Repeat Surgery for Patients Operated in Childhood for Early-Onset Esotropia and Suffering from Persistent Residual,...

Patients operated in childhood for early esotropia may suffer from persistent strabismus, whether residual, recurrent, or consecutive, usually with a more complex oculomotor imbalance than in primitive strabismus.

The clinical data are fundamental, in particular, (1) the basic accommodation-free deviation, (2) the horizontal far/near incomitance, (3) the cyclovertical incomitances and/or A or V pattern, and (4) the motility restrictions. In complicated cases, magnetic resonance tomography of the orbits showed the anomalies of the eye and muscle position. The intraoperative findings have to be taken into account, such as (1) the position of the eyes and (2) the muscle extensibility in antagonistic muscle pairs. Twenty-seven patients, aged 16 to 62, were included in the present retrospective study. All of them had repeat surgery between 2013 to 2018, 15 for residual esotropia and 12 for consecutive exotropia.

In five of the eight patients with posterior fixation sutures on the medial recti, the residual exo or estropia was moderate and could be corrected with a recession or tuck of the lateral recti. In the three other patients with pronounced esotropia, revision of the posterior fixation sutures was carried out. In 19 patients (11 esotropia and 8 exotropia) with only prior conventional surgery, the surgical choice for the residual deviation went electively to the muscles that were most responsible for the motor imbalance, without using posterior fixation sutures. In 4 of these 19 patients, the deviation was small due, in particular, to residual incomitances. For any persistent cyclovertical incomitance, the overacting oblique muscles were recessed, and, in four patients with an A or V pattern, the lateral rectus insertions shifted to the horizontal meridian in the same procedure.

The two main difficulties are to assess (1) the imbalance of the active and passive muscle force and (2) the surgically induced incomitances.