Journal List > J Korean Ophthalmol Soc > v.60(2) > 1116279

Lee, Kim, and Kim: Short-term Surgical Outcomes of Rectus Muscle Plication and Resection in Intermittent Exotropia

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 1

Consecutive 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.

jkos-60-169-g001
Figure 2

Operative 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.

jkos-60-169-g002
Figure 3

Postoperative 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).

jkos-60-169-g003
Figure 4

Anterior 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.

jkos-60-169-g004
Table 1

Baseline characteristics according to operative method

jkos-60-169-i001

Values are presented as mean ± standard deviation or number (%).

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.

Table 2

Consecutive changes of postoperative deviations at distant fixation according to the operative method analyzed by linear mixed model

jkos-60-169-i002

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

jkos-60-169-i003

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.

Notes

Conflicts of Interest The authors have no conflicts to disclose.

References

1. Jenkins RH. Demographics geographic variations in the prevalence and management of exotropia. Am Orthop J. 1992; 42:82–87.
crossref
2. Ing MR, Pang SWL. The racial distribution of strabismus. In : Reike RD, editor. Strabismus. 3rd ed. Vol. 1. New York: Grune & Stratton;1978. p. 107–109.
3. Jo KI, Pak BG. A clinical study on strabismus in children. J Korean Ophthalmol Soc. 1981; 22:143–151.
4. Von Noorden GK. Divergence excess and simulated divergence: diagnosis and surgical management. Doc Ophthalmol. 1969; 26:719–728.
pmid
5. Romano R. Worldwide surveys of current management of intermittent exotropia by MD strabologists. Binocular Vision & Eye Muscle Surgery. 1993; 8:167–176.
6. Parks MM, Mitchell PR, Wheeler MB. Concomitant esodeviations. In : Tasman W, Jaeger EA, editors. Duane's Foundations of Clinical Ophthalmology. 1st ed. Vol. 1. Philadelphia: Lippincott Williams & Wilkins;2002. p. 12.
7. Wright KW, Lanier AB. Effect of a modified rectus tuck on anterior segment circulation in monkeys. J Pediatr Ophthalmol Strabismus. 1991; 28:77–81.
crossref pmid
8. Park C, Min BM, Wright KW. Effect of a modified rectus tuck on anterior ciliary artery perfusion. Korean J Ophthalmol. 1991; 5:15–25.
crossref pmid
9. Arroyo-Yllanes ME, Escanio-Cortés ME, Pérez-Pérez JF, Murillo-Murillo L. Unilateral tucking of the inferior rectus muscle for dissociated vertical deviation. Cir Cir. 2007; 75:7–12.
10. Schild AM, Fricke J, Rüssmann W, Neugebauer A. Kestenbaum procedure on the vertical rectus muscles with simultaneous compensation of the induced cyclodeviation for nystagmus patients with chin-up or chin-down head posture. Graefes Arch Clin Exp Ophthalmol. 2009; 247:1395–1400.
crossref pmid
11. von Noorden GK. Binocular vision and ocular motility. Therapy and management of Strabismus. 5th ed. St Louis: CV Mosby;1990. p. 351–352.
12. Spoor DK, Hiles DA. Occlusion therapy for exodeviation in young children, a three-year follow-up. Am Orthoptic J. 1983; 33:116–120.
13. France LW. The role of orthoptic therapy in exodeviations: a basic for orthoptic referral. Am Orthoptic J. 1992; 42:52–64.
14. Kushner BJ. Exotropic deviation: a functional classification and approach to treatment. Am Orthopt J. 1988; 38:81–93.
15. Park JL, Son MH, Yun IH, Won IG. The clinical analysis of surgical methods in intermittent exotropia. J Korean Ophthalmol Soc. 2002; 43:526–532.
16. Kim SJ. Comparison of surgical results between recession and unilateral recession-resection in intermittent exotropia. J Korean Ophthalmol Soc. 1992; 33:733–738.
17. Hur J, Won IG. Surgical results of 79 cases of intermittent exotropia in children. J Korean Ophthalmol Soc. 1990; 31:114–119.
18. Chaudhuri Z, Demer JL. Surgical outcomes following rectus muscle plication a potentially reversible, vessel-sparing alternative to resection. JAMA Ophthalmol. 2014; 132:579–585.
pmid
19. Chaudhuri Z, Demer JL. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Arch Ophthalmol. 2012; 130:1280–1284.
crossref pmid pmc
20. Fang ZT, KeyesMA . A novel mixture of propofol, alfentanil, and lidocaine for regional block with monitored anesthesia care in ophthalmic surgery. J Clin Anesth. 2006; 18:114–117.
crossref pmid
21. Yoo SH, Pineles SL, Goldberg RA, Velez FG. Rectus muscle resection in Graves' ophthalmopathy. J AAPOS. 2013; 17:9–15.
crossref pmid pmc
22. Yan J, Zhang H. The surgical management of strabismus with large angle in patients with Graves' ophthalmopathy. Int Ophthalmol. 2008; 28:75–82.
crossref pmid
23. Alkharashi M, Hunter DG. Reduced surgical success rate of rectus muscle plication compared to resection. J AAPOS. 2017; 21:201–204.
crossref pmid
TOOLS
Similar articles