Long-term comparison of horizontal rectus surgery with vertical tendon transposition and combined vertical tendon transposition and inferior oblique-weakening in V-pattern exotropia.

PURPOSE: To compare the efficacy of bilateral lateral rectus recession with vertical tendon transposition (LRVT) and LRVT combined with inferior oblique (IO) disinsertion for V-pattern exotropia. METHODS: The medical records of patients who had mild-to-moderate (+1 and +2) inferior oblique overaction (IOOA) and underwent half-tendon-width upward LRVT (transposition group), and LRVT with IO disinsertion (combined surgery group) for V-pattern exotropia and who had at least 3 years of postoperative follow-up were reviewed retrospectively. RESULTS: A total of 45 patients were included: 22 in the transposition group and 23 in the combined surgery group. Preoperatively, there were no differences in V pattern, IOOA, or horizontal misalignment in primary position, upgaze, or downgaze between groups. The amount of exotropia in the primary position was 30.2Δ ± 10.7Δ in the transposition group, and 31.6Δ ± 14.1Δ in the combined surgery group (P = 0.974). A significant decrease in V pattern was observed in the combined surgery group and the transposition group at 6 months and 3 years postoperatively (P < 0.001). The reduction of V pattern in the combined surgery group at 6 months (20.2Δ ± 7.8Δ vs 15.6Δ ± 6.9Δ [P = 0.02]) and 3 years (20.1Δ ± 8.1Δ vs 15.2Δ ± 7.1Δ [P = 0.014]) was found to be greater than the transposition group. There were no differences in the success rate in the primary position at 6 months (P > 0.05). CONCLUSIONS: Both tendon transposition with horizontal rectus surgery and combined tendon transposition and IO-weakening surgery decreased V-pattern exotropia. However, combined surgery had a greater effect on decreasing V pattern in patients with mild-to-moderate IOOA.

Does Radioactive Iodine Treatment Damage the Lacrimal System?

PURPOSE: In this prospective study, we aimed to make a quantitative assessment of the lacrimal glands before and after radioactive iodine (RAI) treatment in patients with hyperthyroidism and thyroid cancer. METHODS: The study included 80 eyes of 40 patients. There were 25 patients in group 1 (hyperthyroid group) and 15 patients in group 2 (thyroid cancer group). Group 1 has received low dose ( 131 I) and group 2 high dose ( 131 I). Before, and at the first and sixth month after RAI treatment, all patients underwent ophthalmological examinations, Schirmer tests, TBUT tests, tear osmolarity (TO), and ocular surface examinations. RESULTS: The age and sex characteristics of both groups were similar. Although no significant change was observed in tear film tests before and after treatment in group 1, a significant decrease in Schirmer and TBUT values and a significant increase in TO were observed in group 2 in the first month after treatment. These values returned to normal in the sixth month. Although no Schirmer test was observed lower than 10 mm in any patient before RAI treatment, the Schirmer test was measured 5 to 10 mm in 4 (10%) patients in group 2 in the first month after treatment. Again, in these patients, TBUT was below 10 seconds and TO was greater than 308 mOsm/L. CONCLUSIONS: In this study, although no change was observed in tear function tests in patients receiving low doses of RAI, a decrease in tear secretion and an increase in TO were detected in patients receiving high doses in the early period.

Effect of refractive errors on the results of botulinum neurotoxin administration in patients with infantile esotropia.

PURPOSE: To investigate the effect of refractive errors on the results of patients followed up with infantile esotropia (IE) and treated with botulinum neurotoxin (BNT) injection. METHODS: The files of patients with IE who presented to the ophthalmology pediatric ophthalmology unit and underwent BNT injection into both medial rectus muscles between 2019 and 2021 were reviewed retrospectively. Sixty eyes of 30 patients were included in the study. Patients with additional systemic or ocular diseases and those with a history of ocular surgery were excluded. Distance and near deviations were measured (with the prism cover test or Krimsky method) before and at the first, third, and sixth months after BNT injection. RESULTS: In Group 1 (n = 20) with a spherical equivalent of + 2.0 diopters (D) or less, the mean near and distance deviation value was both 36.8 ± 12.7 prism diopter (PD) before injection. In Group 2 (n = 10) with a spherical equivalent of above + 2.0 D, the near deviation was measured as 35.0 ± 7.1 PD and distance deviation as 31.8 ± 7.9. At six months after BNT injection, the near and distance deviation values were 20.6 ± 12.3 and 20.6 ± 11.6 PD, respectively in Group 1 and 10.1 ± 10.3 and 8.8 ± 10.8 PD, respectively in Group 2. The change in deviation did not statistically significantly differ between the groups (p > 0.05), but the distance and near deviation values were lower in Group 2 at sixth months after BNT injection. CONCLUSIONS: BNT injection is a preferred method in IE. Higher hypermetropic values seem to increase the success of BNT injection.

A Comparative Analysis of Surgical Outcomes for Infantile Esotropia With and Without Prior Botulinum Toxin a Injection.

PURPOSE: To compare the surgical outcomes in patients who had a failed botulinum toxin A injection before surgery versus those who had surgery as primary treatment (primary surgery) for infantile esotropia. METHODS: The files of patients who had strabismus surgery in the Strabismus Unit of Beyoglu Eye Training and Research Hospital between January 2012 and March 2022 were reviewed. This study included 104 eyes of 52 patients with infantile esotropia. The angle of deviation before and 1, 3, and 6 months after botulinum toxin A injection or surgery, complications, pattern deviations, family history, abnormal head position, history of prematurity, intensive care unit admission, and consanguineous marriage were noted. A successful outcome was defined as ocular alignment of 10 prism diopters (PD) or less. RESULTS: The study population consisted of 52 patients: 27 (52%) boys and 25 (48%) girls. In the botulinum toxin A group (n = 26), the mean age at admission was 14.0 ± 6.8 months, whereas the mean preoperative near and far angle of deviation were 41.92 ± 12.2 and 41.3 ± 13.0 PD, respectively. The mean age at the time of surgery was 40.6 ± 18.1 months. In the primary surgery group (n = 26), the mean age at admission was 34.0 ± 15.9 months. The mean preoperative near and far angle of deviation were 37.3 ± 8.0 and 35.3 ± 10.5 PD, respec tively. The mean age at the time of surgery was 48.1 ± 18.5 months. The success rates 6 months after treatment in the botulinum toxin A group and the primary surgery group were 76.9% and 88.5% in near (P > .05) and 80.8% and 88.5% in far (P > .05), respectively. Three patients had transient ptosis and one had consecutive exotropia after botulinum toxin A injection. CONCLUSIONS: In infantile esotropia treatment, strabismus surgery after failed botulinum toxin A injection compared to primary surgery has statistically comparable surgical success rates. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XXX-XXX.].

How Radioactive Iodine Treatment Affects the Retina.

Objective The aim of this study was to quantitatively assess the macular and retinal nerve fiber layer thicknesses in patients with hyperthyroidism and thyroid cancer undergoing radioactive iodine (RAI) therapy. Study Design This prospective study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Bagcilar Training and Research Hospital Clinical Research Ethics Committee. Written informed consent was obtained from the patients following a detailed explanation of the study objectives and protocol. Patient selection was randomized. Patients scheduled for RAI treatment in the Nuclear Medicine Clinic were referred to the ophthalmology clinic, respectively. Patients without additional ocular pathology were included in the study. Methods All patients had received RAI therapy using Iodine-131 for hyperthyroidism or thyroid cancer. A complete ophthalmological examination and measurement of macular and retinal nerve fiber layer thickness using optical coherence tomography were performed on all patients before and at the first and sixth months and in first year after RAI treatment. The results were prospectively evaluated. Results The study included 80 eyes of 40 patients. The hyperthyroid group was group 1, and the thyroid cancer group was group 2. There were 25 patients in group 1 and 15 patients in group 2. The mean age was 43.76 ± 11.85 years (range: 22-65 years) in group 1 and 39.87 ± 9.13 years (range: 30-58 years) in group 2. There was no significant difference between the two groups regarding age and sex ( p > 0.05). In both groups, no significant difference was found in the macular thickness and retinal nerve fiber layer thicknesses values obtained in both eyes before and after the RAI treatment. Conclusion As a result of our study, we observed that RAI intake did not harm the retinal layer.

How to reduce conjunctival cyst formation after strabismus surgery?

PURPOSE: To determine our rate of conjunctival cyst developing after strabismus surgery and to minimize its formation. MATERIALS AND METHODS: The data of 4026 eyes of 2662 patients were included in our retrospective analysis of, those that underwent strabismus surgery at the Beyoglu Eye Training and Research Hospital Strabismus Unit between 2015 and 2021. Clinical characteristics and follow-up data of patients were recorded together with age, sex, and operation type. All patients were examined postoperatively on 1st day, 1st month and 6th month. RESULTS: The mean age of the patients was 15.66 ± 11.81 (1-59 years). While two eyes were operated on in 1494 patients, one eye was operated on in 1168 patients. The surgeries performed were recession and/or resection of the horizontal and vertical rectus muscles and inferior and superior oblique procedures. The conjunctival cyst was detected in 11 patients postoperatively between 20 days and 8 months. The cyst was detected on the nasal side in 7 cases and temporal in 4. CONCLUSION: Conjunctival cyst is a rare complication after strabismus surgery and it is thought to be caused by a proliferation of the conjunctival epithelium. In addition to proper closure of the conjunctiva, attention to personal hygiene, avoidance of contacts that may increase suture contamination, and attention to the fact that the operation period is not long are actions that can help prevent conjunctival cyst formation.

Pulled-in-two syndrome in strabismus surgery for congenital fibrosis of the extraocular muscles.

Purpose: The aim of this study is to present six cases of pulled-in-two syndrome (PITS) in strabismus surgeries and to discuss our prevention and management strategies. Methods: This is a retrospective study presenting cases of PITS during strabismus operations. The medical records of the subjects who underwent operation in the strabismus unit of Beyoglu Eye Training and Research Hospital were reviewed retrospectively, from January 2000 till March 2022. Detailed ophthalmological examination records and angle of deviation were noted. Results: A total of six cases (four males and two females) with a mean age of 37.2 ± 28.0 (min 9-max 71) years were included in this study. All of the cases had congenital fibrosis of extraocular muscles (CFEOM). The most commonly involved muscle was medial rectus (83%). Majority of cases (67%) were adults. In all cases, the muscle was found and reattached to the globe. No patients had diplopia after surgery. Conclusion: PITS is a rare complication that can be seen during strabismus surgeries, and CFEOM patients are in the risk group. Therefore, surgeons should be cautious and prepared in risky patients to be able to manage this complication.

Retinal and choroidal microvasculature is altered after strabismus surgery.

PURPOSE: To evaluate the retinal and choroidal microvasculature after strabismus surgery using swept-source optical coherence tomography angiography (OCTA). METHODS: Thirty-three eyes of 33 patients who underwent horizontal rectus surgery for strabismus were included in this retrospective study. The unoperated fellow eyes were used as the control group. The macular microvasculature was assessed using a 3 × 3 scan pattern centred on the fovea preoperatively, and one week and one month postoperatively. The vessel density (VD) of superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC) were automatically analyzed. The foveal avascular zone (FAZ) was calculated manually using the tool of the device. RESULTS: The VD in SCP demonstrated a significant difference between operated and fellow eyes at one week (p = 0.017). Moreover, a significant increase was observed in the mean VD values in SCP of operated eyes after surgery (p = 0.037). The VD in DCP exhibited no significant differences between operated and fellow eyes before and after strabismus surgery. However, there was a significant difference in VD was observed between operated and fellow eyes one week after surgery (p = 0.001). The mean VD in CC was significantly increased in the operated eyes one week after surgery compared to preoperative values (p = 0.006). CONCLUSION: This study revealed that strabismus surgery may cause transient alterations both in retinal and choroidal microcirculation in the early postoperative period.

Treatment of convergence insufficiency type intermittent exotropia with bupivacaine injection to the medial rectus combined with lateral rectus recession.

PURPOSE: To evaluate the outcomes of combined bupivacaine HCL (BPX) injection in the medial rectus (MR) muscle with recession of the lateral rectus muscle in the treatment of convergence insufficiency-type intermittent exotropia (CI-IXT). METHODS: The medical records of patients who underwent combined injection-recession treatment from January 2019 to January 2020 for CI-IXT were reviewed retrospectively along with a group of age-matched controls with IXT without CI who underwent only unilateral LR recession during the same period. The following data were extracted from the record: age at surgery, average follow-up period, angle of deviation at distance and near and the difference between them before and after surgical procedure, correction of near and distance deviations, and recession dosage. Successful outcome was defined as a distance deviation in primary gaze between ≤10Δ of exophoria/tropia and ≤5Δ of esophoria/tropia. RESULTS: A total of 10 patients and 20 controls were included. Average follow-up was 13.9 ± 3.67 months in the BPX group and 15.9 ± 3.61 months in the control group (P = 0.17). Postoperative distance deviation measured 8.30Δ ± 5.88Δ in the BPX group and 14.67Δ ± 9.83Δ in the control group (P = 0.80). Distance-near differences were significantly reduced in the CI-IXT group receiving BPX, by a mean of 6.60Δ, from a preoperative mean of 10.50Δ ± 3.65Δ to 3.90Δ ± 3.26Δ (P < 0.01). CONCLUSIONS: BPX injection combined with unilateral lateral rectus recession yields outcomes comparable to bilateral lateral rectus recession for distance deviations, and results in reduction of the distance-near difference in the angle of exotropia.

Brown Syndrome: Features and Long-term Results of Management.

OBJECTIVES: The goal of this study was to evaluate surgical techniques and outcomes in patients with Brown's syndrome. METHODS: A retrospective review was conducted of patients who underwent surgery of the superior oblique (SO) muscle between 2003 and 2011 at a referral center. RESULTS: In all, 190 patients (111 female and 79 male) with an age range of 4-50 years were included in the study. The right eye was affected in 98 patients, and the left eye in 92 patients. Abnormal head posture (AHP), ocular movement (OM), and hypotropia were assessed. The greatest improvement of AHP was seen following an SO temporal tenotomy (91%). Patients with a -4 limitation achieved full OM after a SO temporal tenotomy. CONCLUSION: Temporal tenotomy provided the best improvement in limitation of elevation in adduction.

Muscle belly union surgery with or without medial rectus recession for the treatment of high myopic strabismus fixus.

PURPOSE: To evaluate the results of surgery involving the union of the superior rectus muscle and the lateral rectus muscle with or without medial rectus recession (MRc) for the treatment of high myopic strabismus fixus over a 20-year period. METHODS: The medical records of patients who underwent muscle belly union for the treatment of high myopic strabismus fixus were reviewed retrospectively. Patients were classified according to the timing of MRc. In group 1, MRc was performed before muscle union surgery; in group 2, MRc was performed concurrent with muscle union surgery; in group 3, MRc was not performed; in group 4, MRc was performed after muscle union surgery. RESULTS: A total of 50 eyes of 40 patients were included. Mean esotropia decreased from 57.27Δ ± 25.45Δ (range, 8Δ-100Δ) before surgery to 11.67Δ ± 13.85Δ (range, -18Δ to 45Δ) after (P < 0.001); mean hypotropia, from 6.05Δ ± 9.13Δ (range, 0Δ-13Δ) before to 1.20Δ ± 3.03Δ (range, 0Δ-10Δ) after (P < 0.001). Mean abduction improved from -2.82 ± 1.17 (range, -4 to 0) before to -0.75 ± 0.92 (range, -3 to 0) after (P < 0.001); mean elevation, from -1.62 ± 1.62 (range, -4 to 0) before to -0.57 ± 0.90 (range, -3 to 0) after (P < 0.001). Preoperative esotropia and postoperative limitation in abduction were significantly lower in group 3 (P = 0.03; P = 0.01). CONCLUSIONS: Muscle union surgery successfully corrected the restrictive esotropia and hypotropia. MRc in addition to muscle union surgery was not necessary for some patients, for whom preoperative esotropia was lower.

Assessment of Refractive Error Changes and Factors for Decompensation in Patients With Fully Accommodative Esotropia.

PURPOSE: To determine the factors affecting the risk of deterioration and evaluate the refractive error change in patients with fully accommodative esotropia. METHODS: Patients diagnosed as having fully accommodative esotropia (esotropic deviation that started before 7 years of age and less than 8 to 10 prism diopters [PD] of esotropia with full hyperopic correction and/or bifocals) were included in this retrospective population-based cohort study. Refractive error changes were recorded. For comparisons, patients were divided into two groups: nondecompensated fully accommodative esotropia group and decompen-sated fully accommodative esotropia group. RESULTS: Two hundred and twenty-three patients met the inclusion criteria. The mean follow-up time was 5.94 ± 0.31 years (range: 5 to 8 years). The changes in spherical equivalent in the younger than 7 years, 7 to 12 years, and 12 to 17 years groups were statistically significant (P < .001). The decrease of hypermetropia was 0.13 diopters/year between 7 and 12 years and 0.06 diopters/year between 12 and 17 years. Forty-one of 223 patients (18.4%) discontinued spectacle therapy during the follow-up period. Hyperopic error and presence of amblyopia were lower, whereas visual acuity level and presence of near-distance disparity were higher in the spectacle discontinuation group (P < .001, .007, .01, and 0.01, respectively). Deterioration of fully accommodative esotropia occurred in 30 of 223 patients (13.5%). Boys were more likely to require strabismus surgery (P = .32). The mean age at presentation, esotropia angle with and without refractive correction at both near and distance fixation, near distance disparity, and inferior oblique overaction were significantly higher in patients with decompensated fully accommodative esotropia. CONCLUSIONS: Hyperopic error increased from the initial level until 7 years of age, followed by a myopic shift thereafter. Few children had resolution of fully accommodative esotropia and could discontinue spectacle therapy. Children with male gender, higher esotropia angle, older age at presentation, near-distance disparity, and inferior oblique overaction experienced a greater deterioration of the fully accommodative esotropia. [J Pediatr Ophthalmol Strabismus. 2020;57(4):217-223.].

Comparison of different tendon transposition techniques for the treatment of monocular elevation deficiency type 2.

PURPOSE: To compare results of three different tendon transposition techniques (Knapp procedure and two modified techniques) for the treatment of type 2 monocular elevation deficiency (MED) patients. METHODS: The medical records of patients with MED type 2 operated on at a single institution from 2000 to 2016 were reviewed retrospectively. Patients were divided into three vertical transposition groups: (1) full tendon width, (2) augmented surgery; and (3) partial tendon width. Surgical success was defined as no severe limitation of upgaze, hypotropia of <6Δ, and no hypertropia in primary position. Pre- and postoperative vertical deviations in the primary position and limitations in elevation levels were compared. RESULTS: A total of 39 patients were included. The pre- and postoperative deviations in the full-tendon group were 22.50Δ ± 4.17Δ and 3.50Δ ± 1.27Δ, respectively; in the augmented surgery group, 23.75Δ ± 4.78Δ and 1.75Δ ± 1.14Δ; and in the partial-tendon group, 20.50Δ ± 3.98Δ and 4.12Δ ± 2.78Δ. Corrected vertical deviations were 19Δ, 23Δ, and 16Δ, respectively. The pre- and postoperative limitation of elevations were -2.80 and -0.80 in the full-tendon group, -3.20 and -0.90 in the augmented surgery group, and -2.37 and -1.12 in the partial-tendon group. The pre- and postoperative vertical deviation improvements and limitations of elevation were statistically significant (P < 0.05) in all groups. Success was achieved in 29 patients (74%). CONCLUSIONS: In this study cohort, all three procedures were reasonably effective in improving vertical deviations and limitation of elevation.

The Role of Ocular Response Analyzer in Differentiation of Forme Fruste Keratoconus From Corneal Astigmatism.

PURPOSE: To determine the diagnostic accuracy of corneal biomechanical factors in differentiating patients with forme fruste keratoconus (FFKC) from astigmatic and normal cases. METHODS: A total of 50 eyes with FFKC, 50 with astigmatism and 50 normal eyes, were included in this study. All patients had a detailed ophthalmologic examination including slit-lamp evaluation, Goldmann tonometry, indirect fundoscopy, topography by Scheimpflug imaging biomicroscopic anterior and posterior segment examination, and corneal biomechanical and intraocular pressure evaluation with ocular response analyzer (ORA). RESULTS: All topographic findings were statistically significant among the three groups (P>0.05). Although there was no statistically significant difference in the corneal-compensated intraocular pressure (IOPcc) among the three groups, the Goldmann-correlated intraocular pressure (IOPg), corneal hysteresis (CH), and corneal resistance factor (CRF) were statistically significantly lower in the FFKC group, compared with the other groups (P<0.001). There were no statistically significant difference in the IOPg, CH, and CRF between astigmatism and control groups (P=0.99, 0.79, and 0.86, respectively). The area under the receiver operating characteristic (AUROC) curve was greater than 0.85 for IOPg (0.80), CH (0.85), and CRF (0.90) for discriminating between FFKC and controls; whereas the AUROC was greater than 0.85 for IOPg (0.80), CH (0.79), and CRF (0.85) for discriminating between FFKC and astigmatism groups. CONCLUSION: Based on our study results, in differentiation of patients with FFKC from normal control cases or astigmatic patients, corneal biomechanical parameters play a role particularly in patients with suspicious results. We suggest using ORA in combination with corneal topography for better and more accurate diagnosis of FFKC.

INTRAVITREAL DEXAMETHASONE IMPLANTATION IN PATIENTS WITH DIFFERENT MORPHOLOGICAL DIABETIC MACULAR EDEMA HAVING INSUFFICIENT RESPONSE TO RANIBIZUMAB.

PURPOSE: To evaluate the effectiveness of a single intravitreal injection of dexamethasone implant in resistant diabetic macular edema that have different morphological types. METHODS: In this retrospective study, 31 patients (35 eyes) with persistent diabetic macular edema, who underwent a single injection of dexamethasone implant, were evaluated. Diabetic macular edema was classified into three types: diffuse retinal thickening (n = 10), cystoid macular edema (n = 13), and serous retinal detachment (n = 12). Primary outcome measures were best corrected visual acuity, and central macular thickness. RESULTS: The three subgroups were similar in terms of age and gender (P > 0.05). Total duration of diabetes was significantly less in the serous retinal detachment subgroup (P = 0.01). There were no differences in the best corrected visual acuity between the three subgroups until the sixth month. However, the best corrected visual acuity was significantly better in the diffuse retinal thickness subgroup at the sixth month (P = 0.008). Regarding the central macular thickness values, it was statistically better in serous retinal detachment than in diffuse retinal thickening and cystoid macular edema subgroups till the sixth month (P = 0.001). However, at the sixth month, there was not any statistical difference between subgroups regarding central macular thickness values. Antiglaucomatous agents were required in 4 (11.4%) patients throughout the study. CONCLUSION: Treatment algorithms should differ according to the morphology of diabetic macular edema; however, more data is needed to give specific recommendations.

Does severity of dermatochalasis in aging affect corneal biomechanical properties?

PURPOSE: The aim of this study was to investigate the possibility of a relationship between corneal biomechanical properties and different grades of dermatochalasis. PATIENTS AND METHODS: Patients were assigned to four groups according to the severity of their dermatochalasis: normal (Group 1), mild (Group 2), moderate (Group 3), and severe (Group 4). An Ocular Response Analyzer device was used to measure corneal hysteresis (CH), corneal resistance factor (CRF), and corneal-compensated intraocular pressure (IOPcc). RESULTS: We found no significant differences in the mean values of the CH, CRF, and IOPcc of all groups (P=0.75, P=0.93, and P=0.11, respectively). However, CH and IOPcc were negatively correlated in Group 1, Group 2, and Group 3 patients (P=0.013, r=-0.49; P=0.015, r=-0.52; and P=0.011, r=-0.47, respectively), but this correlation was not apparent in the Group 4 patients (P=0.57, r=0.12). CRF and IOPcc were correlated, but only in Group 4 (P=0.001, r=0.66). CONCLUSION: Severe dermatochalasis was associated with altered corneal biomechanical properties. Some of the important visual consequences of dermatochalasis and related diseases (such as floppy eyelid syndrome) can be understood by considering corneal biomechanical alterations.

Amniotic membrane in the management of strabismus reoperations.

PURPOSE: To reduce postoperative scar formation and to improve duction using amniotic membrane (AM) in strabismus reoperations. METHODS: A prospective study of interventional case series comprised of 14 patients with restrictive strabismus. Objective clinical findings (visual acuity, angle of deviations and degree of duction deficits) were recorded in both the pre- and post-operative periods. Strabismus surgery included the excision of adhesions and scar tissue, repositioning of extraocular muscles (according to the degree of deviations) and placement of two sheets, one between muscle and tenon and the other between muscle and sclera. Conjunctival recession with covering of the bare sclera using AM was also performed. RESULTS: The mean preoperative deviation of the patients was 34.3 prism diopters (PD) and mean post-operative deviation was 4.6 PD. The mean pre-operative duction deficit of the patients was 1.7; mean post-operative duction deficit was 0.2. Postoperatively all patients improved in relation to deviation and duction. Less than 8 PD deviations with no duction deficits were achieved in 12 (86 %) of the patients. CONCLUSIONS: Amniotic membrane placement around the extraocular muscle improves the duction and decreases the residual angle of deviations by inhibiting postoperative scar formation.