Augmented Surgery for Esotropia Associated With High Hypermetropia

Historically, surgical formulas for the management of accommodative esotropia have been based on the residual deviation with full hypermetropic correction. This "standard surgery" has resulted in a high incidence of undercorrection. In response to the large number of undercorrections with standard surgery, the authors have devised a formula for augmenting the amount of rectus recession based on the average of the near deviation with and without correction. In this study, we compare augmented surgery to standard surgery in patients who underwent bilateral medial rectus recessions for residual esotropia after prescribing full hypermetropic spectacle correction. Seventy patients with acquired esotropia after 6 months of age, and hypermetropia of +3.00 or more, were retrospectively studied. Thirty of these patients had undergone standard surgery, while 40 had augmented surgery. The follow up on each group was at least 1 year. Of the 30 patients in the nonaugmented group, 22 (74%) had postoperative deviations of 10 prism diopters or less with 8 (26%) showing a significant undercorrection. Of the 40 patients who received augmented surgery, 35 (88%) had postoperative deviations of 10 δ or less and 5 (12%) were exotropic while wearing full hypermetropic correction. Of the 5 patients with a consecutive exodeviation while wearing full hypermetropic correction, 2 corrected to orthotropia by reducing the spectacle correction by +1.50 diopters and +1.25 D (93% success), 2 were converted to orthotropia by removing +3.00 spectacle correction (97% success), and 1 continued to have an intermittent exodeviation even after removing spectacle correction. This brought the overall success rate for augmented surgery to 98%. Fusion results, as measured by Worth Four Dot (W4D) or Titmus Stereo Acuity, showed 10 of the 30 patients with standard surgery (33%) achieved at least peripheral fusion, whereas 26 of 40 (65%) in the augmented group had postoperative fusion. Our conclusion is that augmented surgery provides better postoperative alignment and fusion than standard surgery. We recommend surgical recessions based on the average of the near deviation with correction and near deviation without correction.