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Three-muscle surgery markedly reduces deviation in large-angle infantile esotropia
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Three-muscle surgery yielded good short- and medium-term outcomes in patients with large-angle infantile esotropia, according to a study.
The retrospective study included 18 patients with large-angle infantile esotropia who underwent bilateral medial rectus muscle recession and one lateral muscle resection. Median patient age was 22 months.
Patients had onset of esotropia earlier than 6 months of age, 5/10 or better visual acuity or ability to fixate in each eye, no previous ocular muscle surgery, no neurological abnormalities or developmental delay, no organic ocular disease and preoperative esotropia of at least 55 ∆D at distance with spectacles.
Investigators assessed preoperative and postoperative deviation, overcorrection, undercorrection, need for subsequent horizontal surgery and length of follow-up. Median follow-up was 32 months.
Orthotropia to within 10 ∆D or less was achieved in 14 patients (78%).
Mean deviation decreased significantly, from 68.8 ∆D preoperatively to a median of 1 ∆D (P < .005).
Four patients had marked residual esotropia greater than 15 ∆D, requiring further surgery. No significant overcorrection greater than 10 ∆D was reported.
Disclosure: The authors have no relevant financial disclosures.
Perspective
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Scott E. Olitsky, MD
This is a small non-comparative series, and it is therefore not possible to make any direct comparisons to two-muscle surgery for patients with large-angle infantile esotropia. Although the authors report a low incidence of overcorrection, it should be noted that more than 20% of the patients had a significant undercorrection, which required another surgery. Both undercorrections and overcorrections should be considered an unwanted outcome, and one is not more favorable than the other. Undercorrections often occur in the setting of large-angle strabismus because too little surgery is performed at the time of initial correction. This is true for both two-muscle and three-muscle surgery. Historically, two-muscle surgery had a higher rate of undercorrection because of concerns that larger recessions would lead to significant duction deficits. This is no longer thought to be true by most strabismus surgeons. This study does show that good results are obtainable in a large percentage of patients with large-angle esotropia by performing greater amounts of surgery. The choice between two- and three-muscle surgery remains open to debate.
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