Efectividad de la cirugía monocular en la exotropía sensorial de gran ángulo / Effectiveness of the surgery monocular in the sensorial exotropia of great angle

La exotropía sensorial se define como una desviación ocular divergente unilateral o bilateral, dada por anomalías oculares congénitas o adquiridas; es más frecuente en adultos. El objetivo de la cirugía de estrabismo en el adulto es restablecer la visión binocular, reduciendo la diplopía y al lograr el alineamiento ocular, mejorar su estética, por lo que antes de realizar la cirugía se debe tratar la causa que provoca la baja visión. El procedimiento quirúrgico de elección es la cirugía monocular, pero si la desviación es grande se realizará cirugía binocular. Se presenta una paciente femenino de 25 años de edad portadora de lentes de contacto por miopía elevada del ojo derecho (9,00 -0.75 x 105º con 0,2 de agudeza visual mejor corregida), exotropía de más de 25º por Hirschberg, limitación de aducción del ojo derecho y por método de oclusor y prismas a 6 metros sin cristales y con sus lentes de contacto, ambos ojos 50 ∆ b interna, no estereopsia y suprime ojo derecho. Por todas las ventajas que presenta la cirugía monocular, se decidió realizarla en el ojo derecho, se colocó anestesia local peribulbar, se realizó recesión amplia del recto lateral a 12 mm y se realizó 8 mm de resección del recto medial; en el postoperatorio se logró 10 ∆ b interna y por momentos ortotropia; refirió diplopía post quirúrgica que resolvió espontáneamente. Los resultados quirúrgicos en la exotropía sensorial son menos alentadores ya que con el tiempo pueden evolucionar hacia la hipercorrección o hacia la recurrencia(AU)

Sensory exotropía is defined as a unilateral or bilateral divergent ocular deviation, given by congenital or acquired ocular anomalies, and is more frequent in adults. The objective of the strabismus surgery in adults is to reestablish binocular vision, reduce diplopía, improve ocular alignment and enhance quality of life; before performing surgery the cause of low vision should be treated. The preferred surgical procedure is a monocular approach, but if there is a large deviation a binocular procedure should be performed. The case presented Is a 25 year-old female with high myopia of the right eye (-9.00 -0.75 x 105º with 0.2 of best corrected visual acuity), exotropía of more than 25º for Hirschberg, limitation of aducción of the right eye and with both the oclusor method and prisms to 6 meters without glasses and with her contact lenses, both eyes have 50∆ of internal base, no estereopsia and suppression of the right eye. For its advantages a monocular approach (of the right eye) was preferred, with peribulbar anesthesia: recession to 12mm of the lateral rectus combined with 8 mm of resection of the medial rectus; in the postoperative she presented a 10∆ intern base deviation and for moments ortotropia; she referred diplopia that solved spontaneously. The surgical results in sensory exotropía are less encouraging since they have higher hypercorrection and recurrence rates(AU)

Clinical observation of monocular rectus surgery for adult sensory exotropia / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To evaluate the effect of monocular rectus surgery for adult sensory exotropia. <p>METHODS: Totally 76 cases of adult sensory exotropia of degree -15^△ to -160^△(-68.36^△±30.77^△)examined through Krimsky method were included into this study. A total of 16 cases, 37 cases and 23 cases with different degrees of strabismus were treated separately with routine amount monocular lateral rectus recession, routine amount monocular medial rectus resection plus lateral rectus recession, and exceed constant amount monocular medial rectus resection plus lateral rectus recession. Follow-up was performed at 1d, 1wk, 1, 3 and 6mo after operation. The eye position, monocular movement, intraocular pressure(IOP), slit lamp, and fundus of these patients were examined. <p>RESULTS:After surgery, 67 cases(88%)were positive and 9 cases(12%)were undercorrection. The postoperative intraocular pressure of operative eye at 1wk was equal to preoperative(<i>P</i>=0.090), and IOP decreased to a valley value at 1mo(<i>P</i><0.01), there was no significant difference in intraocular pressure between 3mo and 1mo(<i>P</i>=0.092), and no significant difference in intraocular pressure between 6mo and 3mo(<i>P</i>=0.123). And 2 cases(3%)had inflammatory reaction induced by anterior segment ischemia at 1d and 1wk postoperative visits, and they recovered at 1mo follow-up visit; 4 cases(5%)experienced an external dysfunction at the 1, 3 and 6mo follow-up. <p>CONCLUSION:Monocular rectus surgery has a good therapeutic effect on adult patients with sensory exotropia; the decrease in intraocular pressure secondary to the detached rectus is worth the attention of the surgeon; the incidence of complications after detaching monocular of two rectus muscles is comparable low. Exceed constant amount rectus strabismus surgery for sensory exotropia may result in limited function of postoperative ocular hyperextension.

Surgical Outcome of Sensory Exotropia with Distant-Near Disparity

PURPOSE: To assess clinical features of sensory exotropia with distant-near disparity, surgical outcome, and compare according to amount of medical rectus resection. METHODS: Authors retrospectively reviewed medical records of patients of sensory exotropia with follow-up over 6 months. We defined patients with over 10 prism diopter (PD) disparity as distant-near disparity sensory exotropia (DND-XT) and without disparity as basic sensory exotropia (B-XT). First, we analyzed and compared data of visual acuity, cause and age of visual loss, amount of deviation. Second, Surgical failure was analyzed with dividing DND-XT into conventional surgery group as Parks' formula and reduced medial rectus resection group in accordance with disparity. Surgical success was defined as less than 10 PD deviation in distant, near fixation. RESULTS: B-XT consisted of 58 patients (40 males) and DND-XT of 33 patient (13 males). There was no significant difference between 2 groups in onset and cause of visual loss, deviation at distant fixation. But, log MAR visual acuity of worse eye was better in DND-XT than B-XT (1.74 +/- 0.78, vs. 2.10 +/- 0.74, p = 0.039). Average deviation in distant fixation in DND-XT was 46.55 +/- 16.59 PD in distant and 14.93 +/- 8.91 PD in near fixation. All patients underwent surgery of medial rectus resection and lateral rectus recession and average deviation was 6.83 +/- 7.71 PD at distant fixation, 3.02 +/- 0.69 PD at near fixation at last follow-up. Among 33 patients, 16 patients underwent conventional amount of surgery and 17 patients with reduced medial rectus resection. In patient with conventional surgery, 9 patients were surgical failure (8 patients of over-, 1 patient of under-correction) but in patient with reduced amount of resection, only 1 patient was under-correction. CONCLUSIONS: As a result of medial rectus resection and lateral rectus recession in DND-XT, more surgical failures due to over-correction were observed with conventional resection and higher surgical success was attained in consideration of disparity.

Clinical Features Associated with the Direction of Deviation in Sensory Strabismus

PURPOSE: To assess the clinical features associated with the direction of deviation in sensory strabismus and postoperative stability of strabismus angles. METHODS: The authors retrospectively reviewed the medical records of 98 patients diagnosed with sensory strabismus who were treated surgically. Among the factors analyzed were sex, age, direction of strabismus, preoperative visual acuity, age at onset of visual loss, cause of primary sensory deficit, refractive error, age at operation, deviation angle at 1 and 6 months postoperatively and after at least 5 years. RESULTS: At baseline, 20 patients (20.4%) had esotropia and 78 (79.6%) had exotropia. Common causes of primary sensory deficit were corneal opacity (25.5%), vitreoretinal disorder (23.5%), and congenital cataracts (16.3%). The proportion of esotropia increased significantly as the refractive error of the sound eye became more hyperopic. The older the patients were when they lost their vision, the higher the proportion of exotropia. Patients with longer duration of vision loss were more likely to have a larger deviation angle with exotropia, but the association was not significant with esotropia. CONCLUSIONS: Patients with sensory strabismus tend to develop exotropia. Refractive error of the sound eye and age at onset of vision loss were associated with the direction of strabismus. Despite poor sensory fusion even after surgery, more than 50% of patients maintained a stable eye position.

Supermaximal Recession and Resection in Large-Angle Sensory Exotropia

In cases of extropia with an exodeviation angle over 50 prism diopter (PD), a 3- or 4-muscle surgery is a rational option. But, in patients with sensory exotropia, there is usually a strong preference for a monocular procedure to avoid surgery on the single seeing eye. Thus, we confined surgery to visually poor eyes, and performed a medial rectus muscle resection with a mean of 10.3 mm (range, 9-11 mm) and a lateral rectus muscle recession with a mean of 12.8 mm (range, 10-14 mm) in 4 adult sensory exotropia patients who had a mean deviation of 82.3 PD (range, 75-90 PD). The mean postoperative angle of exodeviation was 2.0 PD (range, ortho-8 PD). The limitation on abduction was not disfiguring. Other expected disfigurements, such as narrowing of the palpebral fissure or enophthalmos, were not conspicuous. The mean follow-up period was 4.5 months (range, 3-7 months). In large-angle sensory exotropia, instead of additive surgery on the seeing eye, supermaximal medial rectus resection and lateral rectus recession only on the visually poor eye is a clinically feasible surgical option.

Comparison of the Stability of Postoperative Alignment in Sensory Exotropia: Adjustable Versus Non-Adjustable Surgery

PURPOSE: To compare the success rates and stabilities of postoperative alignment between adjustable and the non-adjustable surgeries in the treatment of sensory exotropia. METHODS: A retrospective analysis was performed on all patients with sensory exotropia who had undergone unilateral lateral rectus recession and medial rectus resection (R&R) between January 1998 and August 2005. Thirty-four patients underwent conventional R&R, and 20 patients underwent R&R with adjustable suture of the lateral rectus. The surgical results between the two groups were analyzed with regard to the preoperative and post-operative deviation angles and the postoperative drift. The postoperative deviation angle was measured on postoperative day 1 as well as at two weeks, three months, six months and the final visit after surgery. RESULTS: There were no statistically significant differences in the mean preoperative and postoperative deviation angles between the two groups. In 30 (88%) patients in the non-adjustable group and 15 (75%) patients in the adjustable group, postoperative deviation was less than 15 prism diopters (PD) at the three month follow-up. There was no significant difference in the mean postoperative drift between the two groups. CONCLUSIONS: Strabismus surgery with adjustable sutures did not show a significantly better result than surgery without adjustable sutures in the treatment of sensory exotropia. Considering the amount of postoperative exodrift in both groups, we postulate that the immediate ocular alignment after surgery for sensory exotropia should be orthophoric or 5-6 PD of esodeviation.