Partial tendon recession for small-angle vertical strabismus

Temporal Slant Recession of the Inferior Rectus Muscle: A Simple Surgical Treatment for Diplopia Caused by Small Vertical Deviations

BACKGROUND

To evaluate the therapeutic effect of temporal slant recession of the inferior rectus muscle (TSRIRM) for the treatment of small vertical deviations in patients with vertical diplopia, with consideration of the theoretical additive effects of this procedure on ocular torsion and horizontal incomitance.

METHODS

Retrospective review of 11 patients who were treated with TSRIRM. Eight patients with vertical diplopia and small hyperdeviations (up to 6 prism diopters (PDs)) were treated with isolated TSRIRMs. Three patients with vertical diplopia from unilateral superior oblique palsies with large hyperdeviations (>15 PDs) were treated with TSRIRMs in conjunction with contralateral inferior oblique recessions.

RESULTS

Six of the 8 patients with small vertical deviations had successful vertical realignment with elimination of symptomatic diplopia after an isolated TSRIRM. Two of the eight patients had residual hypertropia with symptomatic diplopia. Three additional patients with unilateral superior oblique palsy had successful vertical realignment with elimination of symptomatic diplopia after ipsilateral inferior oblique recession and contralateral TSRIRM. In total, 9 of 11 patients had successful surgical results after TSRIRM.

CONCLUSIONS

TSRIRM provides an effective and reliable treatment for small angle vertical strabismus. Its ease of surgical access renders it useful for implementation in an outpatient neuro-ophthalmology setting.

Inferior oblique recession associated to partial temporal inferior rectus recession in unilateral congenital superior oblique palsy

PURPOSE

To evaluate the effectiveness of inferior oblique recession with contralateral partial temporal inferior rectus recession in patients with decompensated congenital unilateral superior oblique palsy (SOP) in correcting moderate vertical deviations in primary position.

METHODS

The medical records of patients with SOP who underwent inferior oblique recession with contralateral partial temporal inferior rectus recession were reviewed retrospectively. Vertical deviation in primary position, subjective torsion, diplopia, residual deviation, and the deviation decrease were evaluated.

RESULTS

Four patients (three males and one female, age range 29-56 years) with congenital unilateral SOP and mean vertical deviation of 21.0 ± 5.3PD (range 14-25D) in primary position were included. Mean correction of hypertropia in primary position with this technique was 15.5 ± 5.3PD (range 10-20PD). The mean hypertropia on gaze to the contralateral side changed from 30.0 ± 10.8D before surgery to 9.3 ± 7.9D after surgery. Torsion had a mean change of 4.8° of incyclodeviation. Preoperatively, all patients had head tilt and diplopia, which was resolved in all but one patient, who will need surgery. Patients were followed an average of 18 months. No adverse events were reported in any subjects.

CONCLUSION

When performing recession of inferior oblique muscles in SOP associated to a full recession of the contralateral inferior rectus, there is a risk of overcorrection in those with moderate angles. Performing a partial recession in the contralateral inferior rectus eye corrected up to 20PD in primary position in our series, reducing this risk.

Modified Anterior Superior Oblique Tuck: A Case Series

PURPOSE

Selection of the ideal procedure to correct symptomatic excyclotropia depends on several factors including the degree of torsion and associated vertical, horizontal and pattern deviation. Selective tuck of the anterior temporal torsional fibers of the superior oblique (SO) tendon is an alternative procedure to the classical Harada-Ito. The purpose of this study is to report its stability and results.

METHODS

Retrospective review of all consecutive patients with symptomatic excyclotorsion of at least 5º (degrees) treated by selectively splitting and tucking the anterior temporal fibers of the SO tendon. Torsion in primary position was measured using the double Maddox Rods. Patients with additional symptomatic vertical or horizontal diplopia underwent simultaneous surgery on other extraocular muscles.

RESULTS

Five patients were studied. Mean age was 60 ± 8 years (47-67). Mean postoperative follow-up was 10 ± 8 months (3-21). The mean preoperative torsion of 11º±4º (7º-15º) significantly decreased to 3º±2º (p = .03) at the first postoperative visit (16 ± 9 days) and 3 ± 2º during the last visit (P = .03). The procedure corrected 1.4º±0.9º per mm of tuck. Postoperatively no patient complained of torsion. No undesirable vertical or horizontal deviations were noted.

CONCLUSION

This technique is a simple alternative to manage symptomatic excyclotorsion, with significant and stable relief of moderate amounts of torsion and without inducing unexpected vertical or horizontal deviation.

Compartmental Strabismus

Recent reports confirm innervational compartments of select rectus extraocular muscles as well as the superior oblique.¹ Histopathological and orbital imaging studies demonstrate well defined compartmental innervation of the horizontal rectus muscles with less differentiation in the vertical rectus muscles. Acquired vertical misalignment not associated with cyclovertical muscle dysfunction has been associated with horizontal rectus muscle compartment dysfunction. Pattern and other forms of strabismus have been associated with segmental or compartmental abnormal innervation of the extraocular muscles. Taking advantage of segmental function and innervation, selective weakening and strengthening procedures have been used to treat patients with incomitant near/distance disparities, incomitant vertical and torsional strabismus, and patients with A- and V-pattern strabismus.

Current trends of strabismus surgery in a tertiary hospital

OBJECTIVE

To analyze the strabismus surgeries and the outcomes during a year and a half in a tertiary hospital.

MATERIAL AND METHODS

A retrospective study of patients who underwent strabismus surgery. The mean age, sex, diagnosis, diplopia, surgery, anesthesia, adjustable sutures, results, reoperations and follow up time from surgery were analyzed. A good outcome was considered when the final horizontal deviation was less than 10prism diopters (pd) and the vertical deviation less than 5pd without diplopia.

RESULTS

A total of 153 cases were operated on, mean age: 43.14 ±25.58years (61.4%: women). 74.5% of patients were ≥18years (33.33% ≥60). Diplopia was present in 51% of patients. The most frequent deviation was horizontal: 83.6%. The most frequent diagnosis was cranial nerve palsies: 32% (VI nerve: 12.4%), restrictive strabismus: 7.2%, and the aged related distance esotropia: 6.5%. Adjustable sutures were used in 19.7% of cases and topical anesthesia in 65.4%. Good outcomes was present in 79.2% of cases at the end of follow-up. Reoperations were needed in 25.5%. Follow-up evolution time was 11.87 months ±6.5. The sex female (P=.012) and the oblique superior surgery (P=.017) were associated with bad outcome.

CONCLUSION

The adult strabismus surgery was three times more frequent than the children strabismus surgery. The third of the adults that were operated on were ≥60 years. The cranial nerve palsies were the most frequent diagnosis. Adjustable sutures were rarely used. Good outcomes were obtained in most of the patients at the end of follow-up.

Indications and outcome of vertical rectus partial recessions

OBJECTIVE

To assess the indications and results obtained with partial vertical recti recessions in patients with diplopia and small-angle vertical strabismus (≤10 dp).

MATERIAL AND METHODS

A retrospective study was conducted on 9 patients that were operated on with partial temporal or nasal recession of the superior (SR) or inferior rectus (IR), during 2017. A good outcome was considered when diplopia was resolved in primary position and infraversion, at the end of follow-up.

RESULTS

A total of 9 cases were included, with a mean age 66.3 years (55.5% women), diagnosed with sixth nerve palsy (3), incomplete third nerve palsy (2), sagging eye (2), age related strabismus (1), and restrictive strabismus post-retinal surgery (1). Mean preoperative vertical deviation was 8.2 dp in primary position and the post-operative vertical deviation was 0.8 dp (mean difference was statistically significant, P=.007). In 4 cases, the SR was operated on (temporal pole in 3 and nasal in 1). The IR was operated on in 5 patients (temporal pole in 4 and nasal in 1). Mean recession was 3.77mm. In 55.5% of case diplopia was eliminated, and in a 33.3% a well-tolerated, intermittent diplopia persisted. A good outcome was obtained in 88.8% of the cases at the end of follow-up (mean: 7. 1 months), with no over-corrections.

CONCLUSIONS

Partial SR or IR recessions obtained good results in most of the cases with small angle vertical strabismus and diplopia. Although post-operative torsion or modification of the pre-operative torsion was not observed, a prior study should be made of torsion.