adduction deficits are associated with MR insertion abnormalities and tight LRs, but there are frequent exceptions.
Journal of AAPOS