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Treatment of Progressive Esotropia Caused By High Myopia
A New Surgical Procedure Based on Its Pathogenesis
Tsuranu Yokoyama, MD
(Dept. of Pediatric Ophthalmology, Osaka City General Hospital)
Shinsuke Ataka, MD
(Dept. of Ophthalmology, Osaka Ekisaikai Hospital)
Hitoshi Tabuchi, MD, Kunihiko Shiraki, MD and Tokuhiko Miki, MD
(Dept. of Ophthalmology, Osaka City University Medical School)
Definition of Progressive Esotropia Caused by High Myopia
■ Presence of high myopia with an axial length somet
imes greater than 30 mm.
■ Abduction and sursumduction are limited, and the f
orced duction test is positive.
■ Leads to esotropia fixus in some cases.
Coronal MRI Scans of Case 2
3-D Reconstruction from MRI
Frontal viewFrontal view
Temporal viewTemporal view Nasal viewNasal view
Dorsal viewDorsal view
Right Eye of Case 2Right Eye of Case 2
SRSR
MRMR
IRIRLRLR
ONON
SR
ON
LRIR
MR
Summary of Patients
Case No.
SexAge at
Surgery
(years)
Onset
(years)Previous
Surgeries*
Axial Length (mm)
Maximum Angle of Abduction
(deg.) Angle of Deviation
(deg.)R L R L
1 F 53 38 RR 32.37 32.12 -70 -70 +140
2 F 58 35 RR, Tr unknown 34.64 -70 -70 +140
3 F 70 unknown none 27.86 - -67 - +67
4 F 66 51 RR - 29.89 - -15 +35
5 F 45 40 none 35.53 34.63 -40 -20 +40
6 F 62 14 MRR, Tr 30.30 - +5 - +31* RR: recession and resection, Tr: transposition of SR & IR, MRR: medial rectus recession
Possible Surgical Procedures
1. Recession and Resection
2. Recession of the MR
3. Transposition of the LR and MR
4. Superior Fixation of the LR
5. Junction of the SR and LR
Case 4: Joining the SR and LR After Splitting (into halves)
SR
LR
17 Sep 1999
Variables to Evaluate the Results of Surgery
1. The degree of dislocation of the eyeball out
of the muscle cone (angle of dislocation)
2. The maximum angle of abduction
3. The angle of ocular deviation
Measuring the Angle of Dislocation of the Eyeball
Preoperative
181.1 deg.
LR
SR
Postoperative
103.6 deg.
LR
SR
The center positions were measured with Scion Image® software.
0
50
100
150
200
250
300
S1-R
S1-L
S2
S3
S4
S5-R
S5-L
S6
Decrease of the Angle of Dislocation
Preoperative Postoperative
(deg)
Mean 216.7 deg.
Mean 136.4 deg.
Measuring the Maximum Angle of Abduction
30 Sep 1999
L R
Preoperative
Postoperative
20 Sep 2000
Red circles illustrate the range of duction movements for normal subjects.
-80
-60
-40
-20
0
20
40
60
80 S1-R
S1-L
S2
S3
S4
S5-R
S5-L
S6
Improvement of the Max. Angle of Abduction
Preoperative Postoperative
(deg)
Mean –46.3 deg.
Mean +34.0 deg.
20 Aug 1999
Postoperative (52 days after surgery)
PreoperativeCase 1
24 Jan 2000
Postoperative OS (69 days after surgery)
PreoperativeCase 2
2 Dec 1999
16 Mar 2000
Postoperative OD (52 days after surgery)
PreoperativeCase 6
13 Mar 2000
24 Dec 1999
Case 5: Photographic History of Surgery
8 Feb 1999
5 Feb 1999
20 Sep 1999
5 Feb 1999 MR recession OU
21 Sep 1999 SR-LR (split) OD21 Oct 1999
25 Nov 19995 Nov 1999 SR-LR (whole) OS
(split): Junction of split muscles(whole): Junction of whole muscles
Case 5: Changes of Ocular Deviation over Time
0
20
40
60
80
100
1-Feb-99 1-May-99 1-Aug-99 1-Nov-99
(pd) BMR recession
SR-LR (S) OD SR-LR (W) OS
Esotropia reappeared 3 months after bilateral MR recession
85 pd
45 pd
Improvement of the Angle of Deviation
-40
-20
0
20
40
60
80
100
120
140
160
S1
S2
S3
S4
S5
S6
Preoperative Postoperative
(deg)
Mean 75.5 degrees
Mean 15.8 degrees
Conclusions
■ A surgical procedure to bind the superior and
lateral rectus muscles was effective in improving
the ocular motility and deviation in esotropia
caused by high myopia.
■ This procedure worked by restoring the dislocated
eyeball back into the muscle cone.
Conclusions
■ Recession of the medial rectus muscle may not
always be necessary for treating esotropia caused
by high myopia.
■ Resection of the lateral rectus muscle is best
avoided, because it can facilitate dislocation of the
eyeball out of the muscle cone.