Results of Surgical Treatment for Paralytic Strabismus

Young Seung Seo; Seong Eun Kyung; Moo Hwan Chang

doi:10.3341/jkos.2009.50.9.1377

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Seo, Kyung, and Chang: Results of Surgical Treatment for Paralytic Strabismus

Original Article

J Korean Ophthalmol Soc 2009;50(9):1377-1385.

Published online: 7 September 2009

DOI: https://doi.org/10.3341/jkos.2009.50.9.1377

Results of Surgical Treatment for Paralytic Strabismus

Young Seung Seo, MD, Seong Eun Kyung, MD, PhD, Moo Hwan Chang, MD, PhD

Department of Ophthalmology, The Dankook University Medical College, Cheonan, Korea

Address reprint requests to Seong Eun Kyung, MD, PhD Department of Ophthalmology, Dankook University College of Medicine #San 16-5 Anseo-dong, Cheonan 330-715, Korea Tel: 82-41-550-6377, Fax: 82-41-561-0137, E-mail: kseeye@hanmail.net

Received 24 September 2008 Accepted 16 June 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To study the correction effects of standard recession and resection in paralytic strabismus excluding superior oblique palsy.

Methods

Eighteen cases of paralytic strabismus treated by standard recession and resection from March 2005 to October 2007 were retrospectively analyzed.

Results

The average angles of deviation before surgery and after surgery were 55 prism diopters (PD) and 12PD, respectively. Adjustable suturing was performed in 12 cases. The diplopia was improved in 14 out of 18 cases (77%) after surgery. Three cases of the −4 grade paralyzed group had a large residual deviation after surgery. The success rate was 78% (14/18) when success was defined as a residual deviation of less than 15PD. Severe ocular motility limitation (−4 grade) group was less affected than other groups. In the below −3 grade paralyzed groups, patients resolved diplopia in the primary eye position, and did not complain of diplopia by incomitance in the secondary eye position.

Conclusions

Standard recession and resection may actively be attempted in below −3 grade paralytic strabismus patients to resolve diplopia in the primary eye position.

Keywords: Adjustable suture, Diplopia, Incomitant, Paralytic strabismus, Standard recession and resection

References

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Figure 1.

Parinaud syndrome (case 16). The patient shows marked limitation on upgaze.

Figure 2.

Parinaud syndrome (case 16). 5 months later after both IR recession. The patient shows remained hypotropia in the right and left eye.

Figure 3.

Right medial rectus palsy (case 8). The patient shows large exodeviation and severe limitation on adduction in the right eye.

Figure 4.

Right medial rectus palsy (case 8). 2 months after operation. The patient still shows over 60PD exodeviation after recession and resection of the right eye.

Figure 5.

Right medial rectus palsy (case 8). About one week after operation. The patient shows exodeviaiton after ocular fixation to medial canthal tendon.

Table 1.

Causes of incomitant strabismus

Causes of incomitant strabismus	Case No. (%)
3 ^rd nerve palsy	6 (30.0)
6 ^th nerve palsy	2 (11.1)
IO^∗ palsy	1 (5.5)
BOFx^† (SR palsy)	1 (5.5)
Brain lesion	2 (11.1)
Orbital fissure syndrome	1 (5.5)
MR^‡ palsy (except 3 ^rd n. palsy)	5 (27.8)

^∗ IO=inferior oblique muscle;

^† BOFx=blow out fracture;

^‡ MR= medial rectus muscle.

Table 2.

Clinical characteristics of the patients

Case No.	Sex/age	Cause of incomitant strabismus	Grade of paralysis	Deviated angle of primary position	Operation	Deviated angle at postoperative 1 month	Deviated angle at last F/U^†††
1^∗	M^∗∗/	L^§§§)IO palsy	-1	4Δ XT^†,15RHT	R)IO^‡‡ (−)10	Ortho^#	4Δ^ППП LHT
	25				R)SR^§§ (−)4
2	F^††/21	R^‡‡‡)3^rd n. palsy	-3	45ΔXT	R)LR(−)^###8	Ortho	Ortho
					R)MR
					(+)^∗∗∗∗6.25
3	M/67	B)3^rd n. palsy	-3	50ΔXT	R)LR^∗∗∗ (−)9	4ΔXT	Ortho
					R)MR (+)7.5	2ΔLHTП
					L)LR (−)3
					L)IRПП(−)2
4	M/29	R)3^rd n. palsy	-1	20ΔXT,10ΔRHT	R)LR (−)8.5		Ortho
					R)SR (−)4
5	M/37	B)3^rd n. palsy	-4	85ΔXT,15ΔLHT	R)LR (−)10	12ΔXT	30ΔXT
					R)MR^##(+)7	4ΔLHT
					L)LR (−)10
					L)SR (−)5
6^∗	M/26	L)6^th n. palsy	-3	60Δ>ET^‡	L)LR (+)8	15ΔET	35ΔET
					L)MR (−)7
					R)MR (−)7
7	F/45	B)6^th n. palsy	-3	70ΔET	R)LR (+)8	20ΔET	20ΔET
					R)MR (−)6.5	6ΔLHT	6ΔLHT
					L)MR (−)8
8^∗	F/36	R)MR palsy	-4	110ΔXT	R)LR (−)12>	40ΔXT	35ΔXT
					R)MR (+)8
					R)Ocular fixation
9	F/73	R)MR palsy	-3	100ΔXT	R)LR (−)9	Ortho	Ortho
					R)MR (+)7
					L)LR (−)10
					L)MR (+)7
10	F/43	R)3^rd n. palsy	-1	35ΔXT,6ΔRHT	R)LR (−)2	Ortho	Ortho
					R)MR (+)6.5
11	F/51	R)MR palsy	-2	60ΔXT	L)LR (−)9	20ΔXT	15ΔXT
					L)MR (+)7
					R)MR (+)7
12	F/42	MR palsy	-2	25ΔXT,15ΔRHT	R)LR (−)9	6ΔXT	6ΔXT
					L)LR (−)7	15ΔRHT	15ΔRHT
					L)IR (−)5.75
13	M/29	MR palsy	-2	50ΔXT	R)MR (+)5	8ΔXT	8ΔXT
					L)MR (+)5
					L)LR (−)8
14	M/24	L)3^rd n. palsy	-3	50ΔXT,12ΔLHT	R)LR (−)9	Ortho	Ortho
					L)LR (−)9.5
					L)SR (−)8
15	F/41	Lt.BOFx. (SR palsy)	-1	15ΔLHo^§	L)IR (−)5	Ortho	Ortho
16	F/57	Brain (hydrocephalus)	-4	20ΔRHo,25ΔLHo	R)IR (−)5	4ΔRHo	10ΔRHo
		Parinaud syndrome			L)IR (−)6	10ΔLHo	15ΔLHo
17	M/58	L)INO^††††	-3	50ΔXT	R)LR (−)9	Ortho	15ΔXT
					L)LR (−)9
18	M/74	L)superior fissure syndrome	-3	40ΔET,4ΔLHo	R)MR (−)8		Ortho
					L)MR (−)5

^∗ reoperation or 2 stage operation case;

^† XT=exotropia;

^‡ ET=esotropia;

^§ Ho=hypotropia;

^П HT=hypertropia;

^# Ortho=orthotropia;

^∗∗ M=male;

^†† F=female;

^‡‡ IO=inferior oblique;

^§§ SR=superior rectus;

^ПП IR=inferior rectus;

^## MR=medial rectus;

^∗∗∗ LR=lateral rectus;

^††† F/U=follow up;

^‡‡‡ R=right;

^§§§ L=left;

^ППП Δ=prism diopter;

^### (−)=recession;

^∗∗∗∗ (+)=resection;

^†††† INO=internuclear ophthalmoplegia.

Table 3.

Preoperative and postoperative deviated angle according to the grade of paralysis

Grade of paralysis	-1	-2	-3	-4	p-value
Preop.^§ deviated angle (Mean± SD^†)	26.25±11.70PD^∗	50.00±10.00PD	60.13±18.45PD	85.00±35.00PD	0.011^‡
Postop.^∏ deviated angle (Mean± SD)	1.00±2.00PD	14.67±6.05PD	14.00±16.27PD	30±5.00PD	0.049^‡

^∗ PD=prism diopter;

^† SD=standard deviation;

^‡ p-value=one-way ANOVA;

^§ Preop=preoperative;

^∏ Postop=postoperative.

Table 4.

Postoperative deviated angle between mild paralysis group and other paralysis groups

	Mild^† paralysis	Other^‡ paralysis	p-value^§
Postop^∗ deviated angle	1.00±2.00	17.57±14.08	0.001

^∗ Postop=postoperative;

^† Mild=-1 paralysis group;

^‡ Other=-2, −3 and −4 paralysis groups;

^§ p-value=Student t-test.

Table 5.

Postoperative deviated angle between severe paralysis group and other paralysis group

	Other^† paralysis	Severe^‡ paralysis	p-value^§
Postop^∗ deviated angle	10.67±13.25	30.00±5.00	0.027

^∗ Postop=postoperative;

^† Other=-1, −2 and −3 paralysis groups;

^‡ Severe=-4 paralysis group;

^§ p-value=Student t-test.

Table 6.

Postoperative deviated angle between mild, moderate and severe paralysis group

	Mild^†	moderate^‡	Severe^§	p-value^∏
Postop^∗ deviated angle	1.00±2.00	14.18±13.92	30.00±5.00	0.017

^∗ Postop=postoperative;

^† mild=-1 paralysis group;

^‡ Moderate=-2 and −3 paralysis groups;

^§ severe=-4 paralysis group;

^∏ p-value=one-way ANOVA.

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