Medial rectus muscle pulley posterior fixation sutures in accommodative and partially accommodative esotropia with convergence excess

BackgroundThe use of medial rectus pulley posterior fixation sutures to treat esotropia with convergence excess has limited support in the literature. We describe our results using this technique to treat patients with large near–distance disparities.MethodsWe retrospectively analyzed records of patients with accommodative or partially accommodative esotropia and convergence excess 13Δ or greater treated with bilateral medial rectus muscle recessions augmented by pulley posterior fixation. Surgical doses of recessions were calculated for the mean of distance and near deviations. Primary outcome measures were ocular alignment at distance and near and near–distance disparity.ResultsA total of 26 patients were identified by the record review. Mean age at surgery was 5.4 years (range, 1.8-11.0 years) and mean follow-up time 12.7 months (range, 1.0-37.6 months). Mean preoperative distance esotropia was 22.9Δ (range, 0Δ-53Δ), with a mean near–distance disparity of 26.4Δ (range, 13Δ-53Δ). At 1 to 3 months postoperatively, mean distance deviation was 0.5Δ exotropia (range, 18Δ exotropia to 12Δ esotropia), with a statistically significant decrease in mean near–distance disparity to 4.5Δ (range, 0Δ-26Δ; P < 0.001). Three-quarters of patients (77%) achieved 0Δ to 9Δ esotropia at 1 to 3 months, with 4 overcorrections for distance and 2 undercorrections for distance and near. At final follow-up 2 patients had persistent exotropia less than 10Δ.ConclusionsAugmentation of bilateral medial rectus recessions with pulley posterior fixation resulted in a significant decrease in near–distance disparity in this group of patients with accommodative and partially accommodative esotropia and convergence excess, with a low rate of persistent overcorrection for distance.