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Abstract
Purpose
To evaluate the efficacy and safety of medial rectus muscle plication compared to resection, coupled with antagonist muscle recession, as treatments for intermittent exotropia (IXT).
Methods
We retrospectively reviewed the charts of IXT patients treated by a single surgeon and followed-up for at least 6 months between September 2016 and February 2017. The patients were divided into three groups: a bilateral lateral rectus muscle recession (BLR) group, a unilateral lateral rectus recession with medial rectus plication (R&P) group, and a unilateral lateral rectus recession with medial rectus resection (R&R) group. Serial changes in ocular alignment at 4–24 weeks after surgery were compared among the groups. In addition, the operative times were assessed.
Results
We included 119 patients (mean age 6.65 ± 2.79 years). The preoperative exodeviation was 29.81 ± 7.31 prism diopters (PDs) and did not differ among the groups. The R&P group exhibited significantly less postoperative deviation than the BLR group. The operative time was significantly less for the R&P group (25.77 ± 9.29 minutes) than the R&R group (28.97 ± 5.74 minutes). The success rates were identical among groups at 6 months; no severe adverse events were recorded apart from one case of dellen that improved after application of a topical agent.
Conclusions
Plication may reduce the risk for anterior segment ischemia to a level lower than the risks associated with other procedures, and also facilitate reoperation if necessary. We found that R&P took less time but had success rate similar to BLR and R&R. Thus, medial rectus muscle plication for IXT patients is a valuable alternative procedure when the external rectus muscle requires strengthening.
Figures and Tables
 | Figure 1Consecutive changes of postoperative deviation at distant (A) and near (B) fixations according to the operative methods for intermittent exotropia. Plication revealed similar surgical outcomes with resection procedure (A, B). BLR = bilateral rectus muscle recession group; R&P = unilateral lateral rectus muscle recession with medial rectus muscle plication group; R&R = unilateral lateral rectus muscle recession and medial rectus muscle resection group; Mon = month(s). *p < 0.05, **p < 0.01 between BLR and R&P groups by Kruskall-W allis test with post-hoc analysis.
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 | Figure 2Operative times in three groups according to operative method. Plication consumed significantly shorter duration required for the surgery compared to resection procedure. BLR = bilateral rectus muscle recession group; R&P = unilateral lateral rectus muscle recession with medial rectus muscle plication group; R&R = unilateral lateral rectus muscle recession and medial rectus muscle resection group; min = minutes. *p < 0.001 by Kruskall-W allis test with post-hoc analysis.
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 | Figure 3Postoperative status of anterior segment appearance in the right eye of 9-year-old male patient. Dellen was identified at 1 week after lateral rectus muscle recession with medial rectus muscle plication (A, B). Consequently, it was improved by the topical agents after 1 month of the surgery (C, D).
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 | Figure 4Anterior segment appearance (A) with magnification (B) in the left eye of 4-year-old female patient at a couple of months after medial rectus (MR) muscle plication. Elevation over the plicated site of MR muscle was not grossly apparent.
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Table 2
Consecutive changes of postoperative deviations at distant fixation according to the operative method analyzed by linear mixed model
Values are presented as mean ± standard deviation unless otherwise indicated.
BLR = bilateral rectus muscle recession group; R&P = unilateral lateral rectus muscle recession and medial rectus muscle plication group; R&R = unilateral lateral rectus muscle recession and medial rectus muscle resection group; SE = standard error; PD = prism diopters; CI = confidence interval.
*Kruskal-Wallis test.
Table 3
Consecutive changes of postoperative deviations at near fixation according to the operative method analyzed by linear mixed model
Values are presented as mean ± standard deviation unless otherwise indicated.
BLR = bilateral rectus muscle recession group; R&P = unilateral lateral rectus muscle recession and medial rectus muscle plication group; R&R = unilateral lateral rectus muscle recession and medial rectus muscle resection group; SE = standard error; PD = prism diopters; CI = confidence interval.
*Kruskal-Wallis test.
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