Single horizontal rectus muscle vertical augmented transposition with posterior fixation suture in management of monocular elevation deficiency

We describe successful management of three cases of acquired monocular elevation deficiency (MED) with superior transposition of the lateral rectus augmented with a posterior fixation suture with or without simultaneous inferior rectus muscle weakening. In each case, the lateral rectus muscle was transposed superiorly to the superior rectus muscle along the spiral of Tillaux, with maintained distance between the original lateral rectus muscle poles and the limbus. Augmentation was achieved with a posterior fixation suture 8 mm posterior to the muscles' insertion. At the time of lateral rectus transposition, simultaneous inferior rectus recession by 5.5 mm was performed in case 1 whereas simultaneous botulinum toxin injection was performed in case 3. With regards to all three cases, the mean age was 32 years [10-46 years] and the mean follow-up period was 10 months. The mean hypotropia was reduced from 35 prism diopters (PD) (range: 20 to 60 PD) to 4.67 PD (range: 0 to 14 PD) with a mean correction of 32.57 ± 9.34 PD after 9 months. In our experience, full-tendon-width transposition of the lateral rectus to the superior rectus with posterior fixation suture corrects primary position hypotropia in MED and does not always require simultaneous inferior rectus recession. When transposing the lateral rectus muscle along the spiral of Tillaux, the measured distance of the original muscle insertion point to the limbus must be maintained in order to prevent recession of the muscle.

Comparison of different tendon transposition techniques for the treatment of monocular elevation deficiency type 2

PURPOSE

To compare results of three different tendon transposition techniques (Knapp procedure and two modified techniques) for the treatment of type 2 monocular elevation deficiency (MED) patients.

METHODS

The medical records of patients with MED type 2 operated on at a single institution from 2000 to 2016 were reviewed retrospectively. Patients were divided into three vertical transposition groups: (1) full tendon width, (2) augmented surgery; and (3) partial tendon width. Surgical success was defined as no severe limitation of upgaze, hypotropia of <6^Δ, and no hypertropia in primary position. Pre- and postoperative vertical deviations in the primary position and limitations in elevation levels were compared.

RESULTS

A total of 39 patients were included. The pre- and postoperative deviations in the full-tendon group were 22.50^Δ ± 4.17^Δ and 3.50^Δ ± 1.27^Δ, respectively; in the augmented surgery group, 23.75^Δ ± 4.78^Δ and 1.75^Δ ± 1.14^Δ; and in the partial-tendon group, 20.50^Δ ± 3.98^Δ and 4.12^Δ ± 2.78^Δ. Corrected vertical deviations were 19^Δ, 23^Δ, and 16^Δ, respectively. The pre- and postoperative limitation of elevations were -2.80 and -0.80 in the full-tendon group, -3.20 and -0.90 in the augmented surgery group, and -2.37 and -1.12 in the partial-tendon group. The pre- and postoperative vertical deviation improvements and limitations of elevation were statistically significant (P < 0.05) in all groups. Success was achieved in 29 patients (74%).

CONCLUSIONS

In this study cohort, all three procedures were reasonably effective in improving vertical deviations and limitation of elevation.

Single Horizontal Muscle (Medial or Lateral Rectus) Transposition and Inferior Rectus Recession in Monocular Elevation Deficit: A Novel Surgical Technique

PURPOSE

To describe a novel surgical technique for the treatment of monocular elevation deficit and report its short-term outcomes.

METHODS

This was a prospective interventional case series. It was an institutional-based study of 5 patients with monocular elevation deficit. A single horizontal rectus muscle was transposed to 2 mm from the insertion of the superior rectus muscle along the spiral of Tillaux, augmenting it with a non-absorbable suture taken 8 mm behind its insertion. The main outcome measures were primary position hypotropia and elevation deficit at 8 months postoperatively.

RESULTS

The mean age was 12.4 years (range: 6 to 26 years). Four patients underwent lateral rectus transposition and one underwent medial rectus transposition. Inferior rectus recession was done in all patients. The mean follow-up period was 8 months (range: 6 to 12 months). The mean hypotropia reduced from 34.6 prism diopters (PD) (range: 20 to 48 PD) preoperatively to 0.8 PD (range: -4 to 8 PD) at 8 months postoperatively. Additionally, 3 patients had exotropia with a mean of 12 PD (range: 2 to 20 PD) and 2 had esotropia with a mean of 28.5 PD (range: 12 to 40 PD); 1 underwent lateral rectus recession and 1 medial rectus recession. Three patients did not require any horizontal muscle surgery. The mean elevation deficit in abduction, straight up gaze, and adduction improved from 4.4, 3.2, and 2.8 to 2.0, 2.0, and 1.8, respectively. The mean depression deficit was 0.5. No adverse effects were noted.

CONCLUSIONS

Single horizontal muscle transposition with inferior rectus recession allows sparing of at least one horizontal muscle and achieves adequate elevation effect and primary position deviation correction, at least in the short-term follow-up. [J Pediatr Ophthalmol Strabismus. 2019;56(3):183-187.].

To assess the efficacy of vertical muscle surgery for management of hypotropia in monocular elevation deficiency type II

AIM

To assess the efficacy of vertical muscle surgery for management of hypotropia in monocular elevation deficiency (MED) type II. Knapp's is described as standard procedure for management of MED type II. However, it is not graded and has unpredictable amount of correction. Besides this, there is drift towards overcorrection with time and limitation of movements in extreme adduction and abduction. MED is a vertical misalignment for which vertical muscle surgery is also described but limited literature is available.

METHODS

Thirteen fresh cases of MED type II with hypotropia >20 PD and age >4 years were included in our interventional study. All cases underwent superior rectus resection and inferior rectus recession (vertical R&R) depending upon amount of preoperative deviation. Success was defined as hypotropia <5 PD at 1-year follow-up.

RESULTS

Twelve patients (92.30 %) were aligned to within 5 PD. Six patients (46.15 %) had gain in elevation. Bell's phenomenon was improved in six patients (46.15 %). There was no limitation in down gaze in any patient. None gained stereopsis.

CONCLUSION

Vertical R&R is a good alternative for MED type II with predictable amount of correction especially in patients with higher preoperative deviation. It spares horizontal muscles for correction of any associated horizontal deviation.

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 complete vertical rectus paralysis combined with horizontal strabismus

Aims. To report outcomes of the simultaneous surgical correction of vertical rectus paralysis combined with moderate-to-large angle horizontal strabismus. Methods. If a preoperative forced duction test was positive, antagonist muscle weakening surgery was performed, and then augmented partial rectus muscle transposition (APRMT) + partial horizontal rectus recession-resection was performed 2 months later. If a preoperative forced duction test was negative, APRMT + partial horizontal rectus recession-resection was performed. Antagonistic muscle weakening surgery and/or conventional recession-resection of the horizontal and/or vertical muscles of the contralateral eye was performed 2 months later, as needed. Results. Ten patients with a mean age of 22.3 ± 13.0 years were included and mean follow-up was 7.1 months. The mean vertical deviation that APRMT corrected was 21.4 ± 3.7 PD (prism diopter). The absolute deviation in horizontal significantly decreased from a preoperative value of 48.5 ± 27.4 PD to a value of 3.0 ± 2.3 PD 6 months postoperatively. The movement score decreased from a value of -5 ± 0 preoperatively to a value of -2.7 ± 0.8 at 6 months postoperatively. Conclusion. For patients with complete vertical rectus paralysis combined with a moderate- to-large angle of horizontal strabismus, combined APRMT and partial horizontal rectus recession-resection is safe and effective for correcting vertical and horizontal strabismus.

Surgical treatment in patients with double elevator palsy

PURPOSE

To evaluate the effectiveness of surgical treatment performed in patients with double elevator palsy (DEP).

METHODS

Patients diagnosed with congenital DEP between April 2003 and March 2007 were included in the study. The cases with positive traction test had inferior rectus (IR) recession followed by full tendon width muscle transposition Knapp surgery or partial tendon width transposition operation, while those without positive traction test underwent transposition procedure alone. Transposition surgery was combined with recession and resection of horizontal rectus muscles in patients with exotropia according to the amount of horizontal deviation. Eyelid surgery was applied in patients with ptosis following strabismus surgery.

RESULTS

The average age of 13 patients was 14+/-32.5 years (range, 3-60 years). Five patients (38%) were female and 8 patients (62%) were male. The mean preoperative hypotropia was decreased from 29.2+/-3.5 prism diopters (PD) (range, 16-45 PD) to 2.6+/-2.8 PD (range, 0-6 PD) postoperatively. The median amount of horizontal deviation in patients with exotropia (n=4) was 30 PD (range, 25-45 PD) preoperatively; it was reduced to 2 PD (range, 0-8 PD) postoperatively. Mean follow-up period was 14.1+/-2.8 months (range, 6-31 months). Five patients (38%) underwent eyelid surgery, and all achieved cosmetically satisfactory results.

CONCLUSIONS

Transposition surgery alone or combined with IR recession is an effective procedure in treatment of double elevator palsy. In patients with moderate horizontal deviations, recession and resection of horizontal rectus muscles combined with transposition provide correction of the horizontal deviation at the same time.

Management of congenital elevation deficiency due to congenital third nerve palsy and monocular elevation deficiency

PURPOSE

To document the presentation and management of congenital III nerve palsy and monocular elevation deficiency to single ophthalmologist over a 14-year period. Surgical management was reviewed and visual outcome was analysed.

METHODS

A retrospective study was conducted of all patients presenting during a period between 1992 and 2006 to the private practice of a paediatric ophthalmologist, with either congenital III or monocular elevation deficiency. For patients requiring surgical intervention pre- and post-surgical data were documented and analysed.

RESULTS

A total of 19 congenital III and 13 monocular elevation deficiency patients were identified. There were eight surgical patients in each congenital III nerve palsy group and in the monocular elevation deficiency group. The congenital III group had a preoperative mean exotropia for near of -36 prism dioptres (PD) compared with postoperative mean exotropia for near -16 PD. Preoperative mean hypotropia for near of -19 PD was improved to postoperative mean hypotropia of -5 PD. The monocular elevation deficiency group had preoperative mean esotropia for near of +6 PD compared with postoperative mean exotropia for near -5 PD. Preoperative mean hypotropia for near of -15 PD was improved to postoperative mean hypotropia of -7 PD. At last follow up both groups had a majority of mild or no amblyopia noted.

CONCLUSION

Superficially, congenital III and monocular elevation deficiency may appear similar, both frequently having ptosis and hypotropia as features. Careful clinical assessment of the horizontal alignment and the result of forced duction testing will usually allow them to be distinguished. Congenital III more frequently requires surgery for exotropia as well as surgery for hypotropia and monocular elevation deficiency more often requires surgery just for hypotropia. The ptosis surgery is similar for either diagnosis in this study. Significant cosmetic improvement, as well as excellent visual acuity outcomes can be achieved.