Convergence excess esotropia has been treated with bifocals, miotics, medial rectus recession(s), fadenoperation, or a combination of these. However, comparatively few studies on the sensory status of these patients exist. We present the sensory findings in 31 children treated surgically. Twenty-one had fadenoperations combined with bimedial rectus recessions, one had a fadenoperation alone, and nine had augmented bimedial rectus recessions. Five children (16%) achieved bifoveal fusion, 22 (71%) had varying degrees of peripheral fusion, and four (13%) had no detectable binocularity after a mean postoperative follow-up of 2.4 years.

https://bjo.bmj.com/content/bjophthalmol/74/5/278.full.pdf

Convergence excess esotropia treated surgically with fadenoperation and medical rectus muscle recessions.

The present study investigates the results of Cuppers' 'Fadenoperation' in patients with non-accommodative convergence excess esotropia. Particular attention is given to postoperative eye alignment at distance fixation. Group 1 (n=96) included patients with a 'normal' convergence excess. The manifest near angles (mean ET 16.73 degrees +/- 6.33 degrees, range 4 degrees -33 degrees ) were roughly twice the size of the distance angles (mean ET 6.50 degrees +/- 3.62 degrees, range 0 degrees -14 degrees ). These patients were treated with a bilateral fadenoperation of the medial recti without additional eye muscle surgery. Three months after surgery, the mean postoperative angles were XT 0.5 degrees +/- 3.3 degrees (range XT 11 degrees -ET 5 degrees ) for distance fixation, and ET 2.7 degrees +/- 3.6 degrees (range XT 5 degrees -ET 14 degrees ) for near fixation, respectively. Postoperative convergent angles at near fixation >ET 10 degrees were present in two patients (1.9%). Group 2 (n=21) included patients with a mean preoperative distance angle of ET 9.2 degrees +/- 3.7 degrees (range 6 degrees -16 degrees ) and a mean preoperative near angle of ET 23.4 degrees +/- 3.1 degrees (range 16 degrees -31 degrees ). These patients were operated on with a bilateral fadenoperation of the medial recti and a simultaneous recession of one or both medial rectus muscles. Mean postoperative angles were XT 0.5 degrees +/- 4.6 degrees (range XT 12 degrees -ET 7 degrees ) for distance fixation and ET 1.4 degrees +/- 4.5 degrees (range XT 8 degrees -ET 13 degrees ) for near fixation, respectively. In this group, 2 patients (10.6%) had a postoperative exotropia >XT 5 degrees at distance fixation, and two patients had residual esotropia>ET 10 degrees at near fixation. Group 3 (n=17) included patients with a pronounced non-accommodative convergence excess. Near angle values (mean of 17.8 degrees +/- 5.3 degrees, range ET 7 degrees -26 degrees ) were several times higher than the distance angle values (mean ET 1.9 degrees +/- 4.2 degrees, range XT 3 degrees -ET 6 degrees ). These patients were treated with a bilateral fadenoperation of the medial recti and a simultaneous resection of one or both medial rectus muscles. Mean postoperative angles were ET 0.2 degrees +/- 4.7 degrees (range XT 8 degrees -ET 6 degrees ) for distance fixation and 5.3 degrees +/- 6.1 degrees (range XT 3 degrees -ET 12 degrees ) for near fixation, respectively. One patient had a postoperative distance angle >XT 5 degrees, whereas two patients displayed postoperative convergent angles >ET 5 degrees at near fixation.

Posterior fixation suture and convergence excess esotropia.

Cuppers (6) presented the Fadenoperation (Fd) as a splendid tool to correct inconstant squint angles by means of an artificial paresis. The author's practice shows that many cases of apparently constant congenital esotropia, successfully treated by Fd, obviously would be better interpreted as permanently overinnervated adduction excess cases. But even a sophisticated view of the mechanism of the Fd cannot solve the problem of whether or not a stable basic angle really exists in children before the age of five years. The paper, in addition, deals with the results of 304 cases of alternating congenital esotropia and the author's own techniques.

Constant or apparently constant congenital esotropia? A survey of 304 Fadenoperations.

The effectivity of a retroequatorial muscle belt operation, modification of Cuppers' Fadenoperation, is demonstrated by its results in 206 patients with excess esotropia at near and variable angle esotropia. It is shown that this procedure can reduce excess esotropia at near by a significant amount and lessen the extent of variable angle esotropia without causing incomitance in horizontal eye motility. A belt, placed bimedially on both recti muscles, showed to be twice as effective on the deviation at near as on the angle at distance. Proposing a similar mode of action, the atraumatic fixation with the muscle belt can facilitate reoperations in comparison with the Fadenoperation. Damage to the muscle is limited to a minimum.

Results of the bimedial muscle belt

Der Konvergenzexzess ist ein haufiger Befund insbesondere bei kindlichen Schielformen. Die genaue Diagnostik erfolgt nach Vollkorrektur jeglicher unter Zykloplegie gemessenen Hyperopie und umfasst die Messung des latenten und manifesten Schielwinkels bei Fixation in die Ferne und Nahe, die Bestimmung des Nahwinkels unter Entlasten der Akkommodation unter Vorhalten von +3 dpt, die jeweilige Messung der Binokularfunktion und der Akkommodationsbreite. Die Diagnostik ist wichtig zur Einteilung der 3 Arten von Konvergenzexzess, die jeweils unterschiedliche Therapien erfordern: 1) der hypoakkommodative Konvergenzexzess muss dauerhaft mit Bifokalbrille behandelt werden, 2) der normakkommodative in der Regel mit Bifokalbrille, die uber Jahre ausgeschlichen werden kann, insbesondere bei guter Stereopsis, und 3) der nichtakkommodative Konvergenzexzess sowie Patienten mit grosem Fernwinkel durch eine Operation. Als Operation bietet sich eine drehmomentmindernde Schwachung beider Mm. recti mediales an, z. B. die Fadenoperation oder die Y‑Spaltung.

Konservative und chirurgische Therapie des Konvergenzexzesses

The "Fadenoperation" creates an artificial paresis, the effect of which increases in the field of action of the muscle operated upon. The postoperative effect on eye position and motility was studied in order to find the typical curve of influence upon the angle in different directions of gaze. In esotropia a fixation of the medial rectus muscle 13 mm behind its insertion will create an average angle reduction of 4 degrees in the primary position of gaze and 12 degrees (9 degrees long-term) in lateral gaze with the operated eye adducted. - Fadenoperations cause a reduction of (overacting) convergence (non-accomodative), adduction, and changing angle. The paper deals with the majority of patients who show overacting convergence and changing angles but lack an increasing angle in version movements. This means that in lateral gaze overcorrection may occur: From the curve of angle reduction the surgeon can derive a slight exponential decrease of each of the three partial functions. Fadenoperation, therefore, will suit well in patients showing overactions of all three components, but will bring "side effects" in cases which lack one or two of these dysfunctions. Bilateral Fadenoperations produce a minor incomitance pattern.

[Efficacy of the "Fadenoperation" (author's transl)].

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[Efficacy of the "Fadenoperation" (author's transl)].