Kemal YAR, Gülhanım HACIYAKUPOĞLU, Ebru ESEN

Ardıl Ekzotropya Olgularında Medyal Rektus Avansman Cerrahisinin Etkinliği

Amaç: Ardıl ekzotropya nedeniyle cerrahi uygulanan hastalarda medyal rektus avansman cerrahisinin etkinliğini değerlendirmek Materyal ve Metod: Çalışmaya 2008-2013 yılları arasında Çukurova üniversitasi Tıp Fakültesi Göz Hastalıkları Anabilimdalı’ında ardıl ekzotropya nedeniyle cerrahi uygulanan 10’u erkek,10’u kız toplam 20 hasta dahil edildi. Hastaların kayıtları retrospektif olarak incelendi. En iyi düzeltilmiş görme keskinlikleri, ambliyopi varlığı, ilk ameliyattan sonra geçen süre, uygulanan cerrahi yöntemler değerlendirildi. Postoperatif 10 PD ve altı kayma dereceleri başarılı sayıldı. Hastalar ortalama 29,8 ± 21,36 (8-80) ay takip edildi, yeterli takip süresi bulunmayan hastalar çalışma dışı bırakıldı. Bulgular: Hastalardan 6’sına bilateral, 5’ine unilateral olmak üzere toplam 11 hastaya sadece medyal rektus avansmanı uygulanarak istenilen cerrahi sonuç elde edilirken diğer hastalara lateral rektus resesyonu, medyal rektus rezeksiyonu uygulanarak hedeflenen kayma derecesine ulaşılmıştır. Kayma derecesi yalnız avansman cerrahisi uygulananlarda 46,4±9,24 (40-70) PD, ek cerrahi uygulananlarda 65,56 ± 18,78 (40-90) PD olarak tespit edildi. 16 (%80) hastada farklı derecelerde hipermetropi, 7 (%35)’inde ambliyopi mevcuttu. Sonuç: Ardıl ekzotropya cerrahiden yıllar sonra dahi ortaya çıkabilmekte ve geç dönem komplikasyonlarında önemli bir yer tutmaktadır. Bu çalışmada medyal rektus avansman cerrahisi ile elde edilmiş olan % 55 düzeyindeki başarı tercih edilebilir yöntem olduğunu göstermiştir. Ancak geniş açılı kaymalarda hedeflenen düzeltmeye ulaşmak için ek olarak lateral rektus resesyonu ve/veya medyal rektus rezeksiyonun eklenmesi gerekebilir. Cerrahi operasyon geçirmiş olan kas ve çevre dokularda yoğun olarak fibrozis bulunduğundan avansman miktarı ile kayma açısındaki düzelmeyi kesin olarak öngörmek her zaman mümkün değildir.

Anahtar Kelimeler:

Ardıl ekzotropya, Medyal rektus, Avansman cerrahisi

Efficiency of Medical Rectus Advancement Surgery in Consecutive Exotropia

Purpose: To evaluate the efficiency of medial rectus advancement surgery in consecutive exotropia. Material and Methods: The study group consisted of 20 cases, 10 male, 10 female, who were diagnosed as consecutive exotropia and underwent surgery between 2008-2013 at Çukurova University Medical Faculty Ophthalmology Department. Records of the patients were investigated retrospectively. We evaluated best corrected visual acuity, existence of ambliopia, postoperative duration following the first surgery and applied surgical procedures. Postoperative deviation lower than 10 PD were assesed as successful. Mean follow up period was 29,8 ± 21,36 (8-80) months, patients with inadequate follow up period were dismissed from the study group. Results: We only applied bilateral medial rectus advancement surgery to 6 and unilateral medial rectus advancement surgery to 5 patients and obtained intended surgical result in these 11 cases. The other patients underwent lateral rectus recession or/and medial rectus resection operations inorder to reach projected deviation degrees. Deviation was found to be 46,4±9,24 (40-70) PD in cases who only underwent advancement surgery and was 65,56 ± 18,78 (40-90) PD in cases who underwent additional surgical procedure. 16 (%80) of the cases had hypermetropi various dioptries and 7 (%35) had ambliopia. Discussion: Consecutive exotropia can appear years after surgery and is an important late period complication. In this study achievement of %55 success with medial rectus advancement surgery indicates that this is a preferable procedure. But in wide angle deviations additional lateral rectus recession or/and medial rectus resection operations can be applied inorder to reach intended adjustment. Accurrate prediction of the propotion of advancement surgery and adjustment is not always possible because of intensive fybrosis in operated muscles and enviroment tissue.

Keywords:

Consecutive exotropia, Medial rectus , Advancement surgery,

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Cooper EL. The surgical management of secondary exotropia. Trans Am Acad Ophthalmol Otolaryngol. 1961;65:595-608.
Arruga A. Surgical overcorrections. J Pediatr Ophthalmol. 1965;2:15-22.
Windsor CE. Surgically overcorrected esotropia: A study of its causes,sensory anomalies, fusional results, and management. Am Orthopt J.1966;16:8- 15.
Stager DR, Weakley DR, Everett M, Birch EE. Delayed consecutive exotropia following 7-millimeter bilateral medial rectus recession for congenital esotropia. 1994;31:147-50.
Yazawa K. Postoperative exotropia. J Pediatr Ophthalmol Strabismus. 1981;18:58-64.
Ganesh A, Pirouznia S, Ganguly SS, Fagerholm P, Lithander J. Consecutive exotropia after surgical treatment of childhood esotropia: A40-year follow-up study. Acta Ophthalmol. 2011;89:691-5.
Donaldson MJ, Forrest MP, Gole GA. The surgical management of consecutive exotropia. J AAPOS. 2004;8:230-36.
Bietti GB, Bagolini B. Problems related to surgical overcorrections in strabismus surgery. J Pediatr Ophthalmol. 1965;2:11-4.
Bradbury JA, Doran RML. Secondary exotropia: a retrospective analysis of matched cases. J Pediatr Ophthalmol Strabismus. 1993;30: 163-6.
Rosenbaum AL, Jampolsky A, Scott AB. Bimedial recession in high AC/A esotropia. Arch Ophthalmol. 1974;91:251-3.
Pickering JD, Simon JW, Lininger LL, Melsopp KB, Pinto GL. Exaggerated effect of bilateral medial rectus recession in developmentally delayed children. J Pediatr Ophthalmol Strabismus. 1994;31:374-7.
Folk ER, Miller MT, Chapman L. Consecutive exotropia following surgery. Br J Ophthalmol. 1983;67:546-8.
Ing M, Costenbader FD, Parks MM. Early surgery for congenital esotropia. Am J Ophthalmol. 1966;61:1419-27.
Oguz V, Arvas S, Yolar M, Kizilkaya M, Tolun H. Consecutive exotropia following strabismus surgery. Ophthalmologica. 2002;216:246-8
Marcon GB, Pittino R. Dose-effect relationship of medial rectus muscle advancement for consecutive exotropia. J AAPOS. 2011;15:523-6.
Biedner B, Yassur Y, David R. Advancement and reinsertion of one medial rectus muscle as treatment for surgically overcorrected esotropia. Binocul Vis Strabismus Q. 1991;6:197-200
Mittleman D, Folk ER. The surgical treatment of overcorrected esotropia. J Pediatr Ophthalmol Strabismus 1979;16:156-9.
Ohtsuki H, Haesebe S, Takodoro Y, Kobashi R, Watanabe S,Okano M. Advancement of medial rectus muscle to the original insertion for consecutive exotropia. J Pediatr Ophthalmol Strabismus.1993;30:301-5.
Patel AS, Simon JW, Lininger LL. Bilateral lateral rectus recession for consecutive exotropia. J AAPOS. 2000;4:291-4.
Mims JL III, Wood RC. Outcome of a surgical treatment protocol for late consecutive exotropia following bilateral medial rectus recession for esotropia. Binocul Vis Strabismus Q. 2004;19:201-6.
Mohan K, Sharma A, Pandav SS. Unilateral lateral rectus muscle recession and medial rectus muscle resection with or without advancement for postoperative consecutive exotropia. J AAPOS. 2006;10:220-4.
Chatzistefanou KI, Droutsas CD, Chimonidou E. Reversal of unilateral medial rectus recession and lateral rectus resection for the correction of consecutive exotropia. Br J Ophthalmol. 2009;93:742-6.
Yurdakul NS, Ugurlu S. Analysis of risk factors for consecutive exotropia and review of the literature. J Pediatr Ophthalmol Strabismus. 2013;50:268-73.
Birch EE, Stager DR Sr, Berry P, Leffler J. Stereopsis and longterm stability of alignment in esotropia. J AAPOS. 2004;8:146-50.
Kerkhof TB, Houtman WA. Late consecutive exodeviations. Doc Ophthalmol. 1992;82:65-71
Beneish R, Williams F, Polomeno RC &Little JM. Consecutive XT after correction of hyperopia. Can J Ophthalmol. 1981;16:16–8.