Cirugía monocular de 4 músculos extraoculares para la exotropía monocular de gran ángulo / Unilateral four muscle surgery for extra-large monocular exotropia

Introducción La exotropía recurrente es común después de cirugía para exotropía sensorial monocular constante de gran ángulo. La cirugía generalmente se limita al ojo afectado. El debilitamiento simultáneo de los músculos oblicuos ipsilaterales puede mejorar el efecto de la cirugía de los músculos rectos horizontales al disminuir las fuerzas de abducción. Presentamos los resultados de la cirugía simultánea de debilitamiento de los músculos oblicuos combinados con cirugía del músculo recto horizontal ipsilateral con exotropía monocular constante superior a 35 dioptrías prismáticas (DP). Métodos Serie retrospectiva en casos de retroinserción unilateral del recto lateral combinada con resección del recto medial, y debilitamiento simultáneo de ambos músculos oblicuos ipsilaterales. La medida de resultado fue la alineación ocular en la posición primaria. Resultados Se incluyeron 12 ojos de 12 pacientes. La exotropía preoperatoria mejoró de 57,9±15,1DP (rango 35-80; mediana 60) a 3,3±5,5 (rango 0-16; mediana 0) postoperatoriamente (p<0,005). Dos (66%) pacientes con desviación vertical preexistente tuvieron una resolución de su desalineación vertical postoperatoriamente. En el último seguimiento postoperatorio, el 92% de los pacientes tenían una exodesviación de 10DP o menos y 7 (58%) midieron ortotropía. La abducción postoperatoria midió −0,6±1(0 a −3) y la aducción −0,4±0,7 (0 a −2). Conclusión El debilitamiento de los músculos oblicuos puede mejorar el efecto de la cirugía de los músculos rectos horizontales al disminuir las fuerzas de abducción en casos de exotropía monocular de gran ángulo. Como ventaja adicional, la cirugía del músculo oblicuo se puede utilizar simultáneamente para abordar las desviaciones verticales asociadas (AU)

Introduction Recurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD). Methods Retrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position. Results Twelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9±15.1 (range 35–80; median 60PD) to 3.3±5.5 (range 0–16; median 0PD) postoperatively (p<0.005). Two (66%) patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92% of the patients had an exodeviation of 10PD or less (range 0–16PD median 0PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured −0.6±1 (0 to −3) and adduction −0.4±0.7 (0 to −2). Conclusion Weakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations (AU)

Unilateral four muscle surgery for extra-large monocular exotropia.

INTRODUCTION: Recurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD). METHODS: Retrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position. RESULTS: Twelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9 ±â€¯15.1 (range 35-80; median 60 PD) to 3.3 ±â€¯5.5 (range 0-16; median 0 PD) postoperatively (p < 0.005). Two of 3 patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92% of the patients had an exodeviation of 10 PD or less (range 0-16 PD median 0 PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured -0.6 ±â€¯1 (0 to -3) and adduction -0.4 ±â€¯0.7 (0 to -2). CONCLUSION: Weakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations.

Novel Inferior Oblique Muscle Y Splitting Procedure to Minimize the Anti-Elevation Syndrome: A Pilot Study.

Purpose: To describe novel Y splitting procedure of inferior oblique muscle to mitigate the anti-elevation syndrome. Methods: A pilot, prospective interventional study was undertaken to assess the effect of inferior oblique muscle Y-splitting in patients with unilateral 3+ or more overaction. To correct primary gaze hypertropia and the excyclotorsion, a Y-splitting procedure was performed (along with routine horizontal muscle surgery as per the deviation) in 14 subjects. The effect of surgery was assessed at baseline and at 6 months post-intervention. Results: The mean age of 14 subjects was 25.14±7.70 years. The mean pre-operative hypertropia, excyclotorsion and inferior oblique muscle over-action was 18.42±3.50 PD, 14.14±2.65 degrees, and +3.21±0.42 respectively. Following surgery, this was reduced to 1.57±1.74 PD of residual hypertropia (a net correction of 16.85±2.31 PD, p = 0.005), 3.85±1.46 degrees of residual excyclotorsion (a net correction of 10.28±1.72 degrees, p < 0.05), and +0.28±0.46 of residual inferior oblique over-action (a net correction ~+3) at the end of 6 months. Amongst fourteen patients, three patients still experienced residual/variable anti-elevation effect, and during the study period none of them experienced any adverse event and none of them required any additional surgeries. Conclusion: While anteriorizing the inferior oblique muscle to correct primary gaze hypertropia and the excyclotorsion, a novel "Y splitting" procedure can be followed to achieve the desired results with mitigated anti-elevation effect.