Periosteal muscle fixation for large angle incomitant exotropia

Sarah Hull1, Tarang Gupta1, Geoffrey Rose1, David Verity1, Gill Adams1

Meeting:  2019 RANZCO


Date:      -

Session Title: Strabismus

Session Time:      -

Purpose: To describe the evolution of a modified surgical technique for correcting large angle incomitant exodeviations.

Methods: A consecutive series of 26 patients with predominantly third nerve palsy (n = 21, medial rectus palsy = 2, exotropia = 2, Moebius = 1) were operated on between 2005‐2018 by a joint Strabismus/Adnexal team. Retrospective analysis included prism dioptre (PD) deviations and complications.

Results: Three patients missed follow up leaving 23 patients mean age 37.8 years (range 4‐79). All had minimal medial rectus function. Twelve had undergone prior surgery. Pre operative exotropia ranged from 45 to >115 PD. There were 29 operations (19 patients = 1, 4 patients >1) with the medial rectus insertion anchored to retrocaruncular periosteum. The lateral rectus was disinserted then fixated to the lateral orbital rim except for 2 recessions and 5 botulinum toxin injections (4 performed 2005‐6). Medial traction sutures were inserted in 21 of 29 surgeries (8 without performed 2005‐9) for a mean of 5 weeks (range 2‐8). Final review was at a mean 32 months (range 2 to 130) with a mean reduction in deviation of 44 PD (range 10 to 79). The 5 toxin procedures had a mean reduction of 22 PD. There was one complication of exposed ethibond suture that required trimming.

Conclusion: Large angle incomitant exodeviations present a difficult surgical challenge. We advocate a combined bi‐rectus fixation approach with traction sutures to hold the globe in the primary position. Previous surgery does not preclude further surgery with this technique.