Superior Rectus Research Articles

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

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

"Yokoyama procedure" efficacy on non-highly myopic patients with acquired esotropia and hypotropia.

To assess the efficacy of "Yokoyama Procedure," on non-highly myopic patients with acquired esotropia and hypotropia. The study involved 10 eyes of 5 patients with eso-hypotropia. Inclusion criteria were acquired esotropic-hypotropic strabismus with lateral rectus inferior displacement and superior rectus nasal displacement confirmed by magnetic resonance imaging, refractive errors between ±6 D, and axial length < 27 mm. Range of full duction movements and maximum angles of abduction-sursumduction was measured in each eye before and after surgery. All patients underwent T1- and T2-weighted magnetic resonance imaging. The surgery was aimed at creating a junction between the muscle bellies of the superior and lateral rectus muscles. This junction was made approximately 14 mm behind the insertions using a non-absorbable mersilene 5/0 suture (Yokoyama procedure). Mean patient age was 64.8 ± 4.8 years. The mean globe axial length was 25.4 ± 0.76 mm and a mean corresponding spherical equivalent refraction of -3.7 ± 1.7 D was observed. Eight eyes on 10 had mild limitation in abduction, while the remaining 2 had no limitation. Three out of 10 eyes showed a moderate limited sursumduction, 5 eyes were categorized as mild, and the remaining 2 had no limitation. No evident post-operative limitation was present in any eye, in both abduction and sursumduction (p < 0.01). Pre-operative esotropia and hypotropia were, respectively, 32 ± 11 prismatic diopters and 25 ± 5 prismatic diopters, and they were significantly reduced after surgery as 9 ± 1.7 prismatic diopters and 6 ±1 prismatic diopters (p = 0.043), respectively. Yokoyama procedure is an effective, fast, reversible procedure to face eso-hypotropic acquired strabismus, even in patients with a clear magnetic resonance imaging displacement of superior and lateral rectus muscles, and absence of globe dislocation and of elevated myopia.

Clinical analysis of adult onset orbital xanthogranuloma

Objective: To investigate the clinical, imaging and pathological features of adult onset xanthogranuloma. Methods: Retrospective case series study.The clinical data of 4 adult patients with adult onset xanthogranuloma treated in the Tianjin Medical University Eye Hospital from 2015 to 2017 were analyzed. Results: There were 1 male and 3 females, aged 46-73 years, with an average age of 55 years. The duration of eyelid swelling was from 6 months to 6 years. One case was binocular and 3 cases were monocular. There were progressive enlargement of eyelid swelling and subcutaneous cord nodules with poor mobility and no tenderness in all 5 eyes. The eyelid skin in 2 patients (2 eyes) was bulging and yellow. CT examination showed swelling of the eyelids and soft tissue thickening in 5 eyes. There were lacrimal gland enlargement in 3 eyes, upper rectus muscle involvement in 3 eyes, external rectus muscle involvement in 1 eye, lower rectus muscle involvement in 1 eye, superior oblique muscle involvement in 1 eye, and involvement of both the superior and inferior rectus muscles in 1 eye. In 1 patient (1 eye), the lesion showed low and medium signals on T(1) weighted images and T(2) weighted images. Three patients (4 eyes) underwent color Doppler ultrasonography, showing the echo zone in the irregularly shaped eyelid was strong, the internal echo was uneven, the local echo was low, and the boundary was not clear. One of the eyes showed a blood flow signal. All patients underwent surgical resection. The pathological results showed infiltration of foamy tissue cells, Touton cells, lymphocytes and plasma cells. Immunohistochemistry demonstrated 3 patients (4 eyes) expressed CD68, and 1 patient (1 eye) expressed S-100. After 6 months to 2 years of follow-up, 3 patients had no recurrence. One patient developed eye discomfort at 6 months after surgery, and the symptoms were relieved after treatment with triamcinolone. Conclusions: Adult onset xanthogranuloma mainly manifest as eyelid swelling, periorbital mass and skin color changes, generally with no systemic involvement. Imaging examination mainly shows the involvement of soft tissues, lacrimal glands and muscles around the eyelids. The main features of the pathology are infiltration of foamy tissue cells, Touton giant cells, lymphocytes and plasma cells. (Chin J Ophthalmol, 2019, 55: 381-386).

Visual field and orbital computed tomography correlation in dysthyroid optic neuropathy due to thyroid eye disease

ABSTRACTPurpose: The pathogenesis of dysthyroid optic neuropathy (DON) in thyroid eye disease (TED) is thought to be compression of the apical optic nerve by hypertrophied extraocular muscles. We correlated worsening DON to the area occupied by extraocular muscles.Methods: Records of adults with TED DON evaluated from 1/1/2013 to 1/1/2018 were retrospectively reviewed. Each patient’s visual field with the worst mean deviation (MD) was selected. Orbit CT scans were reviewed. Reformatted oblique coronal images were created perpendicular to the optic nerve. The cross-sectional area (CSA) of the orbit and each muscle group was measured and expressed as ratios of the CSA of the orbital apex. Univariate and multivariate analysis was performed for predictors of HVF MD.Results: 34 orbits with TED DON were analyzed. On orbital CT, the superior muscle complex occupied 15% of the apex (range 6–26%), inferior 18% (range 6–33%), lateral 10% (range 4–18%), medial 17% (range 8–27%), and all combined 61% (range 28–80%). Increasing total muscle area and superior complex area correlated with worsening MD. In multivariate linear regression, the superior muscle complex remained a significant predictor of MD (p = 0.01) over total muscle area (p = 0.25).Conclusions: Enlargement of extraocular muscles is common in TED, but DON occurs in only 6%. Our findings demonstrate that as DON worsens, as quantified by visual field MD, the superior muscle complex crowds the apex. This is consistent with the typical inferior visual field findings seen in TED DON. Hypertrophy of the superior rectus and levator palpabrae superioris complex may be predictive of worsening DON.

Minimally Invasive Conjoint Fascial Sheath Suspension for Blepharoptosis Correction.

Blepharoptosis can not only affect facial appearance but physical and mental health as well. Traditional treatments require long recovery time and leave unpleasant scars. In this study, we explored a simple and effective way to correct mild, moderate blepharoptosis and analyzed the causes and precautions for postoperative complications. From March 2014 to May 2017, patients presenting with mild or moderate bilateral or unilateral blepharoptosis underwent minimally invasive blepharoptosis correction using suspension of the conjoint fascial sheath of the levator and superior rectus. Mild blepharoptosis was corrected by 1 or 2 of loops suspension sutures, whereas moderate blepharoptosis was corrected by 3 or 5 loops. The postoperative evaluation, includingthe degree of correction or residual ptosis, asymmetry and presence of lagophthalmos, was performed after a minimum follow-up period of 9months. Forty patients (55 eyelids) were included. The mean followed up period was 13.40 ± 4.60months. Good results were seen in 48 ptosis eyes (87.27%). Double eyelid crease was formed simultaneously without an obvious wound. Two mild ptosis eyelids received a fair result, and 4 moderate ptosis eyelids improved to "mild ptosis." The mean marginal reflex distance 1 significantly increased postoperatively. Long-term follow-up indicates that minimally invasive conjoint fascial sheath suspension works well for mild and moderate ptosis. With its short recovery time, simultaneous double eyelid crease formation and long-lasting effect, the surgery is worth popularizing. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Neuronal Migration Generates New Populations of Neurons That Develop Unique Connections, Physiological Properties and Pathologies.

Central nervous system neurons become postmitotic when radial glia cells divide to form neuroblasts. Neuroblasts may migrate away from the ventricle radially along glia fibers, in various directions or even across the midline. We present four cases of unusual migration that are variably connected to either pathology or formation of new populations of neurons with new connectivities. One of the best-known cases of radial migration involves granule cells that migrate from the external granule cell layer along radial Bergman glia fibers to become mature internal granule cells. In various medulloblastoma cases this migration does not occur and transforms the external granule cell layer into a rapidly growing tumor. Among the ocular motor neurons is one unique population that undergoes a contralateral migration and uniquely innervates the superior rectus and levator palpebrae muscles. In humans, a mutation of a single gene ubiquitously expressed in all cells, induces innervation defects only in this unique motor neuron population, leading to inability to elevate eyes or upper eyelids. One of the best-known cases for longitudinal migration is the facial branchial motor (FBM) neurons and the overlapping inner ear efferent population. We describe here molecular cues that are needed for the caudal migration of FBM to segregate these motor neurons from the differently migrating inner ear efferent population. Finally, we describe unusual migration of inner ear spiral ganglion neurons that result in aberrant connections with disruption of frequency presentation. Combined, these data identify unique migratory properties of various neuronal populations that allow them to adopt new connections but also sets them up for unique pathologies.

Magnetic Resonance Imaging in 14 Patients with Congenital Oculomotor Nerve Palsy

To elucidate the imaging findings of congenital oculomotor nerve palsy by evaluating the oculomotor nerve and extraocular muscles on magnetic resonance (MR) imaging in arelatively large series of 14patients with congenital oculomotor nerve palsy. Ophthalmologic examination of 14consecutive patients diagnosed with congenital oculomotor nerve palsy, and MR imaging of the orbit and oculomotor nerves were performed. Of the 14patients with congenital oculomotor nerve palsy, 13patients (93%) were unilateral and 12patients (86%) had incomplete palsy. On MR imaging, 5patients (36%) had hypoplasia or aplasia of the oculomotor nerve with variable degrees of extraocular muscle atrophy on the affected side. Of the 14patients, nine (64%) had normal-sized oculomotor nerves with or without muscle atrophy. The most frequently involved muscles were the inferior rectus (64%) and medial rectus (50%), followed by the superior rectus (29%) and inferior oblique muscles (14%). None of the 14patients showed an abnormal abducens nerve. Congenital oculomotor nerve palsy was mostly incomplete and hypoplasia or aplasia of the oculomotor nerve was apparent in one third of patients showing variable degrees of extraocular muscle atrophy, mostly of the medial rectus and inferior rectus muscles.

Gene expression profile of extraocular muscles following resection strabismus surgery

This paper aims to identify key biological processes triggered by resection surgery in the extraocular muscles (EOMs) of a rabbit model of strabismus surgery by studying changes in gene expression. Resection surgery was performed in the superior rectus of 16 rabbits and a group of non-operated rabbits served as control. Muscle samples were collected from groups of four animals 1, 2, 4 and 6 weeks after surgery and processed for RNA-sequencing and immunohistochemistry. We identified a total of 164; 136; 64 and 12 differentially expressed genes 1, 2, 4 and 6 weeks after surgery. Gene Ontology enrichment analysis revealed that differentially expressed genes were involved in biological pathways related to metabolism, response to stimulus mainly related with regulation of immune response, cell cycle and extracellular matrix. A complementary pathway analysis and network analysis performed with Ingenuity Pathway Analysis tool corroborated and completed these findings. Collagen I, fibronectin and versican, evaluated by immunofluorescence, showed that changes at the gene expression level resulted in variation at the protein level. Tenascin-C staining in resected muscles demonstrated the formation of new tendon and myotendinous junctions. These data provide new insights about the biological response of the EOMs to resection surgery and may form the basis for future strategies to improve the outcome of strabismus surgery.

Fatiguing Trunk Flexor Exercise Decreases Pain Sensitivity in Postpartum Women.

BackgroundLow back pain (LBP) is common in the general population and among postpartum women. Abdominal muscle exercise is often used to treat LBP, but it is unknown if fatiguing abdominal muscle exercise can produce exercise-induced hypoalgesia (EIH).ObjectivesTo assess pressure pain thresholds (PPTs) at rest and following fatiguing trunk flexor exercise (EIH) in (1) nulligravid and postpartum women to evaluate the impact of pregnancy and childbirth and (2) nulligravid women and men to examine sex differences.MethodsSeventy healthy adults (31 postpartum women, 23 nulligravid women, 16 men) participated. Postpartum and nulligravid women were tested twice (16–18 weeks apart) to identify changes in EIH with postpartum recovery. PPTs were measured at the nailbed and superior rectus abdominis before and after exercise to investigate systemic and local EIH, respectively. Rectus abdominis muscle thickness was assessed with ultrasound.ResultsPostpartum women reported lower PPTs than nulligravid women at the abdomen (p < 0.05) whereas postpartum women had lower PPTs at the nailbed during the first session only. Men reported higher nailbed PPTs (p = 0.047) and similar PPTs at the abdomen than women (p = 0.294). All groups demonstrated EIH at the abdomen (p < 0.05). Systemic EIH was absent in postpartum and nulligravid women (p > 0.05), while men demonstrated hyperalgesia. Local EIH was positively associated with muscle thickness for men and women, which was not significant at the second timepoint.LimitationsAcute exercise response may not reflect changes that occur with exercise training.ConclusionFatiguing trunk flexor exercise produced local EIH for all groups including postpartum and nulligravid women. Clinically, trunk exercises may be useful for acute pain relief for clinical populations that are characterized by pain and/or weakness in the abdominal region muscles in populations with abdominal pain syndromes.

Efficacy of Polytetrafluoroethylene/Polylactide-co-glycolide (PTFE/PLGA) Laminate and PTFE/PLGA Laminate Containing Slow-Releasing Thalidomide in Delayed Adjustable Strabismus Surgery in a Rabbit Model

ABSTRACTPurpose: To evaluate the efficacy of polytetrafluoroethylene/polylactide-co-glycolide (PTFE/PLGA) laminate containing sustained-release thalidomide for delayed adjustable strabismus surgery.Methods: This is a prospective, masked-observer, controlled study using 50 eyes of 25 rabbits. After superior rectus muscle (SRM) recession, a PTFE/PLGA laminate containing thalidomide (group PT, 20 eyes), PTFE/PLGA laminate alone (group P, 20 eyes), or no barrier (group C, 10 eyes) were applied around the SRM. Delayed adjustment was performed at postoperative 3 or 5 weeks. Adjustability, adjustment lengths, adjustment forces, and degrees of adhesion were evaluated.Results: Both groups PT and P showed significantly better adjustability compared to group C at both 3 weeks (100%, 80%, and 0%, respectively) and 5 weeks (100%, 90%, and 0%, respectively). Between groups PT and P, adjustability, adjustment lengths, and forces were not significantly different at 3 and 5 weeks. Group PT showed a significantly lower grade of adhesion between SRM and sclera (SRM/S) compared to group C at both 3 weeks (p = 0.007) and 5 weeks (p = 0.001, respectively). Group P showed no significant difference in adhesion between SRM/S compared to group C at 3 weeks (p= 0.302) but had a lower grade of adhesion after 5 weeks (p = 0.007). There was no significant difference between groups PT and P at 3 weeks (p= 0.143) and 5 weeks (p= 0.716).Conclusions: PTFE/PLGA laminate containing sustained-release thalidomide was effective in reducing adhesion and allowed delayed adjustment in all eyes. However, PTFE/PLGA laminate alone was also equally effective in reducing adhesion compared to controls.

Double-bellied superior rectus muscle.

Congenital variations of extraocular muscles are rare. We report a double-bellied superior rectus muscle, observed in an adult male cadaver aged 70years. The superior rectus muscle had two equal-sized bellies, which took separate origins from the common tendinous ring and united to form a common belly 1cm before the insertion. Due to the duplication, the muscle extended laterally beyond the levator palpebrae superioris. Both its bellies were supplied by oculomotor nerve. To the best of our knowledge, this is the first report on doubling of the belly of the superior rectus muscle.

Rectus Extraocular Muscle Paths and Staphylomata in High Myopia

To investigate the relationship between displacement of extraocular muscles (EOMs) and staphyloma in high myopia using magnetic resonance imaging (MRI). Retrospective case-control study. Setting: Institutional study. Twenty-nine highly myopic patients (46 eyes), 11 age-matched healthy control subjects (21 eyes), and 34 patients (66 eyes) with sagging eye syndrome. MRI was analyzed for aspect ratio (AR) of the ocular cross section, locations of staphylomata and EOMs, and status of superior rectus to lateral rectus (SR-LR) band ligament. Association between staphylomata with EOM paths and the LR-SR band. Several associations of staphylomata were statistically significant (P < .05). Most staphylomata were superotemporal. Myopic patients with staphyloma had larger ARs in quasi-coronal images than in myopic subjects without staphyloma or normal controls. Compared to patients with high myopia without staphyloma and normal controls, when staphyloma was present, there was more inferior LR displacement, larger LR-globe angle, and larger SR-LR displacement angle than in myopic subjects without staphyloma. Staphyloma in the superotemporal quadrant was associated with greater SR-LR angle than in other quadrants. There were significantly more ruptures of SR-LR band ligament in highly myopic patients with staphyloma than in those without staphyloma. Local staphylomata in high myopia reflect ocular asphericity and correlate with EOM paths. Myopic staphylomata are associated with inferior displacement of LR path and defect of the LR-SR band ligament.

Botulinum toxin-A injection in esotropic Duane syndrome patients up to 2 years of age

To evaluate the role of botulinum toxin-A (BTX) injection as the primary treatment for patients with esotropic Duane retraction syndrome ≤2 years of age. The medical records of patients with esotropic Duane syndrome who underwent unilateral or bilateral BTX injection to the medial rectus muscle at or before 2 years of age were reviewed retrospectively. The following data were extracted from the record: laterality, age at the time of injection, primary position deviation, duction deficit, anomalous head posture, globe retraction before and after injection, further surgeries, and complications. Success was defined as permanent resolution of esotropia and head turn in primary position at final follow-up. A total of 15 patients (14 unilateral, 1 bilateral) were included. Before BTX injection the mean primary esotropia at near with full cycloplegic refraction was 29.3Δ ± 14.4Δ; the mean head turn, 23° ± 11°. Mean duration of follow-up was 37±29months (range, 7-96months). Orthotropia and resolution of head turn was achieved in 7 patients (46.7%). In subgroup analysis, success rate gradually decreased from 100% in patients ≤7months of age to 33.3% in patients 8-12months of age, and 20% in patients >12months of age. Seven patients (46.7%) required surgery (medial rectus recession and/or superior rectus transposition) because of residual head turn and esodeviation following BTX. In this patient cohort, orthotropia in primary position and correction of head turn were achieved with a single BTX injection in about half of the patients ≤2 years of age and all patients ≤7months of age. BTX injection early in infancy can obviate the need for surgery in esotropic Duane syndrome.

Superior or inferior rectus transposition in esotropic Duane syndrome: a longitudinal analysis

To evaluate the results of superior rectus transposition (SRT) or inferior rectus transposition (IRT) in esotropic Duane syndrome. The medical records of patients with esotropic Duane syndrome who underwent ciliary vessel-sparing SRT or IRT by a single surgeon in private practice were included. Pre- and postoperative head posture, primary position deviation, fundus torsion, collapse in pattern, and improvement in ductions were analyzed between groups. A total of 21 patients were included: 7 had a V-pattern esotropia and/or larger abduction deficiency in downgaze compared to upgaze and underwent IRT; 14 underwent SRT of which 6 had A pattern and/or larger abduction deficiency in upgaze compared to downgaze. Orthotropia within 10Δ of esotropia was achieved in 10 patients (71.4%) with SRT and 4 patients (57.1%) with IRT. Pattern was reduced and abduction improved in all patients. The improvement in abduction was slightly better in elevation after SRT compared with IRT (1.7±1 vs 1.4±0.7; P=0.4) and in depression after IRT compared to SRT (2±1.2 vs 1.1±0.7; P=0.05). Both SRT and IRT procedures effectively correct the head posture and primary position deviation in esotropic Duane patients. SRT can be advantageous in patients with an A pattern or more limitation of abduction in elevation; IRT, in patients with a V pattern or more limitation of abduction in depression.

Different Surgical Approaches for Treatment of Dissociated Vertical Deviation (DVD).

Introduction:DVD is a rare, poorly understood eye motility disorder of unknown etiology. In socially unacceptable deviation, surgical treatment is an option. We present patients operated with three different surgical methods.Aim:To evaluate and compare different surgical approaches for treatment of dissociated vertical deviation (DVD).Methods:Total amount of 20 patients with DVD of ≥ 20 PD are operated with three different techniques on superior rectus (SR) muscle: Group I with preoperative angle of 20-30 PD was operated with 8 mm recession of SR, Group II with preoperative angle of ≥ 30 PD undergo 3 mm recession with posterior fixation on SR and Group III with preoperative angle of ≥ 30 PD undergo-splitting of SR muscle. Surgeries for associated horizontal deviations were performed before surgery for DVD. Follow up was three years.Results:In all cases amount of DVD deviation was significantly reduced. No binocularity was gained. Although hyperdeviation of affected eye was reduced in all patients, we didn‘t eliminate deviation completely. Despite smaller preoperative angle, residual angle was bigger (6-12 PD) in the patients in group I where only recession of SR was performed, compared to Group II and III where postoperative angle was 4-8 PD in both groups.Conclusion:There are no recommended guidelines for the surgical treatment of DVD and treatment is based more on the surgeon’s experience than evidence based data. In our experience recession of the SR should be method of choice in the cases of smaller deviation. SR recession combined with posterior fixation suture and Y-splitting seems to be a safe and effective method for surgical treatment of unilateral DVD with bigger deviation angles. Y splitting with less surgical complications and increasing effect with time can be a good alternative to posterior fixation surgery.

Computed tomography imaging-based normative orbital measurement in Indian population.

Purpose:This study aims to evaluate normal orbital structures with nonenhanced computed tomography (NCCT) and determine normative data for the Indian population.Methods:CT images of the orbits of 100 patients were retrospectively reviewed on a work station to record the normative data of the orbits. Clinical details of all patients were reviewed to ensure that they did not have ocular/orbital diseases. Both axial and coronal images were utilized to record the data.Results:The mean age of the population evaluated was 34.07 years, with male to female ratio of 1.77. The average orbital index for the left orbit was 97 and for the right side was 103. The mean thickness of left inferior rectus, lateral rectus, medial rectus, and the superior rectus was 3.36 mm, 3.14 mm, 3.80 mm, and 3.75 mm, respectively. The right inferior rectus, lateral rectus, medial rectus, and the superior rectus measured 3.46 mm, 3.14 mm, 3.83 mm, and 3.78 mm, respectively. The optic nerve sheath complex diameter varied between 3.05 mm and 7.17 mm for the left eye and 3.05 mm and 7.0 mm for the right eye.Conclusion:The study provides normative data on various orbital structures in an Indian population. This data is likely to be useful for diagnosing various orbital pathologies and in planning surgical orbital procedures.

Bilateral Symmetric and Asymmetric Superior Rectus Recession for Patients with Dissociated Vertical Deviation.

To evaluate the outcome of bilateral symmetric and asymmetric superior rectus (SR) recessions in patients with bilateral dissociated vertical deviation (DVD) without oblique dysfunction and determine factors that might influence the surgical outcome. Retrospective study. All patients who underwent bilateral SR recession for bilateral DVD from January 2012 to December 2016 at an eye hospital in New Delhi, India were included. Indication for surgery was decompensated DVD in 1 or both eyes. Symmetric SR recession was performed for symmetric DVD and asymmetric SR recession was performed for asymmetric DVD of 10 prism diopters (PD) or more. Patients with a minimum follow-up of 6 months were included. Success was defined as absence of manifest DVD in both eyes at the final postoperative visit. Medical records of 27 patients were analyzed. Their median age at surgery was 8 years [interquartile range (IQR), 6-10 years] and mean follow-up was 16.3 months (range, 6-48 months). Symmetric and asymmetric surgeries were performed in 19 and 8 patients, respectively. The amount of SR recession performed ranged from 5 to 10 mm. The median DVD reduced from 9 PD (IQR, 6-14 PD) to 5 PD (IQR, 3-8 PD) in the right eye (P = 0.015) and 9 PD (IQR, 7-12 PD) to 6 PD (IQR, 3-10 PD) in the left eye (P = 0.016) after surgery. Successful outcome was seen in 63% of patients. There was no difference in successful outcome with respect to age, sex, preoperative horizontal deviation, preoperative vertical deviation, postoperative residual horizontal deviation, surgical technique, asymmetry of SR recession, and magnitude of preoperative DVD. Patients with a preference for fixation were more likely to have a successful outcome. Bilateral SR recession resulted in a success rate of 63% after single operation for bilateral DVD without oblique dysfunction. We found that the probability of a successful outcome did not depend on age at surgery, sex, preoperative horizontal or vertical deviation, magnitude of preoperative DVD, symmetry of SR recession, or surgical technique.

Management of Duane retraction syndrome: A simplified approach.

Duane retraction (or co-contraction) syndrome is a congenital restrictive strabismus which can occur either as an isolated entity or in conjunction with other congenital anomalies and is now listed as a congenital cranial dysinnervation disorder. It is characterized by co-contraction of horizontal recti on attempted adduction causing globe retraction along with variable amounts of upshoots or downshoots. It may have limited abduction or adduction or both and present as esotropic, exotropic, or orthotropic Duane. The diagnosis of this disease is usually clinical. However, recent research has provided a greater insight into the genetic basis of this disease paving a way for a greater role of genetics in the diagnosis and management. This disease can have a varied presentation and hence the treatment plan should be tailor-made for every patient. The indications for surgery are abnormal head posture, deviations in the primary position, retraction and narrowing of palpebral aperture and up- or downshoots during adduction, and sometimes also to improve abduction. The arrival of newer surgical techniques of periosteal fixation (PF) of lateral rectus (LR), partial vertical rectus transposition, or superior or inferior rectus transposition in addition to LR recession with Y-split has vastly improved the management outcomes, providing not only primary position orthophoria but also increased binocular visual fields as well.

Tratamento de paralisia de reto lateral pela transposição do reto superior para o reto lateral

ABSTRACT Objective: To evaluate the results of the surgical technique described by Crouch in the correction of lateral rectal paralysis (LR) esotropia. Methods: A study conducted of six patients with VI cranial nerve palsy, with more than three months, and associated contracture of the medial rectus muscle. The causes of paralysis varied in traumatic, congenital and neuropathic. The patients underwent surgical correction, performed with a technique consisting of the instillation of the superior rectus muscle (SR) and its suture above the insertion of the LR muscle, completed with Foster´s suture (suture joining, 8mm of the muscle insertion, the body of the SR and LR). The patients were followed for six months. Results: Five patients presented preoperative deviation between 30 and 50 prismatic diopter (PD), and one patient presented a deviation greater than 100 PD, and therefore, the patient required surgical reintervention due to residual deviation. The other five patients presented postoperative orthoppy, with better visual acuity and no vertical deviations. Conclusion: The surgery proposed by Crouch has been shown to be a good alternative to conventional techniques, such as Carlson-Jampolsky surgery, being a technically simpler procedure with good results.

Vertical rectus transposition procedures for lateral rectus palsy: A systematic review.

Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words ‘vertical rectus transposition for lateral rectus palsy,” “vertical rectus transposition for abducens palsy,” “superior rectus transposition,” “inferior rectus transposition,” and “Hummelsheim procedure.” References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.