Unilateral Medial Rectus Recession for Small-Angle Esotropia Zane F. Pollard, MD, Donelson
Manley,
Ten patients with small-angle tropia of 18 prism diopters or less
MD
esowere
treated with a unilateral medial rectus recession of 5 mm. Nine of the ten cases considerably improved; one showed only minimal improvement. There were no overcorrections, but two cases did show lateral incomitance with a greater correction on gaze in the field of action of the recessed medial rectus muscle. Two patients became monofixators after the surgery. These had been patients with
believe that of less cannot be im¬
authors Various small-angle esotropia prism diopters
than 15
proved by
surgery.
Jampolsky1
wrote
in 1951 that surgical treatment of these small esotropías of 15 diopters or less is usually not indicated. If sur¬ gery is performed, the best attainable result is a newer, smaller angle of strabismus. He warned that the pa¬ tient may retain the preoperative angle of anomaly. Jampolsky believed this to be especially true if the straSubmitted for publication Feb 16, 1975. From the Department of Pediatric Ophthalmology, the Wills Eye Hospital, Philadelphia. Dr Pollard was a Heed Ophthalmic fellow at the Wills Eye Hospital during the preparation of this paper. Reprint requests to 575 W Peachtree St, NE, Atlanta, GA 30308 (Dr Pollard).
accommodative esotropia who had decompensated and had surgery for the nonaccommodative portion of the total
esotropia. When indicated, the
recession of one medial rectus muscle is a safe and predictable procedure for small-angle esotropia. An average correction of 11.6 prism diopters was obtained at distance and one of 11.3 prism diopters at near.
(Arch Ophthalmol 94:780-781, 1976)
bismus was of long standing. We decided to review our records during the past four years that con¬ cerned patients treated for smallangle esotropia. Our criterion for this study was 18 prism diopters or less. Each patient treated surgically had a medial rectus muscle recession of 5 mm. We analyzed our cases for a functional as well as a cosmetic result to see what value this mode of ther¬ apy has for the ophthalmologist. MATERIALS AND METHODS The ten children in the study came from both the Fight for Sight Clinic at the Wills Eye Hospital and from the private practice of one of the authors (D.M.). All had 18 prism diopters or less of esotropia. Al¬ though the history of onset of the esotropia was often unreliable, only one patient in
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this group was thought by the parents as well as the authors to have congenital eso¬ tropia. The onset in the other patients oc¬ curred at between 1 to 3 years of age. Two patients in the group originally had totally accommodative esotropia that decompensated to become partially accom¬ modative esotropia. One patient had, when measured at the time of surgery, 18 prism diopters of esotropia both at distance and at near with his hyperopic correction while measuring 45 prism diopters at distance and near without his glasses. The second patient had a measurement of 40 prism diopters at distance and near without his glasses and 15 prism diopters of esotropia at distance and near with his hyperopic correction. One patient in the group had a residual esotropia from a previous surgery for con¬ genital esotropia. The previous procedure had been a unilateral recession of the me¬ dial rectus combined with a resection of the homolateral lateral rectus muscle. A second procedure included in this study was a 5 mm recession of the other medial rectus muscle. All ten patients had a 5 mm recession of one medial rectus muscle. Nine of the ten (Table) showed an improvement that was acceptable to us. The one who did not showed an improvement of only 18 prism diopters of esotropia at distance to 12 diop¬ ters at distance, while the near deviation was improved only from 18 to 14 prism diopters of esotropia. Two of the patients showed the monofixation syndrome after
Treatment of Ten Cases of
Esotropia Preoperatively
Small-Angle Esotropia
Amount of
Patient 1
Age of onset, yr
Age at Surgery, yr 15
Distance and Near, Prism Diopters 18 18
Vh
15 15 16 16 18 18 18 18 18 18 16 14 16 16 18 18 16 16
Birth
10
Amount of
Surgery Performed* Recess RMR* 5
Esotropia Postoperatively
Distance and Near, Prism
Diopters
Follow-up, yr 1.5
6
mm
Recess RMR 5 mm Recess RMR 5 mm Recess LMR 5 mm Recess LMR 5 mm Recess RMR 5 mm Recess LMR 5
mm
Recess RMR 5
mm
Recess LMR 5
12 14
mm
Recess LMR 5
mm
RMR, right medial rectus; LMR, left medial rectus. surgery with suppression of one eye at dis¬ tance but fusion at near on the Worth-4Dot test and the Bagolini striated lenses test. These two patients both had decompensated accommodative esotropia. We op¬ erated on the nonaccommodative part of the esotropia in both of them. The remain¬
ing eight patients showed
no evidence of fusion either at distance or near. These eight patients showed alternate suppres¬ sion of either eye depending on which eye was fixating. There was a minimum fol¬ low-up of one year with a maximum of three years.
COMMENT
Surgery for small-angle esotropia has been described previously. Kirkland2 performed unilateral medial rectus recession for a deviation of 15 prism diopters. Kaiser1 in 1957 re¬ ported on recession of one medial rec¬ tus muscle in 12 adult patients with esophoria. All of his patients showed a definite improvement. In 1951, Stine4 reported on 14 cases of eso¬ phoria in which he recessed one medi-
al rectus muscle to the equator. The average amount of correction in his series was 13.6 prism diopters at 608 cm and 16.1 diopters at 33 cm. The correction in his series varied from 3 to 25 diopters at distance and 5 to 36 diopters at near. He had only one case of overcorrection. Our average correc¬ tion was 11.3 diopters for distance and 10.7 diopters for near. The max¬ imum correction at distance was 16 diopters; the least at distance was six diopters. Range for near was 4 to 16. These cases were performed mainly for cosmetic reasons because the fam¬ ily thought the deviation was cosmetically objectionable. Two cases, how¬ ever, did show fusion postoperatively. Bedrossian5 in discussing smallangle strabismus thought that if sur¬ gery was performed on one muscle only, incomitant strabismus would probably occur. He also believed that operating on two muscles posed the danger of overcorrection. He rec¬ ommended a marginal myotomy com-
bined with
a resection of the direct in antagonist order to prevent any incomitance. In our ten cases, lateral incomitance was seen after the reces¬ sion of one medial rectus muscle in two cases with a much larger correc¬ tion of the esotropia being obtained in the field of action of the recessed medial rectus muscle. The result in the straight-ahead position was still cosmetically acceptable in these two cases. We had no cases of overcor¬ rection in our series.
References 1. Jampolsky A: Retinal correspondence in patients with small degree strabismus. Arch Ophthalmol 45:18-26, 1951. 2. Kirkland T: Management of small-angle deviations. Am Orthop J 18:44-48, 1968. 3. Kaiser R: Surgery for esophoria in the adult. Am Orthop J 7:107-108, 1957. 4. Stine G: The surgical treatment of esophoria. Am J Ophthalmol 34:1307-1313, 1951. 5. Bedrossian H: Management of small-angle strabismus. Am Orthop J 18:35-38, 1968.
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Manley,
Ten patients with small-angle tropia of 18 prism diopters or less
MD
esowere
treated with a unilateral medial rectus recession of 5 mm. Nine of the ten cases considerably improved; one showed only minimal improvement. There were no overcorrections, but two cases did show lateral incomitance with a greater correction on gaze in the field of action of the recessed medial rectus muscle. Two patients became monofixators after the surgery. These had been patients with
believe that of less cannot be im¬
authors Various small-angle esotropia prism diopters
than 15
proved by
surgery.
Jampolsky1
wrote
in 1951 that surgical treatment of these small esotropías of 15 diopters or less is usually not indicated. If sur¬ gery is performed, the best attainable result is a newer, smaller angle of strabismus. He warned that the pa¬ tient may retain the preoperative angle of anomaly. Jampolsky believed this to be especially true if the straSubmitted for publication Feb 16, 1975. From the Department of Pediatric Ophthalmology, the Wills Eye Hospital, Philadelphia. Dr Pollard was a Heed Ophthalmic fellow at the Wills Eye Hospital during the preparation of this paper. Reprint requests to 575 W Peachtree St, NE, Atlanta, GA 30308 (Dr Pollard).
accommodative esotropia who had decompensated and had surgery for the nonaccommodative portion of the total
esotropia. When indicated, the
recession of one medial rectus muscle is a safe and predictable procedure for small-angle esotropia. An average correction of 11.6 prism diopters was obtained at distance and one of 11.3 prism diopters at near.
(Arch Ophthalmol 94:780-781, 1976)
bismus was of long standing. We decided to review our records during the past four years that con¬ cerned patients treated for smallangle esotropia. Our criterion for this study was 18 prism diopters or less. Each patient treated surgically had a medial rectus muscle recession of 5 mm. We analyzed our cases for a functional as well as a cosmetic result to see what value this mode of ther¬ apy has for the ophthalmologist. MATERIALS AND METHODS The ten children in the study came from both the Fight for Sight Clinic at the Wills Eye Hospital and from the private practice of one of the authors (D.M.). All had 18 prism diopters or less of esotropia. Al¬ though the history of onset of the esotropia was often unreliable, only one patient in
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/20/2015
this group was thought by the parents as well as the authors to have congenital eso¬ tropia. The onset in the other patients oc¬ curred at between 1 to 3 years of age. Two patients in the group originally had totally accommodative esotropia that decompensated to become partially accom¬ modative esotropia. One patient had, when measured at the time of surgery, 18 prism diopters of esotropia both at distance and at near with his hyperopic correction while measuring 45 prism diopters at distance and near without his glasses. The second patient had a measurement of 40 prism diopters at distance and near without his glasses and 15 prism diopters of esotropia at distance and near with his hyperopic correction. One patient in the group had a residual esotropia from a previous surgery for con¬ genital esotropia. The previous procedure had been a unilateral recession of the me¬ dial rectus combined with a resection of the homolateral lateral rectus muscle. A second procedure included in this study was a 5 mm recession of the other medial rectus muscle. All ten patients had a 5 mm recession of one medial rectus muscle. Nine of the ten (Table) showed an improvement that was acceptable to us. The one who did not showed an improvement of only 18 prism diopters of esotropia at distance to 12 diop¬ ters at distance, while the near deviation was improved only from 18 to 14 prism diopters of esotropia. Two of the patients showed the monofixation syndrome after
Treatment of Ten Cases of
Esotropia Preoperatively
Small-Angle Esotropia
Amount of
Patient 1
Age of onset, yr
Age at Surgery, yr 15
Distance and Near, Prism Diopters 18 18
Vh
15 15 16 16 18 18 18 18 18 18 16 14 16 16 18 18 16 16
Birth
10
Amount of
Surgery Performed* Recess RMR* 5
Esotropia Postoperatively
Distance and Near, Prism
Diopters
Follow-up, yr 1.5
6
mm
Recess RMR 5 mm Recess RMR 5 mm Recess LMR 5 mm Recess LMR 5 mm Recess RMR 5 mm Recess LMR 5
mm
Recess RMR 5
mm
Recess LMR 5
12 14
mm
Recess LMR 5
mm
RMR, right medial rectus; LMR, left medial rectus. surgery with suppression of one eye at dis¬ tance but fusion at near on the Worth-4Dot test and the Bagolini striated lenses test. These two patients both had decompensated accommodative esotropia. We op¬ erated on the nonaccommodative part of the esotropia in both of them. The remain¬
ing eight patients showed
no evidence of fusion either at distance or near. These eight patients showed alternate suppres¬ sion of either eye depending on which eye was fixating. There was a minimum fol¬ low-up of one year with a maximum of three years.
COMMENT
Surgery for small-angle esotropia has been described previously. Kirkland2 performed unilateral medial rectus recession for a deviation of 15 prism diopters. Kaiser1 in 1957 re¬ ported on recession of one medial rec¬ tus muscle in 12 adult patients with esophoria. All of his patients showed a definite improvement. In 1951, Stine4 reported on 14 cases of eso¬ phoria in which he recessed one medi-
al rectus muscle to the equator. The average amount of correction in his series was 13.6 prism diopters at 608 cm and 16.1 diopters at 33 cm. The correction in his series varied from 3 to 25 diopters at distance and 5 to 36 diopters at near. He had only one case of overcorrection. Our average correc¬ tion was 11.3 diopters for distance and 10.7 diopters for near. The max¬ imum correction at distance was 16 diopters; the least at distance was six diopters. Range for near was 4 to 16. These cases were performed mainly for cosmetic reasons because the fam¬ ily thought the deviation was cosmetically objectionable. Two cases, how¬ ever, did show fusion postoperatively. Bedrossian5 in discussing smallangle strabismus thought that if sur¬ gery was performed on one muscle only, incomitant strabismus would probably occur. He also believed that operating on two muscles posed the danger of overcorrection. He rec¬ ommended a marginal myotomy com-
bined with
a resection of the direct in antagonist order to prevent any incomitance. In our ten cases, lateral incomitance was seen after the reces¬ sion of one medial rectus muscle in two cases with a much larger correc¬ tion of the esotropia being obtained in the field of action of the recessed medial rectus muscle. The result in the straight-ahead position was still cosmetically acceptable in these two cases. We had no cases of overcor¬ rection in our series.
References 1. Jampolsky A: Retinal correspondence in patients with small degree strabismus. Arch Ophthalmol 45:18-26, 1951. 2. Kirkland T: Management of small-angle deviations. Am Orthop J 18:44-48, 1968. 3. Kaiser R: Surgery for esophoria in the adult. Am Orthop J 7:107-108, 1957. 4. Stine G: The surgical treatment of esophoria. Am J Ophthalmol 34:1307-1313, 1951. 5. Bedrossian H: Management of small-angle strabismus. Am Orthop J 18:35-38, 1968.
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