Loop Myopexy Research Articles

Zip-up Loop Myopexy in Heavy Eye Syndrome.

To describe and report the results of a zip-up modification for loop myopexy for facilitating a muscle union procedure in heavy eye syndrome. A retrospective chart review was conducted on patients with heavy eye syndrome in whom the modified surgical technique was performed. Superior and lateral rectus muscle bellies were approximated using a suture 4 to 5 mm from the muscle insertion. Muscles were then zipped together by 5-0 polyester sutures placed in an anteroposterior direction using a hand-over-hand technique. Details of the surgical technique were reported. Ductions, versions, and angles of strabismus were evaluated before and after surgery. Complications were reported. A total of 8 patients were identified (mean age: 60.8 ± 7 years). Mean axial length was 33.2 ± 1.2 mm. Mean preoperative horizontal and vertical angles of deviation were 78 ± 20 prism diopters (PD) (range: 50 to 120 PD) and 34 ± 4 PD (range: 30 to 40 PD), respectively. Preoperative limitation of abduction and elevation was -4 to -5 in all patients. An average of seven to eight sutures were used. No intraoperative complications were reported. In 7 patients, both vertical and horizontal angles of deviation were reduced to within 8 PD from orthophoria and limitation of ductions was reduced to null or -1 after surgery. Undercorrection occurred in 1 patient with bilateral heavy eye syndrome who had unilateral surgery. No recurrences developed over a median of 6 months of follow-up. A zip-up modification for loop myopexy can facilitate the surgical procedure to achieve a satisfactory outcome in heavy eye syndrome. [J Pediatr Ophthalmol Strabismus. 2024;61(4):279-286.].

Hemi-Jensen Procedure as Heavy Eye Syndrome Treatment: A Case Series

Introduction : Heavy eye syndrome is an acquired myopia-associated strabismus characterized by esotropia and hypotropia accompanied by abduction and elevation limitations. This case series reports two heavy eye syndrome patients that underwent hemi-Jensen procedure combined with medial rectus recession with good postoperative result.
 Case Illustration : A 60-year-old female had right eye (RE) fixed inward and bilateral high myopia (S-13.00 D). RE Hirschberg test: >45° esotropia and hypotropia and RE axial length (AL) 28.3 mm. Second patient, a 53-year-old female, had both eyes fixed inward and bilateral high myopia (S-12.00 D). Both eyes Hirschberg test: >45° esotropia and hypotropia, left eye AL 31.4 mm, and prephthisis RE. Intraoperative identification of both patients revealed displacement of superior and lateral rectus muscles. No surgery performed on prephthisis eye. Hemi-Jensen procedure combined with medial rectus recession resulted in orthophoria (first patient) and central position in primary gaze (second patient), with improved ocular motility on both patients.
 Discussion : Heavy eye syndrome occurs in eyes with high myopia. The elongated globe in high myopia results in superotemporal herniation of the globe and superior and lateral rectus muscles displacement, which increases depression and adduction force. Hemi-Jensen procedure is a loop myopexy procedure which corrects the deviated muscle paths in heavy eye syndrome. Concurrent medial rectus recession can be performed with hemi-Jensen procedure if there is likely contracture of medial rectus.
 Conclusion : Heavy eye syndrome is a strabismus fixus condition which occurs in eyes with high myopia. Hemi- Jensen procedure is an effective treatment for heavy eye syndrome which improves ocular alignment and motility.

Pediatric myopic strabismus fixus: clinical features and surgical outcomes of silicone band loop myopexy

ABSTRACT Purpose To evaluate the clinical profile of myopic strabismus fixus (MSF) in children and surgical outcomes of silicone band loop myopexy. Method We retrospectively reviewed records of children presenting with MSF who underwent silicone band loop myopexy between January 2008 and December 2020 at a tertiary eye care center. Data concerning demographics, refractive error, axial length, extra-ocular motility, and ocular alignment pre-operatively and post-operatively, intra- and post-operative complications, ocular and systemic associations, were evaluated. The long-term effects of band loop myopexy on ocular alignment stability, motility improvement, and myopia progression were analyzed. Surgical outcome was defined as post-operative orthotropia or heterotropia less than or equal to 20 PD. Results A total of0 eyes of 7 patients (median age: 5 years; 5 boys and 2 girls) who underwent band loop myopexy were included in the study. Among them, three children underwent bilateral and four children underwent unilateral band loop myopexy. Medial rectus recession was performed only in two patients as a part of initial procedure. The median follow-up duration was 7 years. Most of the children, i.e. six of them presented with esotropia-hypotropia and only one patient presented with exotropia-hypotropia complex. The median pre-operative measurements were esotropia of 62.5 PD, hypotropia of5 PD, and exotropia of4 PD. Postoperative average primary position deviation measured was close to 9–10 PD of esotropia. The overall motility improved to −1 from −3. Conclusion The clinical profile of MSF in children is almost similar to adults. This condition is a rare entity among adults as well as children. Majority of children with MSF presented with esotropia-hypotropia complex. Silicone band loop myopexy with or without medial rectus recession proves to be a reliable surgical procedure as it provides stable outcomes in terms of ocular alignment and motility among children.

Augmented loop myopexy with concurrent intraocular lens implantation for myopic strabismus fixus.

To evaluate safety profile and surgical outcomes of loop myopexy with concurrent intra-ocular lens implantation in cases of myopic strabismus fixus (MSF). A retrospective chart review of patients who underwent loop myopexy with concurrent small incision cataract surgery with intra-ocular lens implantation between January 2017 and July 2021 for MSF at a tertiary eye care centre was undertaken. A minimum of 6 months of follow-up after surgery was required for inclusion. The main outcome measures were improvement in alignment postoperatively, improvement in extra-ocular motility postoperatively, intraoperative and postoperative complications and post-operative visual acuity. 12 eyes of 7 patients (male (6): female (1)) underwent modified loop myopexy at a mean age of 46.86 years (range 32-65 years). 5 patients underwent bilateral loop myopexy with intra-ocular lens implantation whereas 2 patients underwent unilateral loop with intra-ocular lens implantation. All eyes underwent additional medial rectus (MR) recession with lateral rectus (LR) plication. At the last follow-up, mean esotropia improved to 16 prism dioptres (PD) (Range: 10-20 PD) from 80 PD (Range:60-90PD), P = 0.016; and success (deviation ≤20PD) was achieved in 73% (95% CI 48 to 89%). Mean hypotropia at presentation was 10 PD (range 6-14 PD), which improved to 0 PD (range 0-9 PD), P = 0.063. Mean BCVA improved from 1.08 LogMar to 0.3 LogMar units. Loop myopexy combined with intra-ocular lens implantation is a safe and effective procedure in the management of patients who have Myopic Strabismus Fixus with visually significant cataract and improves both visual acuity and ocular alignment significantly.

Bilateral myopic strabismus fixus with fat prolapse treated by silicone band loop myopexy and excision of fat

A 60-year-old man presented to our outpatient clinic with chief complaints of progressive inward deviation of both eyes and presence of a yellowish mass in both eyes for 2 years....

Incidence of symptomatic vertical and torsional diplopia after superior rectus transposition for esotropic Duane syndrome and abducens nerve palsy

To report the incidence of symptomatic vertical and torsional diplopia after superior rectus transposition (SRT) for esotropic Duane syndrome and abducens nerve palsy. The medical records of patients with esotropic Duane syndrome or abducens nerve palsy seen at Boston Children's Hospital (2006-2018) and treated with unilateral SRT with or without augmentation was performed. The primary outcome was incidence of postoperative vertical or torsional diplopia in primary position. The secondary outcome was induced vertical deviation in affected side gaze. A total of 69 patients met inclusion criteria: 32 with abducens nerve palsy and 37 with esotropic Duane syndrome. Vertical alignment changed in both hyper- and hypotropic directions. Median pre- and postoperative vertical deviation in primary gaze was 1.1Δ (10th-90th percentile, 0Δ-6Δ hypertropia) and 0.4Δ (10th-90th percentile, 6Δ hypotropia to 8 Δ hypertropia), respectively. Postoperative vertical diplopia occurred in 7%, including 4 of 49 treated with loop myopexy (8%), 1 of 13 without augmentation (8%), and 0 of 7 treated with sclera-fixated augmentation. All but one was successfully treated with prism or secondary surgery. Intorsional change predominated, but no patient had torsional diplopia post adjustment. Vertical misalignment in affected side gaze increased from 19% to 45% after SRT (P=0.01). In this largest-to-date review of patients treated with SRT, with or without MR recession, no patient developed persistent torsional diplopia, while 7% developed symptomatic vertical diplopia in primary position, similar to the reported incidence after balanced vertical rectus transposition. Vertical misalignment in affected side gaze increased, however fusion is already limited by unresolved esotropia in this field.

Suture loop myopexy versus silicone band loop myopexy in the management of myopic strabismus fixus

To compare two different modalities of superior rectus-lateral rectus loop myopexy; suture (SLM) and silicone band loop (SBM), in the treatment of myopic strabismus fixus. The medical records of patients with myopic strabismus fixus who underwent surgical management with either SLM or SBM at a single institution over a period of 4years were retrospectively reviewed. In cases with positive intraoperative forced duction test, the medial rectus muscle was recessed. The primary outcome measures were improvement of primary position esotropia, hypotropia, and limitations of abduction and elevation. The angle between the displaced superior rectus and lateral rectus muscles (angle of globe dislocation) was also assessed by orbital imaging before and after surgery. A total of 21 patients were identified, of whom 10 underwent SLM and 11 underwent SBM. Mean age at surgery was 65.4±5.7years in the SLM group and 68.5±6.4years in the SBM group. Both procedures significantly improved esotropia, hypotropia, angle of globe dislocation, and limitation of abduction and elevation (P<0.0001), with no significant statistical difference between procedures (P>0.05). Intraoperative muscle splitting occurred in 2 cases in the SLM group, and transient foreign body sensation was documented in 3 cases in the SBM group. In this study cohort, both techniques achieved significant correction of ocular deviation, limitation of ocular ductions, and angle of globe dislocation associated with myopic strabismus fixus, with no statistically significant difference between procedures. Operative complications in both groups were mild and innocuous.

Adjustable graded augmentation of superior rectus transposition for treatment of abducens nerve palsy and Duane syndrome

To report the results of adjustable graded augmentation of superior rectus transposition, a novel modification of superior rectus transposition (SRT) designed to reduce postoperative vertical or torsional diplopia. The medical records of patients who underwent adjustable graded augmentation of SRT with or without adjustable medial rectus recession (MRc) from February 2017 to December 2019 were reviewed retrospectively. A Mendez ring was used to monitor torsional change after transposition of the superior rectus muscle to the lateral rectus muscle and after sequential placement of 2 or 3 augmentation sutures by superior rectus-lateral rectus loop myopexy. If excessive mechanical intorsion was induced, the responsible augmentation suture was severed intraoperatively. If torsional or vertical diplopia was noted after recovery, the distal-most augmentation suture was cut. Exotropia was managed by severing the distal-most augmentation suture or by medial rectus adjustment. A total of 8 patients who underwent adjustable graded augmentation of SRT were included (6 using the 3-suture technique): 3 for esotropic Duane syndrome, 2 for abducens nerve palsy, 1 for Moebius syndrome, and 2 for combined trochlear and abducens nerve palsies. Of the 8 patients, 4 had prior strabismus surgery, and 1 patient had previously undergone treatment with botulinum toxin. Severing one augmentation suture in 3 cases resolved vertical (n=2) or torsional (n=1) diplopia and consecutive exotropia (n=2), resulting in excellent alignment and reduction of torticollis to ≤4° in 7 cases. The technique proved insufficient in 1 patient, who had undergone 3 prior strabismus procedures. In this study cohort, adjustable graded augmentation of SRT effectively managed the risk of postoperative vertical or torsional diplopia.

Nasal loop myopexy as a primary procedure to correct exotropia hypotropia complex in high myopia

ABSTRACT Purpose: To evaluate success of nasal loop myopexy as a primary procedure in correcting the ocular deviation in primary position when combined with recession and resection procedure (R&R) in exotropia hypotropia complex in high myopia and to explore the probable cause for deviation. Case reports: We present a case series of three adult males with exotropia hypotropia complex and high myopia with large angle exotropia and hypotropia, with deflection of the courses of superior and medial recti seen intraoperatively. We performed a conventional recession and resection procedure, which was combined with a nasal loop myopexy between the superior rectus (SR) and medial rectus (MR) in the same session, under local anesthesia, to correct the deflected course of SR and MR; with the aim of correcting the deviation in primary position and improving ocular motility, mainly elevation in abduction. Results: We present a case series of three adult males with exotropia hypotropia complex, who were operated between March 2017 and October 2017. In all the three cases described above, it was noted that the preoperative exotropia and hypotropia improved following the combination of nasal loop myopexy with a conventional recession and resection procedure, as shown by improvement in ocular deviation in the primary position (measured by prism bar cover test, PBCT). First patient improved from 50 prism exotropia with 16 prism hypotropia to 5 prisms exophoria and 6 prisms hypotropia in left eye. Second patient improved from 45 prism right exotropia and 10 prism hypotropia to 10 prisms exotropia and 6 prism hypotropia. Third patient improved from 40 prism left exotropia and 20 prisms hypotropia to 10 prism esotropia and 5 prisms hypotropia. Ocular motility showed no restriction following surgery in any of the gazes. Limitation of elevation in abduction, caused due to SR deflection, improved due to repositioning of SR and MR in their anatomical positions in all the cases. In the first patient elevation in abduction improved from −4 to −1; in the second and third patients, it improved from −2 to 0. None of the three adult patients experienced any side effects following the procedure. Conclusion: The combination of recession and resection procedures with nasal loop myopexy was found to be effective in correcting the ocular deviation and limitation to elevation in abduction by correcting the deflected course of superior rectus and medial rectus to result in an effective improvement of elevation in abduction. One case had an overcorrection of exotropia. There were no other major complications.

Surgical Treatment of Myopic Strabismus Fixus by Loop Myopexy Augmented with Scleral Fixation: a Case Report

Objective: To present the clinical findings, surgical procedure and long-term outcome of a Thai patient with myopic strabismus fixus. Case presentation: The patient presented with recurrent progressive esotropia and hypotropia. Two strabismus surgeries were performed 20 years ago. Magnetic resonance imaging (MRI) findings indicated the etiology which was secondary to inferiorly deviated lateral rectus (LR) muscle and medially deviated superior rectus (SR) muscle. The patient had undergone loop myopexy of lateral rectus and superior rectus muscles augmented with scleral fixation and satisfactory result was achieved up to six years after the operation. Conclusion: The patient with myopic strabismus fixus should be evaluated by MRI to confirm the etiology of this disorder. Marked esotropia and hypotropia can be safely aligned by simple loop myopexy augmented with scleral fixation.

Modified loop myopexy technique for severe high myopic strabismus fixus.

This study introduces a modified loop myopexy technique for severe high myopic strabismus fixus. This study aims to evaluate the surgical results of loop myopexy with or without medial rectus recession for the treatment of patients with myopic strabismus fixus. This is a retrospective study in a Chinese teaching hospital. Data was collected from 25 myopic strabismus fixus patients (33 eyes) with restriction in both abduction and sursumduction. First, the loop myopexy technique was performed. Following the loop myopexy technique, a medial rectus recession was performed if esotropia remained. If esotropia and/or hypotropia still persisted, second-stage surgery of the contralateral eye was performed. The main outcome measures were ocular deviations, eye movements and the angles of dislocation of the globe. At the last follow-up, mean deviation of esotropia was significantly improved (10 vs. 92 PD; p=0.000), while mean deviation of hypotropia was improved (6 vs. 32 PD; p=0.008). Mean abduction limitation was improved (-2.7 vs. -5.0; p=0.000); mean elevation limitation improved (-3.2 vs. -5.0; p=0.000). The angle of dislocation of the globe was significantly decreased (103.0 vs. 235.3 D; p=0.002). Modified Yokoyama's surgery effectively corrected the restrictive esotropia and hypotropia, restored the dislocated globe back into the muscle cone and improved the eye movement in severe myopic strabismus fixus.

Heavy eye syndrome with cataract

A 58-year-old female with high myopia, progressive esotropia, hypotropia, abduction limitation diagnosed with heavy eye syndrome and defective vision due to age-related cataract underwent loop myopexy and phacoemulsification with intraocular lens implantation. Postoperatively, the patient had improved ocular motility, better cosmesis, and considerable visual outcome.

Convergent strabismus fixus without high myopia

A 37-year-old woman presented with progressive large-angle esotropia (>140(Δ)) since childhood. Her best-corrected visual acuity was 20/80 in right eye and unrecordable in the left eye because of severe esotropia and limitation of abduction. Computed tomography of the orbits showed presence of nasal displacement of the superior rectus muscle and inferior displacement of the lateral rectus muscle in the left eye, which was confirmed intraoperatively. Intraoperatively, axial length was 23mm in the right eye and 24.6mm in the left eye. Diagnosed with convergent strabismus fixus without high myopia, she underwent medial rectus recession of 8.0mm and superior rectus-lateral rectus loop myopexy. Postoperatively, she had an exotropia of about 8(Δ). This case highlights the possibility of progressive esotropia similar to "heavy eye syndrome" in the absence of high myopia.

A case of myopic strabismus fixus “Fixed” with loop myopexy

Myopic strabismus fixus is a rare condition seen in high myopes and presents with sudden onset of strabismus. This case report describes a high myopic patient who presented with acute onset strabismus and was successfully treated with loop myopexy of superior rectus and lateral rectus muscles.

Loop Myopexy Surgery for Strabismus Associated with High Myopia.

Strabismus associated with high myopia is a rare abnormality of ocular motility, leading to the impairment of abduction and supraduction. Loop myopexy of the superior rectus (SR) and lateral rectus (LR) muscles is now the most preferred surgery for restoring the dislocated eye globe back into the muscle cone. Various procedural modifications have been made based on this concept, and satisfactory outcomes have been reached in most cases. In this paper, we review various surgical modifications published in the literature that are based on the loop myopexy surgery in patients with high myopic strabismus and summarize the applicable scope of different surgical procedures for patients with different degrees of strabismus. Three major surgical procedures are identified and different modifications have been applied based on their concept. Most of these modifications have been proven to be safe and effective and result in good ocular alignments. The selection of such modifications is of great importance in different patients. Careful evaluation before surgery should be made not only to make the correct diagnosis but also to choose an appropriate surgical procedure and offer individualized modifications in the surgery.

Unaugmented Muscle Union Surgery for Heavy Eye Syndrome Without Combined Medial Rectus Recession.

Simple loop myopexy or retro-equitorial muscle union surgery has been shown to effectively treat the strabismus seen in heavy eye syndrome. In most cases, this has been described with combined recession of the medial rectus muscle, particularly where medial rectus contracture was demonstrated on forced duction testing intraoperatively. The authors report the outcomes of muscle union surgery alone without combined medial rectus recession in 29 eyes with heavy eye syndrome. A retrospective review was conducted of 26 patients and 29 eyes with heavy eye syndrome treated with a simple loop myopexy procedure. The preoperative and postoperative deviations in primary position were measured along with restriction in ocular motility in abduction and elevation. Patients with residual esotropia and/or persistence of symptoms were offered a second-stage medial rectus recession procedure. In 21 patients, muscle union was sufficient in improving the diplopia or cosmetic appearance of the eyes. In these cases, the average preoperative deviation improved from 21.2 ± 16.3 to 5.5 ± 9.1 prism diopters (PD). Eight eyes went on to have a second-stage medial rectus recession with excellent outcomes. The authors found that muscle union surgery alone is an effective and successful procedure in restoring the ocular motility disturbance and also in treating heavy eye syndrome. There was a much lower incidence (up to 70% lower) of medial rectus recession than other similar case series. There were no cases of overcorrection and no complications.

Esotropia associated with high myopia.

The aim of the present article is to describe the pathophysiology of esotropia associated with high myopia, commonly known as heavy eye syndrome, and discuss the preoperative evaluation and surgical options in these complex patients. Numerous studies have looked to determine the cause of esotropia in patients with high myopia. Orbital imaging has shown a nasal displacement of the superior rectus muscle and an inferior displacement of the lateral rectus muscle. As such, traditional resection-recession surgery can be ineffective in these patients. Instead, correcting the deviant muscles paths is necessary. Recent studies have shown that loop myopexy with or without medial rectus recession can be performed without sclera fixation sutures to correct the underlying pathophysiology. Heavy eye syndrome or strabismus fixus is a rare restrictive strabismus. Careful preoperative evaluation must be performed in order to correctly diagnose these patients. If posterior globe prolapse with superior and lateral rectus muscle displacement is seen, loop myopexy can be a well tolerated and effective procedure in treating heavy eye syndrome.

Silicone band loop myopexy in the treatment of myopic strabismus fixus: surgical outcome of a novel modification

AimTo evaluate safety profile and surgical outcomes of a novel modification of loop myopexy with silicone band for myopic strabismus fixus (MSF).DesignRetrospective interventional case series.MethodsA retrospective chart review of patients...

Equatorial Loop Myopexy in "Sagging Eye" Syndrome: A Case Report

Equatorial Loop Myopexy in "Sagging Eye" Syndrome: A Case Report

Silicone band loop myopexy in treatment of myopic strabismus fixus: Surgical outcome of a novel modification

Silicone band loop myopexy in treatment of myopic strabismus fixus: Surgical outcome of a novel modification