Practical Aspects and Efficacy of Intraoperative Adjustment in Concomitant Horizontal Strabismus Surgery

Yi, Jonghyon; Chung, Seung Ah; Chang, Yoon Hee; Lee, Jong Bok

doi:10.3928/01913913-20100518-06

Cited by 12 publications

(7 citation statements)

References 16 publications

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“…An anesthesiologist monitored the procedure and on surgeon request, provided individually selected, minimal doses of propofol or alfentanil hydrochloride so that patients remained, or quickly became, alert and cooperative during intraoperative suture adjustment. 16–18 Adjustment was performed in the seated upright position with any required refractive correction, with centered and horizontally eccentric targets at near and distance. Patients were considered to have had adjustable sutures if at least 1 adjustable suture was placed, regardless of whether the muscle position was changed at the time the suture was made permanent.…”

Section: Methodsmentioning

confidence: 99%

Medial Rectus Recession Is as Effective as Lateral Rectus Resection in Divergence Paralysis Esotropia

Zia¹,

Demer²

2012

Arch Ophthalmol

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Objective To propose medial rectus (MR) recession to be equally as effective as lateral rectus (LR) resection, which has heretofore been the preferred treatment for divergence paralysis esotropia (DPE). Methods We examined a 17-year surgical experience comparing LR resection with MR recession in adults with DPE, defined as symptomatic distance esotropia (ET) at least double the asymptomatic ET of 10 or less prism diopters (Δ) at near. Results Twenty-four patients with DPE underwent surgery. Six patients underwent bilateral LR resection and 2 underwent unilateral LR resection (group L), while 13 underwent bilateral MR recession and 3 underwent unilateral MR recession, with the target angle double the distance ET (group M). One of 8 patients in group L and 15 of 16 patients in group M underwent intraoperative adjustable surgery under topical anesthesia. Mean (SD) preoperative central gaze ET measured 15.0 (7.7) Δ at distance and 4.1 (3.4) Δ at near in group L, but 10.4 (6.8) Δ at distance and 0.6 (1.7) Δ at near in group M (P=.15; distance, 0.003, near). Postoperatively, no patient in either group had symptomatic diplopia or convergence insufficiency in follow-up from 8.5 to 40 months. Twice the usual surgical dose of MR recession per prism diopter was required to achieve correction of the distance deviation in DPE as compared with that recommended for ET generally and also for LR resection in the same condition. Conclusions Recession of the MR provides binocular single vision in DPE without convergence insufficiency at near, and it is convenient for intraoperative adjustment under topical anesthesia.

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Section: Methodsmentioning

confidence: 99%

Medial Rectus Recession Is as Effective as Lateral Rectus Resection in Divergence Paralysis Esotropia

Zia¹,

Demer²

2012

Arch Ophthalmol

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“…An anesthesiologist monitored surgery, and administered minimal doses of propofol or alfentanil so that patients remained alert during intra-operative adjustment. 12–14 Surgery comprised limbal conjunctival incision, hooking the entire tendon, bipolar cautery, and stepwise incremental scissors tenotomy at the scleral insertion 30–90% of tendon width (Fig. 1A–C).…”

Section: Methodsmentioning

confidence: 99%

Graded vertical rectus tenotomy for small-angle cyclovertical strabismus in sagging eye syndrome

Zia

Demer

2015

Br J Ophthalmol

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Background/Aims Graded vertical rectus tenotomy (GVRT) is postulated as effective for small angle vertical heterotropia. We aimed to determine dosing recommendations for GVRT in sagging eye syndrome (SES). Methods This was a retrospective, observational study of surgical outcomes for GVRT from 2009–2014 in a single surgeon’s academic practice. There were 37 (20 women) patients of average age 68±10 (standard deviation, SD) years with comitant or incomitant hypertropia ≤10Δ caused by SES. The main outcome measure was the dose-effect of GVRT required to correct intra-operative hypertropia. Results Pre-operative average central gaze hypertropia measured 4.7±2.2Δ. Three patients underwent repeat GVRT for residual or consecutive hypertropia, 1 undergoing it twice. All surgeries were analyzed, increasing the total operations to 41. The inferior rectus (IR) tendon in the hypotropic eye was operated in 32 eyes and the superior rectus (SR) tendon in the hypertropic eye in 9 eyes. Mean tenotomy was 68±19% of tendon width. Hypertropia was always eliminated intraoperatively by progressive GVRT. Mean hypertropia was 1.1±1.6Δ at average 93 days post-operatively. Linear regression demonstrated that 3–6Δ hypertropia correction requires 30–90% graded tenotomy (R2=0.32, P<0.0001), but with substantial individual variability. Undercorrection necessitated reoperation in 10% of cases. Conclusions GVRT precisely corrects hypertropia of up to 10Δ, but because of variable effect, should be performed with intraoperative monitoring under topical anesthesia.

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“…An anesthesiologist monitored the procedure and on surgeon request, provided individually selected, minimal doses of propofol or alfentanil hydrochloride so that patients remained, or quickly became, alert and cooperative during intraoperative suture adjustment. [16][17][18] Adjustment was performed in the seated upright position with any required refractive correction, with centered and horizontally eccentric targets at near and distance. Patients were considered to have had adjustable sutures if at least 1 adjustable suture was placed, regardless of whether the muscle position was changed at the time the suture was made permanent.…”

Section: Methodsmentioning

confidence: 99%

“…In addition to equal effectiveness, MR recession has the advantage of convenience for intraoperative adjustment under topical anesthesia. [16][17][18] The surgical response of common forms of ET and exotropia to rectus muscle surgery has been reported as the amount of angle correction per millimeter of recession or resection. The data of Mojon 28 indicates that horizontal rectus plication alters the horizontal angle by 1.76-2.88 Δ/mm in ET and 2.42-2.84 Δ/mm in exotropia.…”

Section: Commentmentioning

confidence: 99%

Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia

Zia¹,

Demer²

2012

Journal of American Association for Pediatric Ophthalmology and

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Objective-To propose medial rectus (MR) recession to be equally as effective as lateral rectus (LR) resection, which has heretofore been the preferred treatment for divergence paralysis esotropia (DPE).Methods-We examined a 17-year surgical experience comparing LR resection with MR recession in adults with DPE, defined as symptomatic distance esotropia (ET) at least double the asymptomatic ET of 10 or less prism diopters (Δ) at near.Results-Twenty-four patients with DPE underwent surgery. Six patients underwent bilateral LR resection and 2 underwent unilateral LR resection (group L), while 13 underwent bilateral MR recession and 3 underwent unilateral MR recession, with the target angle double the distance ET (group M). One of 8 patients in group L and 15 of 16 patients in group M underwent intraoperative adjustable surgery under topical anesthesia. Mean (SD) preoperative central gaze ET measured 15.0 (7.7) Δ at distance and 4.1 (3.4) Δ at near in group L, but 10.4 (6.8) Δ at distance and 0.6 (1.7) Δ at near in group M (P=.15; distance, 0.003, near). Postoperatively, no patient in either group had symptomatic diplopia or convergence insufficiency in follow-up from 8.5 to 40 months. Twice the usual surgical dose of MR recession per prism diopter was required to achieve correction of the distance deviation in DPE as compared with that recommended for ET generally and also for LR resection in the same condition.Conclusions-Recession of the MR provides binocular single vision in DPE without convergence insufficiency at near, and it is convenient for intraoperative adjustment under topical anesthesia.Divergence paralysis esotropia (DPE)-variably termed divergence insufficiency, divergence insufficiency esotropia, and divergence paresis esotropia-is characterized by comitant esotropia (ET) at distance fixation associated with symptomatic diplopia, fusion at near fixation, and normal saccadic velocities in adduction and abduction. As the name implies, early thinking about DPE was dominated by the presumed pathophysiological concept of a brain lesion involving a putative divergence center. 1,2 Indeed, isolated clinical reports have associated DPE with neurologic conditions such as brain tumors, multiple sclerosis, trauma, subdural hematoma, and tertiary syphilis. [2][3][4][5] Even postulated as a cause of DPE was increased medial rectus (MR) muscle tonicity as a compensatory mechanism for © 2012 American Medical Association Correspondence: Joseph L. Demer, MD, PhD, Jules Stein Eye Institute, University of California, Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095-7002 (jld@ucla.edu). Author Contributions: Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. 8 Therefore, it has most recently been proposed that DPE is more typically a mechanical rather than a neurogenic disorder. Although based on the modern proposal for etiology, the term DPE has become a misnomer; it is used here as a convenience for reference...

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Practical Aspects and Efficacy of Intraoperative Adjustment in Concomitant Horizontal Strabismus Surgery

Abstract: Intraoperative adjustment was effective in concomitant horizontal strabismus surgery and can provide the opportunity to avoid a large overcorrection, especially in cases with moderate angle horizontal muscle surgery.

Cited by 12 publications

References 16 publications

Medial Rectus Recession Is as Effective as Lateral Rectus Resection in Divergence Paralysis Esotropia

Medial Rectus Recession Is as Effective as Lateral Rectus Resection in Divergence Paralysis Esotropia

Graded vertical rectus tenotomy for small-angle cyclovertical strabismus in sagging eye syndrome

Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia

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