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Periosteal fixation of the medial and lateral recti for large-angle incomitant exotropia

  • Oculoplastics and Orbit
  • Published:
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Abstract

Purpose

To describe the evolution of a surgical technique for the correction of large-angle incomitant exodeviations.

Methods

Retrospective review of an interventional case series from 2005 to 2019 in a single centre, with analysis of surgical procedure, prism diopter (PD) deviations and complications.

Results

Thirty-one patients underwent surgery at an average age of 42 years (range 4–75 years) for minimal medial rectus function, mostly from oculomotor nerve palsy (23/31; 74%). The mean pre-operative exodeviation was 75 PD (range 30–200PD). Sixteen patients (52%) had undergone previous strabismus surgery. Thirty-eight operations were performed in which the medial rectus insertion was anchored to the periosteum of the posterior lacrimal crest via a retrocaruncular transconjunctival approach. The ipsilateral lateral rectus (LR) was disinserted and fixed to lateral orbital tissue in 29/38 (76%) operations, injected with botulinum toxin in 5, recessed in 2 and had already undergone maximal LR recession in 2. In all but the first 8 operations, temporary limbal sutures were passed through the eyelids to maximally adduct the globe post-operatively. At last follow-up (mean 24 months; range 2–130), the mean reduction in exodeviation was 49PD (range 10–80) and overall residual deviation was 26PD (range 80PD base-in to 14PD base-out). The 5 LR toxin procedures had a mean reduction of 22PD (range 10–40). Seven patients had persistent diplopia, one a transient corneal erosion and one caruncle suture exposure 4 years after surgery.

Conclusion

Large-angle exodeviations can be markedly improved by bi-rectus fixation. This approach is both safe and effective and can be performed in complex patients with multiple previous procedures.

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Funding

Professor Geoffrey Rose receives some funding from the National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology.

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Authors and Affiliations

  1. Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK

    Sarah Hull, Huda Al-Hayouti, David H. Verity, Geoffrey E. Rose & Gillian G. W. Adams

  2. UCL Institute of Ophthalmology, London, UK

    Sarah Hull, David H. Verity & Geoffrey E. Rose

Authors
  1. Sarah Hull
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  2. Huda Al-Hayouti
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  3. David H. Verity
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  4. Geoffrey E. Rose
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  5. Gillian G. W. Adams
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Contributions

All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data; or the creation of new software used in the work, and revised it critically and approved the version to be published and agree to be accountable for all aspects of the work.

Corresponding authors

Correspondence to Sarah Hull or Gillian G. W. Adams.

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Ethics approval

This study was approved by the Clinical Audit Assessment Committee of Moorfields Eye Hospital (CA17/AD/12).

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For this anonymous, retrospective review of outcomes, individual formal patient consent was not required.

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The authors declare no competing interests.

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Meeting presentations

Poster presentation AAPOS 2018, oral presentation BIPOSA 2018, poster presentation RANZCO 2019

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Supplementary file1 (DOCX 19 KB)

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Hull, S., Al-Hayouti, H., Verity, D.H. et al. Periosteal fixation of the medial and lateral recti for large-angle incomitant exotropia. Graefes Arch Clin Exp Ophthalmol 260, 2347–2351 (2022). https://doi.org/10.1007/s00417-022-05567-z

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  • DOI: https://doi.org/10.1007/s00417-022-05567-z

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