Muscle plication is a type of strabismus surgery that aims to tighten an extraocular muscle by partially folding the muscle under or over itself without disinsertion. The patient is a 14-year-old with alternating esotropia, who previously had a medial rectus recession. Therefore, she underwent plication of the lateral rectus muscle for this procedure.
A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the lateral rectus muscle. The lateral rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. A Stevens tenotomy hook is used to sweep around the muscle to confirm the location of the muscle pole. A caliper is used to mark the predetermined amount of plication, starting at the muscle insertion and marking further posteriorly on the muscle. The muscle is then secured at the location marked by the caliper with a double-armed 6-0 VicrylTM suture with a central bite and double-locking bites at each pole of the muscle. Plication is achieved by bringing the muscle anteriorly and attaching it to the sclera adjacent to the muscle insertion with half-scleral depth bites in crossed-swords fashion. The muscle is tied down to its new location and 6-0 plain gut sutures are used to close the conjunctival incision.
No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The alternating esotropia had improved.
Lateral rectus plication is a safe procedure that can effectively treat esotropia.
By: Michelle Huynh
College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Brita Rook, MD
Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA
Joseph Fong, MD
Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.
The procedure begins with creation of a conjunctival incision in the fornix using Westcott scissors. Tenon’s capsule is dissected to reveal the underlying bare sclera and expose the lateral rectus muscle. The lateral rectus muscle is isolated with a Stevens tenotomy hook followed by a Jameson muscle hook. The conjunctiva is reflected over the toe of the hook. A Stevens tenotomy hook is used to sweep around the muscle to confirm the location of the muscle pole. The remaining Tenon’s attachments are cleared. A caliper is used to mark the predetermined distance of plication, starting at the muscle insertion and marking further posteriorly on the muscle. A double-armed 6-0 VicrylTM suture is used to secure the muscle. One needle arm is used to make a partial thickness central bite followed by a full-thickness bite toward one pole of the muscle. The suture is double locked at the pole of the muscle. The opposite pole of the muscle is secured by taking the same steps with the other needle arm. The muscle is plicated by attaching the muscle to the sclera adjacent to the muscle insertion using half-scleral depth bites in a crossed-swords fashion. The muscle is tied down to its new location. Finally, 6-0 plain gut sutures are used to close the conjunctival incision.
Strabismus surgery is indicated when conservative methods, such as the use of eyeglasses, patching, prisms, and orthoptic exercises, can no longer adequately treat a patient’s eye alignment. Weakening (recession) of the medial rectus muscle or tightening (resection or plication) of the lateral rectus muscle is often performed to manage esotropia.
For procedure setup, the patient was positioned supine and placed under general anesthesia. Povidone-iodine was used to disinfect the peri-orbital skin. Phenylephrine drops followed by dilute povidone-iodine drops were applied to the ocular surface. Sterile drapes were placed over the face and head. An eyelid speculum was placed in the eye. Forced ductions were performed to assess for any restriction of the extraocular muscles.
Preoperative workup includes review of the patient’s history, including prior treatment for strabismus and amblyopia. Symptoms associated with the strabismus, such as diplopia and/or headaches, should be identified. A sensorimotor examination is necessary to diagnose strabismus. A sensorimotor evaluation includes assessment of ocular motility, including ductions and versions, as well as alignment measurements in primary position, at distance and near fixations, in the cardinal gaze positions, and in head tilt positions.1 Motor fusional amplitudes may be useful in select patients. The sensory evaluation includes assessment of stereo vision.
Devising the surgical plan begins with determining whether to operate on one or both eyes. This can depend on whether a patient has had prior strabismus surgery and on the presence of amblyopia. Sometimes the eye to operate is apparent based on the disorder. The number of muscles to operate is the next step in surgical planning and is usually determined by the magnitude of the preoperative deviation. Operation on a single muscle is preferred when the deviation is small to moderate. More muscles may need to be operated when there is a larger deviation. General guidelines have been published to help determine the amount of recession or resection/plication based on the size of the deviation. However, the guidelines should be modified based on the surgeon’s experience and the presence of several factors, including duction limitation, fusion level, associated central nervous system disease, previous strabismus surgery, or abnormal anatomy.1 An anesthesia pre-procedure evaluation is necessary before the surgery.
Strabismus surgery provides a cosmetic benefit as well as the functional benefits of restoring binocular vision and eliminating diplopia and compensatory head postures. The procedure can correct large deviations that may not be practical to address with prisms or eye exercises. Strabismus surgery also leads to more permanent results than botulinum toxin administration.
When planning strabismus surgery, it is necessary to decide whether to recess a muscle, resect or plicate the opposing muscle, or both. Muscle recessions produce a larger effect per millimeter and are associated with less post-operative irritation compared to muscle resections.2,3 Preservation of anterior ciliary circulation patency is an advantage of muscle plication compared to muscle resection.2
Risks of strabismus surgery include bleeding, pain, infection, and damage to nearby structures. Intraoperative risks include scarring and scleral perforation.4 Another potential risk is the slippage of a muscle back in its muscle capsule, which requires further surgery to remedy.5 An epithelial inclusion cyst or granuloma can form when the conjunctiva is closed. The most common cause of patient dissatisfaction is eye misalignment postoperatively, which can be managed with additional procedures or prisms.6 Patients can also experience temporary changes in refraction and diplopia postoperatively.6 The risk of anterior segment ischemia is increased with operations involving three rectus muscles in the same eye or with surgeries on multiple rectus muscles in a patient with compromised blood flow.7
Arkansas Children’s Hospital, Little Rock, AR, USA
1. Coats DK, Olitskey SE. Surgical decision making. In: Philipp, M, ed. Strabismus Surgery and Its Complications. Berlin: Springer; 2007:34-39.
2. Helveston EM. Surgical Management of Strabismus. 5th ed. Belgium: Wagenborg; 2005:199.
3. Trumler AA, Robbins SL, Miller AM, et al. Strabismus Surgery, Horizontal. EyeWiki on the American Academy of Ophthalmology website. https://eyewiki.aao.org/Strabismus_Surgery,_Horizontal#Management. Published 2020. Accessed March 2, 2020.
4. Awad AH, Mullaney PB, Al-Hazmi A, et al. Recognized globe perforation during strabismus surgery: incidence, risk factors, and sequelae. J AAPOS 2000;4:150-3.
5. Lenart TD, Lambert SR. Slipped and lost extraocular muscles. Ophthal Clin North Am 2001;14:433-42.
6. Clark RA, Miller AM, Kozk A, Epley KD, et al. Strabismus Surgery Complications. EyeWiki on the American Academy of Ophthalmology website. https://eyewiki.aao.org/w/index.php?title=Strabismus_Surgery_Complications&redirect=no. Published 2020. Accessed March 2, 2020.
7. Saunders RA, Bluestein EC, Wilson ME, Berland JE. Anterior segment ischemia after strabismus surgery. Surv Ophthalmol 1994;38:456-66.