Recession of the Lateral Recti Effect of
Preoperative
Fusion and Distance-Near
Relationship
Edward L. Raab, MD, Marshall M. Parks, MD
The importance of both preoperative fusion and the distance-near alignment relationship to the results of recession of the lateral recti for correction of exodeviation was studied. Satisfactory alignment was achieved after this procedure in 78% of patients with constant exodeviation and 80% of patients with intermittent exodeviation. In each fusion status, initial overcorrection of up to 20 prism diopters gave the highest percentage of good results (constant exodeviation patients, 88%; intermittent, 89%). Fifty-six percent of the satisfactorily realigned constant exode-
another communication,1 pa¬ tients with exodeviation were studied with regard to (1) binocular alignment in the immediate (2 to 10 day) postoperative period after reces¬ sion of the lateral recti, and (2) the relevance of that measurement to the outcome of surgery. The results ap¬ peared to indicate the superiority of an initial postoperative esodeviation of up to 20 prism diopters after this
In
procedure.
The purposes of this communica¬ tion are to examine the influence of Submitted for publication June 4, 1974. From the Department of Ophthalmology, Children's Hospital of the District of Columbia, Washington, DC. Dr. Raab is presently at the Mount Sinai School of Medicine of the City University of New York. Reprint requests to Mount Sinai School of Medicine, Fifth Avenue and 100th Street, New York, NY 10029 (Dr. Raab).
viation patients and 69% of intermittent exodeviation patients remained satisfactorily realigned over an average follow-up interval of five years. If convergence insuf-
ficiency was present, satisfactory realignments noted at five to eight weeks could
be maintained thereafter in 40% of patients. Where there was no preoperative
convergence insufficiency, satisfactory results were maintained in 64% of patients with "high" and 68% of patients with "normal" distance-near ratios.
the preoperative exercise of fusion by the subject in ordinary visual circum¬ stances, and the relationship of the preoperative distance and near align¬ ments to the result of lateral rectus recession. METHODS The study group consisted of patients who had undergone bilateral lateral rectus recession as an initial procedure for correc¬ tion of exodeviation. Their postoperative alignments had been quantitatively deter¬ mined first at two to ten days, then at five to eight weeks, and at subsequent followup intervals. Criteria for selection, meth¬ ods of measurements, and surgical plan have been described in our previous re¬
port.1
For the classification of fusion status, the patients were considered to demon¬ strate constant exotropia if on cover-un¬ cover testing, or in a few obvious cases
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
by inspection, manifest exodeviation
was
noted. If the deviation at the time of sur¬ gery was latent for any portion of the test situation, it was classified as intermittent. The same patients were assigned to three groups, depending on their preoperative distance-near relationship. This was con¬ sidered "high" if the distance exodeviation was greater than the near by more than 10 prism diopters. The designation "normal" was applied to a distance-near relationship in which the exodeviation at distance was up to 10 prism diopters more convergent or more divergent than the near alignment. A "low" relationship was defined as one in which the exodeviation at near exceeded that for distance by more than 10 prism diopters. The terms usually employed for each of these categories are "divergence excess," "basic exodeviation," and "con¬ vergence insufficiency." The effects of bi¬ nocular occlusion or +3.00 D spheres on the deviation were not considered.
RESULTS We wished to know if preoperative fusion status influenced either the obtaining of a satisfactory surgical result or the determination of the most favorable immediate postopera¬ tive alignment. This was determined in 139 patients. Thirty-six (78%) of 46 patients with constant exodeviation (Table 1) and 74 (80%) of 93 patients with intermittent (distance) exode¬ viation (Table 2) had achieved a satis¬ factory surgical result in five to eight weeks. In each fusion status, initial
Table
1.—Surgical Results in Preoperative Constant Distance Exodeviations for Each Initial (2 to 10 Days) Postoperative Alignment No. of
Alignment at 2 to 10 Days (
Table
Exodeviations for Each Initial (2 to 10 Days) Postoperative
Satisfactory*
No.
)_Cases_at
5 to 8 Weeks Exodeviation >20_.„_._^_ 1 0 Exodeviation 11-20 Exodeviation 1-10 6) 8) ,_
Orthophoria
Vi_1
Esodevlation 1-10 Esodeviation 11-20 Esodeviation >20 *
Satisfactory
¿l_14j
_19j
=
1 46
no more
than 10
1 36
esodeviation
or
2.—Surgical Results in
Preoperative Intermittent Distance
Alignment No. Satis¬
20
(74%)
Alignment
15
(88%)
Days ( ) Exodeviation
(78%)
exodeviation.
at 2 to 10
11-20
}» »} }* "}
1-10
Results in Preoperative Constant and Intermittent Distance Exodeviations No.
Preoperative
Satisfactory*
No.
Remainingt
Satisfactory 20 (56%) Constant 3(5 Intermittent_74_51 (69%)
Exodeviation
at 5 to 8
*
Satisfactory = no more than 10 t Average follow-up 64 months.
Weeks
esodeviation
or
exodeviation.
Weeks
1
Exodeviation
3.—Stability of Surgical
at 5 to 8
>20 Exodeviation
Orthophoria Table
factory*
No. of Cases
Esodeviation 1-10
Esodeviation 11-20
26
(68%)
47
(89%)
Esodeviation >20 *
1 93
Satisfactory or exodeviation. =
no more
1
74
(80%)
than 10
esdevi-
ation
compared in 143 patients whose alignments at two to ten days and five to eight weeks and subsequent stability had been recorded. The sat¬ isfactory alignments at five to eight weeks in the high, normal, and low were
Table 4.—Influence of
Preoperative Distance-Near Relationship of Recession of the Lateral Recti
Preoperative Distance-Near
High
Normal Low
No. of Cases 57 79 7 143
* Satisfactory = no more than 10 t Of satisfactory alignments.
No.
Satisfactory*
at 5 to 8
44 62 5 111
esodeviation
or
Weeks
(77%) (79%) (71%) (78%;
on
Results
No. Remaining
Satisfactory* 28 (64% )t 42 (68%) t 2 (40%)t 72 (65% )t
exodeviation.
distance-near groups were 77%, 79%, and 71%. Subsequent maintenance of a satisfactory alignment was achieved in 64%, 68%, and 40% of the properly realigned patients in each group
overcorrections gave more satisfac¬ tory surgical results (constant group, 88%; intermittent group, 89%) than did small undercorrections and ortho¬ phoria (constant group, 74%; inter¬ mittent group, 68%). We also wished to determine if pre¬ operative fusion status influenced the stability of the surgical result at la¬ ter intervals. In patients whose eyes were satisfactorily aligned at five to eight weeks following recession of
the lateral recti, 56% with constant exodeviations and 69% with inter¬ mittent exodeviations maintained their binocular position. The average follow-up interval was longer than five years in each fusion status1
(Table 3). We sought information regarding
whether the distance-near relation¬ ship that had been determined at the time of operation affected the success of treatment. The surgical results
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
(Table 4).
COMMENT
Our previous report1 indicated that after lateral rectus recession, there remained a high incidence of diver¬ gence from any initially achieved postoperative binocular position. It appears that the desired initial overcorrection to offset the tendency to rediverge is as important in subjects with at least part-time fusion as in those who demonstrated no fusion
preoperatively. The practice of par¬ tially correcting the patient with in¬ termittent exotropia and depending
fusion to "take him the rest of the way" should therefore be dis¬ couraged. The occurrence of surgi¬ cally induced esotropia is a source of dismay, but it occurs less frequently than does recurrence of the original exodeviation. The findings also suggest that re¬ tention of part-time fusion in exo¬ tropia should not be considered suffi¬ cient reason to postpone operation, despite the need for caution against overcorrection of exotropia in the young patient,- since surgical results appear to remain more satisfactory over long-term intervals in patients in whom preoperative fusion had been on
present. number of patients with a low distance-near relationship is too small to allow a firm conclusion, a high vs a normal distance-near rela¬ tionship at the time of surgery did not appear to be a factor in the re¬ sults of recession of the lateral recti. Since no attempt was made to iden¬ tify and separate "true" from "pseudo" divergence excess, as has been recommended by Burian,1 the high distance-near group undoubtedly was
"contaminated" by several members of the normal group. However, the percentages of satisfactory and stable surgical results in these two catego¬ ries were so close that even if the patients had been more precisely iden¬ tified, the comparison of these param¬ eters would not have changed. This suggests that where an easily detect¬ able convergence insufficiency does
exist, attempts at determining a presumably more accurate relation¬ ship of distance-to-near divergent misalignments by methods that do not relate to ordinary use of the eyes ( + 3.00 D spheres, unilateral occlusion) are not critically important if the surgeon desires to employ recession of the lateral recti according to his personal quantitative scheme. not
CONCLUSIONS
Although the
3.
Employing
bilateral lateral
tus recession without
regard
rec¬
to the
preoperative distance-near relation¬ ship did not appear to influence the chance of obtaining a satisfactory alignment at five to eight weeks. 4. Stability of the surgical result
after recession of the lateral recti ap¬ to be lowest when preopera¬ tive convergence insufficiency was present. In exodeviation patients without convergence insufficiency, the relationship of distance to near alignments in ordinary use of the eyes did not influence the main¬ tenance of a satisfactory binocular position after this procedure.
peared
This investigation was supported by a Public Health Service Training Fellowship under Neu¬ rological and Sensory Disease Service grant N0908C66 from the Bureau of State Services.
1. Overconvergence of up to 20 prism diopters in both constant and
intermittent distance exodeviations a better chance for a satisfac¬ tory surgical result than did other ini¬ tial postoperative positions of the eyes. 2. A satisfactory surgical result was more likely to be maintained thereafter if fusion had been present just prior to lateral rectus surgery. gave
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
References 1. Raab EL, Parks MM: Recession of the lateral recti: Early and late postoperative alignments. Arch Ophthalmol 82:203-208, 1969. 2. Jampolsky A: Round table discussion: Symposium on Strabismus, in Transactions of the New Orleans Academy of Ophthalmology. St. Louis, CV Mosby Co, 1971, pp 410-411. 3. Burian HM: Exodeviations: Their classification, diagnosis and treatment. Am J Ophthalmol 62:1161-1166, 1966.
Preoperative
Fusion and Distance-Near
Relationship
Edward L. Raab, MD, Marshall M. Parks, MD
The importance of both preoperative fusion and the distance-near alignment relationship to the results of recession of the lateral recti for correction of exodeviation was studied. Satisfactory alignment was achieved after this procedure in 78% of patients with constant exodeviation and 80% of patients with intermittent exodeviation. In each fusion status, initial overcorrection of up to 20 prism diopters gave the highest percentage of good results (constant exodeviation patients, 88%; intermittent, 89%). Fifty-six percent of the satisfactorily realigned constant exode-
another communication,1 pa¬ tients with exodeviation were studied with regard to (1) binocular alignment in the immediate (2 to 10 day) postoperative period after reces¬ sion of the lateral recti, and (2) the relevance of that measurement to the outcome of surgery. The results ap¬ peared to indicate the superiority of an initial postoperative esodeviation of up to 20 prism diopters after this
In
procedure.
The purposes of this communica¬ tion are to examine the influence of Submitted for publication June 4, 1974. From the Department of Ophthalmology, Children's Hospital of the District of Columbia, Washington, DC. Dr. Raab is presently at the Mount Sinai School of Medicine of the City University of New York. Reprint requests to Mount Sinai School of Medicine, Fifth Avenue and 100th Street, New York, NY 10029 (Dr. Raab).
viation patients and 69% of intermittent exodeviation patients remained satisfactorily realigned over an average follow-up interval of five years. If convergence insuf-
ficiency was present, satisfactory realignments noted at five to eight weeks could
be maintained thereafter in 40% of patients. Where there was no preoperative
convergence insufficiency, satisfactory results were maintained in 64% of patients with "high" and 68% of patients with "normal" distance-near ratios.
the preoperative exercise of fusion by the subject in ordinary visual circum¬ stances, and the relationship of the preoperative distance and near align¬ ments to the result of lateral rectus recession. METHODS The study group consisted of patients who had undergone bilateral lateral rectus recession as an initial procedure for correc¬ tion of exodeviation. Their postoperative alignments had been quantitatively deter¬ mined first at two to ten days, then at five to eight weeks, and at subsequent followup intervals. Criteria for selection, meth¬ ods of measurements, and surgical plan have been described in our previous re¬
port.1
For the classification of fusion status, the patients were considered to demon¬ strate constant exotropia if on cover-un¬ cover testing, or in a few obvious cases
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
by inspection, manifest exodeviation
was
noted. If the deviation at the time of sur¬ gery was latent for any portion of the test situation, it was classified as intermittent. The same patients were assigned to three groups, depending on their preoperative distance-near relationship. This was con¬ sidered "high" if the distance exodeviation was greater than the near by more than 10 prism diopters. The designation "normal" was applied to a distance-near relationship in which the exodeviation at distance was up to 10 prism diopters more convergent or more divergent than the near alignment. A "low" relationship was defined as one in which the exodeviation at near exceeded that for distance by more than 10 prism diopters. The terms usually employed for each of these categories are "divergence excess," "basic exodeviation," and "con¬ vergence insufficiency." The effects of bi¬ nocular occlusion or +3.00 D spheres on the deviation were not considered.
RESULTS We wished to know if preoperative fusion status influenced either the obtaining of a satisfactory surgical result or the determination of the most favorable immediate postopera¬ tive alignment. This was determined in 139 patients. Thirty-six (78%) of 46 patients with constant exodeviation (Table 1) and 74 (80%) of 93 patients with intermittent (distance) exode¬ viation (Table 2) had achieved a satis¬ factory surgical result in five to eight weeks. In each fusion status, initial
Table
1.—Surgical Results in Preoperative Constant Distance Exodeviations for Each Initial (2 to 10 Days) Postoperative Alignment No. of
Alignment at 2 to 10 Days (
Table
Exodeviations for Each Initial (2 to 10 Days) Postoperative
Satisfactory*
No.
)_Cases_at
5 to 8 Weeks Exodeviation >20_.„_._^_ 1 0 Exodeviation 11-20 Exodeviation 1-10 6) 8) ,_
Orthophoria
Vi_1
Esodevlation 1-10 Esodeviation 11-20 Esodeviation >20 *
Satisfactory
¿l_14j
_19j
=
1 46
no more
than 10
1 36
esodeviation
or
2.—Surgical Results in
Preoperative Intermittent Distance
Alignment No. Satis¬
20
(74%)
Alignment
15
(88%)
Days ( ) Exodeviation
(78%)
exodeviation.
at 2 to 10
11-20
}» »} }* "}
1-10
Results in Preoperative Constant and Intermittent Distance Exodeviations No.
Preoperative
Satisfactory*
No.
Remainingt
Satisfactory 20 (56%) Constant 3(5 Intermittent_74_51 (69%)
Exodeviation
at 5 to 8
*
Satisfactory = no more than 10 t Average follow-up 64 months.
Weeks
esodeviation
or
exodeviation.
Weeks
1
Exodeviation
3.—Stability of Surgical
at 5 to 8
>20 Exodeviation
Orthophoria Table
factory*
No. of Cases
Esodeviation 1-10
Esodeviation 11-20
26
(68%)
47
(89%)
Esodeviation >20 *
1 93
Satisfactory or exodeviation. =
no more
1
74
(80%)
than 10
esdevi-
ation
compared in 143 patients whose alignments at two to ten days and five to eight weeks and subsequent stability had been recorded. The sat¬ isfactory alignments at five to eight weeks in the high, normal, and low were
Table 4.—Influence of
Preoperative Distance-Near Relationship of Recession of the Lateral Recti
Preoperative Distance-Near
High
Normal Low
No. of Cases 57 79 7 143
* Satisfactory = no more than 10 t Of satisfactory alignments.
No.
Satisfactory*
at 5 to 8
44 62 5 111
esodeviation
or
Weeks
(77%) (79%) (71%) (78%;
on
Results
No. Remaining
Satisfactory* 28 (64% )t 42 (68%) t 2 (40%)t 72 (65% )t
exodeviation.
distance-near groups were 77%, 79%, and 71%. Subsequent maintenance of a satisfactory alignment was achieved in 64%, 68%, and 40% of the properly realigned patients in each group
overcorrections gave more satisfac¬ tory surgical results (constant group, 88%; intermittent group, 89%) than did small undercorrections and ortho¬ phoria (constant group, 74%; inter¬ mittent group, 68%). We also wished to determine if pre¬ operative fusion status influenced the stability of the surgical result at la¬ ter intervals. In patients whose eyes were satisfactorily aligned at five to eight weeks following recession of
the lateral recti, 56% with constant exodeviations and 69% with inter¬ mittent exodeviations maintained their binocular position. The average follow-up interval was longer than five years in each fusion status1
(Table 3). We sought information regarding
whether the distance-near relation¬ ship that had been determined at the time of operation affected the success of treatment. The surgical results
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
(Table 4).
COMMENT
Our previous report1 indicated that after lateral rectus recession, there remained a high incidence of diver¬ gence from any initially achieved postoperative binocular position. It appears that the desired initial overcorrection to offset the tendency to rediverge is as important in subjects with at least part-time fusion as in those who demonstrated no fusion
preoperatively. The practice of par¬ tially correcting the patient with in¬ termittent exotropia and depending
fusion to "take him the rest of the way" should therefore be dis¬ couraged. The occurrence of surgi¬ cally induced esotropia is a source of dismay, but it occurs less frequently than does recurrence of the original exodeviation. The findings also suggest that re¬ tention of part-time fusion in exo¬ tropia should not be considered suffi¬ cient reason to postpone operation, despite the need for caution against overcorrection of exotropia in the young patient,- since surgical results appear to remain more satisfactory over long-term intervals in patients in whom preoperative fusion had been on
present. number of patients with a low distance-near relationship is too small to allow a firm conclusion, a high vs a normal distance-near rela¬ tionship at the time of surgery did not appear to be a factor in the re¬ sults of recession of the lateral recti. Since no attempt was made to iden¬ tify and separate "true" from "pseudo" divergence excess, as has been recommended by Burian,1 the high distance-near group undoubtedly was
"contaminated" by several members of the normal group. However, the percentages of satisfactory and stable surgical results in these two catego¬ ries were so close that even if the patients had been more precisely iden¬ tified, the comparison of these param¬ eters would not have changed. This suggests that where an easily detect¬ able convergence insufficiency does
exist, attempts at determining a presumably more accurate relation¬ ship of distance-to-near divergent misalignments by methods that do not relate to ordinary use of the eyes ( + 3.00 D spheres, unilateral occlusion) are not critically important if the surgeon desires to employ recession of the lateral recti according to his personal quantitative scheme. not
CONCLUSIONS
Although the
3.
Employing
bilateral lateral
tus recession without
regard
rec¬
to the
preoperative distance-near relation¬ ship did not appear to influence the chance of obtaining a satisfactory alignment at five to eight weeks. 4. Stability of the surgical result
after recession of the lateral recti ap¬ to be lowest when preopera¬ tive convergence insufficiency was present. In exodeviation patients without convergence insufficiency, the relationship of distance to near alignments in ordinary use of the eyes did not influence the main¬ tenance of a satisfactory binocular position after this procedure.
peared
This investigation was supported by a Public Health Service Training Fellowship under Neu¬ rological and Sensory Disease Service grant N0908C66 from the Bureau of State Services.
1. Overconvergence of up to 20 prism diopters in both constant and
intermittent distance exodeviations a better chance for a satisfac¬ tory surgical result than did other ini¬ tial postoperative positions of the eyes. 2. A satisfactory surgical result was more likely to be maintained thereafter if fusion had been present just prior to lateral rectus surgery. gave
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
References 1. Raab EL, Parks MM: Recession of the lateral recti: Early and late postoperative alignments. Arch Ophthalmol 82:203-208, 1969. 2. Jampolsky A: Round table discussion: Symposium on Strabismus, in Transactions of the New Orleans Academy of Ophthalmology. St. Louis, CV Mosby Co, 1971, pp 410-411. 3. Burian HM: Exodeviations: Their classification, diagnosis and treatment. Am J Ophthalmol 62:1161-1166, 1966.
