Embed Size (px)
Citation preview
Use of the combined recession and resectionof a rectus muscle procedure in the managementof incomitant strabismusEmma Dawson, DBO, Natalie Boyle, MB, ChB, MRCOphth, Kasra Taherian, MD, FRCSEd,and John P. Lee, FRCS, FRCP, FRCOphth
BACKGROUND Scott described a method of achieving the effect of a posterior fixation procedure bycombining resection and recession of a rectus muscle, while maintaining the ability toadjust primary position alignment with adjustable sutures.
METHODS A retrospective review of combined recession-resection procedures on rectus musclesbetween 1998 and 2002 was carried out.
RESULTS We identified 22 patients, 17 females and 5 males. The mean age at presentation was 44years. The etiology was felt to be paralytic in seven patients (31.8%), mechanical/restrictive in seven patients (31.8%), and due to residual childhood strabismus in eightpatients (36.4%). Twenty patients had undergone previous strabismus surgery, rangingfrom one to six operations (mean, 1.75). Scott procedures were performed on 25 rectusmuscles of 22 patients; 12 on the lateral rectus muscles, 7 on the inferior rectus muscles,3 on the medial rectus muscles, and 3 on the superior rectus muscles. All but one patienthad a measurable improvement in gaze incomitance, and 11 of 12 who had a mea-surement of the field of binocular single vision showed improvement. Twenty patientshad follow-up periods of 3 months or more, with a range of 3 to 30 months and a meanof 9.35 months.
CONCLUSIONS The combined recession-resection procedure advocated by Scott has a role in the man-agement of incomitant strabismus. ( J AAPOS 2007;11:131-134)
T he challenge of incomitant strabismus surgery is toimprove diplopia and expand the field of singlevision while maintaining good ocular alignment in
primary position. The principle of improving incomitancein gaze away from primary position, known as “matchingthe defect,” typically involves limiting the action of theoveracting contralateral synergist muscle.
The posterior fixation suture technique (faden opera-tion)1 improves misalignment in peripheral gaze positionswhile maintaining alignment in primary position. In thisoperation, a rectus muscle is sutured to the sclera at a pointposterior to its insertion with nonabsorbable sutures. Theeffect is to limit the rotational force of the muscle in itsprimary direction of action, while having little or noeffect on either primary position alignment or rotationsaway from the direction of action of the operated mus-
Author affiliations: Moorfields Eye Hospital, City Road, London, United KingdomPresented at the 29th Annual Meeting of the American Association for Pediatric
Ophthalmology and Strabismus, Kona, Hawaii, March 23-27, 2003.Submitted March 9, 2004.Revision accepted October 30, 2006.Reprint requests: John Lee, FRCS, FRCP, FRCOphth, Moorfields Eye Hospital, City
Road, London EC1V 2PD, United Kingdom (email: [email protected]).Copyright © 2007 by the American Association for Pediatric Ophthalmology and
Strabismus.
1091-8531/2007/$35.00 � 0doi:10.1016/j.jaapos.2006.10.023Journal of AAPOS
cle. The procedure is more effective in neurologicallycaused incomitant strabismus than in mechanically in-duced incomitance.2,3
The faden procedure has disadvantages. Surgery can betechnically difficult, as the access and exposure may bepoor, and it has been suggested that the thin posteriorsclera is relatively easier to perforate.4,5 The faden proce-dure in itself does not materially affect primary positionalignment. It can be combined with a recession or resec-tion with fixed sutures, but not with adjustable sutures.The faden procedure is ineffective when performed on thelateral rectus muscle, probably because that muscle has avery large arc of contact with the sclera.
Scott suggested a procedure that was based upon amodification of the faden principle.6 He performed a largeresection of a rectus muscle and then recessed the muscle,using a standard hang-back/adjustable technique, in a po-sition where the recession amount exceeded the resectionamount. The adjustable suture was used to manipulateprimary position alignment, and the reattachment of mus-cle to sclera at a posterior insertion point produced themechanical effect of a faden operation. Scott reported theuse of the technique on horizontal rectus muscles in threecases, with good results and follow-up of 2 to 11 months.
In 1999 Bock and colleagues7 applied Scott’s techniqueon vertical and horizontal rectus muscles in 12 patients,
with and without adjustable sutures. They modified Scott’s131
Volume 11 Number 2 April 2007132 Dawson et al
technique by reducing the amount of resection, as theywere concerned that problems could arise, in particular, ifa reoperation was required. They obtained good results infour of five patients managed with adjustable sutures andin three of seven patients managed with fixed sutures.Thacker and colleagues8 reported in 1995 on 12 patientswith vertical and horizontal deviation managed with com-bined recess-resect procedures, recessing by double theamount of resection. They reduced incomitance in all casesand eliminated diplopia in 11 of 12 patients. In this study, wereport our experience with the combined recession-resectionprocedure in 22 consecutive patients.
Subjects and MethodsWe performed a retrospective chart review using the surgicaldatabase to identify all of our patients managed with a combinedrecession-resection procedure on one or more rectus musclesbetween 1998 and 2002. We identified 22 patients, 17 female and5 male, with an age range of 8 to 86, and a mean of 44 years. Inall cases the rectus muscle or muscles were resected and then leftin a recessed position, on a hang-back adjustable polyglactin 910suture. All surgery was under general anesthesia, and adjustment,if required, was done approximately 7 to 8 hours later that sameday. In general, we did not perform “supramaximal” resectionsand confined our surgery to not more than 7 mm for a lateralrectus muscle and 5 to 6 mm for other rectus muscles. As weaimed to reduce deviation in primary position, as well as incomi-tance, recessions were always equal to or larger than resections.e-Supplement 1 (available at jaapos.org) provides patient details,the details of the recession-resection procedure, any associatedsurgery, and whether any further surgery was planned. Twentypatients had undergone previous strabismus surgery rangingfrom one to six procedures (mean, 1.75), and 5 patients hadpreceding botulinum toxin treatment. The etiology wasjudged to be paralytic in seven patients (31.8%), mechanical/restrictive in seven patients (31.8%), and due to residual child-hood strabismus in eight patients (36.4%).
Ten cases had a preoperative exodeviation; 8 had an esodevia-tion, and 11 had a vertical deviation on cover test. All cases hadlimited ocular rotation with gaze incomitance in one or morefields of gaze (e-Supplement 1, available at jaapos.org). Nineteenof 22 complained of diplopia; in 7 patients it was in primaryposition.
To illustrate the advantage of this procedure in allowing theability to manage incomitance while maintaining or improvingprimary position alignment, we cite Case 12, a 20-year-old fe-male medical student who presented with a consecutive exotropiawith preserved binocular vision after esotropia surgery on eacheye aged 2 and 4. When first seen, she had symptoms of diplopiadespite base in prism in glasses. She had markedly limited ad-duction of both eyes, right more than left, with horizontal dip-lopia on sidegaze. She measured 20� of exodeviation at 33 cmand 12� at 6 m. We performed bilateral lateral rectus com-bined recess-resect procedures, finding the left lateral rectus at9 mm from the limbus, resecting it by 5 mm and leaving it at 14
mm from the limbus, and finding the right lateral rectus at 9 mm,resecting it at 4 mm, and leaving it at 15 mm from the limbus.Later that day she had a small residual exotropia in primaryposition. The left lateral rectus was recessed a few millimeters,and all sutures were tied. Postoperatively, she measured 1� ofesophoria at near and 4� esophoria at distance with stereopsis onthe Wirt fly and 2/9 circles (200 seconds).
ResultsA combined recession-resection procedure was performedon 25 rectus muscles of 22 patients, a single lateral rectusmuscle in 8 patients, both lateral rectus muscles in 1patient, on the medial and lateral rectus muscles of one eyein 2 patients ( both patients having limitation of bothadduction and abduction of the fellow eye, 1 due to com-plications of endoscopic sinus surgery and 1 with residualabducens nerve palsy due to a glomus jugulare tumor, withpostsurgical limitation of adduction of the paretic eye), ona single medial rectus muscle in 1 patient, and on 7 singleinferior rectus muscles and 3 superior rectus muscles.Surgical dosages for lateral rectus muscles ranged from 4mm resection and recession to 7 mm resection and reces-sion. All medial rectus muscles had 5 mm resection andrecession. Inferior rectus muscles received between 4mm resection and recession and 5 mm resection with 6mm recession. Superior rectus muscles had between 5 mmresection and recession and 5 mm resection with 6 mmrecession. Adjustable sutures were used in 21 of 22 pa-tients, and adjustment was necessary in only 8 patients.Other surgery was done at the same session in sevenpatients. Three patients had oblique muscle weakeningsurgery in association with a combined recession-resectionprocedure on the ipsilateral vertical rectus muscle. Twohad correction of horizontal deviation when the combinedrecession-resection procedure was performed on a verticalrectus muscle. One patient had lateral rectus resectionassociated with a combined recession-resection procedureon the medial rectus muscle for esotropia and latent nys-tagmus with head posture. One patient had superior rectusmuscle faden for a vertical deviation, with the combinedrecession-resection procedure on the horizontal rectusmuscle.
One patient had early slippage of an inferior rectusmuscle. The muscle was explored and repositioned withina few days with a good result. There were no other com-plications of surgery.
Twenty patients had follow-up periods of 3 months ormore, with a range of 3 to 30 months and a mean of 9.35months. Two patients did not attend the 3 month follow-up appointment. e-Supplement 1 shows the patient data.Our findings with the remaining patients that attendedboth a 2 week postoperative appointment and the 3 monthpostoperative appointment was that there was no differ-ence in measurements between the two consecutive visits.All but one patient had improvement in gaze incomitance,assessed by reduction of symptoms of diplopia and im-
provement of eye movements on orthoptic examination.Journal of AAPOS
Volume 11 Number 2 April 2007 Dawson et al 133
In 11 of 12 patients who had measurement of the percent-age field of binocular single vision, this test confirmedimprovement. We analyzed and scored these by themethod of Fitzsimons and White9 to give a percentage ofnormal. In all but one patient, there was improvement inthe percentage score, as shown in Figure 1. Further sur-gery has been performed in two patients and is planned inthree more.
We classified 10 patients as “functional cures,” withabolition of incomitance and a large functional field ofbinocular single vision, between 40% and 80% of normal.One of these patients underwent subsequent strabismussurgery, with a faden procedure on the same inferior rectusmuscle as the combined recession-resection procedure, tofurther widen the field of single vision. The etiology in thisgroup was paralytic in two patients (abducens nerve palsy),mechanical in four (three orbital trauma, one dysthyroid),and related to childhood concomitant strabismus in four(two consecutive exotropia, one residual exotropia, oneresidual esotropia). All had had previous strabismus sur-gery. Combined recession-resection procedures were doneon five unilateral lateral rectus muscles (total eight inseries), three inferior rectus muscles (total seven in series),both lateral rectus muscles in one patient, and both medialand lateral rectus muscles on one eye on another patient.
Six patients were judged partial cures, since they im-proved but required further treatment in the form ofsurgery or prisms. The etiologies were paralytic in three(two bilateral posttraumatic trochlear nerve palsy, oneunilateral trochlear nerve palsy), mechanical in one ( post-operative adherence syndrome), one had an idiopathichypertropia, and one had blepharophimosis syndromewith a right esotropia and manifest latent nystagmus and aface turn toward the fixing eye. Three of this group expe-rienced a surgical overcorrection and reversal of the devi-ation. One inferior rectus muscle slipped within the firstpostoperative week and was repositioned. Later reversalwas seen with one inferior rectus muscle and one superiorrectus muscle, both with posttraumatic trochlear nervepalsy. All of this group had improvement of their originalincomitance, but required further treatment with prisms
FIG 1. Pre- and postoperative percentage fields of binocular single vision;n � 12. BSV, binocular single vision.
or surgery to obtain a satisfactory outcome.
Journal of AAPOS
Four patients judged treatment failures, with minimalchange in ocular rotations. One had a left lateral rectusmuscle combined recession-resection procedure for lim-ited adduction of the other eye following a second surgeryfor childhood esotropia. Improvement was minimal andfurther surgery on the right eye is planned. One patienthas had a long series of ocular muscle procedures4 fordiplopia, originally caused by retinal reattachment surgery,and further surgery is planned. One patient, whose leftmedial rectus muscle was effectively rendered useless byendoscopic sinus surgery, derived no benefit from com-bined recession-resection procedures on the contralateralmedial and lateral rectus muscles, as shown by an incon-sequential change in her percentage field of binocularsingle vision following surgery from 36% to 39%.
A further patient, who sustained right-sided orbitaltrauma in an automobile accident, and initially underwenta right Knapp procedure, had an initial good response to acombination of left superior rectus combined recession-resection procedure and ipsilateral inferior oblique muscledisinsertion, to improve incomitance on upgaze. After the3 month visit she began to notice pain around the righteye and deterioration of her ocular motility. She has sincebeen diagnosed as having collapse of the maxillary sinus onthe right side and awaits faciomaxillary and orbital repair.
Further treatment was undertaken in eight patients. Onepatient had a faden procedure on an inferior rectus musclethat had undergone the combined recession-resection pro-cedure to widen the field of single binocular vision. Onepatient had further adjustable bilateral inferior rectus mus-cle weakening surgery for bilateral fourth nerve palsies.Three patients have surgery planned to further increasethe field of binocular single vision.
Three patients have had subsequent botulinum toxintreatment, two with some improvement in symptoms. Allother cases have had a stable result following combinedrecession-resection procedure surgery.
DiscussionWe conclude that the combined recession-resection pro-cedure has a useful role in the management of symptom-atic incomitant strabismus. The faden procedure remainsvaluable when there is no ocular deviation in primaryposition sufficient to warrant intervention. When strabis-mus is present in primary position, the combined recession-resection procedure is useful and seems to be as effective asa standard faden procedure in expanding the field of singlebinocular vision.
The procedure is particularly valuable when dealingwith incomitance on lateral gaze due to limitation of ad-duction, where the overacting muscle is the contralaterallateral rectus muscle. Recession of the lateral rectus musclemay have a deleterious effect on the primary positiondeviation, and we have found that performing a standardfaden procedure on the lateral rectus muscle has little or
no effect.
Volume 11 Number 2 April 2007134 Dawson et al
The procedure was easy to perform compared with thefaden procedure. In our series, the only operative compli-cation was a slipped inferior rectus muscle, a recognizedcomplication of IR muscle weakening surgery.
References
1. Cüppers C. The so-called “Fadenoperation” (surgical correction bywell defined changes in the arc of contact). In: Fells P, editor. SecondCongress of the International Strabismological Association; Mar-seilles: Diffusion Générale de Librairie; 1976; p. 395.
2. Buckley EG, Meekins BB. Fadenoperation for the management ofcomplicated incomitant vertical strabismus. Am J Ophthalmol 1988;105:304-12.
3. Kouri AS, Bessant DAR, Adams GGW, Sloper JJ, Lee JP. Quan-
titative changes in the field of binocular single vision following afadenoperation to a single vertical rectus muscle. J AAPOS2002;6:294-9.
4. Alio JL, Faci A. Fundus changes following Faden operation. ArchOphthalmol 1984;102:211-3.
5. Lyons CJ, Fells P, Lee JP, MacIntyre A. Chorioretinal scarring afterthe faden operation: a retrospective review of 100 procedures. Eye1989;3:401-3.
6. Scott AB. Posterior fixation: adjustable and without posterior sutures.In: Lennerstrand G, editor. Proceedings VIIth Congress InternationalStrabismological Association CRC Press, Inc.; 1995; p. 399-402.
7. Bock CJ, Buckley EG, Freedman SF. Combined resection and reces-sion of a single rectus muscle for the treatment of incomitant strabis-mus. J AAPOS 1999;3:263-8.
8. Thacker NM, Velez FG, Rosenbaum AL. Combined adjustable rectusmuscle resection- recession for incomitant strabismus. J AAPOS 2005;9:137-40.
9. Fitzsimons R, White J. Functional scoring of the field of binocular
single vision. Ophthalmology 1990;97:33-5.An Eye on the Arts – The Arts on the Eye
At the end of ten days, a new group of doctors came to Yossarian with bad news: he wasin perfect health and had to get out. He was rescued in the nick of time by a patient acrossthe aisle who began to see everything twice. Without warning, the patient sat up in bed andshouted,
“I see everything twice!”A nurse screamed and an orderly fainted. Doctors came running up from every direction
with needles, lights, tubes, rubber mallets and oscillating metal tines. They rolled upcomplicated instruments on wheels. There was not enough of the patient to go around, andspecialists pushed forward in line with raw tempers and snapped at their colleagues in frontto hurry up and give somebody else a chance. A colonel with a large forehead andhorn-rimmed glasses soon arrived at a diagnosis.
“It’s meningitis,” he called out emphatically, waving the others back. “Although Lordknows there’s not the slightest reason for thinking so.”
“Then why pick meningitis?” inquired a major with a suave chuckle. “Why not, let’s say,acute nephritis?”
“Because I’m a meningitis man, that’s why, and not an acute-nephritis man,” retortedthe colonel. “And I’m not going to give him up to any of your kidney birds without astruggle. I was here first.”
In the end, the doctors were all in accord. They agreed they had no idea what was wrongwith the soldier who saw everything twice, and they rolled him away into a room in thecorridor and quarantined everyone else in the ward for fourteen days.
—Joseph Heller (from Catch 22, Simon & Schuster)
Journal of AAPOS
e-Supplement 1. Patient data
No. SexAge at
surgery ( y) IncomitanceCombined recession-resection procedure Adjusted
Other simultaneoussurgery Further treatment Discharge
1 F 26 Limited R adduction L LR � 6 �6 Yes No No DNA2 F 52 Limited R depression L IR �4 �4 No L MR �5 No DNA3 F 68 Limited L elevation R SR �5 �6 Yes No BTXA R MR No4 F 42 Limited L depression R IR �6 �5 No No No No5 F 59 Limited R adduction L LR �7 �7 No No No Yes6 F 39 Limited R adduction L LR �6 �6 No No Re-explore R LR
& MRNo
7 M 61 Limited L abduction R MR �5 �5, R LR �6 �6 No No No Yes8 F 37 Limited R adduction L LR �5 �8 Yes No No Yes9 M 50 L hyper on dextrodepression R IR �5 �7 Yes B MR � & inferiorly
reinsertedR IR advance,
L IR �3.5No
10 F 8 R ET increases on R gaze L MR �5 �9 No L LR �5 No Yes11 F 38 Limited R adduction L LR �6 �6 No No RMR faden No12 F 20 Limited R adduction L LR �5 left 14 mm from
limbus, R LR�4 left 15mm from limbus
Yes No No Yes
13 F 26 Limited L elevation R SR �5 �5 Yes R IO disinsertion No No14 F 86 Limited R laevodepression L IR �5 �5 No No Prisms No15 F 58 Limited L adduction R LR �6 �8, R MR �5 �5 No No BTXA L LR No16 M 65 Limited R depression L IR �5 �5 (slipped L IR
repositioned 1 week later)Yes No BTXA R IR No
17 M 38 Limited R adduction L LR �6 �6 Yes No No Yes18 F 55 Limited L adduction R LR �6 �6 No No No Yes19 M 52 Limited R depression L IR �4 �4 No No L IR faden Yes20 F 44 Limited R depression L IR �5 �5 No L SO posterior
tenotomyNo Yes
21 F 30 Limited R elevation L SR �5 �5 No L IO disinsertion No No22 F 17 Limited R adduction, L
hyper on laevoversionL LR �5 �5 LR found at
10.5 set 16 mmNo L SR faden No No
R: right; L: left; B: bilateral; �: recession; �: resection; MR: medial rectus; LR: lateral rectus; SR: superior rectus; IR: inferior rectus; SO: superior oblique; IO: inferior oblique;VI: sixth nerve palsy; IV: fourth nerve palsy; CS: convergent squint; DNA: did not attend; BTXA: botulinum toxin.
Volume 11 Number 2 April 2007 Dawson et al 134.e1
Journal of AAPOS
