Surgery for esotropia under topical anesthesia

Stereoacuity and Related Factors in Healthy Preschool Children: The Nanjing Eye Study

Purpose: To assess the distribution of stereoacuity and related factors in healthy preschool children aged 48-60 months in eastern China. Methods: This cross-sectional study was part of the Nanjing Eye Study, a longitudinal population-based cohort study. In 2016, preschool children without any neurological problems or ophthalmological abnormalities completed comprehensive eye examinations, including visual acuity, ocular alignment and movements, cycloplegic refraction, axial length, interpupillary distance, Titmus stereotest, anterior segment, and fundus examination. Multivariate linear regression model was used to determine the factors associated with stereoacuity score, and logistic regression model was used to determine the factors associated with subnormal stereoacuity (worse than 40 arc-seconds). Results: Among 942 healthy preschool children (mean age = 55 months), the mean (SD) stereoacuity was 81 (2.3) arc-seconds with majority (76.5%) worse than 40 arc-seconds. In the multivariate analysis, older age (p = 0.001) and better presenting visual acuity (PVA) (p = 0.01) were independently associated with better stereoacuity score. Older age was also associated with low risk of subnormal stereoacuity (odds ratio = 0.37,p < 0.001 for age 57-60 months compared to age 48-51 months). Conclusions: The maturation of stereopsis has not completed by the age of 48-60 months. Age and PVA should be taken into account when evaluating stereopsis in healthy preschoolers. The significant associations of age and PVA with stereoacuity provide valuable insights into possible intervention for healthy preschool children with poor stereoacuity.

Long-term Surgical Outcomes in the Sagging Eye Syndrome

BACKGROUND/AIMS

Strabismus due to sagging eye syndrome (SES) caused by age-related connective tissue involution is now an established cause of diplopia in older people. High suspicion of the condition results in early recognition, often obviating extensive neurological investigations and enabling surgical correction of the strabismus.

METHODS

This retrospective study reviewed surgical results in 93 patients (40 males) of average age 68 ± 12 years, who had small-angle strabismus due to SES, during the 20-year period 1994-2014.

RESULTS

In central gaze, mean distance pre-operative esotropia was 4.2 ± 7.5Δ (mean, SD), while mean hypertropia was 4.7 ± 5.9Δ. Surgeries comprised medial rectus (MR) recession; lateral rectus (LR) resection; plication, imbrication, and superior transposition of the LR to the superior rectus (SR) for esotropia; and graded vertical rectus tenotomy (GVRT) or vertical muscle recession for hypertropia. Mean post-operative immediate and long-term deviation after 316 ± 265 months average follow-up was 0.2 ± 1.2Δ and 1.1 ± 2.7Δ esotropia (both distance), respectively, and 0.00Δ and 1.1 ± 2.7Δ, respectively, for hypertropia. Strabismus recurred in 19 cases.

CONCLUSIONS

Progressive connective tissue involution in SES may occasionally result in symptomatic recurrences of the small-angle strabismus in about 20% of patients, irrespective of surgical procedures performed, possibly because of progressive involutional changes. This risk should be disclosed pre-operatively.

Graded vertical rectus tenotomy for small-angle cyclovertical strabismus in sagging eye syndrome

BACKGROUND/AIMS

Graded vertical rectus tenotomy (GVRT) is postulated as effective for small-angle vertical heterotropia. We aimed to determine the dosing recommendations for GVRT in sagging eye syndrome (SES).

METHODS

This was a retrospective, observational study of surgical outcomes for GVRT from 2009 to 2014 in a single surgeon's academic practice. There were 37 (20 women) patients of average age 68±10 (SD) years with comitant or incomitant hypertropia ≤10Δ caused by SES. The main outcome measure was the dose-effect of GVRT required to correct intraoperative hypertropia.

RESULTS

Preoperative average central gaze hypertropia measured 4.7±2.2Δ. Three patients underwent repeat GVRT for residual or consecutive hypertropia, one undergoing it twice. All surgeries were analysed, increasing the total operations to 41. The inferior rectus tendon in the hypotropic eye was operated in 32 eyes, and the superior rectus tendon in the hypertropic eye in 9 eyes. Mean tenotomy was 68±19% of tendon width. Hypertropia was always eliminated intraoperatively by progressive GVRT. Mean hypertropia was 1.1±1.6Δ at average 93 days postoperatively. Linear regression demonstrated that 3-6Δ hypertropia correction requires 30%-90% graded tenotomy (R(2)=0.32, p<0.0001), but with substantial individual variability. Undercorrection necessitated reoperation in 10% of cases.

CONCLUSION

GVRT precisely corrects hypertropia of up to 10Δ, but because of variable effect, it should be performed with intraoperative monitoring under topical anaesthesia.

Selection of patients and results of 25 years of topical anesthesia and adjustable suture surgery

BACKGROUND AND PURPOSE

The author has used adjustable suture techniques either in the operating room with topical anesthesia or at a later time after retrobulbar or general anesthesia for over 25 years. Careful selection of patients is essential to the success of this technique. It is the purpose of this paper to report the selection criteria used and to compare the results of the two methods utilized.

PATIENTS AND METHODS

One hundred eighty-three patients were included in this study: 123 were operated upon with topical anesthesia. For comparison, sixty patients were included who had adjustment later in the day or the next day after having retrobulbar or general anesthesia. Both horizontal and vertical strabismus cases were included.

RESULTS

Adjustable techniques done in the operating room or at a later time have both shown significant improvement in the strabismus angle following one operation in 86% of the cases. Diplopia was eliminated in 63% of patients with this complaint. (63% and 64.5% in the two groups, respectively). Seventeen of 123 patients having topical anesthesia (13.8%) required a second operation, and 8 of 60 (13.3%) of those having a later adjustment needed further surgery.

CONCLUSION

Careful selection of patients undergoing strabismus surgery allows successful topical muscle adjustment in the operating room with results similar to adjustments done following retrobulbar or general anesthesia at a later time.

Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia

OBJECTIVE

To propose medial rectus (MR) recession to be equally as effective as lateral rectus (LR) resection, which has heretofore been the preferred treatment for divergence paralysis esotropia (DPE).

METHODS

We examined a 17-year surgical experience comparing LR resection with MR recession in adults with DPE, defined as symptomatic distance esotropia (ET) at least double the asymptomatic ET of 10 or less prism diopters() at near.

RESULTS

Twenty-four patients with DPE underwent surgery. Six patients underwent bilateral LR resection and 2 underwent unilateral LR resection (group L), while 13 underwent bilateral MR recession and 3 underwent unilateral MR recession,with the target angle double the distance ET (group M). One of 8 patients in group L and 15 of 16 patients in group M underwent intra operative adjustable surgery under topical anesthesia. Mean (SD) preoperative central gaze ET measured 15.0 (7.7) Δ at distance and 4.1 (3.4) Δ at near in group L, but 10.4 (6.8) Δ at distance and 0.6 (1.7) Δ at near in group M (P=.15; distance, 0.003, near). Postoperatively, no patient in either group had symptomatic diplopia or convergence insufficiency in follow-up from 8.5 to 40 months. Twice the usual surgical dose of MR recession per prism diopter was required to achieve correction of the distance deviation in DPE as compared with that recommended for ET generally and also for LR resection in the same condition.

CONCLUSIONS

Recession of the MR provides binocular single vision in DPE without convergence insufficiency at near, and it is convenient for intraoperative adjustment under topical anesthesia.