0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Changes in Lateral Comitance After Asymmetric Horizontal Strabismus Surgery

Carolyn P. Graeber, MD1,2; David G. Hunter, MD, PhD1,2
[+] Author Affiliations
1Department of Ophthalmology, Boston Children’s Hospital, Boston, Massachusetts
2Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
JAMA Ophthalmol. 2015;133(11):1241-1246. doi:10.1001/jamaophthalmol.2015.2721.
Text Size: A A A
Published online

Importance  Asymmetric horizontal strabismus surgery is often performed to correct primary gaze alignment without considering the symptoms that may result from misalignment in the patient’s side gaze. Surgical choices influence alignment in side gaze and may contribute to functional and social deficits.

Objective  To identify the surgical procedures associated with changes of alignment in side gaze to help inform surgical planning for patients with horizontal strabismus.

Design, Setting, and Participants  The medical records of 1081 horizontal strabismus surgical procedures that were performed at Boston Children’s Hospital during a 2-year period were retrospectively reviewed. Only records with strabismus measurements recorded in the right and left gaze before and after surgery were included. Data analysis was conducted from September 1, 2012, through June 7, 2015.

Main Outcomes and Measures  Change in comitance (CIC), determined by measuring the horizontal comitance (the difference between right- and left-gaze strabismus measurements) before and after surgery.

Results  The review identified 569 patients who met the inclusion criteria. Of the 491 patients with comitant preoperative alignment, 59 developed postoperative incomitance, of whom 53 (89.9%) had asymmetric surgery. Of the 78 patients with incomitant preoperative alignment, 36 patients’ (46.2%) deviation had improved to comitance after surgery; 32 (88.9%) of these patients had asymmetric surgery. Asymmetric 2-muscle surgery had a median CIC of 4.0 while symmetric 2-muscle surgery had a median CIC of 1.5 (difference in CIC, 2.5; 95% CI, 2.0-3.0; P < .001). A CIC of 25 prism diopters or more was observed in 6 patients who underwent asymmetric surgery (0 with symmetric surgery). New postoperative incomitance was symptomatic in at least 17 patients (28.8%).

Conclusions and Relevance  Asymmetric strabismus surgery can treat incomitant deviations, but it can also create symptomatic incomitant deviations in patients who were previously comitant. Surgical planning should include consideration of the potential for CIC, including the potential for unsatisfactory appearance in side gaze. Patients with binocular vision will be sensitive to diplopia in any gaze direction; in such cases, the consequences of asymmetric surgery should be considered with particular care.

Figures in this Article

Figures

Place holder to copy figure label and caption
Figure 1.
Change in Comitance (CIC) After Horizontal Strabismus Surgery

A, Comparison of symmetric vs asymmetric surgery. The box represents the 25th to 75th percentile; the line near the center of the box, the median. Whisker boundaries indicate the first and 99th percentile. The top and bottom 1.0% are plotted above and below, respectively. B, Change in comitance based on the number of muscles that received surgery. C, Change in comitance in children vs adults. D, Direction of CIC after symmetric vs asymmetric surgery. Δ Indicates prism diopters.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Change in Comitance Induced by Asymmetric vs Symmetric Surgery in Patients With Preoperative Comitance

Ten patients (12.0%) received 1-muscle asymmetric surgery; 41 (24.1%), 2-muscle asymmetric surgery; 2 (12.5%), 3-muscle asymmetric surgery; 6 (2.4%), 2-muscle symmetric surgery; and 0 (0%), 4-muscle symmetric surgery. The larger change was considered the less favorable outcome.

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,116 Views
0 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Case 1

brightcove.createExperiences();