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 Table of Contents  
Year : 2017  |  Volume : 110  |  Issue : 3  |  Page : 105-108

Adult divergence insufficiency esotropia: a comparison of lateral rectus resection, medial rectus recession, and miniplication of lateral rectus

Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission14-May-2017
Date of Acceptance09-Jul-2017
Date of Web Publication6-Nov-2017

Correspondence Address:
Manar A Ghali
Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, 2134
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejos.ejos_34_17

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The aim of this study was to compare the outcomes and efficacy of three surgical procedures for correction of adult divergence insufficiency esotropia: lateral rectus resection (LRR), medial rectus recession (MRR), and Wright lateral rectus miniplication (LRMP).
Patients and methods
A retrospective study was conducted on 22 patients with adult divergence insufficiency esotropia who were operated between 2012 and 2016; eight of them underwent LRR, six underwent MRR, and eight underwent LRMP. Their age ranged from 45 to 68 years. Esotropia was at least 10Δ greater at distance than at near. All patients did not have significant esotropia at near [0–6 prism diopter (PD)] with fusion at near; all of them complained of diplopia for far with no underlying neurological diseases. The mean follow-up period was 24 (12–40) months. Achieving single vision at far and postoperative deviation of up to 5 PD was considered a successful result.
Age at presentation was 45–68 years, with mean age of 56.8±7.7 years. All the cases underwent bilateral surgeries. In group LRR, the preoperative angle of deviation at far was 20.5±5.8 prism diopter(PD) and for near was 2.9±2.4 PD. In group MRR, the preoperative angle of deviation at far was 21.7±6.1 PD and for near was 3.5±2.8 PD. In group LRMP, the preoperative angle of deviation at far was 21.4±8.5 PD and for near was 3.1±2.7 PD. Postoperative, no cases of diplopia were reported along the follow-up period in groups MRR and LRMP, whereas one case of the eight cases of group LRR showed diplopia. The postoperative angles for far in LRR, MRR, and LRMP groups were 2.38±2.1, 2.5±2.3, and 2.25±1.8 PD, respectively.
The three procedures had excellent outcomes in eliminating diplopia and postoperative alignment, but LRMP has the advantage to be vessel sparing, less invasive, reversible, and being able to be done with topical anesthesia.

Keywords: divergence insufficiency, esotropia, lateral rectus resection, medial rectus recession, miniplication

How to cite this article:
Ghali MA. Adult divergence insufficiency esotropia: a comparison of lateral rectus resection, medial rectus recession, and miniplication of lateral rectus. J Egypt Ophthalmol Soc 2017;110:105-8

How to cite this URL:
Ghali MA. Adult divergence insufficiency esotropia: a comparison of lateral rectus resection, medial rectus recession, and miniplication of lateral rectus. J Egypt Ophthalmol Soc [serial online] 2017 [cited 2018 Dec 15];110:105-8. Available from: http://www.jeos.eg.net/text.asp?2017/110/3/105/217701

  Introduction Top

Adult divergence insufficiency esotropia (ADIE) typically presents in individuals with older age. Rochester Epidemiology Project study demonstrated that 10.6% of cases of adult strabismus, with median age of 74 (range: 19–92) years were presented with ADIE [1]. ADIE is most commonly defined as an acquired comitant esotropia (ET) that is at least 10Δ greater at distance than at near [2]. It was thought that ADIE resulted from inadequate functioning of a divergence center in the brain [3]; an idea was introduced by Guyton [4] who stated that increased convergence over time leads to divergence insufficiency by time.

Chaudhuri and Demer [5] suspected orbital connective tissue degeneration (sagging eye syndrome) to be the cause, and they did MRI for these patients, which revealed significant lateral rectus pulley displacement.

The horizontal binocular diplopia for distance significantly impaired quality of patients’ life. Surgical and nonsurgical treatments have been advocated [6],[7]. Base-out prisms are effective for smaller deviation, but in patients who do not prefer prismatic correction or with larger deviation, surgery was recommended. Resection of one or both LR muscles has been proven to be effective [8]. Medial rectus recession (MRR) was also reported as effective as LR resection [9],[10]. Leenheer and Wright [11] advocated miniplication to treat small-angle strabismus, which can be used in ADIE. The aim of this work is to compare the efficacy and outcomes of LRR, MRR, and LRMP in the treatment of ADIE.

  Patients and methods Top

A retrospective study was conducted on 22 patients with ADIE operated in the Ophthalmology Department, Zagazig University, in the period between 2012 and 2016. The study was approved by the Institutional Review Board of faculty of medicine, Zagazig University.

Only patients with orthophoria or asymptomatic esophoria of no more than 8 PD (Δ) at 33 cm with symptomatic distance ET with far near disparity of 10Δ or more were included. Operations were done at least 6 months after complaining of diplopia.

The patients were divided into three groups according to type of surgery done for them: lateral rectus resection (LRR) group (n=8), MRR group (n=6), and lateral rectus miniplication (LRMP) group (n=8).

Comparisons among groups were performed for age, sex, best-corrected visual acuity measured with logarithm of minimum angle of resolution, spherical equivalent refractive error, preoperative distance and near deviation, preoperative convergence amplitude measured with base-out prisms, amount of strabismus surgery performed, and postoperative angle of deviation at near and far until last follow-up visit.

In LRR group, all cases underwent symmetrical LRR (4.5–7 mm); in MRR, symmetrical bilateral recession of medial rectus (4–5.5 mm) was done; and in LRMP, bilateral lateral rectus 6/0 polyglactin 9/0 sutures were secured to the central 3–4 mm of the muscle belly (4–6.5 mm) posterior to the insertion and was passed to the sclera anterior to the insertion to plicate the central part of the muscle.

All the cases were done under general anesthesia; only three cases of LRMP group were performed with 1% lidocaine hydrochloride solution as topical anesthesia.

Achieving single vision at far and postoperative deviation of up to 5Δ was considered a satisfactory result.

The collected data were coded and analyzed using SPSS (SPSS Inc., IBM Company, Chicago, USA). The level of significance was set at P value less than 0.05. The power of study was at 80–95% confidence interval. Mean, median, SD, and range were used for quantitative data summarization, and one-way analysis of variance test and Kruskal–Wallis test were performed for their analysis. For qualitative data summarization, number and percentage were used, and χ2test was performed for analysis.

  Results Top

Of the 22 patients with ADIE, eight underwent symmetrical bilateral LRR in group LRR, six patients underwent symmetrical bilateral MRR in group MRR, and eight underwent bilateral LRMP. [Table 1] shows the comparison among the three groups according to preoperative data.
Table 1 Intergroup comparison according to preoperative data

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In all cases (except for one case in LRR group), there was satisfactory postoperative improvement in binocular alignment in primary gaze for distance with no induction of near diplopia in any case.

In LRR group, one case showed postoperative ET angle greater than 5 PD, and in MRR group, one case showed exotropia greater than 5 at near, whereas in LRMP group, the postoperative angle at near and far was up to 5 PD. [Table 2] shows intergroup comparison according to amount of surgery done, postoperative angle at near and far, surgical dose–response effect, and diplopia relief. There was no statistically significant difference between the results of the three techniques.
Table 2 Comparison among the three groups according to amount of surgery and postoperative results

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  Discussion Top

Patients with ADIE may undergo surgical treatment if they do not respond to or tolerate the treatment with prism. The surgical treatment of ADIE can be approached by different techniques. As the cause of divergence insufficiency is further elucidated, treatments may evolve as well, to target the pathological causes [12]. Daniel and Jacobson [13] recommended deferring consideration of strabismus surgery in patients with ADIE for a sufficient period of time after patients’ complain of it, as some cases resolve spontaneously. In this study, operations were done for the included cases after at least 6 months of ADIE onset.

LRR has been advocated by many authors for ADIE [14],[15], as they claimed that it improved distance ET without causing convergence insufficiency at near. In this study, 87.5% of LRR group had a satisfactory result with no diplopia, which is comparable to previous studies [16]. No recurrence occurred through mean follow-up period of 24 months, though other studies reported recurrence rate [8].

Chaudhuri and Demer [10] concluded that MRR is as effective as LRR in treatment of ADIE. In this study, we did bilateral MRR (4–5.5 mm), and the angle at distance improved from 21.7 to 2.5 PD, which is comparable to the results of Bothun and Archer [17] who showed improvement of results from 20.4 to 3.4 PD. In our study, no cases of near diplopia were reported after MRR compared with three cases in their study.

Breidenstein et al. [18] reported that both MRR and LRR are effective. In their MRR group, the angle at distance improved from 19.75 to 3.2 PD compared with our study, where the improvement was from 21.7 to 2.5 PD, whereas in their LRR group, the preoperative angle for far improved from 17.7 to 2.6 PD compared with our results, which showed improvement from 20.5 to 2.3 PD.

In this study, LRMP was done for eight patients with 100% success rate and no reported cases of diplopia; three cases of them were done under topical anesthesia.

The mean surgical dose–response effect was calculated in MRR group, and it was 2.02 PD/mm which was less than recommended the dose for other types of ET by Parks et al. [19], which was 2.9 PD/mm ([Figure 1]a). The reason for greater needed of MRR for correction of ADIE than other forms might be related to the sag of medial rectus pulley in older patients who are candidates for connective tissues degeneration [20].
Figure 1 The amount of medial rectus (MR) recession (a) and lateral rectus resection (b) recommended by Parks et al. to correct other types of esotropia is lesser than that needed to correct adult divergence insufficiency esotropia. LR, lateral rectus; SDR, surgical dose–response; study, this study. Parks: Parks et al. study. [19].

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The mean dose–response was also calculated in LRR, and it was 1.7 PD/mm, which is smaller than that recommended in other types of ET, which is 2.27 PD/mm ([Figure 1]b). Therefore, it is recommended to increase the amount of MRR and LRR in the treatment of DIE. Chaudhuri and Demer [10] also recommended twice the usual surgical dose of MRR per prism diopter and LRR to achieve correction of distance ET in ADIE compared with that recommended for other types of ET.

A number of patients were presented by Clark who underwent lateral rectus equatorial myopexy for sagging eye syndrome in age-related distance ET. Although this technique shows promise, it is still under active investigation [21].

This study had some limitations such as small sample size and relatively short follow-up period. Therefore, future studies are needed based on larger sample size with longer follow-up period.

  Conclusion Top

The three techniques are effective in the treatment of ADIE with excellent outcomes in eliminating diplopia, though the LRMP has the advantage of being vessel sparing, less invasive, reversible, and being able to be done with topical anesthesia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Martinez-Thompson JM, Diehl NN, Holmes JM, Mohney BG. Incidence, types and lifetime risk of adult-onset strabismus. Ophthalmology 2014; 121:877–882.  Back to cited text no. 1
Kirkeby L. Update on divergence insufficiency. Int Ophthalmol Clin 2014; 54:21–31.  Back to cited text no. 2
Bruce GM. Ocular divergence: its physiology and pathology. Arch Ophthalmol 1935; 13:639–660.  Back to cited text no. 3
Guyton DL. The 10th Bielschowsky lecture. Changes in strabismus over time: the roles of vergence tonus and muscle length adaptation. Binocul Vis strabismus Q 2006; 21:81–92. [PubMed]  Back to cited text no. 4
Chaudhuri Z, Demer JL. Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients. JAMA Ophthalmol 2013; 131:619–625.  Back to cited text no. 5
Stangler-Zuschrott E. Convergent strabismus in the age of presbyopia (author’s transl) (in German). Klin Mon bl Augenheilkd 1976; 168:775–783.  Back to cited text no. 6
Hoover DL, Giangiacomo J. Results of a single lateral rectus resection for divergence and partial sixth nerve paralysis. J Pediatr Ophthlamol Strabismus 1993; 30:124–126.  Back to cited text no. 7
Thacker NM, Velez FG, Bhola R, Britt MT, Rosenbaum AL. lateral rectus resections in divergence palsy: results of long term follow up. J AAPOS 2005; 9:7–11.  Back to cited text no. 8
Archer SM. the effect of medial versus lateral rectus muscle surgery on distance-near incomitance. J AAPOS 2009; 13:20–26.  Back to cited text no. 9
Chaudhuri Z, Demer JL. Medial recession is as effective as lateral rectus resection in divergence paralysis esotropia. Arch Ophthalmol 2012; 130:1280–1284.  Back to cited text no. 10
Leenheer RS, Wright KW. Mini-plication to treat small angle strabismus: a minimally invasive procedure. J AAPOS 2012; 16:327–330.  Back to cited text no. 11
Pineles SL. Divergence insufficiency esotropia. Surgical treatment. Am Orthopt J 2015; 65:35–39.  Back to cited text no. 12
Jacobson DM. Divergence insufficiency revisited natural history of idiopathic cases and neurological associations. Arch Ophthalmol 118:1237–1242.  Back to cited text no. 13
Stem RM, Tomsak RL. Magnetic resonance images in case of divergence paralysis. Surv Ophthalmol 1986; 30:397–401.  Back to cited text no. 14
Schanzer B, Bordaberry M, Jeffery AR, McNeil DE, Phillips PC. The Child with divergence paresis. Surv Ophthalmol 1998; 42:571–576.  Back to cited text no. 15
Stager DR Sr, Black T, Felius J. Unilateral lateral rectus resection for horizontal diplopia in adults with divergence insufficiency. Grafes Arch clin Exp Ophthalmol 2013; 251:1641–1644.  Back to cited text no. 16
Bolhun LD, Archer SM. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. L AAPOS 2005; 9:3–6.  Back to cited text no. 17
Breidnstein BG, Robbin SL, Granet DB, Acera EC. Comparison of the efficacy of medial rectus recession and lateral rectus resection for treatment of divergence insufficiency. J Pediar Ophthalmol Strabismus 2015; 52:173–176.  Back to cited text no. 18
Parks MM, Mitchell PR, Wheeler MB. Concomitant esodeviation. In: Tasman W, Jaeger EA, editors. Duane’s foundation of clinical ophthlamology. Philadelphia, PA: Lippincott Williams and Wilkins; 2002. p. 12.  Back to cited text no. 19
Clark RA, Demer JL. Effect of aging on human rectus extraocular muscle paths demonstrated by magnetic resonance imaging. AM J Ophthalmol 2002; 134:872–878.  Back to cited text no. 20
Clark R. Lateral rectus equatorial myopexy for sagging eye syndrome. Leonard Apt meeting: Advanced topics in pediatric ophthalmology and strabismus. Los Angeles: Jules Stein Eye Institute, University of California; 2014  Back to cited text no. 21


  [Figure 1]

  [Table 1], [Table 2]


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