Elevating the hypotropic globe

Observation on the curative effect of horizontal rectus transposition combining recess-resect treatment on monocular elevation deficiency with horizontal strabismus

Purpose

To explore the clinical effect of horizontal rectus transposition combining recess and resect treatment on monocular elevation deficiency (MED) with horizontal strabismus.

Methods

Ten patients (10 eyes) scheduled to undergo horizontal rectus transposition combining recess-resect surgery to treat MED with horizontal strabismus in the ME Department of Ophthalmology of the First Affiliated Hospital of Guangxi Medical University between July 2016 and February 2022 were included in the study. The degree of vertical and horizontal prism strabismus, the grading of upper movement of the paralyzed eye, and the improvement of binocular vision were evaluated before and after the surgery.

Results

Horizontal rectus transposition combined with recess and resect treatment was used to treat 10 patients with MED combined with horizontal strabismus. A good curative effect was seen in eight patients. The differences in the degree of vertical strabismus, the degree of horizontal strabismus, and the movement function of the paretic eyes before and after surgery were significantly different (all P < 0.05). The binocular haplopia function in six patients was reconstructed in the primary position after surgery.

Conclusion

Horizontal rectus transposition combining recess-resect is easy to perform, and the number of recti involved in the surgery is small. This approach can effectively correct the eye position, improve eye movement, and reconstruct binocular vision in patients with MED by combining horizontal strabismus.

Management of esotropia: hypotropia in neurofibromatosis type 1 - simulating myopic strabismus fixus

A 28-year-old man presented with a progressive inward deviation of the left eye in the last 4 years. Examination revealed -3 abduction and elevation deficit in the left eye with 50 prism diopters (PD) esotropia and 12 PD of hypotropia. The patient had multiple fibromas on the forearms with pulsatile globe and was diagnosed as neurofibromatosis type 1. Myopic strabismus fixus was suspected. MRI revealed left temporal lobe herniation through a dysplastic sphenoid wing, compressing the posterior half of the superior rectus and lateral rectus muscles, resulting in an esotropia-hypotropia complex. Surgical treatment involved suture myopexy (Yokoyama's technique) of the left superior rectus and lateral rectus muscles with a 6.5 mm left medial rectus recession. Two months postoperatively, the patient had minimal residual esotropia and hypotropia. MRI orbits should always be performed in high myopes with strabismus to assess extraocular muscle pathways.

Congenital Double Elevator Palsy with Sensory Exotropia: A Unique Surgical Management

Purpose:

To report a unique surgical approach for congenital double elevator palsy with sensory exotropia.

Case Report:

A 7-year-old boy with congenital double elevator palsy and sensory exotropia was managed surgically by Callahan's procedure with recession and resection of the horizontal recti for exotropia without inferior rectus recession, followed by frontalis sling surgery for congenital ptosis.

Conclusions:

Favourable surgical outcome was achieved without any complication.

Comparison of augmented and nonaugmented modified Knapp procedure for the treatment of nonrestrictive double elevator palsies

PURPOSE

To compare surgical results of augmented and nonaugmented modified Knapp procedure, for the treatment of nonrestrictive double elevator palsies (DEP).

METHODS

The medical records of patients with congenital DEP were reviewed retrospectively. Patients were divided into three treatment groups: standard transposition (group A), Foster transposition (group B), and resection transposition (group C). Pre- and postoperative vertical deviation in primary position, ocular motility, and binocular vision were compared.

RESULTS

Thirty patients were enrolled. The pre- and postoperative deviations in group A were 34.7^Δ ± 8.6^Δ and 6.5^Δ ± 6.5^Δ; in group B, 38.6^Δ ± 14.6^Δ and 5.7^Δ ± 9.3^Δ; and in group C, 43.1^Δ ± 10.3^Δ and 8.5^Δ ± 6.1^Δ. The corrected vertical deviation of group B (32.9^Δ ± 5.7^Δ) and group C (34.6^Δ ± 5.0^Δ) were greater than that of group A (28.1^Δ ± 3.6^Δ; P = 0.03, 0.002). The pre- and postoperative measures of upgaze in group A were -3.7 and -1.8; in group B, -4.0 and -1.3; and in group C, -3.6 and -2.0. The average improved upgaze in group B (2.6 ± 0.5) was statistically significantly better than that in group A (1.9 ± 0.6) and group C (1.5 ± 0.5; P = 0.03, 0.002). There was no significant difference in the surgical effect on downgaze in three groups (P > 0.05). The surgical outcome was satisfactory in 19 (63.3%) patients with preoperative vertical devation of ≤40^Δ.

CONCLUSIONS

All transpositions are reasonably effective in treating vertical deviations of <35^Δ without obviously limiting downgaze in DEP. Augmented procedures could correct greater vertical deviation of 30^Δ-40^Δ. The Foster transposition demonstrates the strongest effect in improving upgaze.

Surgery for Supranuclear Monocular Elevation Deficiency

PURPOSE

We report a novel approach to surgery for monocular elevation deficiency (MED).

METHODS

A retrospective review of 5 patients undergoing surgery for supranuclear MED between 2003 and 2014. All patients had intact Bell's phenomenon, hypotropia, limited elevation above the primary position, and negative forced duction testing of the paretic eye. Preoperatively all patients preferred chin-up head posture and three had pseudoptosis or ptosis. One of the 5 had prior vertical muscle surgery. Surgery correction for the MED consisted of near maximal superior rectus recession on the contralateral sound eye.

RESULTS

Compensatory chin-up head position and alignment in primary position was improved in all patients. Average age at surgery was 5.3 years. Average superior rectus recession was 9.7 mm. Mean follow-up was 4.8 years (range 12 months to 11.5 years). The vertical deviation of the paretic eye in primary position postoperatively was orthotropic for 2, hypotropic for 2, and overcorrected for 1.

CONCLUSIONS

In cases of supranuclear MED (double elevator palsy) contralateral superior rectus recession based on the innervational principle is a simple and reliable alternative surgical approach compared to published results of the Knapp transposition procedure. Additionally, it holds the possibility for decreased complications and less complicated future surgical treatment options.

Surgical management of monocular elevation deficiency combined with inferior rectus restriction

PURPOSE

To evaluate the results of ipsilateral inferior rectus (IR) recession, when performed alone or in combination with contralateral superior rectus (SR) recession in patients with monocular elevation deficiency (MED) and IR tightness.

METHODS

The medical records of patients with MED and tight IR muscle were retrospectively reviewed. Patients underwent either ipsilateral IR recession alone (IR group) or combined with contralateral SR recession (IR+SR group). Pre- and postoperative ocular motility and alignment and fundus torsion were analyzed. Abnormal head posture was recorded. All patients were followed for at least 6 months.

RESULTS

A total of 23 patients were identified. Mean patient age at time of surgery was 9.8 ± 8.7 years (range, 3-45 years). Ten patients underwnet ipsilateral IR recession 5-8 mm; 13 patients, 4 mm ipsilateral IR recession combined with 5-12 mm contralateral SR recession. Both groups experienced marked improvement in ocular alignment in the primary position (P = 0.34). However, there was a statistically better ocular alignment in both upgaze (P = 0.03) and downgaze (P < 0.01) in the IR+SR group, with a lower degree of fundus intorsion (P < 0.01). An ipsilateral head tilt developed in 70% of patients in the IR group and in 54% of patients in the IR+SR group.

CONCLUSIONS

In this patient cohort, combined contralateral SR recession with ipsilateral IR recession reduced postoperative IR underaction and achieved better ocular alignment in upgaze and downgaze.

Double elevator palsy, subtypes and outcomes of surgery

PURPOSE

To describe the clinical manifestations of subtypes of double elevator palsy and to report the outcomes of surgery in these patients.

METHODS

This retrospective study was conducted on hospital records of patients with double elevator palsy at Labbafinejad Medical Center over a ten-year period from 1994 to 2004. Patients were classified into three subgroups of primary elevator muscle palsy (9 subjects), primary supranuclear palsy with secondary inferior rectus restriction (4 subjects) and pure inferior rectus restriction (7 subjects) according to forced duction test (FDT), force generation test (FGT) and Bell's reflex. Patients in the first group underwent Knapp procedure, the second group received Knapp procedure and inferior rectus recession simultaneously and in the third group vertical recess-resect or mere inferior rectus recess operation was performed. Success was defined as final residual deviation ≤5 PD and ≥25% improvement in restriction after all operations.

RESULTS

Overall 20 subjects including 10 male and 10 female patients with mean age of 12.6±9.3 (range 1.5-32) years were operated during the mentioned period which included 9 cases of primary elevator muscle palsy, 4 patients with primary supranuclear palsy and secondary inferior rectus restriction, and 7 subjects with pure inferior rectus restriction. Mean follow-up was 22.0±20.0 (range 3-63.5) months. Mean pre and postoperative deviation was 32.0±8.0 PD and 3.8±8.0 PD (P<0.001) respectively, and mean restriction before and after the operation(s) was -3.5±0.7 and -2.3±1.2 (P<0.001), respectively. Success rate was 77% for correction of deviation and 80% for improvement in muscle restriction.

CONCLUSION

Surgery for double elevator palsy must be individualized according to FDT, FGT and Bell's reflex. The outcomes are favorable with appropriate surgical planning.

Management of Marcus Gunn jaw winking synkinesis

PURPOSE

To report the outcomes of a management protocol for Marcus Gunn jaw winking synkinesis.

METHODS

The records of 31 patients (16 female, 15 male) presenting to a tertiary referral center with Marcus Gunn jaw winking synkinesis between 1993 and 2003 were retrospectively analyzed. Generally, patients with mild wink and a small degree of ptosis underwent unilateral upper eyelid retractor surgery. Patients with a moderate or marked wink and ptosis underwent bilateral levator weakening procedures and brow suspension. Patients were assessed and treated for amblyopia and vertical strabismus before ptosis surgery.

RESULTS

Mean patient age was 11.23 years (median, 8 years; range, 10 weeks to 31 years). Ipsilateral hypotropia was noted in 8 patients (26%), with a median visual acuity in the ptotic eye of 20/30 (range, 20/20 to 20/40), compared with 20/20 in those without hypotropia. Patients who underwent unilateral surgery had good correction of ptosis, with equal palpebral apertures and symmetrical contour but had a detectable wink on formal testing. Patients who underwent bilateral surgery had equal palpebral apertures and symmetrical contour, with wink elimination. Mean follow-up was 31 months (all patients) and mean postoperative follow-up was 22 months.

CONCLUSIONS

Patients with Marcus Gunn jaw winking synkinesis can present at a wide age range. There may be an associated vertical muscle imbalance, which should be managed before ptosis surgery to avoid ptosis undercorrection and allow amblyopia management. Nearly all patients use the synkinesis to reduce the underlying true ptosis to a less noticeable "habitual" ptosis or to maintain binocularity. Surgical approach will differ, depending on whether the synkinesis, ptosis, or both are the main concern. Satisfactory results with a low complication rate can be achieved with the use of this management protocol.

Unilateral congenital ptosis with ipsilateral superior rectus muscle overaction

PURPOSE

Congenital ptosis may be accompanied by weakness of the ipsilateral superior rectus muscle. We report the finding of a hypertropia of the ipsilateral eye in patients with isolated unilateral congenital ptosis that became manifest only in upgaze.

METHODS

Seventy consecutive patients with congenital ptosis were recalled and 58 reexamined. Examination included assessment of visual acuities, palpebral apertures, levator muscle function, and an orthoptic examination. Particular attention was paid to the assessment of upgaze.

RESULTS

Thirty-eight patients had an isolated unilateral congenital ptosis. Four patients had bilateral ptosis, six had upgaze deficits, and ten others had a variety of other syndromes associated with ptosis. Seventeen of the 38 patients with isolated unilateral congenital ptosis were found to have an ipsilateral hypertropia on upgaze. The size of the vertical deviation varied from 5 to 30 prism diopters and, in the more severe cases, produced a cosmetic problem that became more noticeable after successful ptosis surgery. In one of these patients, a superior rectus muscle posterior fixation suture was effective in reducing the hypertropia.

CONCLUSION

Of a number of possible causes for the ipsilateral hypertropia in upgaze in patients with unilateral congenital ptosis that we observed either a misdirection syndrome within the superior division of the oculomotor nerve or an exaggerated Bell's reflex is the most likely.

Effectiveness of inferior transposition of the horizontal rectus muscles for acquired inferior rectus paresis

Full inferior transposition of the horizontal recti (inverse Knapp procedure) was performed on four patients with unilateral inferior rectus muscle weakness. The patients were followed up over time to determine the medium- and long-term effectiveness of the procedure. All of the patients had single binocular vision without the use of prisms in the primary position of gaze and three in the reading position after a mean postoperative follow-up interval of 21/2 years. The mean primary position preoperative vertical deviation was 20.3 delta and the mean primary position postoperative vertical correction was 19.5 (range, 16 to 24) delta. The field of binocular single vision was assessed quantitatively and scored 2.4% preoperatively compared with 52.3% postoperatively. There was no decrease in the effect of the procedure over time. Additional surgery may still be required to correct symptomatic residual vertical down-gaze diplopia.

Vertical transposition of the horizontal recti (Knapp procedure) for the treatment of double elevator palsy: effectiveness and long-term stability

Full tendon width vertical transposition (Knapp procedure) of the horizontal recti is an established treatment for double elevator palsy (DEP) but the long-term stability of the surgical results have not been well studied. We undertook a retrospective study to determine the overall effectiveness of the Knapp procedure, the postoperative stability of alignment, and the influence of prior inferior rectus muscle recession (IRc) on the magnitude of correction. Nineteen patients with DEP underwent a Knapp procedure. Eight were corrected to within 5 delta of orthophoria, six were undercorrected, and five were overcorrected by at least 5 delta after a mean follow-up of 3 years (to last visit or to further surgical intervention). The average vertical correction was 37.5 delta in patients who underwent a prior IRc compared with 21.1 delta in patients with no prior IRc (p = < 0.0017). Over and undercorrections were more likely to occur in patients with prior IRc. Postoperative drift was towards increased effect in all patients. The seven patients with long-term (> 36 months) follow-up demonstrated an increased magnitude of correction (average = 12.6 delta) over an average follow-up of 76 months. The Knapp procedure had an increasing effect over time but the amount of vertical correction did not correlate with the size of the preoperative vertical deviation and was less predictable when a prior IRc had been performed.

Amblyopia and strabismus in congenital ptosis

Seventeen per cent of 216 cases of simple congenital ptosis developed amblyopia and 19% had a squint. Of those patients with amblyopia, 14% had amblyopia attributable to stimulus deprivation, 21% had anisometropic amblyopia and 51% had strabismic amblyopia. Early refraction, orthoptic assessment and treatment and, where the pupillary axis is occluded, surgery to prevent stimulus deprivation amblyopia are recommended.

Transposition surgery in childhood strabismus

Transposition surgery involves an alteration in the mechanical properties of muscle action, such that the direction of movement of the eye following contraction of the muscle is modified. Though often used in the management of more complex motility disorders we have investigated the role of such surgery in concomitant childhood strabismus, and report the results of a computer model prediction and a retrospective review of cases.

Management of ipsilateral ptosis with hypotropia

Thirty-one patients presented for surgical correction of unilateral hypotropia of the globe and blepharoptosis. The hypotropia and pseudoptosis were corrected by Knapp procedures. The Bell's phenomenon was thereby improved, allowing safe correction of the true ptosis, generally by an anterior levator resection whose magnitude depended on measured levator function.