Effect analysis of partial transposition of vertical rectus combined with medial rectus recession under microscope on treatment of complete abducens nerve palsy esotropia / 上海交通大学学报（医学版）

Objective: To investigate the clinical effect of partial transposition of the vertical rectus combined with medial rectus recession on the treatment of abducens nerve palsy esotropia under the microscope. Methods: Nine patients with abducens nerve palsy esotropia were treated in Suzhou Kowloon Hospital, Shanghai Jiao Tong University School of Medicine from March 2015 to June 2017. The strabismus surgery was performed under the microscope, with partial transposition of the vertical rectus combined with medial rectus recession. Postoperative follow-up was performed to observe the effect. Results: After 1 week, 7 patients’ primary position were orthotopic(within ±10Δ), and 2 patients were undercorrection (+15Δ and +20Δ). Abduction function of all the patients improved significantly. The eyes could cross the midline. After 1 month, 6 patients’ primary position were orthotopic (within ±10Δ), 3 patients were undercorrection(respectively +15Δ, +15Δ and + 30Δ). After 1 year, 5 patients’ primary position were almost orthotropia (within ±10Δ), and 4 patients were undercorrection (respectively +15Δ, +15Δ, +30Δ and +40Δ). Conclusion: Partial transposition of the vertical rectus combined with medial rectus recession under the microscope is a safe and effective surgical method in treatment of complete abducens nerve palsy esotropia. It can not only improve the ocular position, but also effectively improve the abduction function of the paralytic eye. However, it is easy to be undercorrection in the long-term.

Clinical Characteristics and Outcomes of Smartphone Overusers with Acute Acquired Comitant Esotropia

PURPOSE: To evaluate the clinical features and treatment outcomes of smartphone overusers with acute acquired comitant esotropia. METHODS: We retrospectively reviewed the medical records of patients ≥ 15 years of age who used a smartphone for > 4 hours a day for > 1 year, and who were diagnosed with acute acquired comitant esotropia from May 2011 to January 2016. We analyzed sex, age at the time of manifestation and duration of esotropia, refractive error, deviated angle at the first and final visits, and the results of refraining from smartphone use, use of the Fresnel prism, and surgery for esotropia. RESULTS: A total of 13 patients were studied, including 8 males and 5 females. The mean age at development of esotropia was 22.7 ± 9.7 years. The mean duration of esotropia before the first visit was 28.0 ± 33.0 months, and the mean follow-up period was 16.4 ± 16.4 months. The mean angle of esotropia was 21.8 ± 7.0 prism diopters (PD) at distance and 22.2 ± 7.9 PD at near. There were eight myopic patients; the other patients were emmetropia. The esotropia of all patients did not improve after refraining from smartphone use. There was no improvement in five patients who were wearing the Fresnel prism for ≥ 4 months. A total of six patients were treated with bilateral medial rectus recession; only one patient remained orthotropic at postoperative 6 months, three patients were undercorrected, and two had a recurrence. CONCLUSIONS: Esotropia persisted after refraining from smartphone use or wearing a Fresnel prism in acute acquired comitant esotropia patients who were smartphone overusers, and the surgical prognosis of these patients was relatively poor.

Surgical outcome of extra-large recession of unilateral medial rectus for small angle esotropia in adults / 国际眼科杂志(Guoji Yanke Zazhi)

·AIM: To evaluate the surgical outcomes of adults who underwent extra - large recession of unilateral medial rectus ( UMR) for the treatment of concomitant esotropia less than +30 prism diopter ( PD) .·METHODS: The medical records of 20 patients ( 30 eyes) who underwent surgical correction of concomitant esotropia less than +30 PD were retrospectively reviewed. Patients with esotropia who were previously treated with one or two surgical procedures of adjustable suture ( 10 eyes as observation group with extra-large recession of UMR as 8-9mm, 10 eyes as control group with bilateral MR recession as 4-5mm) were included in the study. The binocular alignment and adduction function were evaluated at postoperative 3d and 3mo.·RESULTS: The male-female rate of the patients was 13:7. The mean age at surgery was 28. 2 ± 19. 9 years old (range:18-42 years old). At 3d after operation, the eye position of the observation group was - 3△ to + 10△(+5. 02△±2. 39△). That of the control group was -2△ to+10△(+4. 86△± 2. 28△). The difference between the two groups was significant (t=4. 36,P<0. 05). At 3mo after operation, the eye position of the observation group was+4△ to +11△(+4. 31△± 1. 65△). That of the control group was +3△to +10△(+3. 91△±2. 68△). The difference between the two groups was not significant (t= 2. 01,P>0. 05). There was no statistic difference in the postoperative AC/A between two groups (3. 09±0. 15 vs 3. 16±0. 09; t=2. 18,P> 0. 05 ) in postoperative 3mo. Three eyes of the observation group had adduction limitation in postoperative 3d, while none of patients in control group had this. None in the two groups showed the limitation in postoperative 3mo.· CONCLUSION: The surgical correction with UMR recession less than 9mm is safe in small angle esotropia adults, without adduction limitation.

Surgical Outcomes Dependent on the Amount of Hyperopia in Infantile Esotropia

PURPOSE: In the present study, short-term and long-term surgical outcomes dependent on the amount of hyperopia in patients with infantile esotropia were analyzed. METHODS: In this study, 80 patients with infantile esotropia who underwent both medial rectus recession from 2007 to 2011 and followed up for at least 36 months were retrospectively examined. The patients were divided into two groups according to the degree of hyperopia: ≥ +3.0 D (high hyperopia [HH], n = 59 patients) and < +3.0 D (non-high hyperopia [NH], n = 21 patients). Clinical characteristics analyzed included surgical success rate and dose-response relationship at the 3-month and 3-year postoperative follow-ups. RESULTS: Initial preoperative alignment (NH: 44.8 ± 10.2 PD, HH: 42.7 ± 11.6 PD, p = 0.450), surgical success rates (NH: 69.5% (41/59), HH: 71.4% (15/21), p = 0.837), under-correction rates (NH: 23.7% (14/59), HH: 9.5% (2/21), p = 0.191) and over-correction rates (NH: 6.8% (4/59), HH: 19.1% (4/21), p = 0.138) were not statistically significantly different between the NH and HH groups. A tendency towards a larger dose-response relationship was observed with HH (NH: 3.9 PD/mm, HH: 4.3 PD/mm) at the 3-month postoperative follow-up, but was not significant (p = 0.105). At the 3-year postoperative follow-up, exodrift was in progress and the dose-response relationship was significantly higher in the HH group than NH group (NH: 3.9 PD/mm, HH: 4.9 PD/mm, p = 0.010). A difference between the groups with amblyopia was observed (NH: 8.5% (5/59), HH: 23.8% (5/21), p = 0.146), although without statistical significance. CONCLUSIONS: The surgical success rate of infantile esotropia was not statistically associated with the amount of hyperopia. There was no statistical association between the dose-response relationship and amount of hyperopia at the postoperative 3-month follow-up, but a statistical association was found in the high dose-response relationship in the HH group at the postoperative 3-year follow-up. Therefore, the conventional amount of recession or muscle resection should be modified in high hyperopic (≥ +3.0 D) infantile esotropia, and long-term postoperative follow-up is necessary.

Comparison of Functional Equator-Considering and Parks Methods in Bilateral Medial Rectus Recession for Esotropia

PURPOSE: To compare the surgical outcomes of functional equator-considering and Parks' methods in infantile esotropia and partially accommodative esotropia. METHODS: The medical records of 96 patients with infantile esotropia and partially accommodative esotropia who underwent bilateral medial rectus muscle recession by functional equator-considering and Parks' methods were reviewed retrospectively. The surgery success rate at 1 month, 3 months, 6 months and 12 months was compared by the deviation angle measurement. RESULTS: Overall success rates were not statistically different between the 2 groups. Additionally, there were no differences in surgical success rate of functional equator-considering and Parks' methods in infantile esotropia and partially accommodative esotropia. When the patients were divided into 2 groups based on 40 PD, no significant difference in success rate between the 2 groups was observed. When patients were divided into 2 groups based on 22 mm of axial length, there was no statistical difference observed. Postoperative overcorrection was 2 (4%) in the functional equator group and 3 (6.5%) in Parks' method group and postoperative undercorrection was 9 (18%, 19.6%) in each group. The incidence of undercorrection in the Parks' method group was significantly higher in the greater than 22 mm axial length group (7, 35.0%) than in the less than 22 mm group (2, 7.7%) (p = 0.029). CONCLUSIONS: There was no statistically significant difference in surgical success rate between the functional equator and Parks' methods in infantile esotropia and partially accommodative esotropia.

Effect of Both Medial Rectus Recession in Large Angle Infantile Esotropia

PURPOSE: To evaluate of the effect of bilateral medial rectus recession in the patients who showed large angle (>50 prism diopters, PD) infantile esotropia as comparing small angle (50 PD, 14 patients) and small angle group (

Clinical Results of Unilateral Medial Rectus Recession in Consecutive Esotropia and Non-accommodative Esotropia

PURPOSE: To compare the effect of medial rectus recession in consecutive esotropes who had previous monocular medial rectus resection and lateral rectus recession and in non- accommodative esotropes (NAET) with small angle of deviation who had no prior operation. METHODS: We studied the results of unilateral medial rectus recession at postoperative 2 and 6 months in 7 consecutive esotropes and 19 NAET with deviation angle around 20 PD, and analyzed the corrected amount for 1 mm medial rectus recession. We regarded deviated angle of+/-8 PD at orthophoria as successful operation. RESULTS: The abosolute value of remained deviation in consecutive esotropes and NAET were 4.86+/-5.67 PD and 9.05+/-3.95 PD at postoperative 2 months, and 5.42+/-7.89 PD and 8.26+/-4.45 PD at postoperative 6 months, respectively. There were significant differences between at postoperative 2 and 6 months (p0.05). The average amount of corrected deviation for 1 mm recession at postoperative 6 months was 5.84 PD in consecutive esotropes and 2.97 PD in NAET, which were significant differences (p<0.05). CONCLUSION: Unilateral medial rectus recession in consecutive esotropes may be a useful and first choice of operation procedure when considering second operation. The amount of correction for 1 mm medial rectus recession is larger in consecutive esotropes than in NAET, possibly due to previous resection of medial rectus or release of fat adhesion. Therefore the amount of medial rectus recession in consecutive esotropia should be determined after considering the degree of abduction and operative findings.

Bilateral Medial Recti Recession in Infantile Esotropia

Twenty-seven patients with congnital esotropia underwent bilateral medial recti recessions and were follwed up for 6 months or more. The relationship between the amount of bilateral medial rectus recession, the pre- and postoperative alignment was analyzed. The success of sugery was defined from the undercorrection less than 10 prism diopter(PD) to the overcorrection less than 5PD. Nineteen of 27 patients(70.3%) were successful. 3 patients(11.1%) were undercorrected and five(18.5%) were overcorrected. Three patients who showed overcorrection more than 20PD were recessed 7mm or more. The standard deviation of postoperative alignment was 2.2 in patients with preoperative alignment less than 50PD, and 17.4 in those with 50PD or more. The difference was significant(p<0.05). When preoperative alignment was 25 to 55PD and the amount of surgery was 4 to 7mm, there was high linear correlation between the amount of surgery and the corrected angle. However, close observation for consecutive exotropia will be necessary when preoperative alignment is more than 50PD and the amount of recession is more than 7mm.

Treatment for Convergence Excess Esotropia by Slanted Medial Rectus Muscle Recession

To investigate whether the slanted medial rectus recession can correct excess esotropia at near without overcorrection at distance and reduce the distance-near deviation difference, we examined 11 convergence excess esotropia patients who had deviation at near exceeding distance esotropia by 15PD or more, and underwent this operation. They composed of 7 partially accommodative esotropia with high AC/A ratio and 4 nonaccommdodative convergence excess esotropia. The surgical procedure consisted of bilateral, symmetrical slanted recession of the medial rectus muscle. The amount of recession of the upper and lower margins were calculated so as to correct the esotropia with correction at distance, and near respectively. The preoperative mean near and distance deviation were 33.8PD and 15PD, and each decreased to 9.2PD and 4.3PD postoperatively. The preoperative mean distance-near deviation difference were 18.8PD, and decreased to 5.4PD postoperatively. The 3 patients decreased over 10PD in the distancenear deviation difference. In conclusion, the surgical procedure, as bilateral slanted medial rectus recession, can correct excess esotropia at near without overcorrection at distance and reduce the distance-near deviation difference. Therefore, the bilateral slanted medial rectus recession may be used as the method of surgical treatment in convergence excess esotropia.

3 Cases of Mobius Syndrome

Mobius syndrome is a rare congenital disease characterized by unilateral or bilateral limitation of abduction and facial palsy due to the 6th and 7th cranial nerve paralysis. In addition, it may be associated with limb anomalies and other cranial nerve paralysis. We experienced three cases of Mobius syndrome characterized by esodeviation associated with bilateral limitation of abduction, bilateral facial atroph, tongue atrophy, congenital amputation of limb, and congenital clubfoot. We performed a large amount of bilateral medial rectus recession and unilateral lateral rectus resection, and obtained cosmetically successful results that orthophoric or less than 10 prism diopter of esotropia in primary postition, but mild limitation of adduction was observed as a complication.

Result of Unilateral Medial Rectus Recession in Moderate Angle Esotropia

We analysed the results of residual esotropia with deviation of 15 to 35 prism diopters after a full correction with bimedial rectus recession and unilateral medial rectus recession. The remained mean deviation at postoperative 2 months was 6.17 prism diopters in unilateral MR recession group and 4.23 prism diopters in BMR recession group. The success rates were 75% in unilateral MR recession group and 87% in BMR recession group at postoperative 2 months, 56% in unilateral MR recession group and 89% in BMR recession group at postoperative 6 months. The difference of success rates in two groups at 2 months is not significant statistically but the success rate of BMR recession group at 6 months was higher than that of unilateral MR recession group significantly. There were no significant differences in success rate and residual deviation between the groups of nonaccomodative, partially accomodative esotropia, and all esotropias under 20 prism diopters. In conclusion, unilateral MR recession is considered as very useful surgical procedure in all kinds of esotropia under 20 prism diopters. But further study in the moderate degree esotropia over 20 prism diopters is need.

The Effect of Jensen Procedure with Medial Rectus Recession in Lateral Rectus Palsy

Jensen procedures with medial rectus recession were performed on 13 eyes of 10 patients with lateral rectus palsy caused by trauma. The cases were reviewed retrospectively to assess efficacy of the procedure and long-term stability. After the average 10.2 months of follow-up period, the 7 patients on whom unilateral Jensen procedures and medial rectus muscle recession were performed improved an average of 45.0 delta, and the 3 patients who underwent bilateral Jensen procedures and medial rectus muscle recession improved an average of 82.3 delta. Preoperatively, 12 eyses demonstrated abduction of -4, and 1 eye demonstrated abduction of -1. Postoperatively, abductions of eyes are as follows: 3 eyes -4, 5 eyes -3, 3 eyes -2, and 2 eyes -1. 10 eyes (76.9%) showed improved abduction of lateral rectus muscle, but 3 eyes(23.1%) were not changed. 4 patients(40.0%) acquired a functional area of diplopia free vision, but 6 patients(60.0%) did not, 1 patient developed diplopia postoperatively. No significant cases of vertical deviation were created. One showed anterior segment ischemia, but recovered without complications. Based on these results, the Jensen procedure combined with medial rectus recession is effective in correcting palsies of the lateral rectus muscle that is not recovered.

Treatment of Near Esotropia with High AC/A Ratio

The patients with accommodative esotropia due to high AC/A(accommodative convergence/accommodation) ratio show prominent esodeviation and can not fuse without bifocals at near. The purpose of this study is to eliminate prominent near esotropia in those patients and let them fuse at near without bifocals. We performed unilateral or bilateral medial recti recti recessions according to the angle of near esotropia in 14 patients. Twelve patients showed orthophcria or small esophoria less than 12 delta. Eleven of these patients obtained solid fusion after surgery except 3-year-old patient who could not understand the stereopsis test. One patient had esophoria of 20 delta after surgery and showed gross stereopsis. The other patient recurred 27 delta of intermittent esotropia. Twelve of 13 patients(92.3%) could fuse without bifocals at near. The recession of medial rectus or recti was effective on the removal of prominent near esotropia and obtaining fusion without bifocals. Furthermore it did not disturb angle of deviation and fusion at distant. We recommend this procedure as a secure and effective treatment for near esotropia caused by high AC/A ratio.

One Muscle Surgery on the Small Angle Esotropia

Twenty patients with small angle esotropia of 12 delta - 20 delta were treated with a unilateral medial rectus recession of 4.0 - 5.0 mm. Eighteen of the 20 patients(90%) showed 8 delta or less horizontal deviations after surgery. The average amount of angle corrected with 4.0 mm recession in 15 delta esotropia group was 15 delta that with 4.5 mm recesstion in 15 delta - 20 delta esotropia group was 14.8 delta and that with 4.5 - 5.0 mm recession in 20 delta esotropia group was 15.2 delta. The average amount of angle corrected with 4.0 mm, 4.5 mm, 5.0 mm recession were 12 delta, 15 delta and 14.6 delta respectively. The recession of one medial rectus muscle is a safe, predictable and simple procedure for the surgical treatmont of small angle esotropia.

One Muscle Surgery on the Small Angle Esotropia

Twenty patients with small angle esotropia of 12 delta - 20 delta were treated with a unilateral medial rectus recession of 4.0 - 5.0mm. Eighteen of the 20 patients (90%) showed 8 delta or less horizontal deviations after surgery. The average amount of angle corrected with 4.0mm recession in 15 delta esotropia group was 15 delta, that with 4.5mm recesstion in 15 delta - 20 delta esotropia group was 14.8 delta and that with 4.5 - 5.0mm recession in 20 delta esotropia group was 15.2 delta. The average amount of angle corrected with 4.0mm, 4.5mm, 5.0mm recession were 12 delta, 15 delta and 14.6 delta respectively. The recession of one medial rectus muscle is a safe, predictable and simple procedure for the surgical treatmont of small angle esotropia.