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Simultaneous three or four horizontal rectus muscle surgery versus two-staged surgery for large angle congenital esotropia in children : a randomized controlled trial.

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Large angle congenital esotropia is commonly seen in South Africa. The optimal surgical approach for angles larger than 50 prism dioptres (PD) esotropia is controversial. Conventional bilateral medial rectus muscle recessions used for smaller angles is not sufficient to achieve and maintain alignment in large angles. Large esotropias therefore either require very large medial rectus muscle recessions, or surgery on the medial rectus as well as one or both lateral rectus muscles. In the past supramaximal medial rectus recessions have been associated with late consecutive exotropia and other long term complications. Three or four horizontal rectus muscle surgery can be performed as one procedure or as staged surgery. In staged surgery the medial rectus muscles of both eyes are recessed, the residual angle measured and the lateral rectus muscles resected for the remaining deviation during a second procedure. One would expect the two procedure surgery to have greater accuracy with lateral rectus resections once the effect of the initial medial rectus recession surgery has been established. I could find no data comparing the outcome between one and two procedure surgery. KwaZulu-Natal is one of the largest provinces in South Africa and patients in rural areas need to travel long distances to the hospital. Financial resources are limited. I wanted to know how the outcome between a single three or four muscle procedure compares to a staged procedure. If the results are similar, a single procedure would save patients time and money, avoid exposure of the child to a second general anaesthetic and save valuable theatre time and resources. The purpose of this comparative study was to compare the outcome of a single three or four horizontal rectus muscle surgery to a staged procedure in children aged 9 months to 16 years with large angle congenital esotropia presenting to the Eye Clinic at Inkosi Albert Luthuli Central Hospital from March 2011 to July 2014. All children with congenital esotropia and angles larger than 50PD within the required age group who had not had previous strabismus surgery, significant refractive errors, amblyopia, eye pathology leading to poor vision or neurological problems were recruited for the study. Each child was randomly assigned to one of two treatment groups (one procedure or two procedure staged surgery 6 to 12 weeks apart). The surgery was performed by a single surgeon. The amount of rectus muscle surgery was based on standard of care surgical tables. Alignment in the two groups was compared 6 weeks after the final procedure. I hope that the results of this study would assist in optimizing the management of children with large angle congenital esotropia.