Nasal Transposition Research Articles

Comparison Between Temporal Versus Nasal Anterior Transposition of the Inferior Oblique Muscle for Management of Dissociated Vertical Deviation with Inferior Oblique over Action: Two Years Follow Up

Background: anterior nasal transposition (ANT) is a relatively new procedure which can be used to eliminate inferior oblique over action. An advantage of this procedure over temporal anterior transposition is that it avoids ante-elevation syndrome. Objective: to compare anterior temporal transposition (ATIO) of the inferior oblique muscles versus anterior nasal transposition (ANT) in management dissociated vertical deviation (DVD) with inferior oblique muscle over action (IOOA). Patients and Methods: The study included 50 eyes of 28 patients with DVD of at least 10 prism dioptres ? in the eye involved. The patients were divided into two groups. Group A (25 eyes of 15 patients) managed by temporal anterior transposition (ATIO) of the inferior oblique muscles and Group B (25 eyes of 13 patients) managed by nasal anterior transposition (ANT) of the inferior oblique muscles. All patients were followed for at least 24 months postoperatively. The size of preoperative and postoperative angle of DVD, grade of IOOA preoperative and postoperative, need for repeated surgeries and complications were recorded and evaluated. Results: In group A the mean DVD angle was decreased in primary positions from 21.11±4.32 ? to 9.5 ±4.7 ? (P<0.001) and from 19.5±4.6 ? to 5.51 ±2.65? (P<0.001) in group B mean IOOA grade was decreased from +2.0 ±0.7 to +0.18±0.4 in group A (P<0.001) and from +2.5 ±0.7 to +0.1±0.5 (P<0.001) in group B. In group B, two patients developed hypotropia of 5 and 6 PD. Persistent IOOA (+1) was observed postoperatively in two eyes in each group. Limited elevations in abduction developed in 3 patients in group A, the incidence of recurrence rate after 24 months was 2 eyes 10% in group A and one eye 5% in group B. Conclusion: Anterior transpositions either temporal or nasal of the inferior oblique muscles are safe and effective in management of DVD with inferior oblique muscle over action. Anterior nasal transposition (ANT) is more effective in correction of DVD with less incidence of antielevation syndrome and recurrence of DVD, however may induce persistent hypotropia.

Fascia lata augmented nasal transposition of split lateral rectus for reoperation of complete third nerve palsy

Complete third nerve palsy causes incomitant strabismus. Traditional recession and resection procedures often yield limited outcome. Nasal transposition of split lateral rectus were reported to correct the deviation successfully. However, this procedure was mainly recommended in primary cases, with concerns of lateral rectus contracture and extensive scarring in re-operative cases. Therefore, we developed a technique of fascia lata augmentation for split lateral rectus for nasal transposition in reoperative cases.

Long-term outcomes of adjustable nasal transposition of split lateral rectus muscle for third nerve palsy—an international perspective

The purpose of this study was to report the worldwide experience of strabismus surgeons treating complete third nerve palsy with nasal transposition of the split lateral rectus muscle.

Clinical and ocular motor complications of extraocular muscle extirpation for infantile nystagmus syndrome

To describe the effects of extraocular muscle extirpation performed after previous eye muscle surgery in a 20-year-old woman with infantile nystagmus syndrome (INS) for whom we have 19years of follow-up data. Clinical examinations were performed. Eye movement data analysis was carried out using the eXpanded Nystagmus Acuity Function (NAFX) and longest foveation domain (LFD). The patient re-presented to the authors at age 20, 2years after bilateral anterior myectomy of the horizontal rectus muscles, bilateral anterior nasal transposition of the inferior oblique muscle, and bilateral superior oblique recessions. Evaluation revealed deterioration in nystagmus at lateral gaze angles, new incomitant strabismus with severe loss of convergence, limited ductions, saccadic hypometria, slow saccades, and hypo-accommodation. Also, there was a pre- to post-extirpation minimal change of 21% in her peak NAFX, a 50% decrease in LFD, plus a predominant, asymmetric, multiplanar oscillation. It appears that in this patient, horizontal extirpation failed to abolish the nystagmus and caused significant, new, symptomatic deficits interfering with many of the patient's visual functions.

Bell's phenomenon in thyroid-associated inferior rectus myopathy.

To examine Bell's phenomenon in patients with unilateral thyroid-associated inferior rectus myopathy and changes in this phenomenon after inferior rectus muscle recession. This prospective interventional study included 12 patients who underwent inferior rectus muscle recession with or without nasal transposition. Bell's phenomenon was examined before and 3 months after surgery. The upper eyelid was held open by a finger to prevent complete eyelid closure. Then, the distance of upward excursion of the inferior corneal limbus or the corneal light reflex was measured during voluntary maximum forced eyelid closure. The pre- and postoperative distances of upward excursion on the affected side were statistically compared with the preoperative distance on the unaffected side using the Mann-Whitney U test, and the pre- and postoperative distances on the affected side were statistically compared using paired t-test. The relationships among postoperative changes of Bell's phenomenon, patient age, the amount of recession and nasal transposition of the inferior rectus muscle, postoperative angle of ocular deviation, and reduction in the angle after surgery were analyzed using stepwise multiple regression analyses. The preoperative measurement of Bell's phenomenon was significantly shorter on the affected side (1.6 ± 1.6 mm) than the unaffected side (4.3 ± 1.6 mm; P = 0.001). However, the distance on the affected side significantly increased after surgery (4.1 ± 1.9 mm; P < 0.001), compared to the preoperative distance on the unaffected side (P = 0.843). Using a stepwise method, all variables were deleted from the regression equation. Bell's phenomenon decreased on the affected side, which improved after inferior rectus muscle recession.

Anterior and nasal transposition of inferior oblique muscle in cases of superior oblique palsy

To report long-term outcome of inferior oblique anterior and nasal transposition in superior oblique palsy. The medical records of patients with superior oblique palsy who underwent inferior oblique anterior nasal transposition were reviewed retrospectively. A comprehensive ophthalmic evaluation, including prism bar cover test and measurement of torsion, was performed for all cases. One-year postoperative results were evaluated for alignment in primary gaze, contralateral gaze, and upgaze; reduction in inferior oblique overaction and changes in fundus torsion to assess long-term outcome of the procedure. A total of 12 patients were included. Three cases also underwent horizontal muscle surgery. Mean age at the time of surgery was 20.6years. The median preoperative hypertropia was 21.5Δ (range, 12Δ-36Δ), corrected to 4.5Δ (range, 2Δ-10Δ) at 12months postoperatively (P=0.002). Median inferior oblique overaction decreased from +3 (range, +1 to +4) to 0 (range, -1 to +1). Preoperative fundus extorsion was 19.2° ± 6.7°; postoperative, 0.58° ± 1.8° (P<0.001). No consecutive hypotropia or underaction in elevation was observed in 10patients; 1 patient complained of torsional diplopia in upgaze. Extorsion was eliminated and head tilt improved in all patients. Inferior oblique anterior and nasal transposition resulted in good long-term outcomes in our patients with superior oblique palsy presenting with hypertropia, inferior oblique overaction, and extorsion in primary gaze.

Inferior rectus nasal transposition as a procedure of choice for acquired superior oblique palsy

Dear editor It is with great interest that we read the paper published by Okamoto et al.1 In this paper, the authors retrospectively evaluated 135 cases who underwent inferior rectus nasal transposition for acquired or decompensated superior oblique palsy. The authors concluded that inferior rectus nasal transposition decreased the excyclotorsion effect with the added advantage of long-term stability and also allowing for simultaneous correction of the vertical deviation. They have positively described the effect of inferior rectus nasal transposition, as the surgery does not involve any procedure on the oblique muscles in the first place. Also, as described by the authors, retaining the superior conjunctiva for glaucoma filtration surgeries, if need be, makes it a novel approach. Lesser postoperative incidence of Brown’s syndrome is an added advantage. In support of preferring inferior rectus nasal transposition to the Harada–Ito procedure, the authors state that the latter was associated with a higher rate of regression. But the study quoted in this regard, ie, that by Nishimura and Rosenbaum,2 shows that few patients had a follow-up period of more than 1 year, which may be inadequate to draw a conclusion. Moreover, in a subsequent study3 with a minimum follow-up period of 2 years, it was found that regression was encountered in fewer cases than reported previously. We also feel the paper is lacking in a few important details which would influence the outcome of the surgery. Superior oblique palsy is known to have a vertical deviation in the form of hypertropia in most cases.4 Okamoto et al, though not mentioned clearly, from what we could interpret, performed inferior rectus recession on the ipsilateral side along with an inferior rectus nasal transposition in most cases, and this cannot explain the correction of hypertropia. Inferior rectus recession is likely to induce further hypertropia in the involved eye. Inferior rectus recession, if at all, has been performed in the other eye in order to achieve symmetry, as done by Kushner.5 Also, the amount of hypertropia to be corrected preoperatively and the postoperative residual amount are important considerations which were not mentioned in the study. Okamoto et al considered a minimum follow-up period of 3 months, which we feel is insufficient to conclude that this procedure offers long-term stability. As there were a total of eight cases where regression was encountered, five occurring within 1 year of surgery and three cases occurring after 1 year, longer follow-ups may have led to a different outcome. To conclude, inferior rectus nasal transposition may be considered as a good alternative to the Harada–Ito procedure, and may additionally be done as a procedure of choice in cases with minimal vertical deviation and minimal inferior oblique overaction as in cases of Knapp class II superior oblique paresis or when a previous oblique muscle surgery has been performed.6

Surgical effects of nasal transposition of inferior rectus muscle - 135 cases of acquired superior oblique palsy.

Nasal transposition of the inferior rectus (IR) muscle, which is transposed nasally with the insertion parallel to the spiral of Tillaux, could correct excyclotropia. However, as far as we are aware, there have been no reports examining the surgical effects of this procedure in multiple cases. Therefore, we examined the surgical effects of IR nasal transposition in 135 cases with acquired trochlear nerve palsy at Hyogo College of Medicine Hospital, Nishinomiya, Japan. One muscle width of IR nasal transposition corrected an average 5.6° in excyclotorsion, while bilateral IR nasal transposition corrected average 10.9°. This result shows this procedure is accurate quantitatively. Moreover, IR nasal transposition in combination with IR recession or resection can correct vertical deviation and excyclotorsion simultaneously. The results of this study suggest that IR nasal transposition should become first-line treatment for acquired superior oblique palsy.

Adjustable nasal transposition of split lateral rectus muscle for third nerve palsy.

Third nerve palsy causes disfiguring, incomitant strabismus with limited options for correction. To evaluate the oculomotor outcomes, anatomical changes, and complications associated with adjustable nasal transposition of the split lateral rectus (LR) muscle, a novel technique for managing strabismus associated with third nerve palsy. Retrospective medical record review appraising outcomes of 6 consecutive patients with third nerve palsy who underwent adjustable nasal transposition of the split LR muscle between 2010 and 2012 with follow-up of 5 to 25 months at a tertiary referral center. Adjustable nasal transposition of the split LR muscle. The primary outcome was postoperative horizontal and vertical alignment. Secondary outcomes were (1) appraising the utility of adjustable positioning, (2) demonstrating the resultant anatomical changes using magnetic resonance imaging, and (3) identifying associated complications. Four of 6 patients successfully underwent the procedure. Of these, 3 patients achieved orthotropia. Median preoperative horizontal deviation was 68 prism diopters of exotropia and median postoperative horizontal deviation was 0 prism diopters (P = .04). Two patients had preoperative vertical misalignment that resolved with surgery. All 4 patients underwent intraoperative adjustment of LR positioning. Imaging demonstrated nasal redirection of each half of the LR muscle around the posterior globe, avoiding contact with the optic nerve; the apex of the split sat posterior to the globe. One patient had transient choroidal effusion and undercorrection. Imaging revealed, in this case, the apex of the split in contact with the globe at an anterolateral location, suggesting an inadequate posterior extent of the split. In 2 patients, the surgical procedure was not completed because of an inability to nasally transpose a previously operated-on LR muscle. Adjustable nasal transposition of the split LR muscle can achieve excellent oculomotor alignment in some cases of third nerve palsy. The adjustable modification allows optimization of horizontal and vertical alignment. Imaging confirms that the split LR muscle tethers the globe, rotating it toward primary position. Case selection is critical because severe LR contracture, extensive scarring from prior strabismus surgery, or inadequate splitting of the LR muscle may reduce the likelihood of success and increase the risk of sight-threatening complications. Considering this uncertainty, more experience is necessary before widespread adoption of this technique should be considered.

Nasal lateral rectus transposition combined with medial rectus surgery for complete oculomotor nerve palsy

Complete paralysis of the oculomotor nerve results in the lateral rectus and superior oblique muscles acting unopposed and the eye being fixed in an abducted, slightly depressed and intorted position. The goal of strabismus surgery in such cases is to achieve an acceptable alignment in primary position. Simple recession-resection procedures may not yield acceptable results, and numerous other procedures have been attempted, with limited success. We report the outcome of nasal transposition of two halves of the lateral rectus muscle combined with medial rectus surgery in 3 cases of total oculomotor nerve palsy.

New strabismus surgical techniques

Five new strabismus surgical procedures were developed by the authors and were presented as a workshop at the AAPOS annual meeting of the American Association for Pediatric Ophthalmology and Strabismus. They are summarized here to introduce these methods to the reader and provide surgeons with more options in approaching difficult strabismus problems. Diagnosis and correction of consecutive strabismus attributable to stretched scar is discussed. The pulley posterior fixation procedure is a unique approach to correct high accommodative convergence or to augment a maximal medial rectus recession. Diagnosis and repair of the partial avulsion (flap tear) of a rectus muscle allows correction of some restrictive strabismus following blunt trauma. The nasal myectomy of the inferior oblique muscle corrects persistent inferior oblique overaction without sacrificing the tether effect gained by a previous anterior transposition of the inferior oblique. The full advancement of the superior oblique tendon offers another option to strengthen a weak superior oblique muscle.

Adjustable split nasal transposition of the lateral rectus muscle for complete third nerve palsy

Adjustable split nasal transposition of the lateral rectus muscle for complete third nerve palsy

Anterior and Nasal Transposition of the Inferior Oblique Muscle for Iatrogenic Superior Oblique Palsy

Anterior and Nasal Transposition of the Inferior Oblique Muscle for Iatrogenic Superior Oblique Palsy

Vertical Rectus Surgery for Knapp Class II Superior Oblique Muscle Paresis

To evaluate the efficacy of treating Knapp class II superior oblique muscle palsy with 7-mm nasal transposition of the ipsilateral inferior rectus muscle combined with recession of the contralateral inferior rectus muscle when the primary position hypertropia is 10 prism diopters (PD) or less. A retrospective review of 8 consecutive patients with superior oblique muscle paresis who had nasal transposition of the inferior rectus muscle in the paretic eye and recession of the inferior rectus muscle in the nonparetic eye. Ocular motility, including objective and subjective torsion, were evaluated before and after surgery. The mean (SD) preoperative hypertropia was 5 PD (1.5) and 13.1 (3.6) PD in the primary position and downgaze, respectively. After surgery the mean (SD) hypertropia was 1.25 (1.0) and 3.25 (1.3) PD in the primary position and downgaze, respectively. The mean (SD) subjective excyclotropia decreased from 6.6 degrees (1.3 degrees) preoperatively to 0.5 degrees (0.9 degrees) after surgery, and there was a mean (SD) objective decrease in the excyclotorsion of the paretic eye by 7.8 degrees (1.4 degrees). All patients were diplopic before surgery and asymptomatic after surgery. Treatment with 7-mm nasal transposition of the ipsilateral inferior rectus muscle combined with recession of the contralateral inferior rectus muscle can effectively treat Knapp class II superior oblique muscle palsy when the primary position hypertropia is 10 PD or less.

Anterior and nasal transposition of the inferior oblique muscle for dissociated vertical deviation associated with inferior oblique muscle overaction

To determine outcomes after anterior and nasal transposition of the inferior oblique muscle for dissociated vertical deviation (DVD) associated with inferior oblique overaction. A total of 10 patients who had bilateral DVD with ipsilateral inferior oblique muscle overaction were included in this study. Patients underwent anterior and nasal transposition of the inferior oblique muscles to the medial edge of the inferior rectus muscle insertion; the horizontal rectus muscle was operated on for horizontal strabismus in 2 cases. The primary outcome variables were changes in DVD, inferior oblique muscle action, V pattern, and vertical deviation in primary and side gazes. Patients were evaluated 6 to 10 months (mean, 7.3 months) postoperatively for alignment and oculomotor examination. Mean age at the time of surgery was 17.5 years. The average preoperative DVD for all eyes was 18.3(Delta) +/- 6.8(Delta), which decreased to 5.0(Delta) +/- 3.1(Delta) (p < 0.001) at 6 months. Mean inferior oblique muscle overaction decreased from +2.1 (range, +1 to +3) to +0.40 (range, -1 to 2). The mean preoperative V pattern was 24.9(Delta). After surgery, the mean correction of the V pattern was 14.8(Delta). Four patients developed 2(Delta) to 5(Delta) postoperative hypotropias in primary position at 6 months. Anterior and nasal transposition of the inferior oblique muscle reduces DVD, V pattern, and inferior oblique muscle overaction with minimal complications.

A Case of Congenital Absence of the Superior Oblique Muscle Treated With Anterior and Nasal Transposition of the Inferior Oblique Muscle

Purpose: To report a patient with absence of the superior oblique (SO) muscle of the left eye, who showed improvement after anterior and nasal transposition of the inferior oblique muscle for left hyperdeviation and right head tilt. Case summary: A two-year-old boy presented with hypertropia of the left eye and right head tilt. Alternate prism-cover test in the primary position demonstrated 18 prism diopters (PD) of left hypertropia, which increased to 35 PD in the left head tilt position. A version test demonstrated overaction of the left inferior oblique muscle and underaction of the left superior oblique muscle. As an orbit CT scan showed absence of the SO muscle, the patient was diagnosed with congenital absence of SO and left anterior and nasal transposition of the inferior oblique muscle was performed. Three weeks after surgery, the patient presented with orthotropia at distant and near. The version test revealed normal oblique muscles. There was no vertical deviation shown on the Bielschowsky head tilt test. The abnormal head posturing was no longer observed. Conclusions: The authorsreport a patient manifesting abnormal head posture and hypertropia, diagnosed with absence of SO muscle, which was successfully corrected using anterior and nasal transposition of the inferior oblique muscle.

Transposition gerader Augenmuskeln zur Behandlung komplexer Motilitätsstörungen

Transposition techniques alter the muscle paths thereby creating new directions of muscle force. Extraocular muscle transposition procedures have been used to treat abducens palsy, Duane's retraction syndrome, double-elevator palsy and other complex ocular motility abnormalities. The purpose of this study was to evaluate the surgical and functional results of rectus muscle transposition in patients with different aetiologies of severe ocular motility deficits. Between 1992 and 2008 rectus muscle transposition surgery has been performed on 31 patients. In this retrospective case series one patient with an abducens nerve palsy is presented as an example. In addition, six patients with motility disorders of different aetiologies who had transposition manoeuvers were evaluated. Preoperative, surgical and postoperative data are reported. Rectus muscle transposition has been performed because of severe functional loss of the lateral rectus muscle, the superior rectus muscle or the medial rectus muscle as well as in myopic strabismus fixus. One of the patients had traumatic sixth nerve palsy. The underlying pathology in patients who had superior transposition of the horizontal rectus muscles were double-elevator palsy, congenital oculomotor nerve palsy and hypotropia caused by sphenoid wing hypoplasia. A nasal transposition of the vertical rectus muscles was performed in traumatic and tumour-associated muscle loss of the medial rectus muscle. The large preoperative deviations were markedly reduced postoperatively and even ocular motility partially improved. Transposition surgery seems to be a suitable procedure for the treatment of complex ocular motility disorders. In cases of a complete lack of function of an extraocular muscle or in complex, uncommon conditions, which are difficult to treat with any other surgery, muscle transposition seems to be an effective procedure.

114: Simple office-based assessment of changes in torsional strabismus

Introduction: The various existing inferior oblique weakening procedures (eg, anterior transposition, nasal transposition, nasal myectomy) result in reduced elevation in adduction but also in torsional changes (typically intorsion). The gold standard for objective torsion is funduscopy and is difficult to assess quantitatively in the office. Fundus photography is not always available in the office and may be difficult to achieve in children.

The Combination Nasal Transposition Flap and Melolabial Flap in Reconstruction of Difficult Nasal Defects

*Both authors are affiliated with the Department of Dermatology, Billings Clinic, Billings, Montana Address correspondence and reprint requests to: J. Michael Wentzell, MD, 2825 Eighth Avenue North, PO Box 35100, Billings, MT 59107, or e-mail: [email protected] Bradley K. Draper, MD, PhD, and J. Michael Wentzell, MD, have indicated no significant interest with commercial supporters.

The Combination Nasal Transposition Flap and Melolabial Flap in Reconstruction of Difficult Nasal Defects

*Both authors are affiliated with the Department of Dermatology, Billings Clinic, Billings, Montana Address correspondence and reprint requests to: J. Michael Wentzell, MD, 2825 Eighth Avenue North, PO Box 35100, Billings, MT 59107, or e-mail: [email protected] Bradley K. Draper, MD, PhD, and J. Michael Wentzell, MD, have indicated no significant interest with commercial supporters.