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Surgical Outcome of Single-Staged Three Horizontal Muscles Squint

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Surgical Outcome of Single-Staged Three Horizontal Muscles Squint Eye (2010) 24, 1171–1176 & 2010 Macmillan Publishers Limited All rights reserved 0950-222X/10 $32.00 www.nature.com/eye 1 2 1 1 Surgical outcome of FHS Lau , DSP Fan , WWK Yip , CBO Yu and CLINICAL STUDY DSC Lam2 single-staged three horizontal muscles squint surgery for extra-large angle exotropia Abstract Introduction Purpose To report the surgical outcomes of Large angle exotropias have great impact on 24 patients undergoing single-staged three patients’ lives. Scatterfield et al1 described the horizontal muscles squint surgery for negative impacts on strabismic patients extra-large angle exotropia. including negative self-images, poor Patients and methods Prospective case series interpersonal relationships, school performance, of 24 consecutive patients with primary and job security. A person with strabismus is exotropia 460 prism diopters (PD) at distant considered by others to be inferior in many of and underwent single-staged three horizontal the personality characteristics.2 The correction muscles squint surgery from 2003 to 2006. of strabismus in adults has been shown to Surgery consisted of bilateral lateral rectus improve the quality of psychosocial functioning recession of 9.0 mm for 50 PD exotropic for the majority of adults.3 Moreover, 1Hong Kong Eye Hospital, correction. For every 5 PD remaining angle strabismus surgery can also realign the visual Kowloon, Hong Kong, exceeding 50 PD, we additionally performed axes to eliminate diplopia and improvement of People’s Republic of China 1.0 mm of unilateral medial rectus resection. The stereopsis.4 Morris et al5 and Kushner and 2Department of mean follow-up period was 15.8 months (range 6 Morton have found that even in adults with Ophthalmology and Visual 6.0–38.0 months; SD 9.5 months). long-standing strabismus, they may have Sciences, The Chinese Results The mean age at surgery was 31.2 restoration of binocular vision after their eyes University of Hong Kong, years old (range 7–78 years old, SD 18.2 years are aligned. Hong Kong Eye Hospital, old). The mean distant preoperative deviation However, there are limited studies on the Kowloon, Hong Kong, People’s Republic of China was 71.3 PD (range 60–85 PD, SD 7.7 PD). No outcome of surgical management for extra-large limitation of eye movement or diplopia was angle exotropia. Debate still exists to what Correspondence: DSP Fan, found. The success rate was higher in the would be the best treatment. Some advocate Department of intermittent group (88.2%) than the constant bilateral lateral rectus recession as it is a quicker Ophthalmology and Visual group (42.9%) (P ¼ 0.02) and in cases with and simpler procedure and leaves the medial Sciences, preoperative deviation of o80 PD (84.2%) rectus untouched for subsequent surgery.7 The Chinese University of Hong Kong, compared with those with deviation X80 PD Others have suggested a simultaneous three or University Eye Center, 8–10 (40.0%) (P ¼ 0.042). four muscles surgery. Moreover, reference 3/F, Hong Kong Eye Conclusion Measurement of preoperative tables are mainly designed for two muscles Hospital, 147K, deviation and the surgery for extra-large angle surgery, the amount of deduction after two Argyle Street, exotropia made management of this condition muscles surgery is still controversial. The few Kowloon, Hong Kong, People’s Republic of China. difficult. Single-staged three horizontal reports addressing the surgical outcomes of Tel: þ 852 2762 3150; muscles squint surgery can be one of the extra-large angle exotropia diversified in their Fax: þ 852 2715 9490. options. Further researches on management population and the surgical method. The E-mail:dorothyfan@ of exotropia of 480 PD are warranted. definition of large angle varied with some cuhk.edu.hk Eye (2010) 24, 1171–1176; doi:10.1038/eye.2010.5; recruiting cases of 435.0 prism diopters (PD) published online 5 February 2010 only.11 The aetiologies of the cases included Received: 29 May 2009 12 Accepted in revised form: primary, consecutive and trauma cases. 21 November 2009 Keywords: large angle exotropia; single staged; Individualizing the surgery by adjustable Published online: 5 February strabismus surgery sutures may theoretically improve the surgical 2010 Three muscles surgery for large angle exotropia FHS Lau et al 1172 outcome. However, not all the patients are suitable of one half tendon width was performed for patients candidates for adjustable sutures. Here, we report the with V pattern defined as angle in elevation exceeded surgical results of one-staged three horizontal muscles that in depression by 15 prism dioptres.13 surgery for primary large angle exotropia. Successful motor alignment was defined as esodeviation between 1 and 10 PD, orthotropia or exodeviation between 1 and 10 PD during the most Materials and methods recent follow-up, at least 6 months postoperatively.14 A prospective study was conducted on all consecutive A stereoacuity of p55 s of arc was considered as patients with primary extra-large angle primary bifixation. A stereoacuity of o600 s, but 455 s of arc exotropia undergoing strabismus surgery at Hong Kong was considered as gross stereopsis.15 Eye Hospital from June 2003 to December 2006. SPSS 11.5 for Windows statistical software was used in Patients with primary large angle intermittent or the analyses. w2 tests were used to assess association constant exotropia with angles 460 PD at distant were between the variables observed. A P-value of o0.05 was included. We excluded all paralytic squint, cases with considered as statistically significant. history of earlier strabismus surgery, coexisting ocular We certify that all applicable institutional and disease apart from refractive error and amblyopia, governmental regulations concerning the ethical use of restricted eye movements, or strabismus with a human volunteers/animals were followed during this secondary cause. Ethics Committee approval was taken. research. All patients underwent a complete ophthalmologic examination before and after the operation. The age at Results operation, gender, visual acuity, preoperative near and distant deviation, details of surgery, surgical There were 24 patients: 15 males and 9 females. The complication, postoperative angle measurement, and mean age at operation was 31.2 years. (range 7–78 years; length of follow-up were recorded. The cases were seen SD 18.2 years). Seven (29.2%) of them had constant 1 week before the operation. They were reassessed at exotropia and 17 (70.8%) had intermittent exotropia. postoperative Day 1, Week 2, Month 1, Month 3, and then The mean age of operation for patients in the constant every 3 months after the operations. All the cases were exotropia group was 34.9 years and that for the followed up for at least 6 months postoperatively. intermittent exotropia group, 29.6 years (P ¼ 0.50). Two Preoperative and postoperative deviations with near (8.3%) of the patients had anisometropic amblyopia with (33 cm) and distant target (6 m) were measured with Snellen acuity 6/12 in the worse eye. All the remaining alternate prism cover test using loose prisms. The patients were having bilateral visual acuities equal to or preoperative and postoperative sensory statuses were greater than Snellen acuities of 6/9. The overall mean determined in all patients by Frisby Stereotest (Clement preoperative near deviation was 71.5 PD (range 60–85 Clarke International Ltd, 15 Wigmore Street, London, PD, SD 7.7 PD) and mean preoperative distant deviation W1H 9LA, UK). was 71.3 PD (range 60–85 PD, SD 7.7 PD). Patients in the All the operations were performed under general constant exotropia group (mean 76.4 PD, range 65–85 PD, anaesthesia by two experienced surgeons. Both muscle SD 9.0 PD) had a larger preoperative near deviation than recession and resection were performed with limbal the intermittent group (mean 69.4 PD, range 60–80 PD, approach with direct scleral fixation sutures using 6 SD 6.3 PD) (P ¼ 0.04). The mean preoperative distant 1 o’vicryl (6-0 S-24 8 mm 4 C Spatula, Ethicon Coated deviation for the constant exotropia group was 74.3 PD Vicryl, polyglactin 910, Johnson & Johnson, Belgium). (range 55–85 PD, SD 9.8 PD) and the mean deviation for Conjunctival wounds were closed by 8 o’vicryl suture the intermittent exotropia group was 69.4 PD (range (8-0 TG140-8 6.5 mm 3/8c Spatula, Ethicon Coated Vicryl, 60–85 PD, SD 6.6 PD) (P ¼ 0.166). Eight patients (33.3%) polyglactin 910, Johnson & Johnson). All muscle were having V pattern, defined as above. recession measurements were measured from the muscle All patients underwent 9.0 mm bilateral lateral rectus insertion. We adopted a surgical approach with minimal recessions and unilateral medial rectus resection, medial rectus resection. Maximal bilateral lateral rectus according to the surgical plan described. The mean recessions of 9 mm were performed aiming for a medial rectus resection performed was 4.2 mm (range correction of 50 PD. Any exotropia exceeding the 50 PD 2.0–7.0 mm, SD 1.4 mm). The mean follow-up period was would be corrected by unilateral medial rectus resection 15.8 months (range 6.0–38.0 months, SD 9.5 months). No on the non-dominant eye. We used an approach with significant observable postoperative abduction deficit 1 mm unilateral medial rectus resection for every was noted in all the patients. One of the patients 5 PD of exotropia after the bilateral lateral rectus developed a conjunctival cyst postoperatively, which recessions. An upwards transposition of the lateral rectus subside spontaneously. There were no other Eye Three muscles surgery for large angle exotropia FHS Lau et al 1173 postoperative complications. The overall mean angle of angles) against the amount of medial rectus resection postoperative exodeviation at the last follow-up for near performed in the two groups of patients.
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