|Year : 1982 | Volume
| Issue : 4 | Page : 275-277
The surgical treatment of horizontal concomitant squint-an appraisal
JN Rohatgi, HK Singh, AA Siddique
Dept. of Ophthalmology, Patna Medical College Hospital, Patna, India
J N Rohatgi
Department of Ophthalmology Patna Medical College Hospital Patna-4. Bihar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rohatgi J N, Singh H K, Siddique A A. The surgical treatment of horizontal concomitant squint-an appraisal. Indian J Ophthalmol 1982;30:275-7
|How to cite this URL:|
Rohatgi J N, Singh H K, Siddique A A. The surgical treatment of horizontal concomitant squint-an appraisal. Indian J Ophthalmol [serial online] 1982 [cited 2020 Feb 27];30:275-7. Available from: http://www.ijo.in/text.asp?1982/30/4/275/29448
Surgery in a concomitant horizontal squint aims at rendering the visual axes of the two eyes parallel in all meridian and without any conscious effort. Though this is rarely achieved but to try to get as near the ideal as possible, it is felt that any associated vertical element should also be taken into consideration when the initial surgery is being planned.
Such a surgery could be weakening an overacting muscle or shortening (or strengthening) a relatively weak muscle. Under the heading of strengthening a weak muscle, resection is the modern choice in preference to advancement alone or advancement with resection.
An old procedure of muscle tucking to strengthen the weak muscle was demonstrated as far back as 1923 by Calkins Faulkner in 1944 also commented on its usefulness.
In tenoplication (Buckling-the author's nomenclature) on the other hand, after the muscle-tendon has been folded upon itself, sutures are passed through the muscle folds down into the episcleral and in the denuded scleral tissues underneath. And this was our operation of choice as a strengthening procedure in the majority of cases under review.
The present series is based on nine hundred cases of concomitant horizontal squint who were operated upon during the last twenty years (1960-1979) at the Patna Medical College Hospital as well as in my private clinic. The break up of the cases was as follows
A fair number of our cases came in for surgery in the higher age group of 15 to 20 years.
The number of children in the age group of 3 to 6 years (who underwent surgery) was about 15%. The large percentage of cases were, children in the age group of 7 to 14 years and thus, could be labelled as cases mainly for cosmetic surgery.
It is important to keep in mind that cases of esotropia could be both congenital and accomodative in type. The accommodative type manifests typically about the age of 22 to 3 years and may be associated with (a) high hypermetropia or (b) a high Ac/A ratio or (c) low fusinonal divergence-as in a case of congenital cataract.
Sometimes congenital esotropes which have been corrected early in life, reconverge a few years after as the accommodative convergence exceeds the poor fusional divergence. From surgical view point such cases could be subdivided into four (4) groups:
(i) Those where the deviation is less than 10°-55 cases. (ii) Group II- Deviation of 1020° convergence - 98 cases (iii) Group III- 20 to 30° convergence - 287 cases and (iv) Group IV Over 30 0sub convergence -150 cases.
Group I- In 55 cases, the angle of deviation was less than 10 0sub . In them only medial rectus recession varying from 3 to 5 mm depending on the age of the patient was found adequate to correct the deviation.
Thus, for a child of 4 to 5 years of age, a 3 mm. recession was good enough, whereas for the same angle of deviation, in a patient ten years of age, a 5 mm. recession of medial rectus was necessay to obtain full correction of the deviation.
Group II- 10 to 20° convergence-After a 5 mm recession of the internal rectus muscle-42 cases had plication of the lateral rectus by 3 to 4 mm. In another 56 cases, the lateral rectus was resected by the same amount. The average degree of undercorrection was 4 to 5° in case with resection, whereas in those with plicatio only a few cases had un Iercorrection and th average figure was 1 to 2 0 .
Group III - 20-30° convergence- All cas had a medial rectus recession of 5 mm, In addition 197 cases had lateral rectus plication of 6mm and another 90 cases had lateral rectus resected by 6 mm. The average under correction in those with resection was 6-9 where as with plication it was 4 to 5°.
Group IV- Over 30° convergence-Both group of cases had undercorrection. Such cases were mostly alternating in type and in them both eyes were operated at the same time with plication or resection of the weak muscle along with recession of the overactive muscle. Against a 8 to 9 mm of Buckling only 7 mm. of Resection was done. It was felt, however, that a buckling of 8 to 9 mm. produces an undue pressure on the eyeball Hence, in later cases the amount of buckling did not exceed 7 mm and these consequently had greater degree of under-correction.
Exotropia or Divergent group of cases-Thera were 310 cases under going surgery in this group.
Group I - Cases with deviation less than 10° had only lateral rectus recession.
Group II -(10-20° divergence). In these cases a recession of 5 mm. of lateral rectus was done. Along with it 60 cases had a Buckling of medial rectus by 5 mm and another 30 cases had resection of M.R. by 5 mms. The degree of under-correction was an average of 2 to 3 and 3-4 degree respectively.
Group 111-20 . 30° divergence-In these cases an equal amount of 6 mm. of Resection and or Buckling was carried along with recession of 6 to 7 mm of lateral rectus. The degree of undercorrection was an average 4 to 5 degree in buckling group as against 5 to 10 degree in resection group.
Group IV-In this group of cases because the operation had to bedistributed in both eyes on account of higher degree of divergence and alternating nature of most of the cases the results were not satisfactorily comparable.
Thus, so far the strengthening operation is concerned (in correction of horizontal concomitant) of the two procedures of buckling and resection it was felt that while tenoplication or buckling is an old procedure and not such in vogue-all the same it was a satisfactory operation for (1) With this operative technique-the average degree of correction is better or more than that with simple resection mm to mm.
2. The operation is safer for at the slightest evidence of overcorrection. It is easy to rectify the mistake which is not feasible with resection.
3. The procedure of buckling can easily be handled even by a beginner is squint surgery. The amount of plication or buckling has varied from 3 to 9 mm depending on the angle of deviation to be tackled. After initial experience, it was felt that a buckling of 8 to 9 mm. may cause undue tension to the eyeball and hence, for early cases, the amount of buckling has not exceeded seven (7) mm.
| References|| |
Calkins J. W. 1823, Am. J. of Opththalmol 6: 910.
Faulkner, S. H., Scully E and Carter E. E. 1941, Brit. J. Ophthal. 28: 1941,
[Table - 1], [Table - 2]