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Bilateral recession of superior rectus muscles: Its influence on A and V pattern strabismus
Bilateral Recession of Superior Rectus Muscles: Its Influence on A and V Pattern Strabismus Ntlida B. Melek, MD, Teodora Mendoza, MD, and Alberto O. Ciancia, MD Purpose:To determine whether bilateral superior rectus recession modifies A and V pattern strabismus. Patients and Methods:Three patients with V patterns and eight patients with A patterns underwent bilateral superior rectus recession with neither oblique muscle surgery nor vertical displacement of the horizontal rectus muscles. Another three patients with A patterns underwent simultaneous superior oblique tenotomy and superior oblique recession. Results:Two of the patients with V patterns demonstrated an increase in the V pattern after surgery; one was unchanged. Five of the patients with A patterns converted to V patterns after surgery. In the remaining three patients the pattern was eliminated. The three patients who underwent superior oblique tenotomy along with superior rectus recession had large shifts toward V pattern (mean shift, 40 A). Conclusion: Bilateral superior rectus recession tends to increase V patterns and reduce A patterns. Superior rectus recession may be synergistic with superior oblique tenotomy in collapsing an A pattern. (J AAPOS 1998;2:333-5)
issociated vertical deviation (DVD) and A or V patterns are present in a high percentage of patients with congenital esotropia. Various surgical techniques have been proposed for the treatment of both of these motility disorders. 1-6 One of the most widely used and effective treatments for DVD is recession of both superior rectus muscles. In theory, weakening both superior rectus muscles should have an effect on A or V patterns because the superior rectus muscles are secondary adductors. Mso, weakening of the superior rectus muscles should result in a greater percentage of elevation coming from the inferior oblique muscles. This should cause a relative divergence in upgaze. The purpose of this study was to determine the influence of bilateral superior rectus recessions on A and V pattern strabismus.
D
SUBJECTS AND METHODS Clinical records of patients who underwent operation by ~:he authors between January 1980 and January 1995 were reviewed. The search identified 251 patients who underwent surgery for DVD. From the latter, 11 were identified as meeting the following inclusion criteria for this study: From the Pediatric Ophthalmology Foundation, BuenosAires, Argentina. Submitted May 20, 1997. Revision acceptedMay 18, 1998. Reprint requests: N(lida B. Melek, MD, Fundacion Ofialmolog/a Pedidtrica, Callao 1395, (1023) BuenosAires, Argentina. Copyright © 1998 by the American Association for Pediatric Ophthalmology and Strabismus, 1091-8531/98 $5.00 + 0 7~/1/94267
Journal of AAPOS
(1) the presence of A or V pattern strabismus; (2) they had not undergone prior surgery on the oblique muscles or the superior rectus muscles; (3) they had not undergone prior vertical displacement of the horizontal rectus muscles; and (4) follow-up was a minimum of 1 year. Bilateral superior rectus recessions were performed either symmetrically or asymmetrically with a range of 5 mm to 14 mm. All patients simultaneously underwent surgery on one or more horizontal rectus muscles; none underwent oblique muscle surgery. The presence of A or V patterns was determined by measuring patients in 30 degrees upgaze and 30 degrees downgaze. All horizontal measurements were made with the prism and alternate cover test. A second group of patients was identified who met the above criteria, except that they also underwent simultaneous bilateral superior oblique tenotomy with bilateral superior rectus recession. This group was studied to see whether the effect of superior rectus recession might be synergistic with superior oblique tenotomy in collapsing an A pattern. RESULTS Three patients had V pattern strabismus, and eight had A pattern strabismus. Table 1 shows the clinical characteristics of the patients in this series. Before surgery the mean vertical incomitance of the horizontal deviation (eg, the magnitude of the A or V pattern) of the three patients with V patterns was 6 A (range, 3 to 10 A). After surgery this had increased to a mean of 17 A (range, 5 to 2 7 A). For the eight patients with A patterns the mean vertical incomitance of the horizontal deviation December 1998 3 3 3
Jou,val of M P O S Volume 2 Number 6 December 1998
334 Melek, Mendoza, and Ciancia TABLE 1. Clinical findings of patients
Patient no.
Strabismus Preop type pattern (preop/postop) (size,* type)
Postop Magnitude of pattern change of pattern (size, type) after surgery
Elimination of pattern
Surgery (mm)
V patterns 1 ET/ET 5AV 5AV 0A No Res LROU5, Rec RSR 8, LSR 10 2 XT/XT 3AV 19AV 16A No Rec LROU7.5, Rec RSR 8, LSR 10 3 XT/ET 10 A V 27 A V 17 A No Rec LLR 5, Rec RSR 14, LSR 10 A patterns 4 XTET 5AA 6AV 11A No Rec RLR 4, LLR 7, Rec RSR 8, LSR 10 5 XT/0rtho 13 A A 3A V 16 A No Rec LLR 6, Rec RSR 12, LSR 10 6 XT/0rtho 15 A A No pattern 15 A Yes Rec LLR 6, Rec RSR 8, LSR 10 7 XT/Ortho 15 A A No pattern 15 A Yes Rec LLR 6, Rec RSR 12, LSR 10 8 ET/XT 5AA 5AV 10A No Rec MROU 5, Rec RSR 7, LSR 5 9 ET/0rtho 10 A A 5A V 15 A No Rec MROU 4.5, Rec SROU 10 10 ET/ET 7A A 5A V 12 A No Res LROU6, Rec RSR 9, LSR 12 11 ET/Ortho 10 A A No pattern 10 A Yes Rec MROU 5, Rec SROU 10 Simultaneous procedurest 12 ET/ET 17 A A 5A V 22 A No Rec MROU 5.5, Rec RSR 10, LSR 12, TenotomyS00U 13 XT/XT 38 A A 12 A V 50 A No Rec RSR 8, LSR 10, Tenotomy S00U 14 XT/XT 35AA 12 AV 47 A No Rec LROU6, Rec RSR 12, LSR 10, Tenotomy SOOU *Sizeof patternis magnitudeof incomitanceof the horizontaldeviationbetweenupgazeand downgaze. tPatientswho underwentsimultaneoussuperiorrectusrecessionsand superiorobliqueweakening. ET,Esotropia;XT,exotropia;Ortho, orthotropia;Rec, recess;Res, resect;MR, medialrectus;LR, lateralrectus;SR, superiorrectus; SO, superioroblique.
was 10 A (range, 5 to 15 A) before surgery. After surgery five had switched to manifesting a V pattern, and three showed no vertical incomitance of the horizontal deviation. The mean vertical incomitance of the horizontal deviation after surgery in the eight patients with an A pattern (including the three who had no pattern after surgery) was 3 k (range, 0 to 6 k). From this chart review of 251 patients, we also identified three patients who had an A pattern, superior oblique overaction, and DVD. They had 17 A, 35 A, and 38 A of A pattern, respectively, before surgery. Each was treated with bilateral superior oblique weakening and bilateral superior rectus recessions. After surgery all three had switched to a V pattern with a mean value of 10 k (range, 5 to 12 k). The mean value of the shift toward V pattern was 40 A. This is more than we would expect to see from superior oblique weakening alone, suggesting that concurrent superior rectus recessions has a synergistic effect on the collapse of an A pattern.
DISCUSSION Relatively large graded bilateral superior rectus recessions, or superior rectus recessions combined with posterior fixation sutures, have been recommended by some authors for treating DVD for almost two decades. 1,2,4 However, to our knowledge the literature does not address the effect of superior rectus weakening on A or V patterns. This is an important issue because DVD and either A or V patterns frequently coexist. They are often surgically corrected simultaneously. Coats et al 7 reported 19 cases of A pattern strabismus with coexisting DVD and superior oblique overaction.
Fifteen of the patients underwent surgery, of whom 13 were available for postoperative follow-up. Some were treated with superior rectus recessions, some with superior oblique weakening, and a few with both. The authors did not mention the magnitude of the A patterns before or after surgery. They did indicate that in four cases in which only bilateral superior rectus recessions were performed, the A pattern was eliminated. This is similar to our findings. McCall and Rosenbaum 8 described four patients with A pattern strabismus, superior oblique overaction, and DVD who underwent bilateral superior rectus recessions and tenectomy of the posterior two thirds of the superior oblique tendon. Before surgery the amount of A pattern measured 14 A, 20 A, 25 A, and 36 A, respectively. After surgery the A pattern was eliminated in two patients, was reduced to 6 A in one patient, and was converted to an X pattern in another. In their patients, the decrease in the A pattern may have in part been a result of the superior rectus recessions and in part a result of the superior oblique surgery. The number of cases we are describing in this retrospective study is too small to permit us to draw firm conclusions or make meaningful statistical analysis. Nevertheless, we believe that the results suggest that bilateral superior rectus recessions do have an effect on A and V patterns, with a trend toward decreasing the former and increasing the latter. This suggests that in patients with DVD, superior oblique overaction, and A patterns, simultaneous weakening of both superior oblique muscles and superior rectus muscles should be reserved for patients with a large degree of A pattern.
Journal of AAPOS Volume 2 Number 6 December 1998
Melek, Mendoza, and Ciancia 335
References i. Magoon E, Criciger M, JampolskyA. Dissociatedvertical deviation: an asymmetric condition treated with large bilateral superior rectus recession. J Pediatr Ophthalmol Strabismus 1982;19:152-6. 2. von Noorden GK. Indications of the posterior fixation operation in strabismus. Ophthalmology 1978;85:512-20. 3. SpragueJB, Moore S, Eggers H, Knapp P. Dissociated vertical deviation: treatment with faden operation of Ciippers. Arch Ophthalmol 1980;98:465-8. 4. Velez G. Dissociated vertical deviation. Graefes Arch Clin Exp Ophthatmol 1988;22:117-8.
5. Elliott R, Nankin SJ. Anterior transposition of the inferior oblique. J Pediatr Ophthalmol Strabismus 1981;18:35-8. 6. Kratz R, Rogers G, Bremer M, Leguire L. Anterior tendon displacement of the inferior oblique for DVD. J Pediatr Ophthalmoi Strabismus 1989;26:212-7. 7. Coats D, Paysee E, Sato M, Helveston EM. "A" pattern horizontal strabismus, dissociated vertical deviation and superior oblique overaction. In: Lennerstrand G, editor. Update on strabismus and pediatric ophthalmology.London: CRC Press. p. 380-4. 8. McCall L, Rosenbaum A. Incomitant dissociated vertical deviation and superior oblique overaction. Ophthalmology 1991;98:911-8.
A n Eye o n the Arts - T h e Arts o n the Eye
Explaining Blindness To A Child It is like m a n y nights growing seamlessly into one, it is like m a n y flames sliding into each other until they're one big fire, it is like colored wallpaper being slowly covered by India ink, it is like greasy soot blotting out the sparkling new snow, it is like a hundred black flies devouring a white piece of cheese, it is like a gleaming aluminum train being swallowed by a hungry tunnel, it is like bright birds in the zoo, buntings, canaries, parrots and snowy owls suddenly sprouting black feathers and becoming ravens, it is like the only T V in the world losing its screen, it is like the sun and the m o o n and all the stars collapsing into black holes in the sky... - - F e l i x Pollak (from Tunnel Visions [writings of a poet going blind]). Reprinted with permission of Spoon River Press.
issociated vertical deviation (DVD) and A or V patterns are present in a high percentage of patients with congenital esotropia. Various surgical techniques have been proposed for the treatment of both of these motility disorders. 1-6 One of the most widely used and effective treatments for DVD is recession of both superior rectus muscles. In theory, weakening both superior rectus muscles should have an effect on A or V patterns because the superior rectus muscles are secondary adductors. Mso, weakening of the superior rectus muscles should result in a greater percentage of elevation coming from the inferior oblique muscles. This should cause a relative divergence in upgaze. The purpose of this study was to determine the influence of bilateral superior rectus recessions on A and V pattern strabismus.
D
SUBJECTS AND METHODS Clinical records of patients who underwent operation by ~:he authors between January 1980 and January 1995 were reviewed. The search identified 251 patients who underwent surgery for DVD. From the latter, 11 were identified as meeting the following inclusion criteria for this study: From the Pediatric Ophthalmology Foundation, BuenosAires, Argentina. Submitted May 20, 1997. Revision acceptedMay 18, 1998. Reprint requests: N(lida B. Melek, MD, Fundacion Ofialmolog/a Pedidtrica, Callao 1395, (1023) BuenosAires, Argentina. Copyright © 1998 by the American Association for Pediatric Ophthalmology and Strabismus, 1091-8531/98 $5.00 + 0 7~/1/94267
Journal of AAPOS
(1) the presence of A or V pattern strabismus; (2) they had not undergone prior surgery on the oblique muscles or the superior rectus muscles; (3) they had not undergone prior vertical displacement of the horizontal rectus muscles; and (4) follow-up was a minimum of 1 year. Bilateral superior rectus recessions were performed either symmetrically or asymmetrically with a range of 5 mm to 14 mm. All patients simultaneously underwent surgery on one or more horizontal rectus muscles; none underwent oblique muscle surgery. The presence of A or V patterns was determined by measuring patients in 30 degrees upgaze and 30 degrees downgaze. All horizontal measurements were made with the prism and alternate cover test. A second group of patients was identified who met the above criteria, except that they also underwent simultaneous bilateral superior oblique tenotomy with bilateral superior rectus recession. This group was studied to see whether the effect of superior rectus recession might be synergistic with superior oblique tenotomy in collapsing an A pattern. RESULTS Three patients had V pattern strabismus, and eight had A pattern strabismus. Table 1 shows the clinical characteristics of the patients in this series. Before surgery the mean vertical incomitance of the horizontal deviation (eg, the magnitude of the A or V pattern) of the three patients with V patterns was 6 A (range, 3 to 10 A). After surgery this had increased to a mean of 17 A (range, 5 to 2 7 A). For the eight patients with A patterns the mean vertical incomitance of the horizontal deviation December 1998 3 3 3
Jou,val of M P O S Volume 2 Number 6 December 1998
334 Melek, Mendoza, and Ciancia TABLE 1. Clinical findings of patients
Patient no.
Strabismus Preop type pattern (preop/postop) (size,* type)
Postop Magnitude of pattern change of pattern (size, type) after surgery
Elimination of pattern
Surgery (mm)
V patterns 1 ET/ET 5AV 5AV 0A No Res LROU5, Rec RSR 8, LSR 10 2 XT/XT 3AV 19AV 16A No Rec LROU7.5, Rec RSR 8, LSR 10 3 XT/ET 10 A V 27 A V 17 A No Rec LLR 5, Rec RSR 14, LSR 10 A patterns 4 XTET 5AA 6AV 11A No Rec RLR 4, LLR 7, Rec RSR 8, LSR 10 5 XT/0rtho 13 A A 3A V 16 A No Rec LLR 6, Rec RSR 12, LSR 10 6 XT/0rtho 15 A A No pattern 15 A Yes Rec LLR 6, Rec RSR 8, LSR 10 7 XT/Ortho 15 A A No pattern 15 A Yes Rec LLR 6, Rec RSR 12, LSR 10 8 ET/XT 5AA 5AV 10A No Rec MROU 5, Rec RSR 7, LSR 5 9 ET/0rtho 10 A A 5A V 15 A No Rec MROU 4.5, Rec SROU 10 10 ET/ET 7A A 5A V 12 A No Res LROU6, Rec RSR 9, LSR 12 11 ET/Ortho 10 A A No pattern 10 A Yes Rec MROU 5, Rec SROU 10 Simultaneous procedurest 12 ET/ET 17 A A 5A V 22 A No Rec MROU 5.5, Rec RSR 10, LSR 12, TenotomyS00U 13 XT/XT 38 A A 12 A V 50 A No Rec RSR 8, LSR 10, Tenotomy S00U 14 XT/XT 35AA 12 AV 47 A No Rec LROU6, Rec RSR 12, LSR 10, Tenotomy SOOU *Sizeof patternis magnitudeof incomitanceof the horizontaldeviationbetweenupgazeand downgaze. tPatientswho underwentsimultaneoussuperiorrectusrecessionsand superiorobliqueweakening. ET,Esotropia;XT,exotropia;Ortho, orthotropia;Rec, recess;Res, resect;MR, medialrectus;LR, lateralrectus;SR, superiorrectus; SO, superioroblique.
was 10 A (range, 5 to 15 A) before surgery. After surgery five had switched to manifesting a V pattern, and three showed no vertical incomitance of the horizontal deviation. The mean vertical incomitance of the horizontal deviation after surgery in the eight patients with an A pattern (including the three who had no pattern after surgery) was 3 k (range, 0 to 6 k). From this chart review of 251 patients, we also identified three patients who had an A pattern, superior oblique overaction, and DVD. They had 17 A, 35 A, and 38 A of A pattern, respectively, before surgery. Each was treated with bilateral superior oblique weakening and bilateral superior rectus recessions. After surgery all three had switched to a V pattern with a mean value of 10 k (range, 5 to 12 k). The mean value of the shift toward V pattern was 40 A. This is more than we would expect to see from superior oblique weakening alone, suggesting that concurrent superior rectus recessions has a synergistic effect on the collapse of an A pattern.
DISCUSSION Relatively large graded bilateral superior rectus recessions, or superior rectus recessions combined with posterior fixation sutures, have been recommended by some authors for treating DVD for almost two decades. 1,2,4 However, to our knowledge the literature does not address the effect of superior rectus weakening on A or V patterns. This is an important issue because DVD and either A or V patterns frequently coexist. They are often surgically corrected simultaneously. Coats et al 7 reported 19 cases of A pattern strabismus with coexisting DVD and superior oblique overaction.
Fifteen of the patients underwent surgery, of whom 13 were available for postoperative follow-up. Some were treated with superior rectus recessions, some with superior oblique weakening, and a few with both. The authors did not mention the magnitude of the A patterns before or after surgery. They did indicate that in four cases in which only bilateral superior rectus recessions were performed, the A pattern was eliminated. This is similar to our findings. McCall and Rosenbaum 8 described four patients with A pattern strabismus, superior oblique overaction, and DVD who underwent bilateral superior rectus recessions and tenectomy of the posterior two thirds of the superior oblique tendon. Before surgery the amount of A pattern measured 14 A, 20 A, 25 A, and 36 A, respectively. After surgery the A pattern was eliminated in two patients, was reduced to 6 A in one patient, and was converted to an X pattern in another. In their patients, the decrease in the A pattern may have in part been a result of the superior rectus recessions and in part a result of the superior oblique surgery. The number of cases we are describing in this retrospective study is too small to permit us to draw firm conclusions or make meaningful statistical analysis. Nevertheless, we believe that the results suggest that bilateral superior rectus recessions do have an effect on A and V patterns, with a trend toward decreasing the former and increasing the latter. This suggests that in patients with DVD, superior oblique overaction, and A patterns, simultaneous weakening of both superior oblique muscles and superior rectus muscles should be reserved for patients with a large degree of A pattern.
Journal of AAPOS Volume 2 Number 6 December 1998
Melek, Mendoza, and Ciancia 335
References i. Magoon E, Criciger M, JampolskyA. Dissociatedvertical deviation: an asymmetric condition treated with large bilateral superior rectus recession. J Pediatr Ophthalmol Strabismus 1982;19:152-6. 2. von Noorden GK. Indications of the posterior fixation operation in strabismus. Ophthalmology 1978;85:512-20. 3. SpragueJB, Moore S, Eggers H, Knapp P. Dissociated vertical deviation: treatment with faden operation of Ciippers. Arch Ophthalmol 1980;98:465-8. 4. Velez G. Dissociated vertical deviation. Graefes Arch Clin Exp Ophthatmol 1988;22:117-8.
5. Elliott R, Nankin SJ. Anterior transposition of the inferior oblique. J Pediatr Ophthalmol Strabismus 1981;18:35-8. 6. Kratz R, Rogers G, Bremer M, Leguire L. Anterior tendon displacement of the inferior oblique for DVD. J Pediatr Ophthalmoi Strabismus 1989;26:212-7. 7. Coats D, Paysee E, Sato M, Helveston EM. "A" pattern horizontal strabismus, dissociated vertical deviation and superior oblique overaction. In: Lennerstrand G, editor. Update on strabismus and pediatric ophthalmology.London: CRC Press. p. 380-4. 8. McCall L, Rosenbaum A. Incomitant dissociated vertical deviation and superior oblique overaction. Ophthalmology 1991;98:911-8.
A n Eye o n the Arts - T h e Arts o n the Eye
Explaining Blindness To A Child It is like m a n y nights growing seamlessly into one, it is like m a n y flames sliding into each other until they're one big fire, it is like colored wallpaper being slowly covered by India ink, it is like greasy soot blotting out the sparkling new snow, it is like a hundred black flies devouring a white piece of cheese, it is like a gleaming aluminum train being swallowed by a hungry tunnel, it is like bright birds in the zoo, buntings, canaries, parrots and snowy owls suddenly sprouting black feathers and becoming ravens, it is like the only T V in the world losing its screen, it is like the sun and the m o o n and all the stars collapsing into black holes in the sky... - - F e l i x Pollak (from Tunnel Visions [writings of a poet going blind]). Reprinted with permission of Spoon River Press.