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Surgical Management of Small Angle Strabismus Dr V Short Review Surgical management of small angle strabismus Dr V. Akila Ramkumar and Dr Ketaki S. Subhedar Department of Pediatric Small angle deviation refers to deviations <15 to expose the tendon and making successive small Ophthalmology, Sankara prism diopters (PD). Standard rectus muscle reces- cuts in the rectus muscle at the insertion until the Nethralaya, Chennai, India sion–resection is designed to correct moderate to desired effect is achieved. Over half the tendon large angle strabismus >10 PD. Small angle eso- was removed starting at one pole, leaving one Correspondence: deviations and vertical deviations cause astheno- tendon pole attached to sclera, resulting in the cut Dr V. Akila Ramakumar, pic symptoms and diplopia which may be frustrat- tendon slanting back at an angle of 45°. A 60– Associate Consultant, Paediatric ing for the patient and surgeons alike. This can be 70% tenotomy, or removing 6–7 mm of tendon, Ophthalmology and Strabismus. true for primary deviations and unfortunately corrects ∼4Δ of strabismus. Email: [email protected] even in postoperative patients. Several non- The slanted tenotomy works by effectively surgical management options to overcome the moving the insertion, thus changing the vector of diplopia include prisms, botuliniuminjections, muscle force and potentially inducing incomi- Bangarters filters and the last resort of self-guided tance. A vertical deviation could be induced if an coping mechanism. If these fail or any of these upper tenotomy of one medial rectus muscle was are non-desirable, then the alternative solution performed along with a lower tenotomy on the would be the surgical intervention. Unfortunately, contralateral medial rectus muscle. Likewise, an A small angle strabismus surgery is prone for over pattern could theoretically be induced, or a V correction when using standard recess–resect pro- pattern treated, if the upper poles of both medial cedure. The reason leading to a list of alternative rectus muscles were removed, effectively moving surgical approaches which include the insertions down. This induced incomitance caused by the slanted pole tenotomy was substan- 1. Partial thickness myotomies—marginal tiated by van der Muelen-Schot et al.7 myotomy—Zplasty. The advantages of this procedure include the ease 2. Graded partial tenotomy of vertical rectus for of the procedure, adjustments can be made intra- hypertropia Mini-tenotomy. operatively, less bleeding, sutureless and the temporal incision reduces the risk of infection. Graded partial 3. Mini-plication. tenotomy of vertical rectus muscle may have applica- 4. Single muscle strabismus surgery. tions beyond that has been described. 5. Adjustable fadens/combined recession and resection of a rectus muscle. Mini tenotomy This is usually considered for the treatment of verti- cal deviation of ≤6PD,andhorizontaldeviations Partial thickness myotomy 3 This technique has been in use over the past 150 <16 PD. Kenneth W described mini-tenotomy, a – years. The common procedure today is marginal central tenotomy of 3 mm of tendon insertion, pro- ∼ – Δ myotomy, often performed as ‘Z’ plasty across ducing a correcting effect of 2 3 of strabismus. – Δ one-third to ½ the tendon width. It is used to A correction of up to 4 5 can be obtained if bin- weaken the already dramatically recessed muscle, ocular surgery was performed. For example, a right Δ when recession is not prudent. It is also indicated hypertropia of 4 could be corrected by a right in patients with thin sclera or to weaken a rectus superior rectus tenotomy and left inferior rectus – Δ muscle that has at or near its insertion an tenotomy. An esotropia of 4 6 can be treated with implant, exoplant or encircling element used in bilateral medial rectus tenotomies. This mini- retinal detachment or for glaucoma filtration. tenotomycouldbeadjustedbyremeasuringthe deviation after operating on one muscle and deter- Partial tenotomy/graded tenotomy mine if additional surgery is needed. The size of the In 2000, Alan Scott1 described a rectus muscle tenotomy can be enlarged by resnipping additional fi tenotomy procedure called graded rectus muscle tendon bers for residual deviation. tenotomy which he performed under local anes- thesia to treat small degrees of vertical strabismus. Surgical technique Biglan2 and co-workers did the same in 2004 on Under topical anesthesia following steps can be vertical muscles only. Partial tenotomy can be performed (Figure 1) done as a primary procedure or in reoperations for small angle strabismus to improve diplopia. The (a) Grasp tendon of the rectus muscle centrally procedure was done under sub conjunctival injec- with Wright 0.75-tooth tenotomy forceps tion of lignocaine, conjunctival incision was made through the intact conjunctiva. Sci J Med & Vis Res Foun October 2015 | volume XXXIII | number 3 | 135 Short Review Surgical technique (Figure 2) (a) A swan conjunctival incision is made over the muscle insertion, dissection is done and muscle is grasped centrally ∼5 mm from insertion. (b) A double-armed 6-0 polyglactin 910 suture is placed underneath the forceps the suture is tied in a square knot. (c) The sclera suture is placed anterior to the inser- Figure 1: tion and tied in place to plicate the central portion of the muscle. (d) The final outcome showing plication. (b) Cut the central tendon between the forceps and sclera with blunt Westcott scissors. The mini-plication has many advantages over standard strabismus surgery that requires hooking fi (c) nal outcome shows intact two muscle poles at and removing the muscle. It is less invasive and the extremes of the insertion. These ends main- preserves the integrity of the muscle insertion and tain the stability and a central approach avoids presumably the anterior cilliary vessels, though this the ciliary vessels. was only studied in the full plication procedure. Vicryl suture is used in this procedure as well as in In patients in whom the mini-tenotomy fails to the full plication procedure, because a permanent alleviate the diplopia standard surgery can be suture placed anterior to the muscle insertion will safely done without difficulty. erode through the conjunctiva. It can be done under topical anesthesia and can be reversed. Mini-plication One muscle strabismus surgery 4 The mini-plication described by Kenneth et al. The role of unilateral rectus muscle surgery has Δ Δ was conceived for deviations of 8 to 10 , which been controversial due to the significant number are too small angles for standard surgery. The of under correction and or ocular incomittance. – approximate dose response of the procedure was Recent studies5 have shown that unilateral rectus Δ Δ about 5 to 7 correction in patients without pre- recession or resection is a safe, effective and pre- vious surgery resection and those with a recession dictable treatment for small to moderate angle Δ Δ of the antagonist had a correction of 8 to 10 horizontal deviation including exo-deviation per muscle. The response can be tailored by between 15 and 20 PD, exo-deviation between15 placing the securing suture farther back from the and 40 PD, in patients with under-corrections or muscle insertion. recurrent strabismus and in patients with conver- gence or divergence insufficiency. Single muscle surgeries are often resurgeries. Residual esotropia or exotropias of ∼15–20 PD respond well with single muscle recessions or resections. Studies show ∼60–90% success rate. The advantage of this is that it limits the surgery to one eye. Combined recession and resection of rectus muscle/adjustable faden procedure Scott6 suggested a procedure that was based on modification of the faden principle for improving incomitance in gaze away from the primary pos- ition. The faden procedure in itself does not affect primary position alignment and is difficult tech- nically and is ineffective on the lateral rectus due to large arc of contact. 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 reattachment of the muscle to sclera at a posterior Figure 2: insertion point produced the mechanical effect of 136 Sci J Med & Vis Res Foun October 2015 | volume XXXIII | number 3 | Short Review faden operation. The combined recession–resection diplopia in patients with small angle strabismus procedure has a useful role in the management of who are not ideal candidates for conservative symptomatic incomitant strabismus. The procedure management. These procedures can be done in the is particularly valuable when dealing with incomi- office under topical or local anesthesia and tance on lateral gaze due to limitation of adduc- provide an alternative to prisms and the standard tion, when the overacting muscle is the strabismus surgery. The key to success is careful contralateral lateral rectus muscle. It seems to be patient selection, analyzing the critical factors like an effective procedure in expanding the field of the angle type-vertical/horizontal, angle size, single binocular vision. angle character—phoria/tropia. Most of the surger- ies described are muscle weakening procedure Conclusion although the weakening effect is limited. The pro- The various causes of small angle strabismus cedures described can be useful addition to a stra- include microtropia, residual deviations after bismus surgeons repertoire. optical and surgical corrections, intermittent squints, sensory micro-strabismus and paretic strabismus. Normal divergence and vertical fusion References amplitudes are small, with divergence measuring 1. Scott AB. Graded rectus muscle tenotomy for small deviations. 4–6PD(Δ) and vertical vergence <2 D. Because of Proceedings of the Jampolsky Festschrift. San Francisco: The Smith-Kettlewell Eye Research Institute; 2000: 215–216. this, even small eso-deviations and vertical devia- 2. Albert W, Biglan , Hye Bin Yim. Graded partial tenotomy of fi tions can cause signi cant asthenopic symptoms vertical rectus muscle for treatment of hypertropia. Trans Am and diplopia, especially when the deviation is Ophthalmol Soc 2004; 102: 169–176.
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