Graded rectus tenotomy in small angle hypertropia due to sagging eye syndrome

Abstract

IntroductionSES is an orbital connective tissue degeneration in which adnexal laxity is associated with inferior shift of the lateral rectus (LR) and other rectus pulleys. Asymmetrical LR sag causes hypotropia and excyclotropia in the more affected eye. We aimed to develop a surgical nomogram for graded rectus tenotomy (GRT), a minimally invasive surgery, in treatment of small angle vertical strabismus in SES.MethodsWe reviewed a 3-year surgical experience in 21 patients with vertical strabismus ≤10Δ caused by SES who underwent adjustable GRT under topical anesthesia that permitted intraoperative alignment measurements. Superior oblique palsy and pattern strabismus were excluded.ResultsAverage patient age was 69 ± 12 years (10 males, 11 females). Mean preoperative central gaze hypertropia measured 4.6Δ ± 2.5Δ. The hypotropic inferior rectus (IR) was tenotomized temporally in 17, and the hypertropic superior rectus (SR) in 4 eyes. Mean tenotomy was 67Δ ± 18% of width at the scleral insertion, reducing hypertropia to zero intra-operatively and 0.9Δ ± 1.7Δ at last follow-up 127 ± 104 days postoperatively. Linear regression demonstrated that 30%-90% tenotomy corrected 3Δ - 6Δ hypertropia (R = 0.55, P = 0.008).DiscussionThe effect of peripheral GRT is moderately predictable, making this technique useful for amelioration of cyclovertical diplopia due to small-angle hypertropia in SES that is otherwise prone to overcorrection by alternative strabismus surgery. However, adjustable technique under topical anesthesia is preferred for optimal outcomes. Even under topical anesthesia, vessel sparing is readily performed during peripheral GRT of the IR.ConclusionsGRT precisely corrects small angle hypertropia in SES, and is convenient for intra-operative adjustment under topical anesthesia. IntroductionSES is an orbital connective tissue degeneration in which adnexal laxity is associated with inferior shift of the lateral rectus (LR) and other rectus pulleys. Asymmetrical LR sag causes hypotropia and excyclotropia in the more affected eye. We aimed to develop a surgical nomogram for graded rectus tenotomy (GRT), a minimally invasive surgery, in treatment of small angle vertical strabismus in SES. SES is an orbital connective tissue degeneration in which adnexal laxity is associated with inferior shift of the lateral rectus (LR) and other rectus pulleys. Asymmetrical LR sag causes hypotropia and excyclotropia in the more affected eye. We aimed to develop a surgical nomogram for graded rectus tenotomy (GRT), a minimally invasive surgery, in treatment of small angle vertical strabismus in SES. MethodsWe reviewed a 3-year surgical experience in 21 patients with vertical strabismus ≤10Δ caused by SES who underwent adjustable GRT under topical anesthesia that permitted intraoperative alignment measurements. Superior oblique palsy and pattern strabismus were excluded. We reviewed a 3-year surgical experience in 21 patients with vertical strabismus ≤10Δ caused by SES who underwent adjustable GRT under topical anesthesia that permitted intraoperative alignment measurements. Superior oblique palsy and pattern strabismus were excluded. ResultsAverage patient age was 69 ± 12 years (10 males, 11 females). Mean preoperative central gaze hypertropia measured 4.6Δ ± 2.5Δ. The hypotropic inferior rectus (IR) was tenotomized temporally in 17, and the hypertropic superior rectus (SR) in 4 eyes. Mean tenotomy was 67Δ ± 18% of width at the scleral insertion, reducing hypertropia to zero intra-operatively and 0.9Δ ± 1.7Δ at last follow-up 127 ± 104 days postoperatively. Linear regression demonstrated that 30%-90% tenotomy corrected 3Δ - 6Δ hypertropia (R = 0.55, P = 0.008). Average patient age was 69 ± 12 years (10 males, 11 females). Mean preoperative central gaze hypertropia measured 4.6Δ ± 2.5Δ. The hypotropic inferior rectus (IR) was tenotomized temporally in 17, and the hypertropic superior rectus (SR) in 4 eyes. Mean tenotomy was 67Δ ± 18% of width at the scleral insertion, reducing hypertropia to zero intra-operatively and 0.9Δ ± 1.7Δ at last follow-up 127 ± 104 days postoperatively. Linear regression demonstrated that 30%-90% tenotomy corrected 3Δ - 6Δ hypertropia (R = 0.55, P = 0.008). DiscussionThe effect of peripheral GRT is moderately predictable, making this technique useful for amelioration of cyclovertical diplopia due to small-angle hypertropia in SES that is otherwise prone to overcorrection by alternative strabismus surgery. However, adjustable technique under topical anesthesia is preferred for optimal outcomes. Even under topical anesthesia, vessel sparing is readily performed during peripheral GRT of the IR. The effect of peripheral GRT is moderately predictable, making this technique useful for amelioration of cyclovertical diplopia due to small-angle hypertropia in SES that is otherwise prone to overcorrection by alternative strabismus surgery. However, adjustable technique under topical anesthesia is preferred for optimal outcomes. Even under topical anesthesia, vessel sparing is readily performed during peripheral GRT of the IR. ConclusionsGRT precisely corrects small angle hypertropia in SES, and is convenient for intra-operative adjustment under topical anesthesia. GRT precisely corrects small angle hypertropia in SES, and is convenient for intra-operative adjustment under topical anesthesia.