Medial transposition of a split lateral rectus muscle in synergistic divergence

Synergistic divergence is a rare congenital ocular motility disorder characterized by paradoxical abduction during attempted horizontal gaze to the contralateral side. It is generally unilateral and associated with limited adduction of the affected eye and large-angle exotropia in primary position. Various surgical techniques have been used to manage this condition, with limited success. We describe our experience using splitting and medial transposition of the lateral rectus muscle on the affected side to treat an 18-month-old girl with synergistic divergence. Postoperative improved motor alignment remained stable through 6 months' follow-up.

Adjustable Posterior Fixation Suture Technique in Adjustable Superior Rectus Transposition

BACKGROUND

Recently, the superior rectus transposition has been widely adopted for the treatment of complete abducens palsy and Duane syndrome. This procedure is useful in that there is a decreased risk of anterior segment ischemia compared to complete vertical rectus transposition, possibly decreased incidence of postoperative-induced vertical deviations than complete vertical rectus transposition, and improvement in abduction compared to simple medial rectus recession. One difficulty with this procedure is the lack of adjustability in most patients. Our group has adopted a new technique for an adjustable posterior fixation myopexy suture for use with patients under topical anesthesia.

METHODS

The superior rectus muscle is temporally transposed to the insertion of the lateral rectus muscle. The corner of the superior rectus muscle that is placed adjacent to the lateral rectus muscle is placed on an adjustable suture. Then, a posterior fixation myopexy suture consisting of a single-armed 6-0 vicryl suture is secured between the superior and lateral rectus muscles, approximately 10 mm from the lateral rectus insertion to drag the superior rectus muscle temporally. This suture is also placed on an adjustable suture. The patient is then positioned sitting up, fixing at a target at approximately 10 feet away from the patient's head. Cover testing is utilized to determine whether any vertical deviation has been induced. If there is a vertical deviation, the posterior fixation suture may be loosened.

RESULTS

We find that this technique to be useful if an induced vertical deviation or an overcorrection occur, and is thought to be due to the reported possible complication of restriction induced by the posterior fixation suture and the transposed rectus muscle.

CONCLUSION

Our technique for performing superior rectus transposition with an adjustable posterior fixation myopexy suture may be useful to surgeons who wish to have an adjustable option as a way to decrease the risk of postoperative complications such as induced vertical deviations and overcorrections.

Combined lateral rectus augmented transposition and inferior rectus recession for monocular elevation deficiency

We report the case of a 21-year-old woman who presented with a drooping right upper eyelid and smaller-appearing right eye, evident since birth. Her visual acuity was 20/30 in the right eye and 20/20 in the left eye. In primary gaze she had a hypotropia of 25^Δ, with a marked elevation limitation and associated true upper lid ptosis of 3 mm. Under local anesthesia, the lateral rectus muscle was transposed to the superior rectus muscle and was augmented by a nonabsorbable suture attaching the superior rectus muscle and lateral rectus muscle 8 mm posterior to the insertion, accompanied by an inferior rectus recession. One year after surgery she was orthophoric in primary position and showed improvement in elevation. The surgical procedure can be performed at the same time as the inferior rectus recession and reduces the risk of anterior segment ischemia.

Double Augmented Vertical Rectus Transposition for Large-Angle Esotropia Due to Sixth Nerve Palsy

PURPOSE

To study the binocular alignment and ocular motility in patients with large-angle esotropia due to sixth nerve palsy treated with double augmented vertical recti transposition.

METHODS

This was a prospective interventional study. Fifteen patients with non-resolving sixth nerve palsy who underwent surgical correction were included in the study. Fourteen patients also underwent an additional medial rectus recession. Two patients with an associated small vertical deviation had a selective augmentation of one vertical rectus muscle. Binocular alignment, ocular motility, duction limitation, improvement in head posture, induced vertical deviations, and field of diplopia-free binocular single vision (when possible) were analyzed. Successful outcome was defined as a residual horizontal deviation of 10 prism diopters (PD) or less with no vertical deviation at final follow-up (6 months).

RESULTS

The double augmented Hummelsheim procedure improved esotropia from 58.3 ± 10.8 PD preoperatively to 7.2 ± 5.1 PD postoperatively (P = .001). Three (20%) patients had residual deviation of greater than 10 PD, of which 1 patient had diplopia and was treated with prisms. Postoperative binocular field of vision was performed in 6 patients, the mean of which was 20° for abduction and 45° for adduction. Three of 6 patients had elimination of face turn and the rest had residual head posture of less than 5°. Two patients had an induced vertical deviation of less than 4 PD. In patients who had selective augmentation, the vertical deviation was completely corrected.

CONCLUSIONS

The patients operated on with double augmentation of the Hummelsheim procedure combined with medial rectus recession had reduced mean primary esotropia and improved diplopia-free field of vision postoperatively. [J Pediatr Ophthalmol Strabismus. 2016;53(6):369-374.].

Orbital Imaging to Identify a "Lost" Lateral Rectus Muscle

A 36-year-old man presented with a large-angle esotropia and limited abduction of the right eye. A computed tomography scan of his orbits showed an absent lateral rectus muscle. At the time of surgery, a normal-appearing lateral rectus muscle was found. Postoperative magnetic resonance imaging showed a present but atrophic lateral rectus muscle.

[Clinical application of orbicularis flap for eyelid groove deformity ]

OBJECTIVE

To discuss the correction of lower baggy eyelid with severe tear trough and eyelid sulcus (groove deformity) and its therapeutic effect.

METHODS

Through incision at the lower eyelid margin, the dissection was performed at the deep surface of the orbicularis muscle to expose the orbital septum and inferior orbital rim periosteum. The orbital fat which was released from orbital septum was repositioned at the inferior orbital rim and fixed on periosteum. If the depression was not completely corrected, the extra orbicularis fixed with periosteum. If the depression was not completely corrected, the extra orbicularis muscle was designed as muscle flap with interior pedicle to further correct the groove deformity.

RESULTS

60 cases were treated with no depression or unsmooth deformity. All the cases were followed up for 3-12 months with satisfactory aesthetic effect.

CONCLUSIONS

Orbicularis flap combined with orbital fat reposition is a simple and effective method for correction of tear trough and eyelid sulcus deformity.

Transposition surgery for inferior rectus fibrosis

Congenital fibrosis of the extraocular muscles is a rare hereditary strabismus disorder. A case of congenital fibrosis of the inferior rectus muscles with severe chin-up posture and bilateral limitation of up gaze is reported. Bilateral large recessions of the tight inferior rectus muscles provided only partial improvement. Residual head posture and hypotropia were successfully corrected with bilateral horizontal rectus muscle transpositions toward the superior rectus muscles, despite persistently tight inferior rectus muscles at the time of surgery.

Isolated inferior oblique myectomy for hypertropia

BACKGROUND

Hypertropia is a condition in which one eye is elevated relative to the other, either intermittently or constantly. It causes significant problem either cosmetically or by abnormal head posture and thus needs to be corrected surgically. This study was conducted to evaluate the success rate and complications of isolated inferior oblique myectomy in patients with hypertropia.

METHODS

Patients having hypertropia (Deviation > 6 prism diopters [PD]) associated with inferior oblique over-action were included in this observational Case-series, conducted from July 2011 to December 2012, at Al Ibrahim eye Hospital, Karachi. Patients underwent unilateral inferior oblique myectomy. Final outcome was considered at the end of three months at which achievement of ≤ 2 PD of hypertropia was considered as a success.

RESULTS

During the study period, 58 patients were included. Hypertropia was most commonly associated with exotropias 23 (39.7%) followed by esotropias in 18 (31%). Mean angle of hypertropia was reduced from 13.55 ± 4.43 prism diopters to 0.48 ± 1.08 prism diopters. Out of 58 patients, 55 (94.8%) had achieved success after surgery while only 3 (5.2%) patients had residual hypertropia of greater than 2 prism diopters (p = 0.001). No direct complications of procedure observed intra-operatively or up to 3 months post operatively but significant overcorrection of residual horizontal deviation observed after horizontal squint surgery in these eyes.

CONCLUSION

Isolated inferior oblique myectomy is highly successful and safe surgical procedure for correction of hypertropia.

Surgical results of a muscle transposition procedure for abducens palsy without tenotomy and muscle splitting

PURPOSE

To report a simple muscle transposition procedure without tenotomy or muscle splitting to treat abducens palsy.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Nine patients with esotropia resulting from abducens palsy whose eyes could not abduct beyond the midline underwent this muscle transposition procedure, in which a suture was inserted through the temporal margin of each vertical rectus muscle. The same monofilament suture also was inserted into each inferotemporal or superotemporal sclera. The lateral margin of each vertical rectus muscle was transposed superotemporally or inferotemporally and was sutured onto the sclera. All 9 patients underwent unilateral muscle transposition, and 6 of the 9 underwent a medial rectus muscle recession combined with muscle transposition in the same eye.

RESULTS

The surgical correction by muscle transposition alone ranged from 24 to 36 prism diopters, and that by muscle transposition and recession of the medial rectus muscle ranged from 50 to 62 prism diopters. The mean correction was 46.3 ± 13.1 prism diopters per eye. All paretic eyes could abduct beyond the midline. No major vertical ductional disturbances developed. Anterior segment ischemia did not occur in any patients.

CONCLUSIONS

This procedure, which achieved the same corrective results as other popular procedures, is simple to perform because it requires only a suture from the muscle to sclera. Tenotomy or splitting of the transposed muscles is unnecessary.

Asymmetric inferior oblique anterior transposition for incomitant asymmetric dissociated vertical deviation

BACKGROUND

Inferior oblique anterior transposition (IOAT) is indicated in patients with incomitant dissociated vertical deviation (DVD) larger in adduction. In general, bilateral surgery is recommended in patients with DVD unless there is deep monocular amblyopia. The purpose of this study is to evaluate the results of asymmetric IOAT in patients with asymmetric incomitant DVD larger in adduction.

METHODS

Retrospective chart review of the records of all patients with incomitant asymmetric DVD associated with inferior oblique (IO) overaction who underwent asymmetric IO weakening procedure. In all patients, the eye with more DVD in adduction underwent IOAT to the temporal corner of the insertion of the inferior rectus (IR) muscle, and the eye with less DVD underwent IOAT to a position 3-4 mm posterior to the insertion of the IR. No other muscles were operated simultaneously. No patient had previous surgery on any cyclovertical extracular muscle.

RESULTS

Fourteen patients were included. Mean age at surgery was 10.3 ± 8.8 years (range 4-33). Primary position DVD preoperatively was 18 ± 2 PD in the eye with the larger DVD compared to 1.1 ± 1.0 PD postoperatively (p < 0.0001). DVD asymmetry between the lateral gaze with the largest DVD and the lateral gaze with the smallest DVD was 9.8 ± 3.1 PD (range 5-14 PD) preoperatively vs 1.1 ± 1.0 PD (range 0-2 PD), (p < 0.0001). Ten patients had preoperative V-pattern >10 PD (24.7 ± 8.7 PD, range 12-50 PD) preoperatively vs no patients postoperatively (mean V-pattern 4.4 ± 2.0 PD), (p < 0.0001). Postoperative follow up was 1.6 ± 0.7 years (range 1-3 years).

CONCLUSION

In patients with asymmetric incomitant DVD, asymmetric IOAT improves lateral incomitance without increasing the risk of antielevation, limitation in upgaze rotation, or hypertropia, or worsening the DVD in the eye with less deviation preoperatively.

Transposition surgery for internuclear ophthalmoplegia

PURPOSE

To report outcomes of an extraocular muscle transposition procedure for surgical correction of internuclear ophthalmoplegia.

METHODS

Records of patients operated on between January 1999 and May 2011 were reviewed to identify patients treated with an extraocular muscle transposition procedure for internuclear ophthalmoplegia. Indications for this procedure included a known unilateral or bilateral internuclear ophthalmoplegia with a large-angle exotropia, a moderate adduction limitation, and a large-angle exodeviation in primary position. All patients underwent orthoptic evaluation preoperatively and postoperatively. Examination included assessment of subjective complaints, visual acuity, deviation in diagnostic positions of gaze, and limitation of ocular motility.

RESULTS

Five patients were identified. The mean reduction in exodeviation at distance after surgery was 59 ± 25 prism diopters, giving a mean percent reduction in exodeviation of 99.6% ± 0.1%. Four of five patients achieved primary position orthotropia at distance; the remaining patient had 2 prism diopters of exodeviation. One patient who had a residual exodeviation after the initial transposition procedure did not have accompanying ipsilateral lateral rectus recession, but achieved orthotropia with a subsequent ipsilateral lateral rectus recession.

CONCLUSION

Transposition surgery is an effective option for surgical treatment of patients with internuclear ophthalmoplegia with exodeviation and diplopia when combined with ipsilateral lateral rectus recession.

Graded anterior transposition of the inferior oblique muscle for V-pattern strabismus

PURPOSE

To evaluate the efficacy of bilateral graded anterior transposition of the inferior oblique muscle for the correction of V-pattern strabismus associated with inferior oblique overaction.

METHODS

Medical records of patients who underwent graded anterior transposition of the inferior oblique muscle for bilateral primary inferior oblique overaction associated with V-pattern strabismus were reviewed. The surgical technique entailed recessing and anteriorly transposing the inferior oblique muscle to various locations along the temporal border of the inferior rectus muscle. The amount of anterior transposition was determined by both the severity of the overaction and the extent of the V pattern. We analyzed the changes in inferior oblique muscle overaction and V-pattern strabismus and the frequency of limited elevation after surgery.

RESULTS

The record review identified 69 patients (138 eyes) who met inclusion criteria. V-pattern esotropia was present in 44 patients (64%) and V-pattern exotropia in 25 (36%). Full correction or undercorrection to <10(Δ) of V pattern was achieved in 82% of esotropia cases and 80% of exotropia cases. Response to surgery was influenced by the severity of the preoperative inferior oblique muscle overaction and the extent of the preoperative V pattern. The grading of the anterior transposition was not a significant independent predictor of surgical response. No patient suffered limitation of elevation postoperatively.

CONCLUSIONS

Anterior transposition of the inferior oblique muscles corrected V-pattern strabismus and reduced inferior oblique muscle overaction without creating limitation of elevation; however, it is unclear whether grading the transposition contribute to the success of the procedure.

[The technique of periorbital defects reconstruction with island orbicularis oculi myocutaneous flap in orbital zone]

OBJECTIVE

To investigate the technique of periorbital defects reconstruction with island orbicularis oculi myocutaneous flap in orbital zone.

METHODS

The upper or lower eyelid island orbicularis oculi myocutaneous flap,medially based,were used for the defects of the periorbital area, according to the position,shape and size of the defects. The donor site was closed directly.

RESULTS

From July 2003 to October 2009, 24 patients were treated in this method, the flaps survived totally. The flap proved to be flexible, safe, relatively simple, and provided good functional and aesthetic results with follow up 6 to 24 months. Complications were minimal.

CONCLUSIONS

The upper eyelid or lower eyelid island orbicularis oculi myocutaneous flap, medially based, is a satisfied method in repairing periorbital defects in one stage with good blood supply, excellent color texture matching and inconspicuous donor scar and deformity.

Unaugmented Vertical Muscle Transposition Surgery for Chronic Sixth Nerve Paralysis

INTRODUCTION

Chronic sixth nerve palsy can cause incapacitating diplopia requiring vertical muscle transposition surgery. Augmentation of surgery, with lateral fixation sutures, medial rectus recession or botulinum toxin injection, is associated with an increased risk of complications.

PURPOSE

Our aim was to evaluate the efficacy and safety of unaugmented full-tendon vertical rectus transposition in chronic sixth nerve paralysis.

METHODS

Longitudinal study of 21 patients with chronic sixth nerve paralysis of longer than 6 months duration, who underwent superior and inferior recti transposition surgery without medial rectus recession or botulinum toxin injection. Details of surgery, preoperative and postoperative examinations including full orthoptic examination were obtained from an electronic database. Outcomes included the change in angle of deviation, the requirement for further surgery to the medial rectus and postoperative improvement in diplopia. SPSS software (Version 12.0.1, SPSS Inc. Chicago, IL) was used to summarize baseline characteristics and outcomes and to compare preoperative and postoperative deviation (paired t-test).

RESULTS

Twenty-one patients (10 (47.6%) men and 11 (52.4%) women) with a mean age of 41 years (range 4 to 74 years) were operated in the period between April 1998 and November 2000. Eighteen patients had unilateral and three had bilateral acquired sixth nerve palsy. Nineteen patients required unilateral surgery and two had bilateral transposition procedures. In patients with unilateral sixth nerve palsy, mean esotropia in primary position before surgery was 46.7 prism-diopters (PD) (95% CI 35.9-57.4 PD) and improved to 14.6 PD after surgery (95% CI 6.4-22.7 PD). The angle of deviation was significantly reduced by an average of 32.1 PD (p < 0.001, paired t-test; 95% CI 22.6-41.6 PD). Over all, 10 patients (55.6%) had a well-controlled esophoria with a postoperative alignment of within 10 PD of orthophoria without diplopia in the primary position, for distance and near. A further six patients (28.6%) required additional medial rectus recessions to achieve success. The only complication observed was slippage of the inferior rectus in one patient (4.2%), who consequently required further surgery.

CONCLUSION

Botulinum toxin infiltration of the medial rectus in vertical rectus transposition surgery may be unnecessary, incurring cost, additional attendances and interventions for patients. Less than a third of all patients in our series required additional medial rectus recession later.

Anterior transposition compared to graded recession of the inferior oblique muscle for V-pattern strabismus

OBJECTIVE

To compare the efficacy of anterior transposition (AT) and graded recession (GR) in the treatment of V- pattern strabismus caused by overaction of the inferior oblique muscle.

METHODS

The charts of surgically treated cases of V-pattern strabismus were analyzed retrospectively and the patients classified as AT or GR. Age, initial horizontal deviation, initial V-pattern and the amount of V-pattern correction were compared between the two groups.

RESULTS

There was no significant difference in age (p = 0.066), initial horizontal deviation (p = 0.59), initial V-pattern (p = 0.15) or the amount of V-pattern correction (p = 0.78) between the two groups.

CONCLUSION

AT is at least as effective as GR in the treatment of V-pattern strabismus caused by overaction of the inferior oblique muscle.

Myectomy versus anterior transposition for inferior oblique overaction

BACKGROUND

Inferior oblique overaction can be either secondary (as a sequela of ipsilateral superior oblique palsy) or primary (commonly associated with horizontal strabismus). Superior oblique underaction often coexists with both primary and secondary inferior oblique overaction. This retrospective case series compares the efficacy of inferior oblique myectomy versus anterior transposition in improving inferior oblique overaction and superior oblique underaction in eyes with either primary or secondary inferior oblique overaction.

METHODS

One hundred twenty eyes of 81 patients were included in this retrospective case series, of which 20 had anterior transposition of the inferior oblique and 100 eyes underwent myectomy. Inferior oblique myectomy was compared with inferior oblique anterior transposition in improving inferior oblique overaction and superior oblique underaction in each diagnostic subgroup. Postoperative outcome was qualitatively and quantitatively assessed. Fisher's exact test was used to compare the outcomes. The quantitative improvement of function in terms of inferior oblique overaction and superior oblique underaction was analyzed by regression analysis.

RESULTS

When postoperative inferior oblique overaction was considered, there was no statistically significant difference between myectomy and anterior transposition in both primary and secondary inferior oblique overaction. Myectomy was superior to anterior transposition in improving superior oblique underaction in both primary inferior oblique overaction (OR = 0.14; 95% CI, 0.015-1.45; p = 0.056) and secondary inferior oblique overaction (OR = 0; 95% CI, 0-0.027; p < 0.001). The quantitative improvement of function showed a significant difference between procedures for superior oblique underaction (t-test; p = 0.005; 95% CI, 0.25-1.3) but not inferior oblique overaction (t-test; p = 0.8; 95% CI, -0.67-0.54).

CONCLUSIONS

This study demonstrates both inferior oblique myectomy and inferior oblique anterior transposition to be effective in correcting primary and secondary inferior oblique overaction. Myectomy is more effective in improving superior oblique underaction associated with both primary and secondary inferior oblique overaction. On this basis, we feel that inferior oblique myectomy has some advantage over anterior transposition in treating combined inferior oblique overaction and superior oblique underaction and can be considered the procedure of choice.

Evaluation of the effectiveness of anterior transposition of the inferior oblique muscle in dissociated vertical deviation with or without inferior oblique overaction

PURPOSE

Anterior transposition of the inferior oblique muscle (ATIO) has been reported to be an effective treatment for dissociated vertical deviation (DVD). In this study, we evaluated the effectiveness of this surgical procedure in patients with DVD alone and in those with DVD with concurrent overactive inferior oblique muscle and compared the results.

METHODS

Nineteen eyes with DVD alone (group 1) and 15 eyes with DVD and concurrent inferior oblique overaction (group 2) underwent ATIO. The amount of DVD and inferior oblique overaction before and after the operation was measured and statistically analyzed.

RESULTS

The average follow-up time for group 1 and group 2 was 9.4 and 9.0 months, respectively. Of a total of 34 eyes, 7 had DVD of more than 15 prism-diopters (pd) [four eyes from group 1 and three eyes from group 2] in which the residual DVD after surgery was more than 5 pd. However, in the 27 eyes with DVD of 15 pd or less (15 from group 1 and 12 from group 2), the residual DVD after the operation was less than 5 pd. (Fisher's exact test, P = .014).

CONCLUSION

ATIO is an effective method for correcting DVD with and without inferior oblique overaction, especially in deviations of less than 15 pd.

Bipedicle orbicularis oculi flap in the reconstruction of the lower eyelid ectropion

BACKGROUND

Lower eyelid ectropion is conventionally reconstructed with a local flap or full-thickness skin graft. However, scar contracture and recurrence of ectropion often occur. This article describes an effective surgical technique for lower eyelid ectropion repair using a bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid.

METHODS

This study prospectively analyzed collected data on the bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion between 1995 and 2004. The flap was used in 12 eyelid procedures for the correction of lower eyelid ectropion, in 10 cases with traumatic ectropion, and in 1 case with bilateral congenital ectropion. In these cases, a strip of orbicularis oculi muscle or a myocutaneous flap from the upper eyelid with two pedicles attached in the medial and lateral canthus was advanced to the lower eyelid to suspend the eyelid and repair the skin defect.

RESULTS

No problem of flap viability was encountered in any of the patients, and all healed well. Deformities were corrected, and evaluation showed satisfactory function and appearance during 0.5 to 6 years (average, 2 years) of follow-up evaluation. Eyelid malposition and bulkiness of the lower eyelid occurred in the early stages, but disappeared gradually about 3 months after the operation. There was no flap contraction, recurrent deformity, or significant donor site morbidity in the follow-up period. The incision scars were almost invisible.

CONCLUSIONS

The application of bipedicle orbicularis oculi muscle or a myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion is effective and reduces postoperative morbidity.

Traumatic tear of the inferior rectus muscle treated with inferior oblique anterior transposition

PURPOSE

To report a case of traumatic tear of the inferior rectus muscle treated with inferior oblique anterior transposition (IOAT).

METHODS

Case report of a 55-year-old man who presented with vertical diplopia (VD) after orbital trauma. Ocular examination disclosed a 62PD right hypertropia (RHT) in the primary position (PPO). The right inferior rectus (RIR) was torn, and the distal stump was fixed to the skin with tape.

RESULTS

Surgery was performed under local anesthesia. The RIR tearing occurred 13 mm from the insertion, and exploration revealed its proximal end. The right inferior oblique (RIO) was intact, although its fibers were loose. Since the RHT did not improve following reattachment of the proximal and distal stumps of the RIR, the distal stump was excised and the proximal end brought forward and sutured 6.5 mm from the limbus. At perioperative evaluation, there was a 25PD RHT in PPO where the VD persisted. The RIO was subsequently isolated, detached, and its distal end, after 6 mm resection, was sutured to a point temporal to the lateral border of the RIR. The patient was reevaluated and had neither RHT nor VD in primary gaze. At the 6-week postoperative evaluation, he was orthotropic in PPO, complaining about diplopia only on extreme downgaze. A mild limitation of right depression was observed. The patient was satisfied with the surgical results and experienced no functional limitations during any activities.

CONCLUSION

IOAT can provide acceptable binocular visual function without the risk of anterior segment ischemia in cases of torn inferior rectus muscle.

Anterior and nasal transposition of the inferior oblique muscles in patients with missing superior oblique tendons

INTRODUCTION

Patients with missing superior oblique (SO) tendons present with overelevation/underdepression in adduction. Unilateral cases often exhibit abnormal head postures, whereas in bilateral cases, there may be a marked V-pattern with upgaze exotropia. These patients may have craniosynostosis.

METHODS

Nine children with unilateral (n = 2) or bilateral (n = 7) absent SO tendons underwent anterior and nasal transposition of the inferior oblique (IO) muscles, some in combination with horizontal rectus recession for horizontal strabismus. They were evaluated 6 to 46 months postoperatively for alignment and oculomotor examination. Cyclodeviations were not evaluated in most children.

RESULTS

Postoperatively, all patients improved. Both unilateral cases were orthotropic with no abnormal head posture. In the bilateral cases, vertical deviation in adduction and exotropia in upgaze had largely cleared, although some symptoms remained, most notably vertical deviation in side gaze (3 patients) and V-pattern esotropia in downgaze (2 patients). A patient missing both SO tendons as well as the left superior rectus muscle, who had the anterior and nasal transposition on the right side only, remained with 25(Delta) left hypotropia.

CONCLUSIONS

Anterior and nasal transposition of the IO muscle reduces overelevation in adduction and helps eliminate or reduce divergence of the eyes in upgaze, but esodeviation may persist in downgaze. This procedure was most effective in unilateral absence of the SO tendon. It is likely to benefit patients with severe congenital fourth nerve palsy in which standard IO muscle weakening procedures have been ineffective.

Tarsal Switch Levator Resection for the Treatment of Blepharoptosis in Patients with Poor Eye Protective Mechanisms

PURPOSE

The authors report the use of a tarsal switch levator resection procedure that opens the palpebral fissure while reducing the risk of postoperative exposure in ptosis patients with poor eye protective mechanisms.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Fifteen consecutive patients of 2 surgeons at Texas Oculoplastic Consultants from July 1997 through July 2005.

INTERVENTION

A composite tarsal-levator-conjunctival graft was taken from the upper eyelid and was transferred to the lower eyelid.

MAIN OUTCOME MEASURES

Clinical assessment of postoperative exposure keratopathy and position of palpebral fissure relative to visual axis.

RESULTS

A composite tarsal-levator-conjunctival graft was taken from the upper eyelid and was transferred to the lower eyelid in 26 eyelids of 15 patients. One patient was excluded because of lack of follow-up. There were 7 men and 7 women; the age ranged from 20 months to 74 years. The average duration of follow-up was 34 months, with a range of 3 to 85 months. The palpebral fissure was moved cephalad in all patients, improving their head position and unmasking their visual axis in primary gaze. One patient experienced exposure symptoms after surgery and required recession of the levator aponeurosis of both upper eyelids. Overall patient satisfaction was excellent.

CONCLUSIONS

The tarsal switch levator resection procedure elevates both the upper and lower eyelids a predetermined amount. This displaces the palpebral fissure superiorly, effectively opening the visual axis in primary gaze and decreasing the risk of postoperative exposure problems in patients with diminished eye protective mechanisms.

Technique for blepharoptosis correction using double-breasted orbicularis oculi muscle flaps

BACKGROUND

The technique that uses the orbicularis oculi muscle flap to elevate the upper eyelid has become a popular surgical alternative for blepharoptosis. This method is especially effective in cases of severe blepharoptosis with poor levator muscle function. In this technique, the superiorly based orbicularis oculi muscle flap (which is connected to the frontalis muscle anatomically) is advanced and attached to the tarsal plate, thus enabling dynamic elevation of the upper eyelid. However, a temporary period of lagophthalmos occurs with the original method. Although the problem is temporary, it typically lasts 2 to 6 months and may lead to serious eye emergencies.

METHODS

We describe a modification that eliminates lagophthalmos, which is the main drawback of the original technique. Two orbicularis oculi muscle flaps are created, one superiorly based and one inferiorly based. The inferiorly based flap corresponds to the strip of pretarsal orbicularis oculi that is considered "excess" and is discarded in other methods. Our aim with this modified technique is to preserve as much of the pretarsal part of the orbicularis oculi muscle as possible, and thus enable immediate tight eyelid closure postoperatively and achieve dynamic, powerful eyelid-opening action.

RESULTS

We have used this technique in 7 patients (11 eyelids total) during the past 5 years and have achieved favorable results. All 11 operated eyelids showed immediate tight closure postoperatively, as well as dynamic, powerful eyelid-opening action.

CONCLUSION

This operation is a good alternative for patients with severe ptosis who have insufficient levator function and for cases that have recurred after operations with other methods. Local native tissues are used and dynamic correction is achieved with a single incision. The need for intensive eye care is eliminated and there is less risk of corneal damage in the early postoperative period. Above all, this technique yields predictable eyelid-opening action.

[Morphological rationale for autografting of musculus rectus ocularis fibers at revascular optic nerve decompression surgery]

The authors made a morphological study of the early proposed and clinically tested revascular optic nerve decompression operation developed to improve blood supply to the initial portion of the optic nerve in glaucoma-induced optic neuropathy. An experiment was carried out on 11 rabbits. The operated and control eyes were enucleated 1, 4, and 6 months after surgery. The experiment has established that muscle autografting into the retroscleral and paraneural space of the optic nerve is followed by a number of cellular reactions with the active participation of satellite cells, some of which may be associated with regenerative processes and presumably regarded as one of the cell autotherapy modalities.

Vertical rectus muscle transposition for bilateral Duane syndrome

BACKGROUND

Augmented transposition of the superior and inferior rectus muscles to the lateral rectus muscle is effective surgical treatment for esotropia in unilateral Duane syndrome. Medial rectus muscle recession in bilateral Duane syndrome may increase the risk of consecutive exotropia and cause limitation to adduction postoperatively. Vertical rectus muscle transposition may be useful in bilateral Duane syndrome with esotropia.

METHODS

We undertook a retrospective review of 11 patients with bilateral Duane syndrome and esotropia in primary position. All patients had vertical rectus muscle transpositions. Six patients had unilateral vertical rectus transpositions (2 eyes with and 4 without suture augmentation). Twelve eyes from 7 children (2 unilateral and 5 bilateral) had transpositions augmented with posterior fixation sutures. Posterior fixation suture were added to large deviations in patients without prior medial rectus recessions.

RESULTS

The preoperative esotropia at distance was 22.8 +/- 6.3 prism diopters (PD). It reduced to 2.0 +/- 6.7 PD postoperatively. (P < 0.001) Esotropia at near changed from 21.0 +/- 5.8 PD preoperatively to 1.2 +/- 8.1 PD postoperatively. (P < 0.001) One patient with a 10-degree face turn had complete resolution postoperatively. One patient had a small undercorrection and developed a vertical deviation requiring additional surgery. All patients had improvement in abduction. Nine of 11 patients did not develop any limitation to adduction. One patient developed a -1 adduction deficit 5 years later. Three patients achieved fusion with a mean stereovision of 67 seconds of arc (range, 80-40 seconds.). Follow-up averaged 22.2 months (range, 1-100 months).

CONCLUSION

Vertical rectus muscle transposition in patients with bilateral Duane syndrome and esotropia is an effective procedure to improve ocular alignment and motility while preserving adduction.

Anterior transposition of the inferior oblique muscle for a snapped inferior rectus muscle following functional endoscopic sinus surgery

A 55-year-old woman was referred with a 4-month history of diplopia following functional endoscopic ethmoidectomy for chronic sinusitis. She had right hypertropia of 14 prism diopters in the primary position that increased to 30 prism diopters in down gaze. Her right eye showed a moderate limitation of motion in down gaze. Orbital imaging demonstrated a snapped right inferior rectus muscle. The inferior oblique muscle was transposed as an initial treatment for the snapped inferior rectus muscle. After surgery, the patient was orthophoric and obtained fusion in the primary position.

Effect of full tendon transposition augmented with posterior intermuscular suture for paralytic strabismus

PURPOSE

To evaluate the results of the full rectus muscle transposition augmented with a posterior intermuscular suture for paralytic strabismus.

DESIGN

Single-center, retrospective, interventional case series.

METHODS

This study retrospectively reviewed the medical records from November 1994 to September 2004 of 16 patients who underwent the full tendon transposition that was augmented with posterior intermuscular suture for paralytic strabismus. This series evaluated the results of a single transposition surgery; five patients had previous nontransposition strabismus surgery. The following data were analyzed before and after the operation: (1) the angle of deviation in the primary position, (2) the presence of diplopia in the primary position, (3) the binocular single visual fields, (4) the presence of an abnormal head posture, (5) the motility of the affected eye, and (6) the procedure that was performed.

RESULTS

The preoperative angle of deviation in the primary position was 59 +/- 22 prism diopter (prism diopter; range, 30 to 115 prism diopter) compared with 17 +/- 12 prism diopter (range, -10 to 40 prism diopter) after the operation. The preoperative binocular single visual fields improved from 0 degrees to 60 +/- 25 degrees (range, 0 to 90 degrees) after the operation. Diplopia in the primary position was resolved in 11 patients (69%) after the operation. There were no complications such as scleral perforation, unwanted vertical deviations, or anterior segment ischemia in any of the cases during the procedure and postoperative follow-up.

CONCLUSION

Full tendon transposition that is augmented with a posterior intermuscular suture is an effective procedure that results in improved ocular alignment in patients with paralytic strabismus and has a favorable complication profile.

[Autologous grafting of extraocular muscles: experimental study in rabbits]

PURPOSE

To evaluate the feasibility of autologous extraocular muscle grafting as a type of muscle expansion surgery.

METHODS

The left superior rectus muscle of twenty-nine rabbits was resected and this fragment was attached to the endpoint of the respective right superior rectus (test group). Thereafter, the superior rectus of the left eye was reattached to the sclera (control group). Both groups were examined during different postoperative periods in order to assess their outcomes.

RESULTS

The presence of hyperemia was slightly more frequent in the grafted group. Secretion and muscle atrophy were negligible in both groups. Fibrosis was greater in grafted animals. These muscles were weaker than the control muscles, although the force required to split muscular parts was always greater than the physiological one.

CONCLUSIONS

This surgical technique was reliable and useful if one intends to achieve muscle expansion without the intrinsic risks of dealing with heterologous/artificial materials.

Large-angle strabismus and primary true muscle transplantation

BACKGROUND

Large-angle strabismus often demands a series of surgeries to achieve satisfactory alignment. This often necessitates bilateral surgery, which patients may be reluctant to undergo.

METHODS

Three patients with large-angle esotropia, not amenable to standard recession and resection procedures, underwent primary true muscle transplantation wherein a fragment of resected extraocular muscle was used to elongate the medial rectus muscle.

RESULTS

Postoperative deviation was within +/- 10 PD of orthophoria and was maintained at follow-up of 6 to 12 months. There was mild underaction of the weakened muscle.

CONCLUSION

True muscle transplantation is a good option because it permits correction of large-angle strabismus with two-muscle surgery, provides a satisfactory cosmetic alignment, and appears safe and predictable.

Combined rectus muscle transposition with posterior fixation sutures for the treatment of double-elevator palsy

PURPOSE

To evaluate the surgical and functional results of full horizontal tendon rectus muscle transposition to the superior rectus (SR) insertion, augmented by posterior fixation sutures, in patients with double-elevator palsy (DEP).

DESIGN

Retrospective nonconcurrent interventional comparative case series.

PARTICIPANTS

Fourteen consecutive patients with DEP.

INTERVENTION

Six patients treated for DEP by vertical transposition of the horizontal muscles to the SR insertion (Knapp procedure) were compared with 8 patients treated by the Knapp procedure combined with fixation of the transposed muscles to the sclera, adjacent to the SR, with nonabsorbable sutures.

MAIN OUTCOME MEASURES

Postoperative ocular alignment, ductions, binocular functions, and rate of reoperation.

RESULTS

Ocular deviation: Mean distance and near deviations decreased by 84% and 83%, respectively (P = 0.012), in the augmented-surgery group versus 48% and 47%, respectively (P = 0.03), in the standard-surgery group. Duction: Mean elevation deficiency in abduction and adduction improved by 64% and 65%, respectively (P = 0.01), in the augmented surgery group versus 42% and 55% (P = 0.02) in the standard group. Binocular functions: 3 patients (37%), all in the study group, gained binocular function. Reoperation was required in 5 patients (83.3%) in the control group. The difference in postoperative improvement between the groups was statistically significant for all 4 parameters. No postoperative complications or duction anomalies were observed during the follow-up period of 15.4 months (standard deviation, 5.5).

CONCLUSIONS

The augmented Knapp procedure with superior posterior fixation suture is the preferred surgical treatment for patients with DEP. Its use in this series avoided the need for multiple surgeries on other extraocular muscles.

Full vertical rectus muscle transposition combined with medial posterior fixation sutures for patients with adduction deficiency

PURPOSE

To compare the surgical and functional results of full tendon rectus muscle transposition to the medial rectus muscle augmented with posterior medial fixation sutures in patients with adduction deficiency (ADD) and Duane's syndrome type 2.

DESIGN

Retrospective nonconcurrent interventional comparative case series.

PARTICIPANTS

Twelve consecutive patients with ADD and Duane's syndrome type 2.

INTERVENTIONS

Six patients treated by the full tendon rectus muscle transposition procedure alone were compared with 6 patients treated by the full tendon rectus muscle transposition combined with posterior medial fixation sutures.

MAIN OUTCOME MEASURES

Postoperative ocular alignment, duction improvement, binocular functions, and reoperation.

RESULTS

In the augmented surgery group, mean distance and near deviation decreased by 74.5% and 74%, respectively, versus 56% and 59%, respectively, in the control group (P = 0.007 and 0.02, between-group comparison for distance and near deviation, respectively). Mean duction improved in 73% of the study group compared with 52% of controls (P = 0.025). No postoperative complications or duction anomalies were observed during follow-up in the entire cohort; reoperation was needed in 1 patient in the study group and in all 6 patients in the control group.

CONCLUSIONS

The augmented full vertical rectus muscle procedure is a beneficial surgical approach for patients with ADD and Duane's retraction syndrome type 2, reducing the need for multiple extraocular muscle surgery.

Unilateral anterior transposition and resection of the inferior oblique muscle for the treatment of hypertropia

BACKGROUND

Anterior transposition of the inferior oblique muscle generally is restricted to bilateral cases because of reports of postoperative ipsilateral hypotropia or significant limitation of elevation when performed unilaterally. We performed unilateral anterior transposition of the inferior oblique muscle in patients with vertical and horizontal strabismus who were at risk of anterior segment ischemia.

PATIENTS AND METHODS

Six patients underwent unilateral anterior transposition of the inferior oblique muscle in combination with a resection of the inferior oblique muscle. Two patients had lost an inferior rectus muscle in a previous procedure, and four patients had coexistent horizontal and vertical strabismus of various etiologies as well as poor unilateral vision.

RESULTS

All six patients achieved vertical alignment within 10 prism diopters.

CONCLUSIONS

Unilateral anterior transposition of the inferior oblique muscle appears to be a useful procedure in selected patients with vertical strabismus.

"Double elevator palsy" eye supraducts during stage II general anesthesia supporting hypothesis of (supra)nuclear etiology

BACKGROUND

Double Elevator Palsy (DEP) was originally given its name because the assumption was, that because the affected eye could not elevate in adduction or in abduction, there must be a paresis of both the Superior Rectus (SR) and the Inferior Oblique (IO). Later, it was thought that DEP was due to a paresis of the ipsilateral SR, since the SR is the main elevator of the eye in both adduction and abduction. Gradually, a group of observations accumulated that indicated that the SR was not paretic at all in DEP, leading to the concept that DEP is due to a unilateral deficit in a nucleus that functions to elevate one eye only, a unilateral center for upgaze. The purpose of this paper is to report a clinical case with findings that further support this last hypothesis.

CASE REPORT

A 15 month old girl presenting with classical signs of DEP of the left eye received a 6 mm recession of the left Inferior Rectus (IR). This was insufficient to eliminate a large chin elevation and a 9 prism diopter left hypotropia in the primary position. At the beginning of the second surgery, at which a vertical transposition of the horizontal muscles of the left eye after the technique of Knapp was planned, it was noticed during anesthesia induction that, as the child passed through stage II of the general anesthesia, both eyes briefly elevated, the DEP affected left eye (post 6 mm IR recession) more than the right. A photograph was taken to record this phenomenon.

DISCUSSION AND CONCLUSION

As of this report, there are now at least 4 distinct circumstances under which distinct elevation of eyes diagnosed with DEP have been observed. These 4 include Bell's phenomenon, Dissociated Vertical Deviation of the affected DEP eye, normal upgaze saccades recorded moving from the downgaze position into the primary position, and now elevation during Stage II of a general anesthetic induction. Further, there is no abnormal head posture (head tilt) in patients with DEP, no Bielschowsky phenomenon. All of these pieces of clinical evidence confirm that DEP is not a palsy at all. Instead, they strongly suggest that it is absence of function of a unilateral center for supraduction.

Anterior segment ischemia following augmented 2-muscle transposition surgery

Anterior segment ischemia (ASI) rarely complicates surgery on fewer than three rectus muscles. We have encountered two women in their early sixties who developed ASI following augmented transposition of the vertical rectus muscles as described by Foster. Both had undergone intracranial surgery.

Costenbader Lecture. The efficacy of rectus muscle transposition surgery in esotropic Duane syndrome and VI nerve palsy

BACKGROUND

Partial tendon transposition was first described by Hummelshein in 1907. Full tendon transposition was reported by Schillinger in 1959. Recently, full tendon transposition with posterior augmentation was reported by Foster in 1997. I will review current thinking concerning the anatomy and physiology of rectus muscle transposition and present our current clinical experience with this procedure in Duane syndrome.

METHODS

A retrospective review of vertical rectus muscle transposition procedures in patients with VI Nerve palsy was performed comparing the postoperative field of single binocular vision, amount of improved abduction, and change in the primary esotropic angle. In addition, a consecutive series of vertical rectus muscle transposition cases for the treatment of esotropic Duane syndrome is presented, evaluating the improvement and head position, abduction, and reduction of the primary position esotropia.

RESULTS

In VI Nerve palsy patients, vertical rectus transposition surgery produces 41 degrees to 71 degrees of binocular visual field with 10 degrees to 21 degrees of binocular field in abduction. In esotropic Duane syndrome the surgical procedure produces 42 degrees to 66 degrees of binocular field and a correction of approximately 15 degrees of face turn. Variability in the efficacy of the procedure is related to the degree of ipsilateral medial rectus contracture.

CONCLUSION

Vertical rectus transposition with posterior fixation can create a binocular diplopia-free field of 40 to 70 degrees in patients with VI Nerve palsy and about 40 to 65 degrees in patients with Duane syndrome. Partial rectus muscle transposition is an effective procedure in cases where surgery on multiple rectus muscles has been or will be required. Orbital wall fixation of the lateral rectus muscle is an effective and reversible method to inactivate a lateral rectus muscle and may be useful in cases of Duane syndrome with marked anomalous innervation and severe cocontraction.

Rectus muscle orbital wall fixation: a reversible profound weakening procedure

INTRODUCTION

Surgical treatment of third nerve palsy, sensory exotropia and strabismus secondary to anomalous innervation of the rectus muscles, frequently require large rectus muscle recessions in an attempt to maintain alignment in the primary position and reduce the effects of misinnervation. The aim of this study was to describe and evaluate the results of inactivation of a rectus muscle by its attachment to the adjacent orbital wall.

METHODS

Seven subjects diagnosed with third-nerve palsy (three cases), Duane syndrome (two cases), sensory exotropia (one case), and congenital aberrant innervation of vertical rectus muscles (one case) underwent rectus muscle inactivation by orbital wall fixation. The rectus muscle was disinserted from the globe and reattached to the adjacent orbital periosteum using non-absorbable sutures. This surgery was performed on the lateral rectus muscle in six subjects, and surgery was performed on both ipsilateral vertical rectus muscles in one.

RESULTS

Postoperatively four of six patients were aligned within 12 prism diopters of orthotropia in primary position. All patients had improvement of the anomalous head posture. In Duane syndrome, lateral rectus inactivation markedly reduced co-contraction and globe retraction. No overcorrections resulted.

CONCLUSION

A rectus muscle may be functionally inactivated when its insertion is attached to the orbital periosteum. Advantages of this procedure over extirpation and free tenotomy include permanent disinsertion of the muscle from globe and reversibility.

Strabismic complications following endoscopic sinus surgery: diagnosis and surgical management

INTRODUCTION

Endoscopic surgical techniques improve the surgeon's view of sinus structures but are subject to extraocular muscle complications that cause permanent diplopia.

METHODS

A series of 15 patients with strabismus following endoscopic sinus surgery was reviewed retrospectively to characterize the type of muscle injury and report the results of surgical correction.

RESULTS

A variety of insults to the medial rectus (MR) muscle occurred, ranging from contusion, hematoma, oculomotor nerve damage with paralysis, muscle transection, and muscle destruction. Inferior rectus and superior oblique muscle trauma was observed. High-resolution computed tomography and magnetic resonance imaging scans proved essential in determining the extent and nature of muscle injury. Surgical approaches included anterior orbitotomy with muscle recovery and transposition procedures.

CONCLUSIONS

Several extraocular muscles may be traumatized. Timing and type of surgical treatment depend on severity, type of injury, and number of muscles involved. If the remaining posterior segment of the MR muscle is longer than 20 mm and is contractile, muscle recovery via anterior orbital approach is suggested. If injury is more severe, muscle transposition procedures may be helpful. In cases where there is coexistent medial and inferior rectus injury, transposition procedures may not be possible. Inactivation of the antagonist and use of an orbital periosteal flap as a globe tether to center it may be options.

Anterior transposition of inferior oblique muscle for treatment of unilateral superior oblique muscle palsy with inferior oblique muscle overaction

Although many weakening procedures for the inferior oblique muscle have been advocated, there is some controversy as to the most beneficial procedure for weakening overacting inferior oblique muscles. This study was undertaken to determine if unilateral anterior transposition of the inferior oblique muscle alone could be a safe and effective procedure for treating unilateral superior oblique palsy from the perspective of hypertropia, inferior oblique overaction, and abnormal head posture. The records of 33 patients, who underwent anterior transposition of the inferior oblique muscle for unilateral superior oblique palsy at our institution between Jan 1995 and Dec 2002, were retrospectively reviewed. The average preoperative inferior oblique overaction was 2.3 +/- 0.64, and the hypertropia in the primary position was 12.3 +/- 7.69 prism diopter (PD). Twenty-six patients showed head tilt to the opposite direction preoperatively. After the anterior transposition of the inferior oblique, inferior oblique overaction was diminished in 32 patients (97%). Twenty-six out of 33 patients (79%) had no hypertropia in the primary position at last postoperative assessment. Of the 26 patients with head tilt before surgery, 21 patients (81%) achieved full correction after surgery. Satisfactory results were obtained in most of the patients in our study with the exception of three patients who required additional surgery. No patient demonstrated postoperative hypotropia in the primary position. None of the patients noticed elevation deficiency or lower lid elevation. The anterior transposition of the inferior oblique was found to be safe and effective for treating superior oblique palsy with secondary overaction of the inferior oblique muscle.

Improvement of horizontal excursion and abduction by vertical muscle transposition in patients with Duane's retraction syndrome type I

PURPOSE

To measure the change in horizontal excursion and improvement of abduction in Duane's retraction syndrome type I after transposition of both vertical rectus muscles and recession of the medial rectus muscle in the affected eye.

PATIENTS AND METHODS

This was a retrospective study of patients undergoing surgery for Duane's retraction syndrome type I. Thirty-six patients were treated by transposition of both vertical rectus muscles in combination with medial rectus recession of the affected eye. Head posture, binocular vision, abduction and adduction of the affected eye, and angle of strabismus were measured before and after surgery.

RESULTS

After surgery, abduction improved by 15.9 degrees +/- 8.1 degrees (mean +/- standard deviation) and adduction decreased by 5.9 degrees +/- 7.2 degrees. Horizontal excursion improved from 43.1 degrees +/- 8.8 degrees to 53.1 degrees +/- 11.8 degrees. One patient had signs of anterior segment ischemia (ie, enlarged, fixed oval pupil and cells in the anterior chamber), which disappeared after local steroid eye drops were administered.

CONCLUSIONS

Surgery enlarges the range of horizontal excursion of the affected eye and causes only a limited decrease in adduction. One patient developed transient anterior segment ischemia. Vertical muscle transposition combined with medial rectus recession is an effective procedure to improve horizontal excursion and abduction in patients with Duane's retraction syndrome type I.

Unilateral inferior oblique anterior transposition for dissociated vertical deviation

PURPOSE

This study analyzes the outcomes after unilateral inferior oblique anterior transposition (IOAT) for manifest dissociated vertical deviation (DVD).

METHODS

A retrospective chart review was conducted for all patients who had unilateral or markedly asymmetric DVD, ipsilateral overaction of the inferior oblique muscle, lack of alternating fixation, and underwent unilateral IOAT surgery between March 1997 and March 2001. In each case, the bunched inferior oblique muscle was anteriorly transposed to the lateral edge of the insertion of the inferior rectus muscle. The primary outcome variable was change in DVD. Secondary outcome variables included inferior oblique muscle action, graded from -4 to +4, and vertical deviation in primary gaze.

RESULTS

Ten consecutive patients met the inclusion criteria. Median age at the time of surgery was 14 years (range, 2 to 41 years.) Mean follow-up was 25 months (range, 6 to 60 months). Ipsilateral DVD in primary position decreased from a mean of 20.2 prism diopters (PD) (range, 14 to 33 PD) to 3.7 PD (range, 0 to 9 PD) (t test, P <.001). Nine (90%) of the patients had an excellent postoperative result (residual DVD of 0 to 4 PD) and one (10%) had a good result (5 to 9 PD). Inferior oblique overaction was eliminated in all patients. Mean inferior oblique muscle action decreased from +2.4 to -1.3. Three patients developed a transient or permanent 4 to 5 PD postoperative ipsilateral hypotropia in primary position. Dissociated vertical deviation in the fellow eye did not develop, or if present preoperatively, did not increase.

CONCLUSIONS

Unilateral IOAT is an effective treatment for unilateral or markedly asymmetric DVD in patients with a strong, contralateral fixation preference. This surgery reduces inferior oblique overaction but may cause an ipsilateral hypotropia.

Vertical transposition of medial rectus muscles for correction of A-pattern anisotropia

BACKGROUND AND PURPOSE

A-pattern esotropias without superior oblique muscle overaction form a small but distinct group among A and V pattern anisotropias. The purpose of this study was to determine the results of ungraded 5 mm bilateral medial rectus muscle transpositions as a treatment of A anisotropia in esotropic patients, and to study these results with relation to the magnitude of preoperative A anisotropia and to the magnitude of preoperative esotropia in primary position.

METHODS

Patient data on all 37 esotropic patients who had 5 mm elevation of the medial rectus muscle insertion for correction of A anisotropia at our institution during the previous 25 years were studied. We considered the surgical result to be "satisfactory" when a total correction, and A pattern less than 10 Prism Diopters (PD) or a V pattern less than 15 PD were obtained. The patients were divided into different groups, according to the magnitude of the preoperative A pattern and according to the magnitude of the preoperative esotropia in primary position. For statistical analysis, the Chi Square and the Fisher Tests were employed.

RESULTS

"Satisfactory" results were found in 70.3% of the cases. The mean correction of A anisotropia was 11.4 PD (76.1%), which corresponded to 2.3 PD per millimeter of transposition. "Unsatisfactory" results were more prevalent in patients with esotropia in primary position larger than 40 PD (p=0.0418).

CONCLUSIONS

A five millimeter vertical transposition (elevation) of both medial rectus muscles is an effective treatment for correction of A anisotropia in most esotropic patients, but is associated with unsatisfactory results when the preoperative esotropia in primary position is larger than 40 PD.

Transposition of the anterior superior oblique insertion as a treatment for excyclotorsion induced from limited macular translocation

PURPOSE

To evaluate the transposition of the anterior superior oblique insertion as a treatment for cyclovertical diplopia accompanied by an awareness of tilted image perceived with the affected eye induced from limited macular translocation (LMT).

DESIGN

Observational case series.

METHODS

Transposition of the anterior part of the superior oblique tendon combined with or without vertical muscle surgery on the affected eye was retrospectively studied in seven patients. Clinical outcome was assessed for binocular and monocular vision. A successful result was defined as restoration of single binocular vision (SBV) at distance and near examined with the Bagolini test with disappearance of a tilted image perceived in the affected eye.

RESULTS

Six of seven patients (86%) became unaware of tilted image, and three patients (43%) obtained successful results after the strabismus surgery. Of these three patients with successful results, one (33%) patient recognized metamorphopsia, whereas two (67%) of the three patients with unfavorable results reported metamorphopsia. Patients with successful results showed a visual acuity of 20/25 or better in the affected eye and a significantly smaller difference in visual acuity between the two eyes than those patients with unfavorable surgical results (0.133 logarithm of the minimal angle of resolution for SBV(+) vs 0.675 logarithm of the minimal angle of resolution for SBV(-); P =.0255).

CONCLUSIONS

The relatively low success for restoration of SBV indicates that strabismus surgery is recommended for patients whose difference in visual acuity between the two eyes is small and who have a high level visual acuity of the affected eye.

Limitation of opposing ductions following augmented horizontal rectus muscle transposition

PURPOSE

To report the effect on ductions in opposing gaze following augmented horizontal rectus muscle transposition to treat cyclovertical muscle palsies.

METHODS

Record review of 5 patients who underwent augmented horizontal rectus muscle transposition for treatment of vertical gaze misalignment secondary to cyclovertical muscle palsy.

RESULTS

Ductions in the direction of the palsied muscle improved in all patients. Four patients (80%) developed significant limitation of vertical gaze in the direction opposite that of the palsied muscle.

CONCLUSIONS

Augmented transposition surgery for vertical muscle palsy can produce considerable limitation of ductions in the direction opposite to that of the paralyzed muscle.

Unilateral anterior transposition of the inferior oblique muscle for correction of hypertropia in primary position

PURPOSE

To evaluate the correction of hypertropia in primary position with unilateral inferior oblique (IO) anterior transposition (IOAT).

METHODS

Ten patients with idiopathic (nonparalytic, restrictive, or dissociated vertical deviation) hypertropia with marked IO overaction, who underwent unilateral IOAT, were prospectively evaluated to observe the correction of the hypertropia in primary position. No previous ocular muscle surgery had been performed. Four patients had esotropia and two had exotropia. In addition to the proposed surgery, horizontal procedures were performed to correct horizontal deviation, but no vertical transposition of horizontal muscles was done. Four patients had hypertropia and IO overaction, without horizontal strabismus, and IOAT was the only procedure performed. The IO muscle was reinserted 1 mm laterally to the lateral extremity of the inferior rectus muscle insertion using only one suture. The statistical analysis was performed by Wilcoxon rank sum test.

RESULTS

The mean absolute correction in primary position was 18.1 prism diopters (PD) (range, 4 to 33), directly proportional to the size of the hypertropia before surgery. Nine of the 10 patients had a residual vertical deviation of </=6 PD. After surgery, 4 patients (40%) presented limited elevation in adduction (-2) in the field of the operated IO, presumably caused by the antielevator effect of the transposed muscle, which did not improve during the follow-up period (range, 2 to 79 months).

CONCLUSION

Unilateral IOAT is an effective technique for correction of large hypertropia associated with marked unilateral IO overaction. Some lower lid curvature deformity and some limitation of elevation were observed in forced upgaze in some patients, but this was of no cosmetic importance.

Foster-type modification of the Knapp procedure for anomalous superior rectus muscles in syndromic craniosynostoses

PURPOSE

To describe the surgical management of anomalous superior rectus muscles in patients with syndromic craniosynostoses.

METHODS

Retrospectively reviewed were case notes of 3 patients with vertical deviations that were thought to have anomalous superior rectus muscles.

RESULTS

All 3 patients had hypotropia preoperatively, and 2 had coexisting exotropia. Two patients exhibited massive subconjunctival fibrosis intraoperatively, but none had undergone previous strabismus surgery, although they had undergone craniofacial procedures. Orbital imaging (either computed tomographic or magnetic resonance imaging scans) confirmed an absent or thinned superior rectus muscle in all 3 patients. All 3 underwent a Knapp procedure with appropriate recession and resection of the transposed horizontal rectus muscles if indicated. A nonabsorbable suture was placed in the sclera at the upper border of each horizontal rectus muscle to draw this border closer to the vertical midline, approximately 16 to 18 mm from the limbus (Foster-type modification). In each case, the hypotropia and upgaze were improved but not completely normalized.

CONCLUSIONS

A Foster-type modification of the Knapp procedure satisfactorily corrected the hypotropia in these patients. Orbital imaging can confirm the presence of an anomalous superior rectus muscle. The massive subconjunctival fibrosis may be explained by the type of previous craniofacial surgery the patients had undergone.