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Abstract
Purpose
To investigate the long-term outcome of lateral rectus (LR) advancement for consecutive esotropia following bilateral LR recession for intermittent exotropia.
Methods
Medical records of 25 patients who underwent LR advancement for consecutive esotropia after bilateral LR recession and who were followed up for more than 24 months postoperatively were reviewed. Patients were divided into two groups: bi- laterallateral rectus recession (BLR) group included 16 patients with consecutive esotropia greater than or the same magnitude as the initial exotropia and who underwent bilateral LR advancement; Unilateral lateral rectus recession (ULR) group included nine patients with consecutive esotropia less than the initial exotropia and who underwent unilateral LR advancement. Main outcome measurements were motor and sensory outcomes and the dose-effect relationship calculated from observed overall and group changes in the angle of deviation per millimeter. Motor success was defined as alignment from orthotropia to exodeviation less than 10 PD at distance. Sensory outcome was described by comparing the Titmus stereoacuity test before and after LR advancement. Sensory successvwas defined at 100 seconds of arc.
Results
Eighteen patients (72.0%) showed satisfactory long-term motor and sensory outcomes. Seventeen (77.3%) of 22 patients showed favorable stereopsis of 100 seconds of arc or more at final observation. The long-term motor success rate of the ULR group was better than that of the BLR group (p = 0.025). The average observed change in the angle of deviation was 3.6 PD/mm at the final visit in all patients. A greater dose-effect relationship was observed in the ULR groupthan in the BLR group at the final visit (p = 0.043).
Conclusions
LR advancement showed favorable motor and sensory outcomes in the majority of patients. The surgical outcome was not favorable in patients in the BLR group with consecutive esotropia of the same magnitude as the initial exotropia. These results require further investigation for verification.
References
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Figure 1.
The Kaplan-Meier rate of motor success between patients with consecutive esotropia of greater than or the same magnitude as the initial exotropia and who underwent bilateral LR advancement (BLR group) and nine patients with consecutive esotropia of smaller than the initial exotropia and who underwent unilateral LR advancement (ULR group) (p=0.025). LR = lateral rectus; BLR = bilateral lateral rectus recession; ULR = unilateral lateral rectus recession.
Figure 2.
Figure 2. Relationship between lateral rectus advancement (mm) and change in angle of deviation (prism diopters) in all patients at the final visit by univariate linear regression analysis. The two dotted lines identify the confidential limits at 95% of the line. R2 = coefficient of determination; PD = prism diopters.
Table 1.
Preoperative characteristics in patients who showed the amount of consecutive esotropia greater than or equal to the amount of preoperative exotropia (BLR group) and in those who showed smaller than the amount of preoperative exotropia (ULR group)
| Characteristic | BLR group (n = 18) | ULR group (n = 9) | p-value |
|---|---|---|---|
| Male/Female (n) | 8/8 | 3/6 | 0.677† |
| Mean age at the initial exotropia surgery (years) | 5.9 ± 2.4 | 7.4 ± 3.4 | 0.329‡ |
| Mean extent of BLR recession (mm) | 12.0 ± 1.2 | 13.0 ± 1.5 | 0.074‡ |
| Mean amount of initial exotropia | |||
| Distance (PD) | 26.6 ± 4.4 | 29.4 ± 4.6 | 0.121‡ |
| Near (PD) | 25.3 ± 4.3 | 29.0 ± 8.0 | 0.229‡ |
| Mean amount of consecutive esotropia | |||
| Distance (PD) | 31.0 ± 6.9 | 20.1 ± 4.3 | <0.001‡ |
| Near (PD) | 32.9 ± 8.6 | 21.6 ± 5.0 | 0.001‡ |
| Stereopsis (arc sec)* | 1190.8 ± 1273.0 | 935.0 ± 1278.7 | 0.456‡ |
| Preoperative binocular mean SE (Dsph) | -1.56 ± 2.19 | -1.86 ± 2.52 | 0.846‡ |
| Interval between two surgeries (months) | 12.0 ± 4.0 | 12.2 ± 5.4 | 0.846‡ |
| Duration of follow-up from re-operation (months) | 38.8 ± 19.6 | 42.3 ± 16.4 | 0.276‡ |
Table 2.
Long-term sensory outcome of lateral rectus advancement for consecutive esotropia in BLR group and ULR group
| BLR group (n = 14) | ULR group (n = 8) | p-value | |
|---|---|---|---|
| Stereopsis before lateral rectus advancement (arc sec) | 1190.8 ± 1273.0 (median 600) | 935.0 ± 1278.7 (median 300) | 0.456* |
| Stereopsis after lateral rectus advancement (arc sec) | 104.6 ± 99.0 (median 100) | 100.0 ± 51.3 (median 90) | 0.500* |
| p-value | 0.001† | 0.012† |
Table 3.
Detailed sequential angle deviation, extent of surgeries for the initial exotropia and consecutive esotropia, and postoperative dose-effect relationship of lateral rectus advancement at postoperative 1 day, 6 months, and the final visit in BLR group
| Initialexodeviation(PD) | Extent of LR rec (mm) | Consecutiveesodeviation(PD) | Extent of LR adv (mm) |
Postoperative angle deviation (PD) |
Dose-effect relationship (PD/mm) |
|||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 day | 6 months | The final visit | 1 day | 6 months | The final visit | |||||
| 1 | 30 | BLR 6.5 | 45 | RLA 6.5, LLA 7.0 | 0 | 10 | 14 | 3.3 | 4.1 | 4.4 |
| 2 | 35 | BLR 7.0 | 40 | BLA 7.0 | 0 | 4 | 8 | 2.9 | 3.1 | 3.4 |
| 3 | 25 | BLR 6.0 | 30 | RLA 6.0, LLA 5.0 | -2 | 0 | 7 | 2.6 | 2.7 | 3.4 |
| 4 | 25 | BLR 6.0 | 30 | RLA 6.0, LLA 5.0 | -2 | 0 | 0 | 2.6 | 2.7 | 2.7 |
| 5 | 25 | BLR 5.5 | 35 | BLA 5.0 | 0 | 4 | 8 | 3.5 | 3.9 | 4.3 |
| 6 | 25 | BLR 6.0 | 35 | BLA 6.0 | 0 | 0 | 6 | 2.9 | 2.9 | 3.4 |
| 7 | 20 | BLR 5.0 | 40 | BLA 5.0 | -6 | 0 | 0 | 3.4 | 4.0 | 4.0 |
| 8 | 20 | BLR 5.0 | 20 | BLA 5.0 | 8 | 10 | 10 | 2.8 | 3.0 | 3.0 |
| 9 | 30 | BLR 6.0 | 30 | BLA 6.0 | 4 | 10 | 14 | 2.8 | 3.3 | 3.7 |
| 10 | 25 | BLR 5.5 | 25 | BLA 5.5 | 0 | 8 | 12 | 2.3 | 3.0 | 3.4 |
| 11 | 30 | BLR 6.0 | 30 | BLA 6.0 | 5 | 2 | 5 | 2.9 | 2.7 | 2.9 |
| 12 | 25 | BLR 6.0 | 25 | RLA 5.0, LLA 6.0 | 0 | 4 | 8 | 2.3 | 2.6 | 3.0 |
| 13 | 25 | BLR 6.0 | 25 | RLA 6.0, LLA 5.0 | 0 | 10 | 14 | 2.3 | 3.2 | 3.5 |
| 14 | 25 | BLR 6.0 | 25 | RLA 6.0, LLA 5.0 | 2 | 16 | 16 | 2.5 | 3.7 | 3.7 |
| 15 | 35 | BLR 7.0 | 35 | RLA 7.0, LLA 5.0 | 0 | 6 | 6 | 2.9 | 3.4 | 3.4 |
| 16 | 25 | BLR 6.0 | 25 | RLA 6.0, LLA 4.0 | 0 | 10 | 14 | 2.5 | 3.5 | 3.9 |
| Mean | 26.6 ± 4.4 | 12.0 ± 1.2* | 31.0 ± 6.9 | 11.3±1.2* | 0.6 ± 3.1 | 5.9 ± 4.9 | 8.9 ± 4.9 | 2.8 ± 0.4 | 3.3 ± 0.5 | 3.5 ± 0.5 |
Table 4.
Detailed sequential angle deviation, extent of surgeries for the initial exotropia and consecutive esotropia, and corrected prism diopters per lateral rectus advancement (mm) at postoperative 1 day, 6 months, and the final visit in ULR group
| Initial exodeviation (PD) | Extent of LR rec (mm) | Consecutive esodeviation (PD) | Extent of LR adv (mm) |
Postoperative angle deviation (PD) |
Dose-effect relationship (PD/mm) |
|||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 day | 6 months | The final visit | 1 day | 6 months | The final visit | |||||
| 17 | 30 | BLR 7.0 | 25 | LLA 7.0 | 0 | 2 | 2 | 3.6 | 3.9 | 3.9 |
| 18 | 30 | BLR 7.0 | 20 | LLA 7.0 | -2 | 0 | 8 | 2.6 | 2.9 | 4.0 |
| 19 | 30 | BLR 6.0 | 14 | RLA 5.0 | 0 | 5 | 5 | 2.8 | 3.8 | 3.8 |
| 20 | 25 | BLR 6.0 | 18 | RLA 6.0 | 0 | 5 | 8 | 3.0 | 3.8 | 4.2 |
| 21 | 30 | BLR 6.0 | 20 | RLA 6.0 | 0 | 6 | 8 | 3.3 | 4.3 | 4.7 |
| 22 | 35 | RLR7.0, LLR 7.25 | 25 | RLA 7.0 | -5 | 2 | 2 | 2.9 | 3.9 | 3.8 |
| 23 | 30 | BLR 7.0 | 20 | LLA 6.0 | -3 | 0 | 0 | 2.8 | 3.3 | 3.3 |
| 24 | 35 | RLR7.0, LLR 7.5 | 25 | LLA 8.0 | -3 | 8 | 8 | 2.8 | 4.1 | 4.1 |
| 25 | 20 | BLR 5.0 | 14 | LLA 4.0 | -5 | 0 | 0 | 2.3 | 3.5 | 3.5 |
| Mean | 29.4±4.6 | 13.0 ± 1.5* | 20.1 ± 4.3 | 6.2 ± 1.2 | -2.0 ± 2.1 | 3.1 ± 3.0 | 4.6 ± 3.6 | 2.9 ± 0.4 | 3.7 ± 0.4 | 3.9 ± 0.4 |
PD = prism dioptres; LR rec = lateral rectus recession; LR adv = lateral rectus advancement; BLR = bilateral lateral rectus recession; RLR = right lateral rectus recession; LLR = left lateral rectus recession; LLA = left lateral rectus advancement; RLA = right lateral rectus advancement; ULR = unilateral lateral rectus recession.
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