Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Medial Rectus Bridge Faden Operations in Accommodative and Partially Accommodative Esotropia With Convergence Excess

Asli Inal, MD; Osman Bulut Ocak, MD; Ebru Demet Aygit, MD; Selcen Celik, MD; Gamze Ozturk Karabulut, MD; Berkay Inal, MD; Muhittin Taskapili, MD; Birsen Gokyigit, MD

Abstract

Purpose:

To evaluate the results of the bilateral bridge Faden operation on the medial rectus muscles with and without recession in the treatment of accommodative and partially accommodative esotropia with convergence excess.

Methods:

A retrospective analysis was performed on the medical records of 103 patients who underwent the bridge Faden operation on both medial rectus muscles, with or without recession, for the treatment of accommodative and partially accommodative esotropia with convergence excess. Preoperative and postoperative near and distance deviations and near–distance disparities were evaluated.

Results:

The study population consisted of 38 (37%) girls and 65 (63%) boys. The mean age was 9.32 ± 5.83 years (range: 1 to 18 years) and the mean follow-up period was 14.49 ± 2.78 months. Fifty-one patients underwent the bridge Faden operation on both medial rectus muscles with recession (recession group) and 52 patients underwent the bridge Faden operation on both medial rectus muscles without recession (no recession group). The mean preoperative amount of esotropia at near was 43.51 ± 7.00 and 24.24 ± 3.56 prism diopters (PD) for the recession and no recession groups, respectively. The mean preoperative amount of esotropia at distance was 26.63 ± 6.86 and 9.22 ± 2.09 PD for both groups, respectively. The mean preoperative near–distance disparity was 17.14 ± 3.00 and 14.05 ± 4.14 PD for both groups, respectively. In both groups, there was a statistically significant difference in the near and distance deviations and the near–distance disparity between preoperative and postoperative values (P < .05). Postoperatively, there was no significant difference between 1 month, 6 months, and 1 year and between 6 months and 1 year (P > .05).

Conclusions:

The bridge Faden operation on both medial rectus muscles either with or without recession was a successful surgical procedure in patients with accommodative and partially accommodative esotropia. During the follow-up period, the success rates did not decrease.

[J Pediatr Ophthalmol Strabismus. 2017;54(6):369–374.]

Abstract

Purpose:

To evaluate the results of the bilateral bridge Faden operation on the medial rectus muscles with and without recession in the treatment of accommodative and partially accommodative esotropia with convergence excess.

Methods:

A retrospective analysis was performed on the medical records of 103 patients who underwent the bridge Faden operation on both medial rectus muscles, with or without recession, for the treatment of accommodative and partially accommodative esotropia with convergence excess. Preoperative and postoperative near and distance deviations and near–distance disparities were evaluated.

Results:

The study population consisted of 38 (37%) girls and 65 (63%) boys. The mean age was 9.32 ± 5.83 years (range: 1 to 18 years) and the mean follow-up period was 14.49 ± 2.78 months. Fifty-one patients underwent the bridge Faden operation on both medial rectus muscles with recession (recession group) and 52 patients underwent the bridge Faden operation on both medial rectus muscles without recession (no recession group). The mean preoperative amount of esotropia at near was 43.51 ± 7.00 and 24.24 ± 3.56 prism diopters (PD) for the recession and no recession groups, respectively. The mean preoperative amount of esotropia at distance was 26.63 ± 6.86 and 9.22 ± 2.09 PD for both groups, respectively. The mean preoperative near–distance disparity was 17.14 ± 3.00 and 14.05 ± 4.14 PD for both groups, respectively. In both groups, there was a statistically significant difference in the near and distance deviations and the near–distance disparity between preoperative and postoperative values (P < .05). Postoperatively, there was no significant difference between 1 month, 6 months, and 1 year and between 6 months and 1 year (P > .05).

Conclusions:

The bridge Faden operation on both medial rectus muscles either with or without recession was a successful surgical procedure in patients with accommodative and partially accommodative esotropia. During the follow-up period, the success rates did not decrease.

[J Pediatr Ophthalmol Strabismus. 2017;54(6):369–374.]

Introduction

Esotropia that is caused by an increased accommodative effort or an abnormally high accommodative convergence–accommodation ratio is referred to as accommodative esotropia. Esotropia is partially accommodative when accommodative factors contribute to but do not account for the entire deviation.1 The surgical course for bilateral medial rectus recession for accommodative and partially accommodative esotropia is often difficult to determine and undercorrections are common in such patients.2 A Faden operation on the medial rectus muscles with or without recession is the standard procedure used to reduce esotropia with convergence excess.3,4 However, revision of the operated muscle is often difficult due to scarring of the muscle and adhesions to the sclera.5,6 For this reason, many modifications to the Faden operation have been developed.3,5,7–10

The bridge Faden operation was first described by Castiella et al.7 and Polenghi.8 After scleral suturing is performed on both sides of the muscle, a knot is made on the muscle without muscle suturation (unlike the classic Faden operation). This variation has all of the advantages of the Faden operation without the risk of muscular damage.8

The aim of this study was to evaluate the results of the bilateral bridge Faden operation on the medial rectus muscles with and without recession in the treatment of accommodative and partially accommodative esotropia with convergence excess.

Patients and Methods

Study Design

In this retrospective study, the medical records from 103 patients who underwent the bridge Faden operation on both medial rectus muscles with or without recession for the treatment of accommodative or partially accommodative esotropia with convergence excess between January 2014 and December 2015 at Beyoglu Eye Research and Training Hospital were reviewed.

The study was approved by the ethics committee of the Okmeydani Research and Training Hospital and followed the tenets of the Declaration of Helsinki. Written informed consent was obtained from the patients or parents.

Examination

Inclusion criteria were accommodative and partially accommodative esotropia (refractive or nonrefractive) and esotropia at near exceeding esotropia at distance by at least 10 prism diopters (PD).

Exclusion criteria were ocular or systemic diseases, a history of previous intraocular or strabismus surgery, neurological or developmental disorders, and a follow-up period of less than 1 year. Patients who had undergone concurrent oblique muscle surgery were also excluded.

The patients underwent a standard ophthalmologic examination, including refraction (cycloplegic refraction via sciascopy and autorefractokeratometer [Retinomax K-plus 3; Right Mfg. Co., Ltd., Tokyo, Japan]), best corrected visual acuity, slit-lamp biomicroscopy, and detailed funduscopy. Visual acuity measurements were obtained with Snellen charts or Lea symbols. Ocular motility was evaluated with alternate prism and cover testing at 6 m and 33 cm and with the Krimsky test for patients of a younger age. Ductions and versions were examined and documented using traditional methods. Examinations were performed preoperatively and postoperatively at 1, 3, 6, and 12 months.

Surgical Procedure

All patients received a posterior fixation suture on both medial rectus muscles at 12 or 13 mm from the insertion of the muscle with a nonabsorbable suture (6.0 Prolene Polypropylene Suture; Ethicon US, LLC, Somerville, NJ). After careful dissection of the connective tissues around the muscle, the suture was fixed to the sclera on both sides of the muscle and a knot was made (Figures 1A–1C). In the recession group, the bridge Faden operation was performed followed by medial rectus recession (Figures 2A–2F).

The steps of the bridge Faden operation. Non-absorbable suture passed through the sclera on (A) one border and (B) the other border of the medial rectus muscle 13 mm from the insertion. (C) Suture tied on the muscle.

Figure 1.

The steps of the bridge Faden operation. Non-absorbable suture passed through the sclera on (A) one border and (B) the other border of the medial rectus muscle 13 mm from the insertion. (C) Suture tied on the muscle.

The steps of the bridge Faden operation with medial rectus recession. (A) Exposure of the medial rectus muscle. (B) Marking of the sclera 13 mm posterior to the insertion of the medial rectus muscle where the bridge Faden suture will be passed. (C) Passage of a non-absorbable suture through the sclera after detaching the muscle. (D) Recession of the medial rectus muscle under the loosened non-absorbable bridge Faden suture. (E) Suturation of the recessed muscle. (F) Completed, tied sutures of the recessed muscle and bridge Faden.

Figure 2.

The steps of the bridge Faden operation with medial rectus recession. (A) Exposure of the medial rectus muscle. (B) Marking of the sclera 13 mm posterior to the insertion of the medial rectus muscle where the bridge Faden suture will be passed. (C) Passage of a non-absorbable suture through the sclera after detaching the muscle. (D) Recession of the medial rectus muscle under the loosened non-absorbable bridge Faden suture. (E) Suturation of the recessed muscle. (F) Completed, tied sutures of the recessed muscle and bridge Faden.

The bimedial bridge Faden operation was performed on patients who had preoperative esotropia of less than 45 PD at near fixation and less than 12 PD at distance fixation. In patients who had preoperative esotropia of greater than 45 PD at near fixation and greater than 12 PD at distance fixation, treatment consisted of symmetric medial rectus recessions combined with the bridge Faden operation. The amount of symmetrical medial rectus recessions was determined by using the standard surgical tables.11

Postoperatively, orthotropia or ±10 PD at near and distance fixations with available optical correction were considered to be satisfactory outcomes. Criteria for a second operation were residual esotropia greater than 16 PD with optical correction and secondary exotropia greater than 16 PD after reduction of the hyperopic correction.

Data Analysis

The Statistical Package for the Social Sciences (SPSS) software (version 23; SPSS, Inc., Chicago, IL) was used for the data analysis. Categorical variables were presented as numbers, and numerical variables were expressed as means and standard deviations. The Kolmogorov–Smirnov test was used to assess the normal distribution of the data and the Wilcoxon signed-rank test was used to compare the differences between preoperative and postoperative values. A P value of less than .05 was considered statistically significant.

Results

A total of 103 patients who underwent the bridge Faden operation between January 2014 and December 2015 were identified. The study population consisted of 38 (37%) girls and 65 (63%) boys. The mean age was 9.32 ± 5.83 years (range: 1 to 18 years). Fifty-one patients underwent the bridge Faden operation on both medial rectus muscles with recession (recession group) and 52 patients underwent the bridge Faden operation on both medial rectus muscles without recession (no recession group). The baseline characteristics of the patients are listed in Table 1.

Baseline Characteristics of Patients

Table 1:

Baseline Characteristics of Patients

In both groups, there were statistically significant differences between the near and distance deviations and near–distance disparities when comparing preoperative values with postoperative values of 1 month, 6 months, and 1 year (P < .05 for each comparison). Postoperatively, no significant differences were found between the near and distance deviations and near–distance disparities between 1 and 6 months, 1 month and 1 year, and 6 months and 1 year (P > .05). The reduction in the near–distance disparity was 82.3% and 82.6% in the recession and no recession groups, respectively. The near and distance deviations are listed in Table 2 and the near–distance disparities at 1 month, 6 months, and 1 year are listed in Table 3. There were no intraoperative complications.

Postoperative Near and Distance Deviations (PD) at 1 Month, 6 Months, and 1 Year

Table 2:

Postoperative Near and Distance Deviations (PD) at 1 Month, 6 Months, and 1 Year

Preoperative and Postoperative Near–Distance Disparity (PD)

Table 3:

Preoperative and Postoperative Near–Distance Disparity (PD)

Postoperatively, 6 patients in the recession group and 2 patients in the no recession group had residual esotropia. In the recession group, 3 patients had a secondary esotropia surgery and 1 patient had secondary surgery for consecutive exotropia. No scarring between the muscle and sclera was observed during the secondary surgeries. On final examination, the results of 88% and 84% of the patients were considered to be successful in the recession and no recession groups, respectively.

Discussion

According to our results, the bridge Faden operation on both medial rectus muscles with or without recession decreased the near and distance deviations and the near–distance disparities in patients with accommodative and partially accommodative esotropia with convergence excess. This decrease was statistically significant and did not change over time. Surgical treatment for patients with large esodeviations at near or minimal to no deviations at distance is particularly difficult. Performing medial rectus recessions that are based on the near deviation angle theoretically increases the risk of eventually creating an exodeviation at distance.12 Alternatively, surgeries that are based on the distance deviation angle often result in unacceptably high degrees of undercorrection.13,14 Our study population was particularly difficult to treat with traditional surgery because of the large near–distance disparity.

Zak15 reported good results with unilateral medial rectus recessions in patients with small deviations at distance and significant deviations at near. According to his results, this treatment should be recommended for patients with a near–distance incomitance no greater than 14 PD. In our study population, the near–distance disparity was greater than 14 PD (17.14 ± 3.00 and 14.05 ± 4.14 PD in the recession and no recession groups, respectively). Zak15 presented smaller amounts of esotropia (average of 18 PD of esotropia at near). In our study, preoperative deviations were 43.51 and 24.24 PD at near and 26.63 and 9.22 PD at distance in the recession and no recession groups, respectively.

Zak15 reported that 50% of the patients studied had a small exodeviation at distance 2 years after surgery. The posterior fixation suture (Faden operation) would seem to be ideal for avoiding this potential long-term complication. The operation aims to produce a weakening, which increases progressively as the eyes move into the field of action of the operated muscle.16

Many authors have reported that a posterior fixation suture with or without medial rectus recession is effective in the treatment of partially accommodative esotropia with convergence excess. Millicent et al.12 reported that most patients (86%) with esotropia only at near fixation were able to maintain satisfactory ocular alignment at near without bifocals. Akar et al.4 evaluated the results of the Faden operation with and without recession for both medial rectus muscles in a group with partially accommodative esotropia with a high accommodative convergence–accommodation ratio. They reported success rates of 71.3% and 78.4% without and with medial rectus recession, respectively. Similarly, bilateral bridge Faden operations were found to be efficient in 84% of esotropias in a study by Thouvenin et al.6 In the current study, we considered results of 88% and 84% in the recession and no recession groups, respectively, to be successful on final examination.

The bridge Faden operation has the same surgical effect as the Faden operation and it is also less aggressive because there is no muscle wound.6 The traditional Faden operation technique is difficult and may result in intraoperative complications such as scleral perforation and postoperative scarring between the muscle and sclera.6,16,17 In the bridge Faden operation, scleral perforation is still a major risk, but a careful surgical technique can minimize this complication. Postoperatively, we controlled the fundus in all cases and did not find any scarring.

Repeated surgeries can also be difficult following the Faden operation. However, some authors reported that secondary surgeries after the bridge Faden operation were easier to perform.6 In our study, four patients underwent a second surgery. We did not encounter any difficulties during secondary surgeries and no scarring between the muscle and sclera was observed.

Due to its retrospective nature, a limitation of this study was that it did not include a control group. However, the bridge Faden operation on both medial rectus muscles with or without recession was a successful surgical procedure in patients with accommodative and partially accommodative esotropia. During the follow-up period, the success rates did not decrease.

References

  1. von Noorden GK, Campos EC. Esodeviations. In: Binocular Vision and Ocular Motility: Theory and Management of Strabismus, 6th ed. St. Louis: Mosby; 2001:311–355.
  2. Wygnanski-Jaffe T, Trotter J, Watts P, Kraft SP, Abdolell M. Preoperative prism adaptation in acquired esotropia with convergence excess. J AAPOS. 2003;7:28–33. doi:10.1016/S1091-8531(02)42017-4 [CrossRef]
  3. Kutschan A, Schroeder B, Schroeder W. Is bimedial muscle belting an alternative procedure to retro-equatorial myopexy in convergence excess esotropia? [article in German]. Ophthalmologe. 2007;104:582–587. doi:10.1007/s00347-007-1540-y [CrossRef]
  4. Akar S, Gokyigit B, Sayin N, Demirok A, Yilmaz OF. Medial rectus Faden operations with or without recession for partially accommodative esotropia associated with a high accommodative convergence to accommodation ratio. Br J Ophthalmol. 2013;97:83–87. doi:10.1136/bjophthalmol-2012-302175 [CrossRef]
  5. Quere MA, Clergeau G, Pechereau A, Fontenaille N, Brasseur G. The retro-equatorial muscular strapping: a technical adaptation of Cuppers's Faden-Operation: a preliminary report (author's transl) [article in French]. Arch Ophtalmol (Paris). 1977;37:531–538.
  6. Thouvenin DA, Sotiropoulos MC, Arné JL, Fournié PR. Esotropias that totally resolve under general anesthesia treated exclusively with bilateral Fadenoperation. Strabismus. 2008;16:131–138. doi:10.1080/09273970802505284 [CrossRef]
  7. Castiella JC, Zato M, Hernani MJ, Castiella G. Operation of the bridge wire: variation to the technique of Cüppers [article in Spanish]. Arch Soc Esp Oftalmol. 1979;39:793–797.
  8. Polenghi F. Modified “Faden operation” (author's transl) [article in German]. Klin Monatsbl Augenheilkd. 1980;176:798–800. doi:10.1055/s-2008-1057555 [CrossRef]
  9. Clark RA, Ariyasu R, Demer JL. Medial rectus pulley posterior fixation is as effective as scleral posterior fixation for acquired esotropia with a high AC/A ratio. Am J Ophthalmol. 2004;137:1026–1033. doi:10.1016/j.ajo.2004.01.012 [CrossRef]
  10. Schroeder B, Schroeder W. Results of the bimedial muscle belt [article in German]. Klin Monbl Augenheilkd. 1992;201:224–230. doi:10.1055/s-2008-1045899 [CrossRef]
  11. Rosenbaum AL, Santiago AP. Clinical Strabismus Management: Principles and Surgical Techniques. Philadelphia: Saunders; 1999.
  12. Millicent M, Peterseim W, Buckley EG. Medial rectus Faden operation for esotropia only at near fixation. J AAPOS. 1997;1:129–133. doi:10.1016/S1091-8531(97)90051-3 [CrossRef]
  13. Kushner BJ, Preslan MW, Morton GV. Treatment of partly accommodative esotropia with a high accommodative convergence-accommodation ratio. Arch Ophthalmol. 1987;105:815–818. doi:10.1001/archopht.1987.01060060101042 [CrossRef]
  14. Akar S, Gokyigit B, Aygit ED, Sabanci S, Demirok A. Is y-split recession of the medial rectus muscle as effective as scleral retroequatorial myopexy of the medial rectus muscle for partially accommodative esotropia with convergence: a report of results in 61 cases. Binocul Vis Strabolog Q Simms Romano. 2013;28:167–175.
  15. Zak TA. Results of large single medial rectus recession. J Pediatr Ophthalmol Strabismus. 1986;23:17–21.
  16. Harcourt B. Faden operation (posterior fixation sutures). Eye (Lond). 1988;2:36–40. doi:10.1038/eye.1988.9 [CrossRef]
  17. Alió JL, Chacon M, Faci A, et al. Muscular structural changes following Fadenoperation. J Pediatr Ophthalmol Strabismus. 1984;21:102–109.

Baseline Characteristics of Patients

CharacteristicRecession GroupNo Recession Group
Age (y)9.76 ± 4.409.05 ± 4.15
Female18 (35.3)20 (38.5%)
Male33 (64.7%)32 (61.5%)
Near deviation angle (PD)43.51 ± 7.0024.24 ± 3.56
Distance deviation angle (PD)26.63 ± 6.869.22 ± 2.09
Follow-up (mo)14.54 ± 2.9114.44 ± 2.68

Postoperative Near and Distance Deviations (PD) at 1 Month, 6 Months, and 1 Year

MeasurementRecession GroupNo Recession Group
1 month
  Near5.73 ± 10.833.18 ± 6.10
  Distance1.77 ± 8.801.22 ± 4.65
6 months
  Near5.59 ± 7.343.00 ± 5.55
  Distance1.95 ± 5.561.03 ± 4.80
1 year
  Near4.29 ± 6.172.55 ± 5.96
  Distance1.08 ± 5.100.74 ± 5.77

Preoperative and Postoperative Near–Distance Disparity (PD)

MeasurementRecession GroupNo Recession Group
Preoperative17.14 ± 3.0014.05 ± 4.14
1 month4.16 ± 5.931.92 ± 4.17
6 months3.22 ± 5.351.96 ± 3.91
1 year3.02 ± 5.231.81 ± 3.67
Authors

From Beyoglu Eye Research and Training Hospital, Istanbul, Turkey (AI, OBO, EDA, SC, GOK, MT, BG); and Okmeydani Research and Training Hospital, Istanbul, Turkey (BI).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Asli Inal, MD, Beyoglu Eye Research and Training Hospital, Bereketzade Mahallesi, Bereketzade Cami Sk. 2/4, 34437, Beyoglu, Istanbul, Turkey. E-mail: a_hamis@yahoo.com

Received: April 01, 2017
Accepted: May 08, 2017
Posted Online: October 09, 2017

10.3928/01913913-20170801-03

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