Plication as an alternative to resection in horizontal strabismus: A randomized clinical trial

Abstract

Purpose: Resections and plications tighten recti although the latter are less traumatic, potentially reversible, quicker, and vascularity preserving. To compare inflammation, scarring, and alignment in horizontal strabismus, operated uniocularly by either resections or plications (with recessions): recession and resection (R&R) or recession and plication (R&P) groups. This was a prospective, patient and assessor blind, randomized trial.

Methods: All consenting strabismus patients qualifying for the first-time uniocular horizontal rectus surgeries underwent detailed ocular examination and were randomized into standard R&R or R&P groups. For the latter, we folded the tendon-muscle strap the desired amount using 6-0 polyglactin, suturing it to its insertion, entailing no disinsertion. We compared the groups for inflammatory grades (individually for congestion, chemosis, discharge, foreign-body sensation, and drop intolerance and aggregated to a total inflammatory score (TIS), scar visibility (SV) at 1 m, and successful alignment (≤10 prism diopter of orthotropia). We used Mann-Whitney and Fisher's exact tests, with significance at P ≤ 0.05.

Results: We randomized 40 patients: 22 to R&R and 18 to R&P. The groups were comparable in age, strabismus onset and duration, and strabismus amount. The inflammatory scores, both individual and TIS, were comparable at all time-points: all P > 0.05. SV proportions were not significantly different: 16/22 in R&R versus 9/18 in R&P; P = 0.19. There were no significant differences in success rates: 14/22 versus 10/18, P = 0.74.

Conclusion: Our study shows that plication is similarly effective as resection, when combined with recession in horizontal strabismus, and should be resorted to more frequently.

Figure 1

Steps of plication: (a) Passing the locking sutures in rectus muscle at the desired position, (b) passing partial thickness scleral sutures at each end of muscle insertion, (c) folding the muscle on the global aspect with the help of wide bore needle, (d) the plicated muscle

Figure 2

Recruitment data of the participants

Figure 3A

Postoperative appearance: Recession and resection group on day 1 (a), at 2 weeks (c) and 6–8 weeks (e) and recession and plication group on day 1 (b), at weeks (d), and 6–8 weeks (f)

Figure 3B

Successful outcome of recession and resection group (a) and of recession and plication group (b)

Figure 4

Group-wise comparison of change in alignment at 6–8 weeks, in prism diopters from baseline per mm of muscle alteration