Comparative surgical outcomes of rectus muscle plication versus resection in horizontal strabismus correction: a systematic review.
PURPOSE Rectus muscle resection is a standard strengthening procedure in horizontal strabismus surgery, but it requires muscle disinsertion and tissue excision. Rectus muscle plication has been proposed as a vessel-sparing alternative that preserves the muscle insertion and may reduce selected technical risks. This review evaluates the comparative effectiveness, safety, and short- to medium-term outcomes of plication versus resection in horizontal strabismus surgery. METHODS This systematic review was conducted according to PRISMA guidelines and registered in PROSPERO. MEDLINE, CENTRAL, Google Scholar, and Web of Science were searched for comparative studies published through January 2025. Eligible studies directly compared rectus muscle plication with resection for horizontal strabismus. Risk of bias was assessed using RoB 2 for randomised trials and the Newcastle-Ottawa Scale for non-randomised studies. RESULTS Fifteen studies were included, comprising six randomised controlled trials and nine non-randomised comparative studies. Overall, 501 patients underwent plication and 576 underwent resection. Both procedures produced clinically meaningful improvement in ocular alignment, with most studies reporting final residual deviations within or near 10 prism dioptres. Across studies reporting formal success rates, plication success ranged from 27.8% to 100% and resection success from 55.3% to 100%; however, success definitions varied substantially, limiting direct comparison. Most studies found no statistically significant difference between procedures. Early overcorrection and postoperative diplopia were lower with plication in some studies. Complications were generally mild. No anterior segment ischaemia was reported, and no slipped or lost muscles were reported in any plication group. Conjunctival swelling or muscle hump after plication was transient and self-resolving. CONCLUSION Rectus muscle plication appears to be a safe and effective alternative to resection for horizontal strabismus, with broadly comparable short- and medium-term alignment outcomes. Plication offers technical advantages, including preservation of anterior ciliary circulation and avoidance of muscle disinsertion, but evidence for long-term durability remains less certain, especially in paediatric intermittent exotropia. Future studies should use standardised success definitions, stratify outcomes by strabismus subtype and age group, and include longer follow-up. Registration: PROSPERO [CRD42024560726].