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Use of the combined recession and resection of a rectus muscle procedure in the management of incomitant strabismus
Use of the combined recession and resection of a rectus muscle procedure in the management of incomitant strabismus Emma Dawson, DBO, Natalie Boyle, MB, ChB, MRCOphth, Kasra Taherian, MD, FRCSEd, and John P. Lee, FRCS, FRCP, FRCOphth BACKGROUND
METHODS RESULTS
CONCLUSIONS
Scott described a method of achieving the effect of a posterior fixation procedure by combining resection and recession of a rectus muscle, while maintaining the ability to adjust primary position alignment with adjustable sutures. A retrospective review of combined recession-resection procedures on rectus muscles between 1998 and 2002 was carried out. We identified 22 patients, 17 females and 5 males. The mean age at presentation was 44 years. The etiology was felt to be paralytic in seven patients (31.8%), mechanical/ restrictive in seven patients (31.8%), and due to residual childhood strabismus in eight patients (36.4%). Twenty patients had undergone previous strabismus surgery, ranging from one to six operations (mean, 1.75). Scott procedures were performed on 25 rectus muscles of 22 patients; 12 on the lateral rectus muscles, 7 on the inferior rectus muscles, 3 on the medial rectus muscles, and 3 on the superior rectus muscles. All but one patient had a measurable improvement in gaze incomitance, and 11 of 12 who had a measurement of the field of binocular single vision showed improvement. Twenty patients had follow-up periods of 3 months or more, with a range of 3 to 30 months and a mean of 9.35 months. The combined recession-resection procedure advocated by Scott has a role in the management of incomitant strabismus. ( J AAPOS 2007;11:131-134)
T
he challenge of incomitant strabismus surgery is to improve diplopia and expand the field of single vision while maintaining good ocular alignment in primary position. The principle of improving incomitance in gaze away from primary position, known as “matching the defect,” typically involves limiting the action of the overacting contralateral synergist muscle. The posterior fixation suture technique (faden operation)1 improves misalignment in peripheral gaze positions while maintaining alignment in primary position. In this operation, a rectus muscle is sutured to the sclera at a point posterior to its insertion with nonabsorbable sutures. The effect is to limit the rotational force of the muscle in its primary direction of action, while having little or no effect on either primary position alignment or rotations away from the direction of action of the operated mus-
Author affiliations: Moorfields Eye Hospital, City Road, London, United Kingdom Presented at the 29th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Kona, Hawaii, March 23-27, 2003. Submitted March 9, 2004. Revision accepted October 30, 2006. Reprint requests: John Lee, FRCS, FRCP, FRCOphth, Moorfields Eye Hospital, City Road, London EC1V 2PD, United Kingdom (email: John.Lee@moorfields.nhs.uk). Copyright © 2007 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2007/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2006.10.023
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cle. The procedure is more effective in neurologically caused incomitant strabismus than in mechanically induced incomitance.2,3 The faden procedure has disadvantages. Surgery can be technically difficult, as the access and exposure may be poor, and it has been suggested that the thin posterior sclera is relatively easier to perforate.4,5 The faden procedure in itself does not materially affect primary position alignment. It can be combined with a recession or resection with fixed sutures, but not with adjustable sutures. The faden procedure is ineffective when performed on the lateral rectus muscle, probably because that muscle has a very large arc of contact with the sclera. Scott suggested a procedure that was based upon a modification of the faden principle.6 He performed a large resection of a rectus muscle and then recessed the muscle, using a standard hang-back/adjustable technique, in a position where the recession amount exceeded the resection amount. The adjustable suture was used to manipulate primary position alignment, and the reattachment of muscle to sclera at a posterior insertion point produced the mechanical effect of a faden operation. Scott reported the use of the technique on horizontal rectus muscles in three cases, with good results and follow-up of 2 to 11 months. In 1999 Bock and colleagues7 applied Scott’s technique on vertical and horizontal rectus muscles in 12 patients, with and without adjustable sutures. They modified Scott’s
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technique by reducing the amount of resection, as they were concerned that problems could arise, in particular, if a reoperation was required. They obtained good results in four of five patients managed with adjustable sutures and in three of seven patients managed with fixed sutures. Thacker and colleagues8 reported in 1995 on 12 patients with vertical and horizontal deviation managed with combined recess-resect procedures, recessing by double the amount of resection. They reduced incomitance in all cases and eliminated diplopia in 11 of 12 patients. In this study, we report our experience with the combined recession-resection procedure in 22 consecutive patients.
Subjects and Methods We performed a retrospective chart review using the surgical database to identify all of our patients managed with a combined recession-resection procedure on one or more rectus muscles between 1998 and 2002. We identified 22 patients, 17 female and 5 male, with an age range of 8 to 86, and a mean of 44 years. In all cases the rectus muscle or muscles were resected and then left in a recessed position, on a hang-back adjustable polyglactin 910 suture. All surgery was under general anesthesia, and adjustment, if required, was done approximately 7 to 8 hours later that same day. In general, we did not perform “supramaximal” resections and confined our surgery to not more than 7 mm for a lateral rectus muscle and 5 to 6 mm for other rectus muscles. As we aimed to reduce deviation in primary position, as well as incomitance, recessions were always equal to or larger than resections. e-Supplement 1 (available at jaapos.org) provides patient details, the details of the recession-resection procedure, any associated surgery, and whether any further surgery was planned. Twenty patients had undergone previous strabismus surgery ranging from one to six procedures (mean, 1.75), and 5 patients had preceding botulinum toxin treatment. The etiology was judged to be paralytic in seven patients (31.8%), mechanical/ restrictive in seven patients (31.8%), and due to residual childhood strabismus in eight patients (36.4%). Ten cases had a preoperative exodeviation; 8 had an esodeviation, and 11 had a vertical deviation on cover test. All cases had limited ocular rotation with gaze incomitance in one or more fields of gaze (e-Supplement 1, available at jaapos.org). Nineteen of 22 complained of diplopia; in 7 patients it was in primary position. To illustrate the advantage of this procedure in allowing the ability to manage incomitance while maintaining or improving primary position alignment, we cite Case 12, a 20-year-old female medical student who presented with a consecutive exotropia with preserved binocular vision after esotropia surgery on each eye aged 2 and 4. When first seen, she had symptoms of diplopia despite base in prism in glasses. She had markedly limited adduction of both eyes, right more than left, with horizontal diplopia on sidegaze. She measured 20⌬ of exodeviation at 33 cm and 12⌬ at 6 m. We performed bilateral lateral rectus combined recess-resect procedures, finding the left lateral rectus at 9 mm from the limbus, resecting it by 5 mm and leaving it at 14 mm from the limbus, and finding the right lateral rectus at 9 mm,
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resecting it at 4 mm, and leaving it at 15 mm from the limbus. Later that day she had a small residual exotropia in primary position. The left lateral rectus was recessed a few millimeters, and all sutures were tied. Postoperatively, she measured 1⌬ of esophoria at near and 4⌬ esophoria at distance with stereopsis on the Wirt fly and 2/9 circles (200 seconds).
Results A combined recession-resection procedure was performed on 25 rectus muscles of 22 patients, a single lateral rectus muscle in 8 patients, both lateral rectus muscles in 1 patient, on the medial and lateral rectus muscles of one eye in 2 patients ( both patients having limitation of both adduction and abduction of the fellow eye, 1 due to complications of endoscopic sinus surgery and 1 with residual abducens nerve palsy due to a glomus jugulare tumor, with postsurgical limitation of adduction of the paretic eye), on a single medial rectus muscle in 1 patient, and on 7 single inferior rectus muscles and 3 superior rectus muscles. Surgical dosages for lateral rectus muscles ranged from 4 mm resection and recession to 7 mm resection and recession. All medial rectus muscles had 5 mm resection and recession. Inferior rectus muscles received between 4 mm resection and recession and 5 mm resection with 6 mm recession. Superior rectus muscles had between 5 mm resection and recession and 5 mm resection with 6 mm recession. Adjustable sutures were used in 21 of 22 patients, and adjustment was necessary in only 8 patients. Other surgery was done at the same session in seven patients. Three patients had oblique muscle weakening surgery in association with a combined recession-resection procedure on the ipsilateral vertical rectus muscle. Two had correction of horizontal deviation when the combined recession-resection procedure was performed on a vertical rectus muscle. One patient had lateral rectus resection associated with a combined recession-resection procedure on the medial rectus muscle for esotropia and latent nystagmus with head posture. One patient had superior rectus muscle faden for a vertical deviation, with the combined recession-resection procedure on the horizontal rectus muscle. One patient had early slippage of an inferior rectus muscle. The muscle was explored and repositioned within a few days with a good result. There were no other complications of surgery. Twenty patients had follow-up periods of 3 months or more, with a range of 3 to 30 months and a mean of 9.35 months. Two patients did not attend the 3 month followup appointment. e-Supplement 1 shows the patient data. Our findings with the remaining patients that attended both a 2 week postoperative appointment and the 3 month postoperative appointment was that there was no difference in measurements between the two consecutive visits. All but one patient had improvement in gaze incomitance, assessed by reduction of symptoms of diplopia and improvement of eye movements on orthoptic examination.
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FIG 1. Pre- and postoperative percentage fields of binocular single vision; n ⫽ 12. BSV, binocular single vision.
In 11 of 12 patients who had measurement of the percentage field of binocular single vision, this test confirmed improvement. We analyzed and scored these by the method of Fitzsimons and White9 to give a percentage of normal. In all but one patient, there was improvement in the percentage score, as shown in Figure 1. Further surgery has been performed in two patients and is planned in three more. We classified 10 patients as “functional cures,” with abolition of incomitance and a large functional field of binocular single vision, between 40% and 80% of normal. One of these patients underwent subsequent strabismus surgery, with a faden procedure on the same inferior rectus muscle as the combined recession-resection procedure, to further widen the field of single vision. The etiology in this group was paralytic in two patients (abducens nerve palsy), mechanical in four (three orbital trauma, one dysthyroid), and related to childhood concomitant strabismus in four (two consecutive exotropia, one residual exotropia, one residual esotropia). All had had previous strabismus surgery. Combined recession-resection procedures were done on five unilateral lateral rectus muscles (total eight in series), three inferior rectus muscles (total seven in series), both lateral rectus muscles in one patient, and both medial and lateral rectus muscles on one eye on another patient. Six patients were judged partial cures, since they improved but required further treatment in the form of surgery or prisms. The etiologies were paralytic in three (two bilateral posttraumatic trochlear nerve palsy, one unilateral trochlear nerve palsy), mechanical in one ( postoperative adherence syndrome), one had an idiopathic hypertropia, and one had blepharophimosis syndrome with a right esotropia and manifest latent nystagmus and a face turn toward the fixing eye. Three of this group experienced a surgical overcorrection and reversal of the deviation. One inferior rectus muscle slipped within the first postoperative week and was repositioned. Later reversal was seen with one inferior rectus muscle and one superior rectus muscle, both with posttraumatic trochlear nerve palsy. All of this group had improvement of their original incomitance, but required further treatment with prisms or surgery to obtain a satisfactory outcome.
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Four patients judged treatment failures, with minimal change in ocular rotations. One had a left lateral rectus muscle combined recession-resection procedure for limited adduction of the other eye following a second surgery for childhood esotropia. Improvement was minimal and further surgery on the right eye is planned. One patient has had a long series of ocular muscle procedures4 for diplopia, originally caused by retinal reattachment surgery, and further surgery is planned. One patient, whose left medial rectus muscle was effectively rendered useless by endoscopic sinus surgery, derived no benefit from combined recession-resection procedures on the contralateral medial and lateral rectus muscles, as shown by an inconsequential change in her percentage field of binocular single vision following surgery from 36% to 39%. A further patient, who sustained right-sided orbital trauma in an automobile accident, and initially underwent a right Knapp procedure, had an initial good response to a combination of left superior rectus combined recessionresection procedure and ipsilateral inferior oblique muscle disinsertion, to improve incomitance on upgaze. After the 3 month visit she began to notice pain around the right eye and deterioration of her ocular motility. She has since been diagnosed as having collapse of the maxillary sinus on the right side and awaits faciomaxillary and orbital repair. Further treatment was undertaken in eight patients. One patient had a faden procedure on an inferior rectus muscle that had undergone the combined recession-resection procedure to widen the field of single binocular vision. One patient had further adjustable bilateral inferior rectus muscle weakening surgery for bilateral fourth nerve palsies. Three patients have surgery planned to further increase the field of binocular single vision. Three patients have had subsequent botulinum toxin treatment, two with some improvement in symptoms. All other cases have had a stable result following combined recession-resection procedure surgery.
Discussion We conclude that the combined recession-resection procedure has a useful role in the management of symptomatic incomitant strabismus. The faden procedure remains valuable when there is no ocular deviation in primary position sufficient to warrant intervention. When strabismus is present in primary position, the combined recessionresection procedure is useful and seems to be as effective as a standard faden procedure in expanding the field of single binocular vision. The procedure is particularly valuable when dealing with incomitance on lateral gaze due to limitation of adduction, where the overacting muscle is the contralateral lateral rectus muscle. Recession of the lateral rectus muscle may have a deleterious effect on the primary position deviation, and we have found that performing a standard faden procedure on the lateral rectus muscle has little or no effect.
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The procedure was easy to perform compared with the faden procedure. In our series, the only operative complication was a slipped inferior rectus muscle, a recognized complication of IR muscle weakening surgery.
4.
References
6.
1. Cüppers C. The so-called “Fadenoperation” (surgical correction by well defined changes in the arc of contact). In: Fells P, editor. Second Congress of the International Strabismological Association; Marseilles: Diffusion Générale de Librairie; 1976; p. 395. 2. Buckley EG, Meekins BB. Fadenoperation for the management of complicated incomitant vertical strabismus. Am J Ophthalmol 1988; 105:304-12. 3. Kouri AS, Bessant DAR, Adams GGW, Sloper JJ, Lee JP. Quantitative changes in the field of binocular single vision following a
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7.
8.
9.
fadenoperation to a single vertical rectus muscle. J AAPOS 2002;6:294-9. Alio JL, Faci A. Fundus changes following Faden operation. Arch Ophthalmol 1984;102:211-3. Lyons CJ, Fells P, Lee JP, MacIntyre A. Chorioretinal scarring after the faden operation: a retrospective review of 100 procedures. Eye 1989;3:401-3. Scott AB. Posterior fixation: adjustable and without posterior sutures. In: Lennerstrand G, editor. Proceedings VIIth Congress International Strabismological Association CRC Press, Inc.; 1995; p. 399-402. Bock CJ, Buckley EG, Freedman SF. Combined resection and recession of a single rectus muscle for the treatment of incomitant strabismus. J AAPOS 1999;3:263-8. Thacker NM, Velez FG, Rosenbaum AL. Combined adjustable rectus muscle resection- recession for incomitant strabismus. J AAPOS 2005; 9:137-40. Fitzsimons R, White J. Functional scoring of the field of binocular single vision. Ophthalmology 1990;97:33-5.
An Eye on the Arts – The Arts on the Eye
At the end of ten days, a new group of doctors came to Yossarian with bad news: he was in perfect health and had to get out. He was rescued in the nick of time by a patient across the aisle who began to see everything twice. Without warning, the patient sat up in bed and shouted, “I see everything twice!” A nurse screamed and an orderly fainted. Doctors came running up from every direction with needles, lights, tubes, rubber mallets and oscillating metal tines. They rolled up complicated instruments on wheels. There was not enough of the patient to go around, and specialists pushed forward in line with raw tempers and snapped at their colleagues in front to hurry up and give somebody else a chance. A colonel with a large forehead and horn-rimmed glasses soon arrived at a diagnosis. “It’s meningitis,” he called out emphatically, waving the others back. “Although Lord knows there’s not the slightest reason for thinking so.” “Then why pick meningitis?” inquired a major with a suave chuckle. “Why not, let’s say, acute nephritis?” “Because I’m a meningitis man, that’s why, and not an acute-nephritis man,” retorted the colonel. “And I’m not going to give him up to any of your kidney birds without a struggle. I was here first.” In the end, the doctors were all in accord. They agreed they had no idea what was wrong with the soldier who saw everything twice, and they rolled him away into a room in the corridor and quarantined everyone else in the ward for fourteen days. —Joseph Heller (from Catch 22, Simon & Schuster)
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e-Supplement 1. Patient data No.
Sex
Age at surgery ( y)
1 2 3 4 5 6
F F F F F F
26 52 68 42 59 39
Limited Limited Limited Limited Limited Limited
7 8 9
M F M
61 37 50
10 11 12
F F F
13 14 15 16
Incomitance
Combined recessionresection procedure
Adjusted
Other simultaneous surgery
Further treatment
Discharge DNA DNA No No Yes No
No No Yes
No No B MR ⫺ & inferiorly reinserted L LR ⫹5 No No
No No BTXA R MR No No Re-explore R LR & MR No No R IR advance, L IR ⫺3.5 No RMR faden No
Yes No No Yes
R IO disinsertion No No No
No Prisms BTXA L LR BTXA R IR
No No No No
Yes No No No
No No No L SO posterior tenotomy L IO disinsertion L SR faden
No No L IR faden No
Yes Yes Yes Yes
No No
No No
L LR ⫹ 6 ⫺6 L IR ⫹4 ⫺4 R SR ⫹5 ⫺6 R IR ⫺6 ⫹5 L LR ⫹7 ⫺7 L LR ⫹6 ⫺6
Yes No Yes No No No
No L MR ⫺5 No No No No
Limited L abduction Limited R adduction L hyper on dextrodepression
R MR ⫹5 ⫺5, R LR ⫹6 ⫺6 L LR ⫹5 ⫺8 R IR ⫹5 ⫺7
No Yes Yes
8 38 20
R ET increases on R gaze Limited R adduction Limited R adduction
F F F M
26 86 58 65
Limited Limited Limited Limited
L elevation R laevodepression L adduction R depression
17 18 19 20
M F M F
38 55 52 44
Limited Limited Limited Limited
R adduction L adduction R depression R depression
L MR ⫹5 ⫺9 L LR ⫹6 ⫺6 L LR ⫹5 left 14 mm from limbus, R LR⫹4 left 15 mm from limbus R SR ⫹5 ⫺5 L IR ⫹5 ⫺5 R LR ⫹6 ⫺8, R MR ⫹5 ⫺5 L IR ⫹5 ⫺5 (slipped L IR repositioned 1 week later) L LR ⫹6 ⫺6 R LR ⫹6 ⫺6 L IR ⫹4 ⫺4 L IR ⫹5 ⫺5
21 22
F F
30 17
Limited R elevation Limited R adduction, L hyper on laevoversion
L SR ⫹5 ⫺5 L LR ⫹5 ⫺5 LR found at 10.5 set 16 mm
No No
R adduction R depression L elevation L depression R adduction R adduction
Yes Yes No Yes No Yes
R: right; L: left; B: bilateral; ⫺: recession; ⫹: resection; MR: medial rectus; LR: lateral rectus; SR: superior rectus; IR: inferior rectus; SO: superior oblique; IO: inferior oblique; VI: sixth nerve palsy; IV: fourth nerve palsy; CS: convergent squint; DNA: did not attend; BTXA: botulinum toxin.
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METHODS RESULTS
CONCLUSIONS
Scott described a method of achieving the effect of a posterior fixation procedure by combining resection and recession of a rectus muscle, while maintaining the ability to adjust primary position alignment with adjustable sutures. A retrospective review of combined recession-resection procedures on rectus muscles between 1998 and 2002 was carried out. We identified 22 patients, 17 females and 5 males. The mean age at presentation was 44 years. The etiology was felt to be paralytic in seven patients (31.8%), mechanical/ restrictive in seven patients (31.8%), and due to residual childhood strabismus in eight patients (36.4%). Twenty patients had undergone previous strabismus surgery, ranging from one to six operations (mean, 1.75). Scott procedures were performed on 25 rectus muscles of 22 patients; 12 on the lateral rectus muscles, 7 on the inferior rectus muscles, 3 on the medial rectus muscles, and 3 on the superior rectus muscles. All but one patient had a measurable improvement in gaze incomitance, and 11 of 12 who had a measurement of the field of binocular single vision showed improvement. Twenty patients had follow-up periods of 3 months or more, with a range of 3 to 30 months and a mean of 9.35 months. The combined recession-resection procedure advocated by Scott has a role in the management of incomitant strabismus. ( J AAPOS 2007;11:131-134)
T
he challenge of incomitant strabismus surgery is to improve diplopia and expand the field of single vision while maintaining good ocular alignment in primary position. The principle of improving incomitance in gaze away from primary position, known as “matching the defect,” typically involves limiting the action of the overacting contralateral synergist muscle. The posterior fixation suture technique (faden operation)1 improves misalignment in peripheral gaze positions while maintaining alignment in primary position. In this operation, a rectus muscle is sutured to the sclera at a point posterior to its insertion with nonabsorbable sutures. The effect is to limit the rotational force of the muscle in its primary direction of action, while having little or no effect on either primary position alignment or rotations away from the direction of action of the operated mus-
Author affiliations: Moorfields Eye Hospital, City Road, London, United Kingdom Presented at the 29th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Kona, Hawaii, March 23-27, 2003. Submitted March 9, 2004. Revision accepted October 30, 2006. Reprint requests: John Lee, FRCS, FRCP, FRCOphth, Moorfields Eye Hospital, City Road, London EC1V 2PD, United Kingdom (email: John.Lee@moorfields.nhs.uk). Copyright © 2007 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2007/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2006.10.023
Journal of AAPOS
cle. The procedure is more effective in neurologically caused incomitant strabismus than in mechanically induced incomitance.2,3 The faden procedure has disadvantages. Surgery can be technically difficult, as the access and exposure may be poor, and it has been suggested that the thin posterior sclera is relatively easier to perforate.4,5 The faden procedure in itself does not materially affect primary position alignment. It can be combined with a recession or resection with fixed sutures, but not with adjustable sutures. The faden procedure is ineffective when performed on the lateral rectus muscle, probably because that muscle has a very large arc of contact with the sclera. Scott suggested a procedure that was based upon a modification of the faden principle.6 He performed a large resection of a rectus muscle and then recessed the muscle, using a standard hang-back/adjustable technique, in a position where the recession amount exceeded the resection amount. The adjustable suture was used to manipulate primary position alignment, and the reattachment of muscle to sclera at a posterior insertion point produced the mechanical effect of a faden operation. Scott reported the use of the technique on horizontal rectus muscles in three cases, with good results and follow-up of 2 to 11 months. In 1999 Bock and colleagues7 applied Scott’s technique on vertical and horizontal rectus muscles in 12 patients, with and without adjustable sutures. They modified Scott’s
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technique by reducing the amount of resection, as they were concerned that problems could arise, in particular, if a reoperation was required. They obtained good results in four of five patients managed with adjustable sutures and in three of seven patients managed with fixed sutures. Thacker and colleagues8 reported in 1995 on 12 patients with vertical and horizontal deviation managed with combined recess-resect procedures, recessing by double the amount of resection. They reduced incomitance in all cases and eliminated diplopia in 11 of 12 patients. In this study, we report our experience with the combined recession-resection procedure in 22 consecutive patients.
Subjects and Methods We performed a retrospective chart review using the surgical database to identify all of our patients managed with a combined recession-resection procedure on one or more rectus muscles between 1998 and 2002. We identified 22 patients, 17 female and 5 male, with an age range of 8 to 86, and a mean of 44 years. In all cases the rectus muscle or muscles were resected and then left in a recessed position, on a hang-back adjustable polyglactin 910 suture. All surgery was under general anesthesia, and adjustment, if required, was done approximately 7 to 8 hours later that same day. In general, we did not perform “supramaximal” resections and confined our surgery to not more than 7 mm for a lateral rectus muscle and 5 to 6 mm for other rectus muscles. As we aimed to reduce deviation in primary position, as well as incomitance, recessions were always equal to or larger than resections. e-Supplement 1 (available at jaapos.org) provides patient details, the details of the recession-resection procedure, any associated surgery, and whether any further surgery was planned. Twenty patients had undergone previous strabismus surgery ranging from one to six procedures (mean, 1.75), and 5 patients had preceding botulinum toxin treatment. The etiology was judged to be paralytic in seven patients (31.8%), mechanical/ restrictive in seven patients (31.8%), and due to residual childhood strabismus in eight patients (36.4%). Ten cases had a preoperative exodeviation; 8 had an esodeviation, and 11 had a vertical deviation on cover test. All cases had limited ocular rotation with gaze incomitance in one or more fields of gaze (e-Supplement 1, available at jaapos.org). Nineteen of 22 complained of diplopia; in 7 patients it was in primary position. To illustrate the advantage of this procedure in allowing the ability to manage incomitance while maintaining or improving primary position alignment, we cite Case 12, a 20-year-old female medical student who presented with a consecutive exotropia with preserved binocular vision after esotropia surgery on each eye aged 2 and 4. When first seen, she had symptoms of diplopia despite base in prism in glasses. She had markedly limited adduction of both eyes, right more than left, with horizontal diplopia on sidegaze. She measured 20⌬ of exodeviation at 33 cm and 12⌬ at 6 m. We performed bilateral lateral rectus combined recess-resect procedures, finding the left lateral rectus at 9 mm from the limbus, resecting it by 5 mm and leaving it at 14 mm from the limbus, and finding the right lateral rectus at 9 mm,
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resecting it at 4 mm, and leaving it at 15 mm from the limbus. Later that day she had a small residual exotropia in primary position. The left lateral rectus was recessed a few millimeters, and all sutures were tied. Postoperatively, she measured 1⌬ of esophoria at near and 4⌬ esophoria at distance with stereopsis on the Wirt fly and 2/9 circles (200 seconds).
Results A combined recession-resection procedure was performed on 25 rectus muscles of 22 patients, a single lateral rectus muscle in 8 patients, both lateral rectus muscles in 1 patient, on the medial and lateral rectus muscles of one eye in 2 patients ( both patients having limitation of both adduction and abduction of the fellow eye, 1 due to complications of endoscopic sinus surgery and 1 with residual abducens nerve palsy due to a glomus jugulare tumor, with postsurgical limitation of adduction of the paretic eye), on a single medial rectus muscle in 1 patient, and on 7 single inferior rectus muscles and 3 superior rectus muscles. Surgical dosages for lateral rectus muscles ranged from 4 mm resection and recession to 7 mm resection and recession. All medial rectus muscles had 5 mm resection and recession. Inferior rectus muscles received between 4 mm resection and recession and 5 mm resection with 6 mm recession. Superior rectus muscles had between 5 mm resection and recession and 5 mm resection with 6 mm recession. Adjustable sutures were used in 21 of 22 patients, and adjustment was necessary in only 8 patients. Other surgery was done at the same session in seven patients. Three patients had oblique muscle weakening surgery in association with a combined recession-resection procedure on the ipsilateral vertical rectus muscle. Two had correction of horizontal deviation when the combined recession-resection procedure was performed on a vertical rectus muscle. One patient had lateral rectus resection associated with a combined recession-resection procedure on the medial rectus muscle for esotropia and latent nystagmus with head posture. One patient had superior rectus muscle faden for a vertical deviation, with the combined recession-resection procedure on the horizontal rectus muscle. One patient had early slippage of an inferior rectus muscle. The muscle was explored and repositioned within a few days with a good result. There were no other complications of surgery. Twenty patients had follow-up periods of 3 months or more, with a range of 3 to 30 months and a mean of 9.35 months. Two patients did not attend the 3 month followup appointment. e-Supplement 1 shows the patient data. Our findings with the remaining patients that attended both a 2 week postoperative appointment and the 3 month postoperative appointment was that there was no difference in measurements between the two consecutive visits. All but one patient had improvement in gaze incomitance, assessed by reduction of symptoms of diplopia and improvement of eye movements on orthoptic examination.
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FIG 1. Pre- and postoperative percentage fields of binocular single vision; n ⫽ 12. BSV, binocular single vision.
In 11 of 12 patients who had measurement of the percentage field of binocular single vision, this test confirmed improvement. We analyzed and scored these by the method of Fitzsimons and White9 to give a percentage of normal. In all but one patient, there was improvement in the percentage score, as shown in Figure 1. Further surgery has been performed in two patients and is planned in three more. We classified 10 patients as “functional cures,” with abolition of incomitance and a large functional field of binocular single vision, between 40% and 80% of normal. One of these patients underwent subsequent strabismus surgery, with a faden procedure on the same inferior rectus muscle as the combined recession-resection procedure, to further widen the field of single vision. The etiology in this group was paralytic in two patients (abducens nerve palsy), mechanical in four (three orbital trauma, one dysthyroid), and related to childhood concomitant strabismus in four (two consecutive exotropia, one residual exotropia, one residual esotropia). All had had previous strabismus surgery. Combined recession-resection procedures were done on five unilateral lateral rectus muscles (total eight in series), three inferior rectus muscles (total seven in series), both lateral rectus muscles in one patient, and both medial and lateral rectus muscles on one eye on another patient. Six patients were judged partial cures, since they improved but required further treatment in the form of surgery or prisms. The etiologies were paralytic in three (two bilateral posttraumatic trochlear nerve palsy, one unilateral trochlear nerve palsy), mechanical in one ( postoperative adherence syndrome), one had an idiopathic hypertropia, and one had blepharophimosis syndrome with a right esotropia and manifest latent nystagmus and a face turn toward the fixing eye. Three of this group experienced a surgical overcorrection and reversal of the deviation. One inferior rectus muscle slipped within the first postoperative week and was repositioned. Later reversal was seen with one inferior rectus muscle and one superior rectus muscle, both with posttraumatic trochlear nerve palsy. All of this group had improvement of their original incomitance, but required further treatment with prisms or surgery to obtain a satisfactory outcome.
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Four patients judged treatment failures, with minimal change in ocular rotations. One had a left lateral rectus muscle combined recession-resection procedure for limited adduction of the other eye following a second surgery for childhood esotropia. Improvement was minimal and further surgery on the right eye is planned. One patient has had a long series of ocular muscle procedures4 for diplopia, originally caused by retinal reattachment surgery, and further surgery is planned. One patient, whose left medial rectus muscle was effectively rendered useless by endoscopic sinus surgery, derived no benefit from combined recession-resection procedures on the contralateral medial and lateral rectus muscles, as shown by an inconsequential change in her percentage field of binocular single vision following surgery from 36% to 39%. A further patient, who sustained right-sided orbital trauma in an automobile accident, and initially underwent a right Knapp procedure, had an initial good response to a combination of left superior rectus combined recessionresection procedure and ipsilateral inferior oblique muscle disinsertion, to improve incomitance on upgaze. After the 3 month visit she began to notice pain around the right eye and deterioration of her ocular motility. She has since been diagnosed as having collapse of the maxillary sinus on the right side and awaits faciomaxillary and orbital repair. Further treatment was undertaken in eight patients. One patient had a faden procedure on an inferior rectus muscle that had undergone the combined recession-resection procedure to widen the field of single binocular vision. One patient had further adjustable bilateral inferior rectus muscle weakening surgery for bilateral fourth nerve palsies. Three patients have surgery planned to further increase the field of binocular single vision. Three patients have had subsequent botulinum toxin treatment, two with some improvement in symptoms. All other cases have had a stable result following combined recession-resection procedure surgery.
Discussion We conclude that the combined recession-resection procedure has a useful role in the management of symptomatic incomitant strabismus. The faden procedure remains valuable when there is no ocular deviation in primary position sufficient to warrant intervention. When strabismus is present in primary position, the combined recessionresection procedure is useful and seems to be as effective as a standard faden procedure in expanding the field of single binocular vision. The procedure is particularly valuable when dealing with incomitance on lateral gaze due to limitation of adduction, where the overacting muscle is the contralateral lateral rectus muscle. Recession of the lateral rectus muscle may have a deleterious effect on the primary position deviation, and we have found that performing a standard faden procedure on the lateral rectus muscle has little or no effect.
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The procedure was easy to perform compared with the faden procedure. In our series, the only operative complication was a slipped inferior rectus muscle, a recognized complication of IR muscle weakening surgery.
4.
References
6.
1. Cüppers C. The so-called “Fadenoperation” (surgical correction by well defined changes in the arc of contact). In: Fells P, editor. Second Congress of the International Strabismological Association; Marseilles: Diffusion Générale de Librairie; 1976; p. 395. 2. Buckley EG, Meekins BB. Fadenoperation for the management of complicated incomitant vertical strabismus. Am J Ophthalmol 1988; 105:304-12. 3. Kouri AS, Bessant DAR, Adams GGW, Sloper JJ, Lee JP. Quantitative changes in the field of binocular single vision following a
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fadenoperation to a single vertical rectus muscle. J AAPOS 2002;6:294-9. Alio JL, Faci A. Fundus changes following Faden operation. Arch Ophthalmol 1984;102:211-3. Lyons CJ, Fells P, Lee JP, MacIntyre A. Chorioretinal scarring after the faden operation: a retrospective review of 100 procedures. Eye 1989;3:401-3. Scott AB. Posterior fixation: adjustable and without posterior sutures. In: Lennerstrand G, editor. Proceedings VIIth Congress International Strabismological Association CRC Press, Inc.; 1995; p. 399-402. Bock CJ, Buckley EG, Freedman SF. Combined resection and recession of a single rectus muscle for the treatment of incomitant strabismus. J AAPOS 1999;3:263-8. Thacker NM, Velez FG, Rosenbaum AL. Combined adjustable rectus muscle resection- recession for incomitant strabismus. J AAPOS 2005; 9:137-40. Fitzsimons R, White J. Functional scoring of the field of binocular single vision. Ophthalmology 1990;97:33-5.
An Eye on the Arts – The Arts on the Eye
At the end of ten days, a new group of doctors came to Yossarian with bad news: he was in perfect health and had to get out. He was rescued in the nick of time by a patient across the aisle who began to see everything twice. Without warning, the patient sat up in bed and shouted, “I see everything twice!” A nurse screamed and an orderly fainted. Doctors came running up from every direction with needles, lights, tubes, rubber mallets and oscillating metal tines. They rolled up complicated instruments on wheels. There was not enough of the patient to go around, and specialists pushed forward in line with raw tempers and snapped at their colleagues in front to hurry up and give somebody else a chance. A colonel with a large forehead and horn-rimmed glasses soon arrived at a diagnosis. “It’s meningitis,” he called out emphatically, waving the others back. “Although Lord knows there’s not the slightest reason for thinking so.” “Then why pick meningitis?” inquired a major with a suave chuckle. “Why not, let’s say, acute nephritis?” “Because I’m a meningitis man, that’s why, and not an acute-nephritis man,” retorted the colonel. “And I’m not going to give him up to any of your kidney birds without a struggle. I was here first.” In the end, the doctors were all in accord. They agreed they had no idea what was wrong with the soldier who saw everything twice, and they rolled him away into a room in the corridor and quarantined everyone else in the ward for fourteen days. —Joseph Heller (from Catch 22, Simon & Schuster)
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Volume 11 Number 2 April 2007
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e-Supplement 1. Patient data No.
Sex
Age at surgery ( y)
1 2 3 4 5 6
F F F F F F
26 52 68 42 59 39
Limited Limited Limited Limited Limited Limited
7 8 9
M F M
61 37 50
10 11 12
F F F
13 14 15 16
Incomitance
Combined recessionresection procedure
Adjusted
Other simultaneous surgery
Further treatment
Discharge DNA DNA No No Yes No
No No Yes
No No B MR ⫺ & inferiorly reinserted L LR ⫹5 No No
No No BTXA R MR No No Re-explore R LR & MR No No R IR advance, L IR ⫺3.5 No RMR faden No
Yes No No Yes
R IO disinsertion No No No
No Prisms BTXA L LR BTXA R IR
No No No No
Yes No No No
No No No L SO posterior tenotomy L IO disinsertion L SR faden
No No L IR faden No
Yes Yes Yes Yes
No No
No No
L LR ⫹ 6 ⫺6 L IR ⫹4 ⫺4 R SR ⫹5 ⫺6 R IR ⫺6 ⫹5 L LR ⫹7 ⫺7 L LR ⫹6 ⫺6
Yes No Yes No No No
No L MR ⫺5 No No No No
Limited L abduction Limited R adduction L hyper on dextrodepression
R MR ⫹5 ⫺5, R LR ⫹6 ⫺6 L LR ⫹5 ⫺8 R IR ⫹5 ⫺7
No Yes Yes
8 38 20
R ET increases on R gaze Limited R adduction Limited R adduction
F F F M
26 86 58 65
Limited Limited Limited Limited
L elevation R laevodepression L adduction R depression
17 18 19 20
M F M F
38 55 52 44
Limited Limited Limited Limited
R adduction L adduction R depression R depression
L MR ⫹5 ⫺9 L LR ⫹6 ⫺6 L LR ⫹5 left 14 mm from limbus, R LR⫹4 left 15 mm from limbus R SR ⫹5 ⫺5 L IR ⫹5 ⫺5 R LR ⫹6 ⫺8, R MR ⫹5 ⫺5 L IR ⫹5 ⫺5 (slipped L IR repositioned 1 week later) L LR ⫹6 ⫺6 R LR ⫹6 ⫺6 L IR ⫹4 ⫺4 L IR ⫹5 ⫺5
21 22
F F
30 17
Limited R elevation Limited R adduction, L hyper on laevoversion
L SR ⫹5 ⫺5 L LR ⫹5 ⫺5 LR found at 10.5 set 16 mm
No No
R adduction R depression L elevation L depression R adduction R adduction
Yes Yes No Yes No Yes
R: right; L: left; B: bilateral; ⫺: recession; ⫹: resection; MR: medial rectus; LR: lateral rectus; SR: superior rectus; IR: inferior rectus; SO: superior oblique; IO: inferior oblique; VI: sixth nerve palsy; IV: fourth nerve palsy; CS: convergent squint; DNA: did not attend; BTXA: botulinum toxin.
Journal of AAPOS