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Original Investigation
August 4, 2022

Effect of Modified Vertical Rectus Belly Transposition vs Augmented Superior Rectus Transposition Plus Medial Rectus Recession for Chronic Sixth Nerve Palsy: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Ophthalmology and Vision Science, Eye & ENT Hospital, Shanghai Medical School, Fudan University, Shanghai, China
  • 2NHC Key Laboratory of Myopia, Fudan University, Shanghai, China
  • 3Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
JAMA Ophthalmol. 2022;140(9):872-879. doi:10.1001/jamaophthalmol.2022.2856
Key Points

Question  Is modified vertical rectus belly transposition plus medial rectus recession (mVRBT-MRc) more effective than augmented superior rectus transposition plus medial rectus recession (aSRT-MRc) for Chinese patients with chronic sixth nerve palsy?

Findings  In this randomized clinical trial of 25 participants, mVRBT-MRc corrected more esotropia than aSRT-MRc at 6-month follow-up visit. The adjusted treatment group difference was 10.9 prism diopters (Δ) (95% CI, 5.3Δ-16.6Δ), favoring mVRBT-MRc.

Meaning  Results of this small trial suggest that mVRBT-MRc is a promising alternative for chronic sixth nerve palsy; however, these findings need to be confirmed in larger cohorts and other locales, with longer-term data as well.


Importance  Both vertical rectus belly transposition (VRBT) and superior rectus transposition (SRT) can be performed simultaneously with ipsilateral medial rectus recession (MRc) and have been shown to be effective for chronic sixth nerve palsy. However, it is unclear whether VRBT is superior to SRT in correcting esotropia.

Objective  To compare the effectiveness of modified VRBT plus MRc (mVRBT-MRc) vs augmented SRT plus MRc (aSRT-MRc) in Chinese patients with chronic sixth nerve palsy.

Design, Setting, and Participants  This parallel-design, double-masked, single-center, randomized clinical trial was conducted from January 15, 2018, to May 24, 2021. The follow-up visits were scheduled at 1 month and 6 months. Eligible Chinese participants with unilateral chronic sixth nerve palsy were randomly assigned to receive either mVRBT-MRc (VRBT group) or aSRT-MRc (SRT group).

Interventions  mVRBT-MRc or aSRT-MRc.

Main Outcomes and Measures  Change of horizontal deviation in primary position from baseline to 6 months.

Results  Of the total 25 eligible participants, the mean (SD) age was 45.4 (12.6) years, with 10 male participants (40%) and 15 female participants (60%). Thirteen participants (52%) were randomly assigned to the VRBT group, and 12 (48%) were randomly assigned to the SRT group. At baseline, the mean (SD) horizontal deviation was 65.7 (10.8) prism diopters (Δ) in the VRBT group and 60.5Δ(14.1Δ) in the SRT group. Similar amounts of MRc were performed in both groups. At 6 months, the horizontal deviation changed from baseline by 66.3Δ in the VRBT group and by 51.5Δ in the SRT group. The adjusted group difference was 10.9Δ (95% CI, 5.3Δ-16.6Δ), favoring the VRBT group (P = .001). Four times as many participants corrected more than 60Δ with mVRBT-MRc compared with aSRT-MRc. The group difference of the improvement of abduction limitation was −0.2 (95% CI, −0.8 to 0.5; P = .64). Although there was a higher proportion of undercorrection in the SRT group (difference, 45%; 95% CI, 16%-75%; P = .01), no differences were identified for other suboptimal outcomes between groups.

Conclusions and Relevance  Compared with aSRT-MRc, mVRBT-MRc showed better effect in correcting esotropia with no differences detected for other suboptimal outcomes. mVRBT-MRc may be a promising alternative surgical procedure for chronic sixth nerve palsy, particularly for large esotropia of more than 60Δ, if these results are confirmed in larger, diverse cohorts with longer follow-up.

Trial Registration  ChiCTR Identifier: ChiCTR-INR-17013705

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