Factors associated with horizontal reoperation in infantile esotropia

doi:10.1067/mpa.2002.120644

Journal of American Association for Pediatric Ophthalmology and Strabismus

Volume 6, Issue 1, February 2002, Pages 15-20

Presented at the 27th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Orlando, Fla, March 25, 2001.

https://doi.org/10.1067/mpa.2002.120644 Get rights and content

Abstract

Purpose: Risk factors for requiring multiple surgeries in infantile esotropia remain unclear. We identified clinical and demographic factors associated with horizontal reoperation in this disease. Methods: A retrospective chart review of patients who underwent surgery from 1994-1997 was performed. Subjects were divided into 2 groups: those requiring only one operation and those requiring 2 or more operations to achieve orthotropia ±10 PD. Results: In 149 patients, the overall horizontal reoperation rate was 34%. There were no statistically significant differences between the 2 groups with respect to mean age at first surgery, mean preoperative deviation, gender, prematurity, Medicaid coverage, parental age, family history of strabismus, or refractive error. The presence of nystagmus, oblique muscle dysfunction, dissociated vertical deviation (DVD), or a variable angle of esotropia was not associated with increased horizontal reoperation rate. There was a greater frequency of horizontal reoperation in patients with amblyopia, although not significant. Premature infants and infants with neurologic dysfunction had a lower incidence of horizontal reoperation, but also not significant. Deviations of less than 30 PD were associated with fewer horizontal reoperations (16% vs 31%, P = .047). Significantly more patients underwent horizontal reoperation when initial surgery was performed at less than or equal to 15 months of age (67% vs 47%, P = .022). Conclusions: Several factors thought to predispose to poor sensorimotor outcome (dissociated vertical deviation, oblique muscle dysfunction, and nystagmus) were not associated with an increased incidence of horizontal reoperation. Horizontal reoperation was less frequent in patients with angles less than 30 PD. Although some studies suggest that early surgical intervention in patients with infantile esotropia affords better sensory outcome, it may be associated with a higher horizontal reoperation rate. (J AAPOS 2002;6:15-20)

Section snippets

Subjects and methods

After appropriate approval from the Institutional Review Board at the University of Oklahoma Medical Center, a retrospective chart review of patients who underwent horizontal eye muscle surgery for the correction of IET at the Dean A. McGee Eye Institute from January 1, 1994, to December 31, 1997, was performed. Patients were included if they had onset of esotropia (ET) before 6 months of age, which was determined by exam, historical information, or photographs when available, and subsequently

Results

A total of 149 patients were identified who met study criteria. Our data evaluation assessed only the patients' horizontal alignment in primary position of gaze. At the time of initial surgery, 140 patients underwent bilateral medial rectus recession through an inferonasal fornix incision. Eight patients had a unilateral recess-resect procedure and 2 patients had a unilateral medial rectus recession. All reoperations occurred within 3 years of the initial surgery. Postoperative follow-up

Discussion

In the literature evaluating the surgical treatment of IET, the most common outcome measure analyzed is postoperative binocular function.3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 Bifoveation after surgery for IET is rare,4, 17, 18, 19 and gross stereopsis is generally present in only a minority (0-36%) of patients.2, 3, 5, 6, 7, 9, 11, 12, 16 Only a few studies report measurable stereopsis (Titmus test) postoperatively in a majority of patients: 71% (n = 7) in the paper by Wright et al,¹⁵

Acknowledgements

The authors thank Drs James M. Richard and Mark H. Scott for the surgical care rendered to the patients in this study.

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The treatment of strabismus in some cases requires surgery in order to strengthen or to weaken the extraocular muscles (EOMs) and thereby restore ocular alignment. However, a large proportion of strabismus patients must undergo additional surgical procedures due to relapse of ocular misalignment (Simonsz and Eijkemans, 2010; Repka et al., 2018; Trigler and Siatkowski, 2002), with inherent physical and emotional distress for the patient as well as the economical impact for the parts involved. The EOMs are a distinct type of muscle with particular characteristics at the functional, structural and gene levels (Fischer et al., 2005; Kjellgren et al., 2003; McLoon and Christiansen, 2010).
This paper aims to identify key biological processes triggered by resection surgery in the extraocular muscles (EOMs) of a rabbit model of strabismus surgery by studying changes in gene expression. Resection surgery was performed in the superior rectus of 16 rabbits and a group of non-operated rabbits served as control. Muscle samples were collected from groups of four animals 1, 2, 4 and 6 weeks after surgery and processed for RNA-sequencing and immunohistochemistry. We identified a total of 164; 136; 64 and 12 differentially expressed genes 1, 2, 4 and 6 weeks after surgery. Gene Ontology enrichment analysis revealed that differentially expressed genes were involved in biological pathways related to metabolism, response to stimulus mainly related with regulation of immune response, cell cycle and extracellular matrix. A complementary pathway analysis and network analysis performed with Ingenuity Pathway Analysis tool corroborated and completed these findings. Collagen I, fibronectin and versican, evaluated by immunofluorescence, showed that changes at the gene expression level resulted in variation at the protein level. Tenascin-C staining in resected muscles demonstrated the formation of new tendon and myotendinous junctions. These data provide new insights about the biological response of the EOMs to resection surgery and may form the basis for future strategies to improve the outcome of strabismus surgery.
Lateral rectus sag and recurrent esotropia in children
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To describe the clinical and intraoperative findings of an anatomic abnormality in children that resembles sagging eye syndrome documented in older adults and that led to recurrent esotropia after surgery.
We reviewed records of 4 patients with substantial recurrent esotropia after bilateral medial rectus recession who required subsequent surgery combining lateral rectus resection with correction of the anatomic abnormality affecting the lateral rectus path. Binocular alignment was sequentially analyzed.
Three young patients (2-3 years of age) presented with acquired esotropia but minimal cycloplegic refractive error. The fourth patient (14 years of age) initially had moderate hyperopia and partially accommodative esotropia, but subsequently developed marked bilateral overelevation in adduction. In all patients, esotropia recurred within 5^Δ of preoperative deviation after bilateral medial rectus recession. Surgical exposure demonstrated that bilateral lateral rectus paths were inferiorly displaced more than one-half tendon width from their normal paths near the globe's equator, despite normal scleral insertions. Equatorial myopexy and lateral rectus resection resulted in stable esotropia correction.
Lateral rectus sag in children creates a type of acquired esotropia and overelevation in adduction poorly responsive to standard surgery but correctable with lateral rectus resection and equatorial myopexy that normalizes the lateral rectus path through permanent scleral fixation.
Goal-determined metrics to assess outcomes of esotropia surgery
2014, Journal of AAPOS
Citation Excerpt :
Larger deviations might be harder to accurately measure, and some surgeons hesitate to operate on more than two horizontal muscles for a primary procedure. Trigler15 and Rajavi5 found that deviations >30Δ were associated with more horizontal reoperations in patients with congenital esotropia. Louwagie and colleagues16 found a greater need for reoperation in patients with a preoperative esotropia of >40Δ.
To report outcomes of esotropia surgery with a goal-determined tool.
A goal-determined outcomes analysis tool was devised to address a quality improvement initiative at Boston Children's Hospital. Surgeons preoperatively ranked four possible goals for intervention: enhancement of binocular potential, restoration of eye contact (reconstructive), management of diplopia, and resolution of torticollis. Criteria for success were goal specific; the primary outcome measure was surgical success at 2-4 months. Secondary outcomes included appraisal of risk factors and a comparison of outcomes with this methodology versus traditional criteria for success based on motor alignment. No patients were excluded based on diagnosis, systemic and ocular risk factors, or intervention performed.
A total of 824 patients underwent esotropia surgery from 2006 to 2012 and returned for evaluation at 2-4 months' follow-up. Of these, 777 had sufficient documentation for inclusion: 372 procedures were performed primarily to improve binocular potential; 238, to restore eye contact; 124, to resolve diplopia; and 43, to remediate torticollis. Excellent (71%) or good (13.7%) results were obtained in 84% of cases. Without associated risk factors, 75% had excellent and 14% had good outcomes. Risk factors were present in 444 (57%). Success diminished with prior strabismus surgery (P = 0.004), preoperative angle ≥50^Δ (P = 0.002), and surgery before 12 months of age (P = 0.003). Patients having surgery to remediate diplopia had the best outcomes (excellent, 79%; good, 8%). Preoperative ranking of goals allowed demonstration of better results than would have been reported with requirement of “traditional” motor alignment criteria (P = 0.009).
Goal-determined methodology can be useful for monitoring outcomes of esotropia surgery in diverse populations.
Factors related to strabismus decompensation after a period of prolonged postoperative stability
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Our study had a large number of cases with similar initial demographics and clinical variables. Previous studies have suggested that the following factors are associated with surgical outcomes: preoperative deviation size,4-6 presence and severity of amblyopia,3 DVD,1,7 age at surgery,2 and duration of misalignment.9 In this study, none of the aforementioned variables were identified as associated with stable long-term surgical results after horizontal strabismus surgery.
To identify factors associated with late decompensation of horizontal strabismus after a period of prolonged (>12 months) postoperative stability.
Charts from all pediatric horizontal strabismus surgical cases from 1999 to 2009 were reviewed. Patients with a distance or near alignment of <10^Δ at the first visit >12 months following surgery were included. The primary outcome was time from surgery to strabismus decompensation. Multiple variables were analyzed using the Cox proportional hazards model.
A total of 185 cases were included. Mean age at surgery was 5.1 years and mean follow-up was 62.2 months. Late decompensation rate was 31%; of these, 54% underwent reoperation. Using two different models, a higher risk of decompensation was associated with both the presence of preoperative oblique dysfunction (P = 0.023/0.002) and larger distance/near deviations at the first >12 months postoperative visit (P = 0.033/0.012).
Worsening of alignment >12 months after horizontal strabismus surgery occurs in almost one-third of patients. Preoperative oblique dysfunction is associated with long-term instability, possibly because it is a surrogate for sensory torsion and poor fusion. Additionally, larger distance and near deviations at >12 months after surgery were each associated with late decompensation. The rate of decompensation for patients with deviations of 0^Δ to <4^Δ was less than those with deviations of 4^Δ to <8^Δ and >8^Δ, suggesting that the biologic behavior of all deviations within the monofixation range (0^Δ to 8^Δ) is not uniform.
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^☆: Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, NY.

^☆☆: No reprints available.

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Major articleFactors associated with horizontal reoperation in infantile esotropia☆,☆☆

Abstract

Section snippets

Subjects and methods

Results

Discussion

Acknowledgements

Surv Ophthalmol

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

J AAPOS

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

J AAPOS

Am J Ophthalmol

Characteristics of infantile esotropia following early bimedial rectus recession

Arch Ophthalmol

Large bilateral medial rectus recession in early esotropia with bilateral limitation of abduction

J Pediatr Ophthalmol Strabismus

Outcome of strabismus surgery in congenital esotropia

Br J Ophthalmol

Major article
Factors associated with horizontal reoperation in infantile esotropia☆,☆☆