The ocular rotational power which a rectus muscle exerts is a product of the muscle's force and the length of the lever arm between the muscle's tangential point of contact with the globe and the centre of rotation of the eye. A recession operation weakens a rectus muscle because the distance between the muscle's origin at the orbital apex and its insertion into the surface of the globe is decreased, so that the muscle becomes slack. Provided that the recession does not exceed the conventional maximum (Table I), the length of the lever arm is not reduced. Even when the eye moves into the field of action of the recessed muscle, the length of the rotational lever arm remains unchanged as the tangential point of muscle action is still on the surface of the globe. If the muscle is over- recessed, not only does it become very slack but the effective lever arm is reduced in length and mechanical restriction of movement ensues. The weakening effect of a conventional recession operation is therefore approximately the same in all directions of gaze in which the muscle is active (Figs. 1 and 2). Table I Maximum recession possible without limiting ocular motility.

/pdf/faden-operation-posterior-fixation-sutures-2hzpfh7sg3.pdf

Faden operation (posterior fixation sutures).

It has been suggested that operating the dominant eye is a more effective way of treatment for exodeviations than the conventional non-dominant eye surgery. We have tested this idea in groups of children and adults with intermittent and constant exotropia. In a first group of 30 patients where the non-dominant eye was operated on, we found that our initial technique resulted in an undercorrection averaging 11 prism diopters. Modification of the technique, by increasing the relative amount of surgery on the non-dominant eye in another group of 41 patients, improved the results significantly in adult patients, but not in children. Operations on the dominant eye in a third group of 26 patients were no more successful than non-dominant eye surgery with the initial technique. Thus, we did not obtain better results in operations on the dominant eye with our technique than we did with surgery on the non-dominant eye.

Effects of surgery on the dominant eye in exodeviations.

Twenty-six patients with small-angle constant or intermittent exotropia of up to 7°, and eight patients with small-angle exophoria of the convergence-insufficiency type, underwent unilateral medial rectus resection. Of the 34 patients, 9 were cured, 19 improved and in 6 surgery failed or there was early recurrence. Improvement occurred usually in patients who had basic microexotropia and in some who had homonymous abnormal retinal correspondence, a factor which limited the sensory results. The sensory, motor, and mechanical factors influencing the procedure are discussed in detail. The resection technique employed is reviewed, demonstrating the advantage of well-controlled results. This paper shows that resecting the medial recti is useful, not only in convergence insufficiency, but also in related small-angle exodeviations, for which a classification is proposed.

Unilateral medial rectus resection in the treatment of small-angle exodeviation.

Evaluation and Management of Intermittent Exotropia

Several therapeutic concepts are in favour of the treatment of intermittent exotropia. The presented paper will try to answer the question, whether this leads to different results, by the review of the 1989 and 1990 cases of two centres. In the Munich Right Isar Eye Hospital (Centre II) during this period 72 patients (already published data) were treated by recession and resection eye muscle surgery against intermittent exotropia or decompensating exophoria. The 111 compared patients of the Department of Orthoptics and Pleoptics at the University Eye Hospital Kiel (Centre I), were mostly treated with bimedial resection procedures. Another difference: diagnostic occlusion and prism correction were done in the Munich patients. There is major evidence that there are two widely different clinical pictures incorporated in the diagnostic frame of the so-called ‘Intermittent Exotropia’. In a third prospective group of patients (10/91 – 3/92), therefore, the prism-acceptance was evaluated.

Two therapeutic concepts in intermittent divergent squint.

Intermittent divergent strabismus represents an entity in terms of motoric characteristics rather than in its sensorial basis. Separate investigations were carried out in two clinics on 156 patients. The results were evaluated together, the authors discussing each case. Only in 27 cases was the condition cured. The main group comprised 78 patients with subnormal binocular vision based on facultative microexotropia and instable/normal correspondence. Basic microexotropia with obligate ARC was found in 51 cases, i.e., more often than expected. Testing the stereo threshold proved to an inadequate criterion for cure.

Binokulare sensorische Defekte beim Strabismus divergens intermittens

It would not make sense to present the dry results without an idea of the conceptions behind. For this reason we shall introduce this communication with a few remarks on technical and indicational problems.

Results of the Fadenoperation in Alternating Convergent Strabismus of the Congenital Type

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Binokulare sensorische Defekte beim Strabismus divergens intermittens

Results of the Fadenoperation in Alternating Convergent Strabismus of the Congenital Type