Marginal Myotomy Research Articles

Оптимизация страбизмологического обследования пациентов при планировании хирургического лечения первичной гиперфункции нижних косых мышц

Purpose. To perform a comparative assessment of the results of strabismological examination of patients with primary inferior oblique muscle overaction according to the generally accepted and proposed methods. To analyze the change in the surgical procedure protocol depending on the results obtained. Material and methods. The research included 123 patients with a bilateral symmetric primary inferior oblique muscle overaction. The generally accepted method consisted in measuring the heterotropia magnitude when moving the gaze while turning the head left right and in measuring the magnitude of when moving the gaze following the ophthalmoscope beam when it is horizontally displaced upwards by 25° and downwards by 35° from 33 cm (assessment of V-pattern and its severity). The proposed method consisted in measuring the hypertropia magnitude of the adducted eye with the maximum fixing movement of the abducted eye gaze and in measuring the heterotropia magnitude with the maximum gaze movement upwards and downwards. Results. After the strabismological examination was carried out according to the proposed method, the average magnitude of hypertropia in adduction and V-pattern in the study group was statistically significantly (p<0.05) changed in the diagnostic protocols. A more prominent magnitude of hypertropia was revealed in 110 patients (89.43%). A more prominent V-pattern was diagnosed in 117 patients (95.12%). Studying the specifics of the oculomotor system disorders in patients resulted in optimization of the surgical procedure protocol in 83 patients according to the proposed method (67.48%). Conclusion. The average under-diagnosis of hypertropia and V-pattern during the examination according to the generally accepted method is 3.98±2.39° and 3.72±2°, respectively. Clarification of the oculomotor imbalance characteristics after the examination according to the proposed method requires a change in the surgical procedure protocol in more than 67% of cases. Key words: primary inferior oblique muscle overaction, V-pattern, gaze position, Botox, partial marginal myotomy, myectomy

Влияние диагностики первичной гиперфункции косых мышц на выбор метода хирургического лечения

Purpose. To carry out a comparative analysis of the results of strabismological examination of patients with primary inferior oblique muscle overaction using the generally accepted and proposed methods. Methods. The research included 123 patients with bilateral symmetric primary inferior oblique muscle overaction. The proposed method consisted in measuring hypertropia magnitude of the adducted eye with the maximum fixing movement of the abducted eye gaze and in measuring heterotropia magnitude with the maximum gaze movement upwards and downwards. Results. As a result of diagnostics according to the generally accepted and proposed method, a statistically significant increase in hypertropia and V-syndrome (р < 0.05) was revealed. A more pronounced degree of hypertropia was detected in 110 patients (89.43 %), more pronounced manifestations of the V-syndrome in 117 patients (95.12 %). In 83 patients (67.48 %), the tactics of surgical treatment was optimized. Conclusions. The average underdiagnosis of hypertropia and V-pattern during the examination according to the generally accepted method is 3.98±2.39° and 3.72±2°, respectively. Key words: primary inferior oblique muscle overaction; V-pattern; Botox; partial marginal myotomy; myectomy.

Treatment Results of Residual-Angles Operated Esotropia by the Method of Z-Shaped Marginal Myotomy

Purpose. Analysis of the results of weakening of previously operated internal rectus muscle by the method of Z-shaped marginal myotomy.Patients and methods. The study included 87 children with an initially large-angle of strabismus. Children age — from 2 to 14 years (average age — 9.09 ± 0.78 years). The initial strabismus angle was from 30° to 60° according to Girschberg (average angle — 45.7° ± 2.3°). All children underwent a staged surgical treatment — recession of the internal rectus muscle and resection of the external rectus muscle in both eyes. The residual deviation angle after two stages of surgical treatment ranged from 6° to 10° (on average up to 9.1° ± 0.75°) according to Girschberg. All patients underwent a Z-shaped marginal myotomy on the operated internal rectus muscle. The follow-up period after surgery ranged from 1 year to 5 years.Results. A satisfactory anatomical result (orthotropy) was achieved in 91 % of cases (79 children), hypocorrection in 9 % of cases (8 children), hypercorrection — 0 %. In 8 patients with hypocorrection, after 6–8 months, the fourth stage of surgical treatment was performed with the method of Z-shaped marginal myotomy of the internal rectus muscle in the paired eye, after which orthotropy was achieved.Conclusion. An analysis of the surgical treatment results of operated esotropia have showed that the method of Z-shaped marginal myotomy makes it possible to weaken the tone of the previously operated internal rectus muscle with minimal trauma. Using the method of Z-shaped marginal myotomy in the treatment of residual-angle strabismus, orthotropy is achieved while preserving the biomechanics of the oculomotor muscles — the internal rectus muscle remains in the plane of its functional action. At initially large-angle of strabismus, conducting a Z-shaped marginal myotomy of the internal rectus muscle after stepwise surgical interventions on the horizontal rectus muscles of both eyes can be recommended as a modern, reliable and effective method of surgical treatment of residual-angle of strabismus, which allows to achieve the planned functional and cosmetic result.

Unilateral graded marginal myotomy for minimally overacting inferior oblique muscle

Unilateral graded marginal myotomy for minimally overacting inferior oblique muscle

COMPARATIVE STUDY BETWEEN INFERIOR OBLIQUE RECESSION AND INFERIOR OBLIQUE RETRO-EQUATORIAL SCLERAL FIXATION (MYOPEXY) IN MANAGEMENT OF PRIMARY INFERIOR OBLIQUE OVER ACTION

Background: Weakening procedures on the inferior oblique muscle are numerous and include myectomy, graded recession- anteriorization, anterior transposition, anterior and nasal transposition, myotomy, marginal myotomy, nasal myotomy, disinsertion, and denervation and extirpation. Recently, New surgical Intervention for weakening of the inferior oblique muscle is inferior oblique retro-equatorial scleral fixation ( Myopexy). Objective: The aim of the study was to compare between recession of inferior oblique muscle(IO) and retroequatorial scleral fixation (myopexy) of inferior oblique muscle in management of primary inferior oblique over action.(IOOA) Patients and Methods: Thirty patients (60 eyes) presented by horizontal strabismus and primary inferior oblique over action, met the inclusion criteria, and were divided into two equal groups: Group A treated by recession of the inferior oblique muscle. And Group B treated by retro-equatorial scleral fixation (myopexy) of the inferior oblique muscle. Results: Both IO graded recession and IO myopexy were equally effective in correcting the degree of IOOA (elevation in adduction) , correcting associated pattern,with no statistical significant difference and both were equally effective in correcting the degree of objective fundus extorsion with no statistical significant difference. Conclusion: Our findings suggested that both surgical groups had positive outcomes, with good response and effect which was stable all over follow up visits uptill 6 months.

COMPARATIVE STUDY BETWEEN INFERIOR OBLIQUE RECESSION AND INFERIOR OBLIQUE RETRO-EQUATORIAL SCLERAL FIXATION (MYOPEXY) IN MANAGEMENT OF PRIMARY INFERIOR OBLIQUE OVER ACTION

Background: Weakening procedures on the inferior oblique muscle are numerous and include myectomy, graded recession- anteriorization, anterior transposition, anterior and nasal transposition, myotomy, marginal myotomy, nasal myotomy, disinsertion, and denervation and extirpation. Recently, New surgical Intervention for weakening of the inferior oblique muscle is inferior oblique retro-equatorial scleral fixation ( Myopexy). Objective: The aim of the study was to compare between recession of inferior oblique muscle(IO) and retroequatorial scleral fixation (myopexy) of inferior oblique muscle in management of primary inferior oblique over action.(IOOA) Patients and Methods: Thirty patients (60 eyes) presented by horizontal strabismus and primary inferior oblique over action, met the inclusion criteria, and were divided into two equal groups: Group A treated by recession of the inferior oblique muscle. And Group B treated by retro-equatorial scleral fixation (myopexy) of the inferior oblique muscle. Results: Both IO graded recession and IO myopexy were equally effective in correcting the degree of IOOA (elevation in adduction) , correcting associated pattern,with no statistical significant difference and both were equally effective in correcting the degree of objective fundus extorsion with no statistical significant difference. Conclusion: Our findings suggested that both surgical groups had positive outcomes, with good response and effect which was stable all over follow up visits uptill 6 months.

Unilateral medial rectus muscle recession combined lateral rectus muscle marginal myotomy for the treatment of Duane's retraction syndrome: A promising surgical procedure.

Background:Duane's retraction syndrome is a congenital eye movement anomaly with narrowing of the palpebral fissure and globe retraction on attempted adduction. There are several surgical approaches to treat the narrowing of the palpebral fissure. The purpose of the present study was to evaluate the efficacy of unilateral medial rectus recession (MRR) muscle combined lateral rectus (LR) muscle marginal myotomy (MM) with unilateral MRR alone in the management of narrowing of the palpebral fissure of patients with Type 1 Duane's retraction syndrome (DRS).Materials and Methods:Twenty-eight patients with unilateral DRS Type 1 were randomly divided into two groups (14 eyes of 14 patients in each group). Age ≥5 years with DRS Type 1 with <20 prism diopters in primary position who were candidates for surgery were consecutively enrolled in this randomized controlled trial. Patients were divided into treatment groups to receive unilateral MR recession with simultaneous MM group or with unilateral MR recession alone. The amount of deviation in primary position, abnormal head position, palpebral fissure width (PFW), and up/down shoot was evaluated before and 3 months after the surgery. This study was registered at the Iranian Registry of Clinical Trials under the registration code IRCT20131229015975N3.Results:PFW increased within MRR/MM group at the end of the study (8.86 ± 1.51) compared with the baseline (7.79 ± 1.48) (P < 0.001). In contrast, in the MRR/MM group, PFW did not increase statistically significantly within the MRR group at the end of the study (8.14 ± 1.35) compared with the baseline (8.07 ± 1.38) (P = 0.67). Mean ± standard deviation of PFW (mm) in MRR/MM group after surgery (8.86 ± 1.51) was statistically significantly higher than that in the MRR group (8.14 ± 1.35), (P = 0.002).Conclusion:The results of our study demonstrate PFW significantly increased after unilateral MRR muscle combined LR muscle MM.

Clinical Aspects of Prevention and Management of Primary Inferior Oblique Muscle Overaction

Background. Primary inferior oblique muscle overaction (PIOOA) may occur for various reasons and happens to 72 % patients with infantile esotropia. The criterion for the first surgical step is prevalence of vertical or horizontal deviation. The choice of tactics weakening inferior oblique muscle is ambiguous.Aims: to carry out retrospective analysis of PIOOA frequency in patients with infantile esotropia; to assess influence of esodeviation reduction by a surgical, chemodenervational or prismatic method on the existing PIOOA dynamics; to assess clinical and functional results of PIOOA treatment.Methods and methods. The retrospective analysis of 572 patients’ cases lay in assessment of PIOOA frequency and rate in patients with infantile esotropia that manifested under 9 months, with different treatment tactics. The prospective part of the research included two groups of patients. Group 1 (106 patients, 222 eyes) – studying the influence of surgical treatment of PIOOA. Group 2 (127 patients, 207 eyes) – studying the effectiveness of surgical PIOOA treatment. Conclusion. PIOOA frequency in case of different treatment tactics for patients with infantile esotropia is from 17 to 69 %, and the degree of its clinical manifestation is from 1.2 ± 0.4 to 2.6 ± 0.8. Bilateral weakening of medial rectus muscle reduces its probability up to 17–19 %, and the degree of its manifestation up to 1.2 ± 0.4. In cases of combination of PIOOA with infantile esotropia from 20 to 25° with paretic component, it is reasonable to carry out esodeviation reduction by means of bilateral recession, chemorecession or prismatic correction as the first treatment stage, whereas the rate of existing PIOOA is credibly reduced. In cases of choice of tactics, which is necessary for clinically significant reduction or elimination of PIOOA, it is reasonable to carry out chemorecession, marginal partial myotomy or myectomy depending on the PIOOA manifestation.

Первичная гиперфункция нижних косых мышц

In the context of the development of modern strabismology debatable issues still remain, among which the most important and long-term is the choice of tactics for the treatment of primary hyperfunction of the inferior oblique muscle. This article presents a literature review of the most significant publications of national and foreign authors concerning this topic. Criteria of differential diagnostics of primary and secondary hyperfunction of the inferior oblique muscle are presented. The main pathophysiological mechanisms of its occurrence are identified: imbalance between the superior and inferior oblique muscles, horizontal muscle dystopia, as well as prolonged occlusion and prismatic correction. The epidemiology of primary hyperfunction of the inferior oblique muscle, which develops in patients under the age of 4 years in more than half of cases, is summarized. Congenital esotropia operated on toddlers is not a clear guarantee of success in the prevention of the development of the current pathology. Primary hyperfunction occurs equally in patients with accommodative and intermittent forms of esotropia, less often in cases of acquired esotropia. The analysis of different classifications of primary hyperfunction is provided. The indications for surgical treatment and the criteria for evaluation of its efficiency are considered. The mono- or bilaterality of hyper-elevation in adduction, its symmetry, the presence of a V pattern determine the tactics and methods of treatment, the choice of which depends on the degree of hypertropy in combination with horizontal deviation. Positive and negative aspects of the most frequently performed surgical interventions on the inferior oblique muscle; technical features of marginal myotomy, myoectomy, recession and anteriorization were evaluated.

Study of binocular vision improvement of different exotropia after marginal myotomy

Study of binocular vision improvement of different exotropia after marginal myotomy

Surgical treatment for residual or recurrent strabismus.

Although the surgical treatment is a relatively effective and predictable method for correcting residual or recurrent strabismus, such as posterior fixation sutures, medial rectus marginal myotomy, unilateral or bilateral rectus re-recession and resection, unilateral lateral rectus recession and adjustable suture, no standard protocol is established for the surgical style. Different surgical approaches have been recommended for correcting residual or recurrent strabismus. The choice of the surgical procedure depends on the former operation pattern and the surgical dosages applied on the patients, residual or recurrent angle of deviation and the operator's preference and experience. This review attempts to outline recent publications and current opinion in the management of residual or recurrent esotropia and exotropia.

Modified marginal myotomy for thyroid-related upper eyelid retraction

The purpose of this study is to report a modified marginal myotomy procedure for thyroid-related upper eyelid retraction using techniques of quantification and contour adjustment for blepharoptosis surgery, of which surgeons have more experience than of upper eyelid retraction surgery. Eleven upper eyelids of ten patients, average age 41.6 years, were operated on. All patients were clinically and biochemically euthyroid at operation without having had progression of eyelid and orbital changes for at least 6 months prior to surgery. Margin reflex distances of upper eyelids (MRD-1; normal, 2.0–5.5 mm) were measured preoperatively and 3 months postoperatively. Upper eyelid contours were also examined before and after surgery. Medial and lateral horns and the distal attachment of levator aponeurosis were incised to produce a levator flap, which was transversely incised in two positions. The edge of the incised levator was fixed on the appropriate part of the tarsus. MRD-1 values were considerably decreased in all cases, ranging from 2.5 to 6.0 mm (average, 3.8 mm). All final MRD-1 results ranged from 2.5 to 5.0 mm (average, 3.4 mm) and the laterality of MRD-1 was within 1 mm higher or lower than the contralateral eyelids, although a patient with bilateral retraction who had only unilateral operation did not show a symmetrical eyelid height to the contralateral one. All eyelids but one showed acceptable upper eyelid contours; the inconsistent eyelid temporally showed nasal flare, but finally acquired a good curvature. Our procedure effectively decreased upper eyelid height with good contour by utilising techniques from blepharoptosis surgery.

Single-Stage Adjustable Strabismus Surgery under Topical Anesthesia and Propofol

Aim: To present our experience with single-stage adjustable strabismus surgery (SSASS) under topical anesthesia and propofol. Materials and Methods: Sixteen patients who either had diplopia before the surgery or were at risk of developing diplopia after the surgery were selected for this operation after evaluating their tolerance for an eyelid speculum. Recession of the lateral recti, recession, resection and advancement of the medial recti, anteriorization of the inferior oblique and marginal myotomy to the superior rectus were the procedures done under topical anesthesia and propofol. The operations were done in two phases; in the first phase, the patients were sedated for 10 minutes with intravenous propofol (2 mg/kg) and the operation was done under topical anesthesia with 2% lidocaine. In the second phase, the patients were conscious and the adjustments were made. Results: None of the patients complained of significant pain during the surgery. No complications occurred during and after the procedure and no patients had diplopia during the postoperative follow-up. Conclusions: Single-stage adjustable surgery is practical and avoids the risks of regional and general anesthesia. The only disadvantage is the pain that some patients experience. We found that it is feasible to use propofol for this surgery; it provides deep sedation and prevents pain from being felt during the operation, and its short elimination half-life provides rapid awakening for the adjustment phase.

Marginal myotomy of the minimally overacting inferior oblique muscle in asymmetric bilateral superior oblique palsies

Purpose: We report the surgical results of marginal myotomy of a minimally overacting inferior oblique muscle in conjunction with traditional recession or myectomy of the greater overacting inferior oblique muscle in 10 patients with asymmetric bilateral superior oblique palsies and asymmetric inferior oblique overaction. Methods: Ten consecutive patients with bilateral superior oblique palsies had a hypertropia in primary position (5-28 PD) and unequal inferior oblique overaction (0 to +2 in the lesser overacting inferior oblique muscle, +2 to +4 in the greater overacting inferior oblique muscle). Reversal of the hypertropia was noted in ipsilateral oblique upgaze. All patients underwent a recession or myectomy of the greater overacting inferior oblique muscle and a marginal myotomy of the lesser overacting inferior oblique muscle. Results: Seven patients had no vertical deviation in primary position, 2 patients had a residual hypertropia of 2 to 3 PD, and 1 patient had a residual hypertropia of 8 PD. The abnormal head position present preoperatively in 8 patients was eliminated or greatly improved after surgery. Postoperatively all but 1 inferior oblique overaction was graded as 0 to trace. Mean follow-up time was 19 months (range, 1.5-68 months). Conclusions: In bilateral superior oblique palsies with asymmetric inferior oblique overaction, a mildly overacting inferior oblique muscle can be corrected by marginal myotomy, combined with a recession or myectomy of the greater overacting inferior oblique muscle. This procedure can reduce or eliminate the hypertropia in primary position while minimizing the possibility of residual inferior oblique overaction. (J AAPOS 2002;6:216-20)

Unilateral rectus resection in the treatment of undercorrected or recurrent strabismus.

When surgery is required for an undercorrection or for a recurrent strabismus that is in the same direction as the previous deviation, traditional options have included a rerecession of the previously operated muscle(s), a marginal myotomy of the previously operated muscle(s) with or without a resection of the direct antagonist, or a bilateral resection of the antagonist muscles. While many surgeons prefer to perform a bilateral resection for these reasons, a unilateral resection would be a useful approach for small to moderate deviations. Data were collected for patients who had undergone a unilateral rectus resection: age, number of prior surgeries, the preoperative deviation, the postoperative deviation at 1 week, 6 weeks, and 6 months, and the amount of surgery performed. An acceptable postoperative result was considered to be any deviation >8 pd. A resection of a single rectus muscle was undergone by 11 3 patients. Complete data were available on 81 of these patients: 60 underwent a unilateral resection of the lateral rectus and 21 underwent a unilateral resection of the medial rectus. Of those patients undergoing a unilateral lateral rectus resection, 90% were acceptably aligned at the 6-month postoperative exam. Among those patients undergoing a medial rectus resection, 95.2% obtained a successful result. A unilateral resection of the medial or lateral rectus is an effective tool in the treatment of undercorrected or recurrent strabismus. It is predictable, stable in the immediate postoperative period, and limits surgery to 1 eye.

The "triple technique" for treating stable Graves' ophthalmopathy.

Graves' ophthalmopathy may range from mild eyelid retraction to a devastating process that involves the entire orbit and culminates in gross ocular congestion, massive proptosis, and even blindness. Whether the ophthalmopathy is mild or severe, patients are managed on an individual basis according to the predominant clinical findings, which may include congestion, myopathy, lid retraction, proptosis, and optic neuropathy. The process usually becomes quiescent after 6 months to 3 years; however, the changes caused by fibrosis (lid retraction and ocular muscle enlargement) are permanent. The cornerstone of surgical treatment for severe cases is bony orbital decompression; however, in our experience, mild to moderate Graves' ophthalmopathy is better treated by combining eyelid surgery and orbital lipectomy. Our approach consists of a conservative orbital lipectomy, the lengthening of the levator-Müller complex by means of marginal myotomies, and a limited lateral tarsal apposition. These three different surgical steps, which have been described previously as isolated procedures, are undertaken on both eyes at the same time and modulated according to the deformity of the patient. The operation can be performed under local anesthesia with sedation, thus allowing intraoperative monitoring of the correction; the patient can be discharged after a few hours. The results in 32 operated eyes of 16 patients have been a marked aesthetic and functional improvement, with no complications after 6 to 18 months of follow-up. The relative simplicity and very low morbidity of this procedure, as well as its reliability, make it ideal in patients with mild to moderate aesthetic and functional impairment who are looking for a substantial improvement but are unwilling to undergo a relatively major procedure such as a transosseous decompression, which, in our opinion, is the operation of choice only when the patient presents with optic neuropathy or major proptosis.

Management of paralytic lagophthalmos with a modified gold-weight implantation technique.

A modified gold-weight implantation technique was used to treat paralytic lagophthalmos in 15 patients. Three patients had suffered extrusions of previously placed gold-weight implants, two had other complications necessitating reoperation, and 10 had no previous surgery. The surgical modifications were intended to reduce the incidence of implant extrusion, postoperative ptosis, and implant visibility beneath the skin. The important changes in the surgical technique included (a) advancing the levator aponeurosis over the implant and (b) adjusting the final eyelid height intraoperatively with levator myotomies. Follow-up ranged from 6 to 11 months. None of the patients in this study had postoperative problems associated with ptosis, implant extrusion, or implant visibility. Mild, prolonged, postoperative edema was noted in several patients. This resolved spontaneously. Mild eyelid retraction and lagophthalmos were seen postoperatively in two patients. This was caused by a failure to perform marginal myotomies at the time of the initial surgeries.

Pathologic changes after inferior oblique marginal myotomy in rabbits.

To evaluate the histopathologic changes after an inferior oblique marginal myotomy with local injection of triamcinolone, an inferior oblique marginal myotomy was performed in 14 white rabbits and they were divided into 2 groups, one group with a local injection of triamcinolone and the other group without triamcinolone injection after a myotomy. At the postoperative one month, an edema of the muscle fibers and an infiltration of the inflammatory cells were observed and at postoperative three months, a fibrous tissue ingrowth around the muscle fibers and an atrophy of the muscle fibers were found and those changes were less prominant in the group with triamcinolone injection. The local injection of triamcinolone after the inferior oblique marginal myotomy would help in decreasing the fibrous tissue ingrowth and the formation of the scar tissue, thus it could be used in augmenting the effect of the inferior oblique marginal myotomy.

Medial rectus re-recession in undercorrected esotropia.

Conventional surgical management of surgically undercorrected esotropia includes bilateral lateral rectus resection, marginal myotomy, and Faden operation. During a 3-year period, 10 patients with surgically undercorrected esotropia had medial rectus re-recession 13.5 mm from the limbus. Successful binocular realignment (to 10 prism diopters or less residual binocular misalignment) was achieved in 9 of the 10 cases for both near and distance measurements.

Medial Rectus Muscle Marginal Myotomies for Persistent Esotropia

We reviewed the records of 18 patients with persistent esotropia after maximal recession of each medial rectus muscle on whom marginal myotomy of both medial recti muscles was subsequently performed. We compared the results in patients with essential infantile esotropia, acquired esotropia, nonaccommodative convergence excess, and nystagmus compensation syndrome. After a follow-up of three years, the mean improvement of esotropia at distance fixation was 9 prism diopters (range, -20 to +41 prism diopters) and was 21 prism diopters at near fixation (range, +4 to +50 prism diopters). The effect of marginal myotomy of previously maximally recessed medial recti muscles is unpredictable. However, we believe it to be an acceptable secondary surgical procedure in selected cases of persistent esotropia. The best results were obtained in essential infantile esotropia.