Neepa M. Thacker

Partial rectus muscle–augmented transpositions in abduction deficiency

PURPOSE Lateral posterior fixation sutures increase the effect of full rectus extraocular muscle transpositions. Partial rectus muscle transposition may be indicated to minimize the risk of anterior ischemia when multiple rectus muscles require surgery to achieve ocular alignment. PURPOSE To report a modification of full vertical rectus muscle transposition with lateral posterior fixation sutures for use in patients at risk for anterior segment ischemia. METHODS Ten cases of unilateral split rectus muscle transposition augmented with lateral posterior fixation sutures were analyzed. Five patients had Duanes syndrome with esotropia in primary position, and five patients had sixth-nerve palsy. RESULTS Seven patients had a history of ipsilateral rectus muscle surgery, and three patients underwent simultaneous surgery on ipsilateral horizontal rectus muscles. In Duanes syndrome patients, the preoperative angle of deviation at distance was 15.8 +/- 5.8 prism diopters (PD) (range, 10 to 25) compared with 3.2 +/- 4.4 PD (range, 0 to 8) postoperatively (P =.005). In patients with sixth-nerve palsy, the preoperative angle of deviation at distance was 45.2 +/- 23.9 PD (range, 16 to 80) compared with -5 +/- 14.1 PD (range, -30 to 5) postoperatively (P =.004). Postoperative binocular single visual fields enlarged in seven of seven patients. CONCLUSION Partial rectus muscle-augmented transposition allows surgery on multiple ipsilateral rectus muscles in (1) Duanes syndrome patients with esotropia, marked cocontraction, and/or limitation to both horizontal rotations and in (2) sixth-nerve palsy patients with ipsilateral medial rectus tightness. Augmented partial rectus muscle transpositions improve ocular alignment and may enlarge binocular single fields in patients with persistent deviations despite previous muscle surgery.

Acquired strabismus following cosmetic blepharoplasty.

The purpose of this study was to report on 12 patients with acquired strabismus following cosmetic blepharoplasty and to identify patterns of strabismus related to the surgical procedure. Clinical ophthalmologic examinations were performed to specifically clarify the type of strabismus. Operative reports of the blepharoplasty procedures were reviewed. Patients were followed for a minimum of 3 months after the blepharoplasty procedure before surgical intervention was considered. Operative findings at corrective strabismus surgery were noted and an attempt was made to correlate these findings with the clinical ophthalmologic examination and the blepharoplasty surgical procedure. Twelve cases of persistent vertical strabismus occurred following blepharoplasty procedures. Five patients had clinical findings consistent with the diagnosis of acquired superior oblique palsy; one of these five patients also showed signs of an acquired Brown syndrome. Seven patients developed an incomitant vertical deviation consistent with an inferior rectus paresis. Strabismus occurred after conventional lower lid, upper lid, and four-lid blepharoplasty with or without laser blepharoplasty. Acquired strabismus accompanied by persistent diplopia may occur as a complication of cosmetic blepharoplasty. Extraocular muscle damage resulting in either superior oblique muscle palsy or inferior rectus paresis was noted in these patients. In some cases, patients with inferior rectus paresis also showed mechanical restriction to upward rotation of the globe.

Extraocular muscle damage associated with endoscopic sinus surgery : An ophthalmology perspective

Background Orbital complications associated with endoscopic sinus surgery are well documented. Damage to the medial rectus muscle results in complicated strabismus and disturbing diplopia. The aim of this study was to characterize the types of extraocular muscle injury and the number of muscles involved that may complicate endoscopic sinus surgery and correlate its occurrence to factors in the surgical procedure itself. Methods A retrospective chart review was performed of 14 patients with strabismus after endoscopic sinus surgery. Operative notes of the surgical procedure, pathology reports of the intraoperative specimens, postoperative pattern of strabismus, the extraocular muscle involved, and the type of muscle injury characterized by orbital imaging were reviewed in each patient. Results In our series, not only the medial rectus muscle but also the inferior rectus and the superior oblique muscles were damaged with multiple muscles being involved in one patient. Extraocular muscle injury varied from hematoma, entrapment of muscle in the fractured orbital wall, damage to the oculomotor nerve entry zone, muscle transection, and partial or complete muscle destruction with entrapment in scar tissue. Use of the microdebrider causes extensive irreparable muscle damage. Conclusion Extraocular muscle damage complicating endoscopic sinus surgery can produce therapeutically challenging complicated strabismus.

Cause of V pattern strabismus in craniosynostosis: a case report

Strabismus is a common association in patients with craniosynostosis or craniofacial dysostosis (60–70%).1–3 V pattern exotropia is the most common ocular motility problem. Various theories have been proposed to explain the cause of the V pattern and surgical attempts to correct it with weakening procedures of the inferior oblique have been disappointing.2,3 This is a case report of one child with this disorder who underwent orbital computed tomography (CT) scans and had a marked improvement of the V pattern following strabismus surgery based on the CT findings. This child with craniosynostosis had undergone six previous cranial surgeries. She had three strabismus surgical procedures including anterior transpositions of the inferior obliques in an …

Surgical results of patients with unilateral superior oblique palsy presenting with large hypertropias.

PURPOSE Surgical management of superior oblique palsy (SOP) is challenging because of combined vertical, horizontal, and torsional misalignment. The authors report the surgical results of patients with large primary position hypertropias (> 20 prism diopters [PD]) due to unilateral SOP. METHODS Criteria for success included correction of the anomalous head posture, primary position alignment between orthotropia and 6 PD of undercorrection, and no reoperation required for residual deviations in any direction of gaze. RESULTS Forty-five patients met inclusion criteria. Mean preoperative alignment in primary gaze was 26.5 ± 6.5 PD compared to 3.0 ± 4.4 PD postoperatively (P < .001). Twenty-three (51%) cases met the criteria for success with one operation. Of the patients who had single muscle surgery, 14% had a successful outcome, with a mean 67% (17.3 PD) reduction in hypertropia. Of patients who underwent simultaneous multiple muscle surgery, 58% met the criteria for a successful result, with a mean 92% (24.6 PD) reduction in primary gaze hypertropia. Success was the highest in patients who underwent ipsilateral inferior oblique combined with contralateral inferior rectus recessions with (60% success) or without (65% success) a Harada-Ito procedure. CONCLUSION Undercorrections are frequent following surgery for unilateral SOP with preoperative deviations greater than 20 PD in primary position, especially after single-muscle surgery. Simultaneous multiple muscle surgery rarely results in overcorrection and is recommended in patients with SOP and more than 20 PD of hypertropia in primary position.