Incidence, Management, and Outcome of Pulled-in-Two Syndrome Associated With Strabismus Surgery

Abstract

Purpose: To report the incidence and outcomes of pulled-in-two syndrome during strabismus surgery and investigate the clinical features and management of the disease. Methods: The medical records of patients who underwent strabismus surgery and developed pulled-in-two syndrome between July 2013 and October 2020 were reviewed retrospectively. The demographic characteristics, intraoperative details (including surgery type and management), and subsequent and final outcomes were extracted from the records. Results: Of the 11,824 strabismus surgeries during the study period, 4 cases of pulled-in-two syndrome were documented, accounting for an overall incidence of 0.034%. The average age of the patients with pulled-in-two syndrome was 61.75 ± 8.99 years. All 4 patients were women; 2 had abducens nerve palsy and the other 2 had myopic strabismus fixus. The inferior rectus muscle was involved in 1 patient and the medial rectus muscle was involved in 3 patients. All of the involved extraocular muscle was lost. One patient achieved orthotropia, and the others were undercorrected after the surgery. Conclusions: Pulled-in-two syndrome is one of the rarest and most severe complications of strabismus surgery. Cranial nerve palsy, advanced age, prior surgery, thyroid-associated ophthalmopathy, and degenerative conditions of the extraocular muscle are risk factors for pulled-in-two syndrome. Therefore, the prevention of pulled-in-two syndrome in patients with these risk factors should be investigated further. [ J Pediatr Ophthalmol Strabismus . 20XX;X(X):XX–XX.]

Rescue of exotropia subsequent to pulled-in-two syndrome of the medial rectus muscle occurring during surgery for high myopic strabismus fixus: A case report

“…A previous study reported 2 cases of pulled-in-two syndrome occurring during strabismus surgery for myopic strabismus fixus, in which lost muscles could not be recovered, but an acceptable appearance was achieved; therefore, they required no additional treatment. [ 8 ] However, our patient showed consequent exotropia of 45 prism diopters; therefore, MR muscle advancement was needed. Our experience highlights 2 crucial points: first, in myopic strabismus fixus, MR tenotomy might cause large overcorrection, and second, it is possible to find the pseudotendon with the slipped true tendon fixed to the sclera, even 3 months after the tenotomy.…”