Indications and outcome of vertical rectus partial recessions

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.

Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment

PURPOSE

To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia.

METHOD

We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42 pd ± 1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion.

RESULTS

Mean age was 46.86 ± 25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5 ± 2.93 (p = 0.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08 ± 8.05 months. There were no overcorrections.

CONCLUSIONS

Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia.

Inferior oblique muscle belly transposition and myopexy for diplopia

To evaluate the outcomes of and review the indications for Inferior oblique muscle belly transposition in adults with diplopia and small-angle hypertropia associated with mild or moderate upshoot in adduction. We retrospectively analyzed data for the six patients who underwent the technique. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal pole of the inferior rectus. Data were collected from October 2018 to April 2020. All six patients had diplopia and mild hypertropia (≤6 prism diopters [pd]) in primary position. Mean preoperative hypertropia was 4.17 pd (range, 2-6 pd). Mean age was 51 ± 28.71 years. The diagnoses were fourth nerve paresis (5) and dissociated vertical deviation (1). All patients had mild/moderate upshoot in adduction. Torticollis was observed in four cases. Diplopia resolved in 5 of the 6 cases. The mean final vertical deviation was 2 pd in straight gaze. Torticollis was eliminated in 2 patients and improved in another 2. The upshoot in adduction was totally eliminated in the six patients. Transitory mild limitation of elevation in adduction was observed in two patients during the first week after surgery. No ocular torsion was diagnosed after surgery. Mean time from surgery was 11.5 months. No overcorrections were recorded. Inferior oblique muscle belly transposition with myopexy is a good alternative procedure in patients with diplopia associated with mild-to-moderate upshoot in adduction and small-angle hypertropia.

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.

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.