particular surgical aspects in strabismus surgery · plan of the presentation • different supply...
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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 …..