Particular surgical aspects in strabismus surgery

Vincent Paris

Spring meeting BSA 2009

Plan of the presentation• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

In case of total III nerve palsy : use of residual functional muscle

Kaufmann

In case of partial III nerve palsyTransposition of the two adjacent sound recti in the direction of the maximal palsy position

( Kaufmann ) See book of Roth & Speeg-Schatz : “La chirurgie oculomotrice” 1995 Masson Ed

III nerve palsy

Displacement of the inferior oblique

• Supply of Inferior Rectus function

• Supply of Superior Oblique function

• With resection

Supply of IR : displacement of the IO at the

tendon of the IR

• Olitsky JPOS 2000, 2005,

• Gamio BV 2002 with

resection

Here : efficacy of a standard method

Variation of the technique

• Simultaneous downward transposition of the medial rectus for lost inferior rectus

Asadi & Falavarjani J AAPOS 2006;10;6:592-593

• Better control of the deviation on downgaze that classical inversed Knapp procedure

------------

MR

IO

LR

Supply of the SOStager transposition in the nasal quadrant BV 2001;16 (1) ; 43-44

Independantly performed by Annie Putteman in a case of rupture of the SO in 2004 ……another belgian story……..

Right absence of SO

Excyclo 20° in downgaze….

Suppression of diplopia…..!

IO resection ( 5mm ) and displacement 5 mm behind the inferior part of the MR

MR

IO

Excyclo 6° in downgaze……No more diplopia in daily life conditions? Drives again , lives again : patient HAPPY

RESULT

Apert syndrome with absence of both IR and SO

on the right eye……

After a “simple” transposition and a 8mm resection

of the IO…..

Just a look for compensation of macular rotation…

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

Available techniques

Roth A , Speeg-Schatz C, la chirurgie oculo-motrice , Masson 1995, 188-190

Oblique slipping of the superior or inferior part of the muscle ( slanting )

Available Techniques• Vertical slipping ( Costenbader-Knapp 1959)

Medial rectus is moved to OPEN the alphabetic pattern : Up for A / Down for V

Lateral Rectus is moved to CLOSE the alphabetic pattern : Down for A / Up for A

Along the spiral of Tillaux

Efficiency of vertical slipping

• Bietti , Boyd ( 1970-71 ) : 10-16 D ( A )• Biedner ( 1994 ) : V éso 15 – 29 D • Garrido ( 2004 ) : 11.4 ( A eso ) • Gravier ( 2006 ) : 10 – 35 D efficacy of

monolateral surgery in intermittent exotropia

« mean efficiency : 3D / mm slipping » (Roth)

Efficiency of vertical slanting

• Ohba ( 2004 ) : 10 D ( V exo ) 20 D ( A )

Exemple of slanting resection

Consequences

• When treating more than 15 D of incomitance

• Slipping of four horizontal muscles• Association of both slipping and slanting

Result after 2 successive steps for V exo with 40 D of incomitance !

Step 1 : slipping 5 mm + resection 7.5 mm of both MR

Step 2 : slipping 5 mm + recession 7 mm of both LR

X 10 up gaze 0 to E’2 downgaze

Particular cases

• V Eso • Normosenrial only in 20° upgaze• 30 D of incomitance

: displacement of 3 mm « Stairs Technique »

Slipping + Slanting techniques

Perfect Result

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

Goal of the technique

• Treating the incomitance• Without using Faden Operation• Easy to perform• Easy to re operate !

History

• Alan B Scott 1994 VII th ISA congress “ posterior fixation : adjustable without

posterior suture…”..based on a large resection associated with

a larger recessionBased on mathematic model from Miller !!

3 cases in horizontal incomitance

Bock , Buckley and Freedman

1999 J AAPOS

Application of Scott’s technique

also in vertical surgery

3 – 5 mm resection

6 – 10 mm recession ( adjustable )

Thacker, Velez and Rosenbaum

2005 J AAPOS

Other applications• John Lee et al 2007 J AAPOS - 22 patients : 12 LR , 7 IR , 3 MR , 3 SR - resection : 5 – 6 mm ( 7 for LR ) - recession : adjustable - improvement in gaze incomitance in all but one

• Cordonnier 2007 BSA - 2 patients : resection 5 recession 10 adjustable - good result after failure of myopexia on IR - good result in Brown syndr

Other application

• Ramasamy et al J AAPOS 2007 - 5 patients for convergence excess - bilat recess/resec in MR ( +/- equal ) - non adjustable

• Our experience - 5 patients for overcorrection : 3 exo, 1

hypo, 1 eso - perfect result with 4-5 mm resection on site

Incomitant overcorrection after IR recession

Lack of binocular vision in lateral gaze

Perfect result after 4 mm IR resection

and 1mm advancement

New idea but old practice

• Our experience in adjustable suture since many years

• In very unpredictable cases , we perform resection of 3 – 5 mm associated with hang back suture

One rectus muscle recess/ resec

• Take place beside/ in place to myopexia• Efficient in muscles where myopexia is

less effective : IR and LR• Simple to perform in complicate cases as

primary or secondary procedure• But myopexia still remains !• Elongation test could also lead to

associated plication

Resection and myopexia ( personal experience )

• In case of laxity of the rectus ( elongation test )• In case of “inverse deviation” ( from near to

distance ) - primary - secondary

• Variation : myopexia in MR and recession of LR Alain Spielmann 2005 JFO

Particular case

• Consecutive exotropia and residual convergence excess

• Advancement of the MR associated with myopexia

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

• In non-accommodative convergence excess / fixation-linked

• Large MR recession combined with smaller LR recession

• Alternative to myopexia • De Clippeleire, Apers, Van Eecckoute,Van

Lammeren, Janssens 1992 ESA

• In important nystagmus without null point position

• Large recession of 8 – 10 mm

• Helveston, Spielmann, Gomez de Liano…

• Better “vision” in some desperate cases. Sometime post op torticollis

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

IR recession : risk of overcorrection

• Associated with its anatomy

• Dual insertion : to the globe and to the tarsus through its capsulo-palpebral head

• Postop progressive traction

Particular aspect of IR surgery

• Fixed suspension of the capsulo-palpebral head ( Jampolsky 1986, Spielmann 1993)• Semi-adjustable suture ( Campos 1990 ) ( only adjustment in the middle of the muscle )• Use of non absorbable suture (Parsa, Guyton ESA 2004)• Recession of 90% of posterior fibers ! ( Gokygit et al ISA 2006 )• Self adjustment of small amount of recession in thyroid-associated retinopathy ( Evens , Godts IOA 2008 )

Left IR fibrosis

Overcorrection in spite of• Fixed with non-

absorbable suture• Let undercorrected

Stable result after repositioning ( F up 1 year )

Consequences

• Avoid to perform IR recession if possible

• If IR recession is necessary :• Prefer non-absorbable suture• Limit the dosage to 4 mm

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

Rectus muscle and torsion

• Useful when oblique surgery is limited rectus muscles can be transposed

• Nasal transposition of IR in case of residual excyclo in downgaze

• Vertical recti splitting for large head tilt associated with nystagmus

( Von Noorden 1991 )

Spielmann technique Partial recession technique of Spielmann for head tilt and nystagmus

New deal in macula translocation: De Clippeleir technique

Rectus muscle in case of IV nerve complete palsy

• Logical ( no oblique innervation )• Rare • High dosage is necessary

• Lack of learning curve• Better after performing surgery for macular

rotation

Right pareusis and left real IV nerve palsy Maximal surgery on obliques + lateral transposition of SR and IR ( still undercorrected )

7stepsofsurgeryforrightpareusisandleftrealIVnervepalsy

OS:IRmovednasally,MRmovedup,scarringtissuemovedfromthetemporaltothenasalquadrant!!!

(Spielmanncopyright)3casespublished

Incyclo / 0° subj

Preop : residual subjective excyclo 16°

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

Idea : when one muscle creates excessive restriction it has to be

Alan B Scott again !! : muscle attachment to the orbital wall

Application to Duane with vertical deviation of mechanical type

( with transposition )

• Parsa ISA 2006Good result in 3 cases

• Ozkan ESA 2008Residual retraction in 3

cases ( < transposition ? )

Persistance of vertical deviation after recession of both Medial and

Other application

• IO periostic fixation for recurrent IOOA

• LR periostic fixation in a case mitochondrial myopathy operated 3 times with maximal surgery

Hard surgery for small result but better than before

• Different supply technique• Alphabetic syndrome and normal oblique

function • Simultaneous resection and recession• Both recession of horizontal recti• Particular aspects of inferior rectus surgery• Rectus surgery for torsion• Periostic fixation• Yokoyama technique in high myopia

New theory of heavy eye syndrome

• 2000 Yokoyama and coworkers

• Myopic staphyloma dislocates the eyeball out of the muscle cone in the superotemporal quadrant, pushing aside the SR and LR muscle

Pushing the globe during the movement to the left : the left eye became capable to pass the midline

Still hypo and eso when pushing in primary position

New surgical technique

• Principle of replacing the globe into the muscle cone

• By means of non absorbable sutures put like a bridge between the SR and the LR

( 11 mm from the insertion ) + 8 mm MR recession

Perfect result : straight eyes in PP and normalization of abduction

It remains to determine when associated MR is necessary

To mention ……

• A few words about the “dictatorship” of Demer and his MRI ……

• “patients with V and IOOA have to receive a MRI before surgery ….” 1999

• “recession of IR in SO palsy is a physiologic therapy….” 2008

Of course , some rare motility disorder can be explained by the asymmetric situations of the pulleys and offer some particular applications…..

From a clinical point of view

• Some pulleys disorders can be investigated during surgery

• Heavy eye syndrome is not completely explained by the pulleys

• Cases resolved only by MRI are rare !

A last remark about traction suture

• In some recurrent case • Non-absorbable material fixed between

the sclera and the lid• In the direction opposed to the deviation

• Ozkan J AAPOS 2006 : use of Botox in large angle exotropia with conventional resec/resess

• “chemical traction suture…”

You must have • Surgical management of strabismus EM HELVESTON The 5th edition just arrives !! Clear ! Cases report

• La chirurgie oculo-motrice A ROTH C SPEEG- SCHATZ International literature ! Complete

Thank you for your attention …..