The role of rectus muscle myectomy in the management of large-angle strabismus for Graves' ophthalmopathy

Assessment of surgical strategies for management of complicated strabismus reoperation in Graves' ophthalmopathy

PURPOSE

Strabismus reoperation in Graves' ophthalmopathy (GO) is complicated and challenging. The purpose of this study was to evaluate the various surgical strategies of strabismus reoperation and their outcomes in patients with GO.

METHODS

A retrospective study was conducted on strabismus reoperations performed at the Zhongshan Ophthalmic Center of Sun Yat-sen University, Guangzhou, China from 2008 to 2018. Data collected included sex, age at surgery, duration of deviation, ocular alignment, ocular motility, various surgical procedures performed and surgical outcomes. Surgical methods included rectus recession for newly developed strabismus, rectus resection for undercorrection and anterior advancement of a previously recessed rectus for overcorrection. Surgical success was defined as an absence of diplopia, a horizontal deviation of ≤ 10 prism diopters (PD) and a vertical deviation of ≤ 5 PD at distance in primary and reading positions.

RESULTS

Of the 153 GO patients receiving strabismus surgery, 27 cases (20 males, 7 females) underwent reoperation for strabismus, with a reoperation rate of 17.6%. Success rates of reoperation in patients with a previous undercorrection and overcorrection were 45% and 71.4%, respectively. Success rates of rectus recession, rectus resection and anterior advancement were 47.1%, 66.7% and 50%, respectively. Two patients underwent the third surgery. The overall success rate was 51.9%.

CONCLUSIONS

Rectus recession is an effective method for GO patients with newly-developed strabismus. Rectus resection may benefit some patients with undercorrection who underwent a maximal degree of rectus recession. Anterior advancement of a previously recessed rectus is effective for cases with overcorrection.

The role of lateral rectus muscle resection for severe esotropia after medial rectus muscle myectomy in Graves' ophthalmopathy

PURPOSE

Persistent diplopia after rectus muscle myectomy is not uncommon but challenging in patients with Graves' ophthalmopathy. We investigated the role of lateral rectus muscle resection for patients after medial rectus muscle myectomy in Graves' ophthalmopathy.

METHODS

We retrospectively reviewed and collected data from patients with persistent diplopia after medial rectus muscle myectomy for Graves' ophthalmopathy who underwent unilateral or bilateral lateral rectus muscle resection. The eyeball deviations in the primary and reading positions before and after the operation were measured. A successful surgical outcome was defined as having less than five prism diopters (PD) in the primary gaze and functional binocular vision in the central 30° field postoperatively.

RESULTS

A total of fifteen patients were included (mean post-myectomy deviation: 35.9 PD, range: 14 to -75 PD). The lateral rectus muscle resection after medial rectus muscle myectomy achieved an 80.0% success rate, with one patient over-corrected and two patients under-corrected.

CONCLUSIONS

The lateral rectus muscle resection is an effective and predictable procedure for managing residual esotropia in Graves' ophthalmopathy patients who have previously undergone medial rectus muscle myectomy.

The effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid ophthalmopathy

PURPOSE

To evaluate the effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy.

METHODS

This retrospective study enrolled 55 eyes of 33 patients treated in our hospital for restrictive strabismus caused by thyroid-associated ophthalmopathy. We performed muscle recession for the obviously restricted extraocular muscles, with 6 weeks of follow-up. Surgical outcomes were compared between the orbital decompression group (DG, n=15) and non-orbital decompression group (NDG, n=18).

RESULTS

A total of 33 patients with Graves' ophthalmopathy who underwent rectus muscle recession surgery were included. Of these, 15 patients had undergone orbital decompression prior to strabismus surgery, and 18 had not. The two groups did not differ in terms of the preoperative horizontal or vertical ocular deviation, degree of restriction of eye movement, degree of diplopia, or mean number of muscles that underwent surgery (P>0.05). There was no significant difference in the preoperative horizontal or vertical ocular deviation, level of eye movement restriction, degree of diplopia and the success rate of the surgery (P>0.05).

CONCLUSION

Rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy during the quiescent period could improve the ocular deviation and diplopia, and orbital decompression performed before strabismus surgery had no significant effect on surgical technique or outcomes of rectus muscle recession surgery.

Postoperative residual vertical deviation affects quality of life in Asian patients with thyroid-associated ophthalmopathy (Graves ophthalmopathy)

PURPOSE

To evaluate the treatment effect of strabismus surgery for Graves ophthalmopathy in an ethnic Chinese population.

STUDY DESIGN

A prospective clinical study.

METHODS

Thirty-one patients with Graves ophthalmopathy who had undergone strabismus surgery at National Taiwan University Hospital between 2012 and 2013 were consecutively recruited. The subjective outcome was evaluated using the Graves' Ophthalmopathy Quality-of-Life (GO-QoL) questionnaire, and the ocular deviation was measured preoperatively and postoperatively by use of a prism cover test.

RESULTS

The GO-QoL scores for visual functioning and appearance improved significantly after surgery (preoperative scores 32.6 ± 19.9 and 43.8 ± 26.4, postoperative scores 55.2 ± 24.4 and 54.1 ± 27.6, respectively; P < .05). Motor success was achieved in 61.3% of the patients, and their postoperative visual scores were higher (61.5 ± 22.5) than the scores of those who experienced motor failure (45.3 ± 26.8, P = .048). The postoperative visual function scores showed a negative correlation with the residual vertical deviation (R² = 0.546, P = .040). A higher increase in GO-QoL visual scores and a lower residual vertical deviation in downgaze were achieved among patients without previous decompression surgery. Our surgical methods resulted in a motor success rate of 76.5% for the correction of vertical deviation.

CONCLUSION

GO-QoL scores and ocular deviation improved significantly after strabismus surgery. Precise correction of vertical deviation was of greater importance than horizontal deviation for visual function scores. Our surgical methods were effective for the correction of vertical deviation in Graves ophthalmopathy.

Risk Factors for Reoperation after Strabismus Surgery among Patients with Thyroid Eye Disease

PURPOSE

To examine risk factors for strabismus surgery reoperation in patients with thyroid eye disease (TED).

DESIGN

Retrospective cohort study.

METHODS

An insurance claims database was used to identify patients with TED who underwent at least one strabismus operation between 2003 and 2019. We recorded specific muscles operated on, as well as the timing and frequency of reoperations. Cox regressions were used to estimate associations between time to reoperation and patient and primary surgery characteristics.

RESULTS

Of the 448 patients who met inclusion criteria, 111 (24.8%) underwent a reoperation. Patients were followed for an average of 5.4 ± 3.0 years after their initial strabismus surgery. The rates of reoperation among patients whose initial surgery involved horizontal muscles only, vertical muscles only, and horizontal and vertical muscles were 29 of 120 (24.2%), 33 of 169 (19.5%), and 49 of 159 (30.8%) respectively (P = .05). The number of muscles operated on initially was the only independent predictor for undergoing a strabismus surgery reoperation (odds ratio, 1.27; 95% confidence interval, 1.03-1.57; P = .03). The number of muscles operated on initially was also associated with shorter time to first reoperation (hazard ratio, 1.22; 95% confidence interval, 1.02-1.46; P = .03). Age at first surgery, time between diagnosis of TED and first strabismus surgery, gender, race, and use of adjustable sutures were not associated with time to reoperation.

CONCLUSIONS

Approximately 1 in 4 patients with TED require reoperation after strabismus surgery. The number of muscles operated on was the only independent predictor for both undergoing a reoperation and time to first reoperation.

Sequential changes in intraocular pressure during strabismus surgery in patients with thyroid eye disease

BACKGROUND/AIMS

To investigate the sequential change in intraocular pressure (IOP) during strabismus surgery in patients with thyroid eye disease (TED).

METHODS

This prospective study included patients with TED who underwent strabismus surgery (medial rectus [MR], inferior rectus [IR], and superior rectus [SR] recession) between March 2018 and December 2020. The IOP was measured six times during surgery (5 min after intubation, after isolation of the muscle using a hook and dissection of the surrounding tissue, immediately before muscle detachment, immediately after muscle detachment, after reattachment of the muscle, and after closure of the conjunctiva).

RESULTS

Thirty-five eyes of 18 patients were included. The mean IOP at first was 21.1 mmHg, which significantly increased to 28.6 mmHg after muscle isolation. The IOP significantly decreased to 15.5 mmHg after muscle detachment. This increased to 19.1 mmHg after muscle reattachment. The last IOP was 18.9 mmHg. There were similar patterns of sequential change in the IOP among the three muscles. The MR showed the highest increase in IOP. The IR showed the lowest mean IOP compared with the other two muscles.

CONCLUSIONS

The IOP was elevated during the isolation and dissection of the surrounding muscle tissue, especially in the MR. The IOP significantly decreased after muscle detachment and was maintained until the last measurement, even after muscle reattachment. IR showed the lowest IOP among the three muscles during surgery.

Medial rectus disinsertion for management of chronic complete sixth nerve palsy

PURPOSE

To report the outcomes of the medial rectus (MR) disinsertion procedure for the management of refractory esotropia (ET) with or without Abnormal head posture (AHP) in chronic complete sixth nerve palsy.

METHODS

This is a retrospective case series of patients with sixth nerve palsy who suffered from residual ET and diplopia following the conventional strabismus surgeries and underwent MR disinsertion procedure between April 2017 and February 2020. This procedure was offered to the patients who declined to use prism and did not wish to perform surgery on the fellow eye. The demographic and clinical data, including sex, age, visual acuity, pre and postoperative angle of strabismus, duction limitations, results of forced duction and force generation tests, details of prior strabismus surgeries, orbital CT scan findings, and follow up duration were collected from the medical records.

RESULTS

Six patients were enrolled in this study. Mean age was 35.0  ±  14.0 years, and mean follow-up was 15.3  ±  5.9 months. The ET at the Primary position (PP) was 35.0  ±  18.4 prism dioptre (PD) before MR disinsertion, which decreased to 14.2  ±  17.4 PD after MR disinsertion procedure. Four cases needed additional complementary surgeries to improve residual ET in PP. No case developed overcorrection. Abduction deficiency was -5.0  ±  1.3 before MR disinsertion, which improved to - 2.8  ±  0.5 units at last follow-up. The mean of induced adduction deficiency was - 2.9  ±  0.4 at last follow-up.

CONCLUSIONS

MR disinsertion can be considered in patients with chronic complete sixth nerve palsy and refractory diplopia when the conventional methods have failed.

Superior rectus recession for hypertropia in thyroid-associated ophthalmopathy

PURPOSE

To assess the outcomes of superior rectus-weakening surgery in patients with thyroid-associated ophthalmopathy (TAO).

METHODS

The medical records of patients with TAO who were treated with surgical weakening of the superior rectus muscle at the Zhongshan Ophthalmic Center from 2008 to 2018 were reviewed retrospectively. Data collected included sex, age at surgery, duration of deviation, ocular alignment, ocular motility, surgical procedures, and outcomes. Surgical success was defined as the absence of diplopia and a vertical deviation of ≤5^Δ in primary and reading positions.

RESULTS

A total of 33 patients (mean age 45.7 years; 17 males) were included. Of the 33 patients, 28 received unilateral superior rectus recession, with a success rate for primary surgery of 79%. The mean preoperative hypertropia of 35.1^Δ ± 19.3^Δ was significantly reduced to 3.9^Δ ± 9.7^Δ. Ocular infraduction restriction significantly improved from a preoperative average of -5.3 ± 1.9 to -1.3 ± 1.3 postoperatively. Five patients underwent superior rectus tenotomy, with only 2 cases having a successful final outcome. For 27 of 33 cases, only a single surgery was required; 6 cases required a second surgery. The overall final success rate was 76%.

CONCLUSIONS

In our study cohort, superior rectus recession with or without traction suture for hypertropia in thyroid-associated ophthalmopathy resulted in a high rate of success.

The impact of orbital bony or fat decompression on the outcome of strabismus surgery in patients with Graves' ophthalmopathy

BACKGROUND/PURPOSE

To compare the outcomes of strabismus surgery in patients with Graves' ophthalmopathy (GO) who had undergone bone removal orbital decompression (BROD) or fat removal orbital decompression (FROD) with those who had not undergone any orbital decompression.

METHODS

The records of patients with GO who underwent strabismus surgery over a period of 66 months were retrospectively reviewed.

RESULTS

Eighty-nine patients with a mean age of 55.1 ± 11.9 years were identified in this study. Twenty-two patients had prior BROD, 20 patients had prior FROD and 47 patients had no orbital decompression. Patients who had prior orbital decompression had an average of 1.6 strabismus surgeries per patient which was significantly higher compared to 1.2 strabismus surgeries in patients who had no orbital decompression (p = 0.02). The overall success rate of strabismus surgery was 68.2%, 80.0% and 80.9% following BROD, FROD and no orbital decompression respectively. The overall success rate of strabismus surgeries in patients with GO was 61% after the first surgery and 78% after the final surgery.

CONCLUSION

The management of strabismus in GO is complex and difficult. Prior orbital decompression is associated with more strabismus surgeries per patient with a trend towards a lower success rate for strabismus surgery. FROD is comparable to BROD with regards to its effects on the outcome of subsequent strabismus surgeries.