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Combined superior oblique tuck and adjustable suture recession of the ipsilateral superior rectus for long-standing superior oblique palsy
Combined Superior Oblique Tuck and Adjustable Suture Recession of the Ipsilateral Superior Rectus for LongStanding Superior Oblique Palsy Martin S. Cogen, MD, and Benjamin W. Roberts, MD Purpose: Unilateral long-standing superior oblique palsy may lead to superior rectus overaction/contracture requiring surgery of multiple extraocular muscles to correct the hypertropia. We review our technique of tucking the superior oblique combined with immediate postoperative adjustable suture recession of the ipsilateral superior rectus. Methods: Twelve patients during the course of 2.5 years with longstanding vertical diplopia unrelated to closed head trauma or systemic disease who underwent our surgical technique were identified. The hypertropia in all patients was largest across the lower field (Knapp class 5) or nasal and lower fields (Knapp class 4). Outcome measures were primary-position hypertropia and vertical diplopia. Results: The mean preoperative hypertropia in primary gaze measured 17.8 PD (range, 4 to 30). The mean 2-week postoperative vertical deviation was 1.3 PD (range, 4 PD hypotropic to 6 PD hypertrophic). The mean 6-week postoperative vertical deviation was 1.9 PD (range, 2 PD hypotropic to 12 PD hypertrophic). Diplopia in primary and down gaze, which was universally present before surgery, resolved in 11 of the 12 patients (92%). Conclusions: This combination of procedures appears to be a highly successful choice for treatment of unilateral long-standing superior oblique palsy. Advantages for both patient and surgeon include adequate exposure through a single conjunctival incision, elimination of risks to the contralateral eye, and immediate intraoperative suture adjustment of the ipsilateral superior rectus. (J AAPOS 2003;7:195–199) uperior oblique palsy is the most common isolated palsy of an extraocular muscle that requires surgery.1-4 The most common signs and symptoms include hypertropia, extorsion of the involved eye, head tilt, and/or diplopia.3,5 This diagnosis is often made by initial observation of the patient and can be confirmed with measurements of the hypertropia in the diagnostic fields along with a positive Bielschowsky head-tilt test. The most common etiologies include congenital and idiopathic (63%). Closed-head trauma is the most common cause of acquired fourth-nerve palsy (34%). Other causes, including cerebrovascular disease, tumor, sinusitis, and myasthenia gravis, are rare (3%).4 Surgical treatment is
S
From the Department of Ophthalmology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama. Supported by an unrestricted grant from Research to Prevent Blindness and the Alabama Eye Institute. Presented at the American Association for Pediatric Ophthalmology and Strabismus Annual Meeting, Seattle, Washington, March 20 –24, 2002. Submitted May 25, 2002. Revision accepted February 3, 2003. Reprint requests: Martin S. Cogen, MD, 700 18th Street South, Suite 601, Birmingham, AL 35233. Copyright © 2003 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2003/$35.00 ⫹ 0 doi:10.1016/S1091-8531(03)00013-2
Journal of AAPOS
highly effective; success rates are 77% to 85%.4-6 Factors influencing the surgical plan include magnitude of hypertropia,3 bilaterality,4 anatomic status of the superior oblique tendon,2 torsion,6 and occupational and functional needs of the patient. Many strabismologists directly or indirectly still use Knapp’s classification for superior oblique palsy, described in 1974,3 which maps the pattern of deviation as measured by the prism and cover test in the 9 diagnostic positions of gaze. The cases presented in this report fall within Knapp class 4, where the deviation is largest along the nasal and lower fields (Figure 1), or Knapp class 5, where the deviation is largest across the lower field. We analyzed surgical treatment for patients with unilateral long-standing (⬎ 6 months’ duration) superior oblique palsy that was believed to be idiopathic or congenital in all but 2 cases. Similar patients have been described previously by Jampolsky and Scott7 in whom superior rectus overaction/contracture was associated with the long-standing superior oblique paresis. Aseff and Munoz1 more recently proposed weakening the ipsilateral superior rectus for such cases and combining this weakening with various other procedures for the superior oblique palsy. We review cases in which tucking the paretic superior oblique was combined with simultaneous weakening of the ipsilateral superior rectus using immediate postopJune 2003
195
196
Cogen and Roberts
Journal of AAPOS Volume 7 Number 3 June 2003
FIG 1. Diagnostic measurements of 1 patient (Knapp class 4) with long-standing right superior oblique palsy and secondary superior rectus contracture. RHT, right hypertropia; PD, prism diopters.
erative adjustable suture recession to successfully treat long-standing superior oblique palsy with spread of comitance where the deviation was greatest along the lower field. We started doing this technique because of our previous experience and disappointment with under-corrections in ipsilateral side gaze and down gaze associated with persistent diplopia (especially in the reading position) when just the lax superior oblique tendon was corrected. These previous patients achieved good results with a second procedure involving adjustable suture recession of the ipsilateral superior rectus.
METHODS We evaluated 12 consecutive patients who presented with long-standing unilateral superior oblique palsy and spread of comitance with evidence of ipsilateral superior rectus contracture treated by 1 surgeon (MSC) between April 1999 and July 2001. Inclusion criteria required no history of closed head trauma or underlying systemic disease known to be associated with superior oblique palsy. The duration of the palsy was ⬎ 6 months in all patients, and follow-up was required for at least 6 weeks after surgery. The chief complaint of “diplopia” was reported in each case. A complete eye examination was performed for each patient. This included visual acuity, refraction, slit lamp examination, and dilated fundus examination with specific attention to objective torsion. Motility examination included versions and ductions, prism and alternate cover testing in the diagnostic positions of gaze, and head tilt test. Forced ductions were performed at the time of surgery. Subjects included 10 male and 2 female patients with a mean age of 43 years (range, 13 to 73). Ten subjects were white, and 2 were African American. The etiology of the superior oblique palsy was believed to be idiopathic or congenital in 10 cases. One patient (no. 12) suffered direct injury to the superior oblique tendon after a knife injury to the superonasal orbit. In 1 patient (no. 2), the superior oblique palsy developed after retinal detachment repair with scleral buckle placement around the affected eye. All surgical procedures were performed under general anesthesia using comaintenance with subhypnotic but syn-
ergistic doses of intravenous propofol and midazolam. The technique has been previously described.8 Briefly; all patients received a standardized induction of midazolam (2 mg), fentanyl (100 g), and propofol (1.0 to 1.5 mg/kg). A laryngeal mask airway (LMA) was positioned, and patients spontaneously breathed 65% nitrous oxide and 35% oxygen. Anesthesia was maintained with a stepped-down infusion (10-minute intervals) of propofol at 167, 133, 100, and finally 50 g/kg/min. Patients also received a concurrent infusion of midazolam (1g/kg/min). Forced traction testing revealed a lax superior oblique tendon and tight superior rectus in all cases. The superior oblique was isolated temporal to the superior rectus through a superotemporal conjunctival fornix incision, and the lax tendon was placed on a tucking instrument, which was adjusted until the doubled-over tendon was moderately taut but not so tight as to indent the underlying sclera. The base of the tendon was then secured with 2 interlocking “figure-of-8” nonabsorbable 5-0 Mersilene (Ethicon, Somerville, NJ) sutures. Forced traction testing was then repeated superonasally, and the superior oblique tendon tuck was judged to be satisfactory if there was moderate limitation to elevation above the midline with the globe in the fully adducted position. The superior rectus was then placed on a suspension recession from its original insertion using a slipknot adjustable suture of absorbable 6-0 Vicryl (Ethicon) sutures. Five minutes before the end of surgery, topical tetracaine, 0.5%, was placed on the operative eye. At the completion of surgery, all anesthetic agents were stopped, and the LMA was removed. Five minutes later, the patients received 0.5 mg flumazenil, a benzodiazepine antagonist, reverse the midazolam. Adequate cognition and saccadic eye movements were believed to be the appropriate points at which to begin suture adjustment, and these were achieved within 10 minutes in all cases. The patients were then seated upright on the operating table and asked to focus on a 20/400 Snellen letter “E” on the far wall. Cover testing was performed, and the superior rectus was adjusted as necessary. The goal and end point of suture adjustment was orthophoria in primary gaze and relief of diplopia.
Journal of AAPOS Volume 7 Number 3 June 2003 TABLE 1. Patient data Patient Information Cause of SO palsy
Cogen and Roberts
Preop deviation
No. 1: 61 y, male
Congenital/idiopathic
RHT ⫽ 25
No. 2: 73 y, male
Scleral buckle
RHT ⫽ 25
No. 3: 37 y, male
Congenital/idiopathic
No. 4: 55 y, female
Congenital/idiopathic
RHT ⫽ 20, X⫽6 RHT ⫽ 12
No. 5: 54 y, male
Congenital/idiopathic
No. 6: 46 y, male
Congenital/idiopathic
No. 7: 13 y, female
Congenital/idiopathic
LHT ⫽ 4, X⫽2 RHT ⫽ 16, X ⫽ 14 LHT ⫽ 30
No. 8: 47 y, male
Congenital/idiopathic
RHT ⫽ 25
No. 9: 55 y, male
Congenital/idiopathic
No. 10: 15 y, male
Congenital/idiopathic
No. 11: 15 y, male
Congenital/idiopathic
RHT ⫽ 14, X ⫽ 10 LHT ⫽ 20, X ⫽ 8-10 LHT ⫽ 12
No. 12: 48 y, male
Knife injury
RHT ⫽ 10
Procedure Tuck RSO 8 mm, recess RSR 5 mm Tuck RSO 6 mm, recess RSR 9 mm Ruck RSO 10 mm, recess RSR 4 mm Tuck RSO 12 mm, Recess RSR 3 mm Tuck LSO 5 mm, recess LSR 2 mm Tuck RSO 10 mm, recess RSR 4 mm Tuck LSO 16 mm, recess LSR 3.5 mm Tuck RSO 14 mm, recess RSR 2 mm Tuck RSO 8 mm, recess RSR 4 mm Tuck LSO 12 mm, recess LSR 2 mm Tuck LSO 8 mm, recess LSR 2 mm Tuck RSO 6 mm, recess RSR 4 mm
197
OR alignment
2-wk postop
6-wk postop
Preop diplopia
Ortho
Ortho
Ortho
Yes
No
RHT ⫽ 2
RHT ⫽ 6
RHT ⫽ 12
Yes
Yes*
Ortho
RHT ⫽ 3
RHT ⫽ 3
Yes
No
Ortho
RHT ⫽ 2
Ortho
Yes
No
Ortho
L hypo ⫽ 4
Ortho
Yes
No
Ortho
X⫽6
X⫽8
Yes
No
Ortho
LH ⫽ 4
L hypo ⫽ 2
Yes
No
Ortho
RH ⫽ 4
RH ⫽ 4
Yes
No
Ortho
X⫽6
X⫽6
Yes
No
Ortho
X ⫽ 10
X ⫽ 10 LHT ⫽ 4 Ortho
Yes
No
Yes
No
Yes
No
Ortho
Ortho
Ortho
Ortho
—
Postop diplopia
SO, superior oblique; preop, preoperative; OR, operating room; postop, postoperative; RHT, right hypertropia; RSO, right superior oblique; RSR, right superior rectus; ORTHO, orthophoria; X, exotropia; LHT, left hypertropia; LSO, left superior oblique; LSR, left superior rectus; L hypo, left hypotropia; RH, right hyperphoria; LH, left hyperphoria.
Postoperative measurements were performed at 2 and at 6 weeks after surgery. The presence or absence of diplopia was recorded as was any abnormal head posture. Success was defined as (1) lack of diplopia in primary and down gaze and (2) elimination of torticollis.
RESULTS Table 1 lists the patient data. Preoperative hypertropia ranged from 4 to 30 PD (mean, 17.8) in primary gaze. The deviation increased along the lower field (Knapp class 5) or along the nasal and lower fields (Knapp class 4) in all patients. Two-week postoperative vertical deviation in primary gaze ranged from 4 PD hypotropic to 6 PD hypertrophic (mean, 1.3). Six-week postoperative vertical deviation in primary gaze ranged from 2 PD hypotropic to 4 PD hypertrophic (mean, 0.9) with the exception of 1 patient (no. 2) who had a deviation of 12 PD and required a second procedure to correct the diplopia. This patient could not be adjusted to orthotropic in the operating room despite maximum loosening of the superior rectus suture. The average amount of superior oblique tendon tuck measured 9.6 mm (range, 5 to 16). The average superior rectus recession measured 3.7 mm (range, 2 to 5 mm in all but case no. 2, who had a 9-mm recession). Compared with operating room alignment, vertical drift at 2 weeks wasⱕ 4 PD in all patients and at 6 weeks was ⱕ 4 PD in 90% (10 of 11) of the patients. One patient was unavailable for the 6-week measurement but was included in the 2-week data
(Figure 2). Torticollis resolved in all cases. Diplopia, which was universally present before surgery, resolved in 11 of the 12 cases (92%).
DISCUSSION A specific subsets of patients may benefit from a superior oblique tendon tuck combined with a simultaneous superior rectus recession on an adjustable suture. These include patients who have a long-standing superior oblique palsy with secondary superior rectus overaction or contracture. We have found this problem to be much more common than Aseff and Munoz1 suggested. They reported 6 cases after reviewing consecutive strabismus surgeries during the course of 8 years.1 We found 12 cases during the course of 2.5 years. The chronicity of the problem leads to hypertropia that is not limited to the field of the superior oblique. Nevertheless, in all 12 patients reviewed, the deviation was still greatest in the field of vertical action of the superior oblique. The etiology of the superior oblique palsy in all but 2 of our patients was believed to be of congenital or idiopathic etiology. Congenital superior oblique palsies have characteristic signs and symptoms,2 including early (often vague) onset, absence of specific inciting event, torticollis, facial asymmetry, underaction of superior oblique, large vertical fusional amplitudes, and head tilt for longer than 6 months. There was no history of closed head trauma nor evidence of systemic illness—including uncontrolled hy-
198
Cogen and Roberts
Journal of AAPOS Volume 7 Number 3 June 2003
FIG 2. Patients undergoing combined superior oblique tuck and adjustable suture superior rectus recession. Open squares represent operating room alignment immediately after suture adjustment. Closed circles represent 2-week postoperative alignment. Open triangles represent 6-week postoperative alignment. *Patient could not be adjusted to orthophoria and required a second procedure. **Patient unavailable after 2-week measurement.
pertension, diabetes, dysthyroidism, or myasthenia gravis—in any of these patients. One patient had a previous retinal detachment repaired with scleral buckle encircling band, and 1 patient suffered a knife injury to the upper lid with an unrepaired conjunctival laceration in the superonasal quadrant that probably resulted in unrecognized injury to the superior oblique tendon. Other surgical combinations have yielded satisfactory results, but these often require making a second surgical incision or operating on the contralateral eye. An example of this is ipsilateral superior rectus recession or inferior oblique weakening combined with contralateral inferior rectus recession.1 A second example is ipsilateral superior oblique tuck combined with contralateral inferior rectus recession. Either procedure requires operating on the normal eye to correct a problem of the paretic eye. Another possible complication is lower lid retraction, which may result from recessing the inferior rectus. On the other hand, with a superior oblique tuck and simultaneous superior rectus recession, both muscles can be isolated from the same conjunctival incision. The superior oblique tendon is tucked close to its insertion under the superior rectus. An adjustable suture is placed on the superior rectus and adjusted as necessary. With this procedure, the normal (contralateral) eye is not exposed to any risks. Iatrogenic Brown’s syndrome from tucking the superior oblique is a concern, but it rarely persists in patients with
congenital palsy in whom the tendon is usually abnormally lax. The two patients with injury near the superior oblique might be eliminated from this series, but they appear particularly instructive. As mentioned above, patient no. 2 had a postoperative deviation of 12 PD and required a second procedure to correct the diplopia. This patient had had a previous retinal detachment repaired with pars plana vitrectomy, lensectomy, and scleral buckle placement. A significant amount of scar tissue was found during the first strabismus surgery. This patient’s superior rectus was maximally loosened on the adjustable suture. The recession measured 9.0 mm posterior to the original insertion, at which point the sutures holding the muscle became slack, and the muscle would not slide further posterior. This was almost double the second-largest recession required in all other patients. Nevertheless, the patient had a residual hypertropia in the operating room, which only increased at the 2- and 6-week postoperative measurements. A subsequent recession of the ipsilateral inferior oblique decreased the vertical deviation to a phoria of 7 PD and resulted in relief of diplopia. Thus, it would appear that significant scarring around the superior oblique or superior rectus is a poor prognostic sign and may result in a lower success with our treatment strategy. Also, the need to adjust the patient’s intraoperative alignment to orthophoria seems apparent, and any residual
Journal of AAPOS Volume 7 Number 3 June 2003
Cogen and Roberts
hypertropia probably indicates a need for additional extraocular muscle surgery. In contrast, patient no. 12 sustained direct injury to the superior oblique but had minimal scarring. This patient adjusted to orthophoria with a more typical 4.0-mm recession of the superior rectus and behaved similarly to the congenital/idiopathic group. Therefore, direct trauma to the superior oblique is not necessarily a contraindication to this treatment strategy.
CONCLUSION
199
The need for temporary patching as well as the prolonged discomfort of long suture ends abrading the ocular surface are avoided, and extended time in the recovery room is eliminated. With a high rate of success, the procedure is convenient, comfortable, and includes the flexibility and precision required to achieve satisfactory binocular alignment and relief of diplopia. References
The subset of patients described in this article has a vertical deviation that cannot be corrected by operating on only 1 muscle. Tucking the superior oblique alone would greatly improve the hypertropia in its field of action, but this would not correct the hypertropia/diplopia in ipsilateral side gaze and down gaze caused by the chronic contracture of the superior rectus. Because a second muscle must be manipulated, choosing the ipsilateral superior rectus (1) eliminates risks and potential complications to the opposite eye by avoiding the normal contralateral yoke inferior rectus and (2) makes the surgery technically easier for both the patient and surgeon. Immediate postoperative adjustable suture techniques offer additional practical benefits. While the patient is still in the operating room, sterile conditions are easier to maintain, and ancillary personnel and surgical instruments are readily available.
1. Aseff AJ, Munoz M. Outcome of surgery for superior oblique palsy with contracture of ipsilateral superior rectus treated by superior rectus recession. Binocul Vis Strabismus Q 1998;13:177-80. 2. Flanders M, Draper J. Superior oblique palsy: diagnosis and treatment. Can J Ophthalmol 1990;25:17-24. 3. Helveston EM, Krach D, Plager DA, Ellis FD. A new classification of superior oblique palsy based on congenital variations in the tendon. Ophthalmology 1992;99:1609-15. 4. Jampolsky A, Scott AB. Ocular deviations. Int Ophthalmol Clin 1964; 4:675-701. 5. Knapp P. Classification and treatment of superior oblique palsy. Am Orthopt J 1974;24:18-22. 6. Metz HS, Lerner HL. The adjustable Harada-Ito procedure. Arch Ophthalmol 1981;99:624-6. 7. Noorden GK, Murray E, Wong SY. Superior oblique paralysis. Arch Ophthalmol 1986;104:1771-6. 8. Cogen MS, Guthrie ME, Vinik HR. The immediate postoperative adjustment of sutures in strabismus surgery with comaintenance of anesthesia using propofol and midazolam. J AAPOS 2002;6:241-5.
An Eye on the Arts – The Arts on the Eye
“ ‘O’ ” Lily reads. Then turns to Mercedes. “We’re almost there.” Mercedes knows only that her sister is being guided. She looks down into Lily’s eyes, and Lily feels her back open up like a book on either side of her spine, onto a dark and endless corridor full of something Mercedes craves. This is the look of Reverence. Like the look of Pity, it is frightening. But Lily has learned how to remain Lily while receiving such a look. She holds her eyes the way you might hold your arms when looking up at someone who is in danger of falling from a high place: still, steady, outstretched. This discourages the person from jumping and killing you both, for perhaps they just wanted to know there was someone waiting below to catch them. The way Lily looks when she calmly holds out her eyes in this manner is what the lookers of Pity and Reverence call “beatific”. ——Anne-Marie MacDonald (from Fall on Your Knees)
S
From the Department of Ophthalmology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama. Supported by an unrestricted grant from Research to Prevent Blindness and the Alabama Eye Institute. Presented at the American Association for Pediatric Ophthalmology and Strabismus Annual Meeting, Seattle, Washington, March 20 –24, 2002. Submitted May 25, 2002. Revision accepted February 3, 2003. Reprint requests: Martin S. Cogen, MD, 700 18th Street South, Suite 601, Birmingham, AL 35233. Copyright © 2003 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2003/$35.00 ⫹ 0 doi:10.1016/S1091-8531(03)00013-2
Journal of AAPOS
highly effective; success rates are 77% to 85%.4-6 Factors influencing the surgical plan include magnitude of hypertropia,3 bilaterality,4 anatomic status of the superior oblique tendon,2 torsion,6 and occupational and functional needs of the patient. Many strabismologists directly or indirectly still use Knapp’s classification for superior oblique palsy, described in 1974,3 which maps the pattern of deviation as measured by the prism and cover test in the 9 diagnostic positions of gaze. The cases presented in this report fall within Knapp class 4, where the deviation is largest along the nasal and lower fields (Figure 1), or Knapp class 5, where the deviation is largest across the lower field. We analyzed surgical treatment for patients with unilateral long-standing (⬎ 6 months’ duration) superior oblique palsy that was believed to be idiopathic or congenital in all but 2 cases. Similar patients have been described previously by Jampolsky and Scott7 in whom superior rectus overaction/contracture was associated with the long-standing superior oblique paresis. Aseff and Munoz1 more recently proposed weakening the ipsilateral superior rectus for such cases and combining this weakening with various other procedures for the superior oblique palsy. We review cases in which tucking the paretic superior oblique was combined with simultaneous weakening of the ipsilateral superior rectus using immediate postopJune 2003
195
196
Cogen and Roberts
Journal of AAPOS Volume 7 Number 3 June 2003
FIG 1. Diagnostic measurements of 1 patient (Knapp class 4) with long-standing right superior oblique palsy and secondary superior rectus contracture. RHT, right hypertropia; PD, prism diopters.
erative adjustable suture recession to successfully treat long-standing superior oblique palsy with spread of comitance where the deviation was greatest along the lower field. We started doing this technique because of our previous experience and disappointment with under-corrections in ipsilateral side gaze and down gaze associated with persistent diplopia (especially in the reading position) when just the lax superior oblique tendon was corrected. These previous patients achieved good results with a second procedure involving adjustable suture recession of the ipsilateral superior rectus.
METHODS We evaluated 12 consecutive patients who presented with long-standing unilateral superior oblique palsy and spread of comitance with evidence of ipsilateral superior rectus contracture treated by 1 surgeon (MSC) between April 1999 and July 2001. Inclusion criteria required no history of closed head trauma or underlying systemic disease known to be associated with superior oblique palsy. The duration of the palsy was ⬎ 6 months in all patients, and follow-up was required for at least 6 weeks after surgery. The chief complaint of “diplopia” was reported in each case. A complete eye examination was performed for each patient. This included visual acuity, refraction, slit lamp examination, and dilated fundus examination with specific attention to objective torsion. Motility examination included versions and ductions, prism and alternate cover testing in the diagnostic positions of gaze, and head tilt test. Forced ductions were performed at the time of surgery. Subjects included 10 male and 2 female patients with a mean age of 43 years (range, 13 to 73). Ten subjects were white, and 2 were African American. The etiology of the superior oblique palsy was believed to be idiopathic or congenital in 10 cases. One patient (no. 12) suffered direct injury to the superior oblique tendon after a knife injury to the superonasal orbit. In 1 patient (no. 2), the superior oblique palsy developed after retinal detachment repair with scleral buckle placement around the affected eye. All surgical procedures were performed under general anesthesia using comaintenance with subhypnotic but syn-
ergistic doses of intravenous propofol and midazolam. The technique has been previously described.8 Briefly; all patients received a standardized induction of midazolam (2 mg), fentanyl (100 g), and propofol (1.0 to 1.5 mg/kg). A laryngeal mask airway (LMA) was positioned, and patients spontaneously breathed 65% nitrous oxide and 35% oxygen. Anesthesia was maintained with a stepped-down infusion (10-minute intervals) of propofol at 167, 133, 100, and finally 50 g/kg/min. Patients also received a concurrent infusion of midazolam (1g/kg/min). Forced traction testing revealed a lax superior oblique tendon and tight superior rectus in all cases. The superior oblique was isolated temporal to the superior rectus through a superotemporal conjunctival fornix incision, and the lax tendon was placed on a tucking instrument, which was adjusted until the doubled-over tendon was moderately taut but not so tight as to indent the underlying sclera. The base of the tendon was then secured with 2 interlocking “figure-of-8” nonabsorbable 5-0 Mersilene (Ethicon, Somerville, NJ) sutures. Forced traction testing was then repeated superonasally, and the superior oblique tendon tuck was judged to be satisfactory if there was moderate limitation to elevation above the midline with the globe in the fully adducted position. The superior rectus was then placed on a suspension recession from its original insertion using a slipknot adjustable suture of absorbable 6-0 Vicryl (Ethicon) sutures. Five minutes before the end of surgery, topical tetracaine, 0.5%, was placed on the operative eye. At the completion of surgery, all anesthetic agents were stopped, and the LMA was removed. Five minutes later, the patients received 0.5 mg flumazenil, a benzodiazepine antagonist, reverse the midazolam. Adequate cognition and saccadic eye movements were believed to be the appropriate points at which to begin suture adjustment, and these were achieved within 10 minutes in all cases. The patients were then seated upright on the operating table and asked to focus on a 20/400 Snellen letter “E” on the far wall. Cover testing was performed, and the superior rectus was adjusted as necessary. The goal and end point of suture adjustment was orthophoria in primary gaze and relief of diplopia.
Journal of AAPOS Volume 7 Number 3 June 2003 TABLE 1. Patient data Patient Information Cause of SO palsy
Cogen and Roberts
Preop deviation
No. 1: 61 y, male
Congenital/idiopathic
RHT ⫽ 25
No. 2: 73 y, male
Scleral buckle
RHT ⫽ 25
No. 3: 37 y, male
Congenital/idiopathic
No. 4: 55 y, female
Congenital/idiopathic
RHT ⫽ 20, X⫽6 RHT ⫽ 12
No. 5: 54 y, male
Congenital/idiopathic
No. 6: 46 y, male
Congenital/idiopathic
No. 7: 13 y, female
Congenital/idiopathic
LHT ⫽ 4, X⫽2 RHT ⫽ 16, X ⫽ 14 LHT ⫽ 30
No. 8: 47 y, male
Congenital/idiopathic
RHT ⫽ 25
No. 9: 55 y, male
Congenital/idiopathic
No. 10: 15 y, male
Congenital/idiopathic
No. 11: 15 y, male
Congenital/idiopathic
RHT ⫽ 14, X ⫽ 10 LHT ⫽ 20, X ⫽ 8-10 LHT ⫽ 12
No. 12: 48 y, male
Knife injury
RHT ⫽ 10
Procedure Tuck RSO 8 mm, recess RSR 5 mm Tuck RSO 6 mm, recess RSR 9 mm Ruck RSO 10 mm, recess RSR 4 mm Tuck RSO 12 mm, Recess RSR 3 mm Tuck LSO 5 mm, recess LSR 2 mm Tuck RSO 10 mm, recess RSR 4 mm Tuck LSO 16 mm, recess LSR 3.5 mm Tuck RSO 14 mm, recess RSR 2 mm Tuck RSO 8 mm, recess RSR 4 mm Tuck LSO 12 mm, recess LSR 2 mm Tuck LSO 8 mm, recess LSR 2 mm Tuck RSO 6 mm, recess RSR 4 mm
197
OR alignment
2-wk postop
6-wk postop
Preop diplopia
Ortho
Ortho
Ortho
Yes
No
RHT ⫽ 2
RHT ⫽ 6
RHT ⫽ 12
Yes
Yes*
Ortho
RHT ⫽ 3
RHT ⫽ 3
Yes
No
Ortho
RHT ⫽ 2
Ortho
Yes
No
Ortho
L hypo ⫽ 4
Ortho
Yes
No
Ortho
X⫽6
X⫽8
Yes
No
Ortho
LH ⫽ 4
L hypo ⫽ 2
Yes
No
Ortho
RH ⫽ 4
RH ⫽ 4
Yes
No
Ortho
X⫽6
X⫽6
Yes
No
Ortho
X ⫽ 10
X ⫽ 10 LHT ⫽ 4 Ortho
Yes
No
Yes
No
Yes
No
Ortho
Ortho
Ortho
Ortho
—
Postop diplopia
SO, superior oblique; preop, preoperative; OR, operating room; postop, postoperative; RHT, right hypertropia; RSO, right superior oblique; RSR, right superior rectus; ORTHO, orthophoria; X, exotropia; LHT, left hypertropia; LSO, left superior oblique; LSR, left superior rectus; L hypo, left hypotropia; RH, right hyperphoria; LH, left hyperphoria.
Postoperative measurements were performed at 2 and at 6 weeks after surgery. The presence or absence of diplopia was recorded as was any abnormal head posture. Success was defined as (1) lack of diplopia in primary and down gaze and (2) elimination of torticollis.
RESULTS Table 1 lists the patient data. Preoperative hypertropia ranged from 4 to 30 PD (mean, 17.8) in primary gaze. The deviation increased along the lower field (Knapp class 5) or along the nasal and lower fields (Knapp class 4) in all patients. Two-week postoperative vertical deviation in primary gaze ranged from 4 PD hypotropic to 6 PD hypertrophic (mean, 1.3). Six-week postoperative vertical deviation in primary gaze ranged from 2 PD hypotropic to 4 PD hypertrophic (mean, 0.9) with the exception of 1 patient (no. 2) who had a deviation of 12 PD and required a second procedure to correct the diplopia. This patient could not be adjusted to orthotropic in the operating room despite maximum loosening of the superior rectus suture. The average amount of superior oblique tendon tuck measured 9.6 mm (range, 5 to 16). The average superior rectus recession measured 3.7 mm (range, 2 to 5 mm in all but case no. 2, who had a 9-mm recession). Compared with operating room alignment, vertical drift at 2 weeks wasⱕ 4 PD in all patients and at 6 weeks was ⱕ 4 PD in 90% (10 of 11) of the patients. One patient was unavailable for the 6-week measurement but was included in the 2-week data
(Figure 2). Torticollis resolved in all cases. Diplopia, which was universally present before surgery, resolved in 11 of the 12 cases (92%).
DISCUSSION A specific subsets of patients may benefit from a superior oblique tendon tuck combined with a simultaneous superior rectus recession on an adjustable suture. These include patients who have a long-standing superior oblique palsy with secondary superior rectus overaction or contracture. We have found this problem to be much more common than Aseff and Munoz1 suggested. They reported 6 cases after reviewing consecutive strabismus surgeries during the course of 8 years.1 We found 12 cases during the course of 2.5 years. The chronicity of the problem leads to hypertropia that is not limited to the field of the superior oblique. Nevertheless, in all 12 patients reviewed, the deviation was still greatest in the field of vertical action of the superior oblique. The etiology of the superior oblique palsy in all but 2 of our patients was believed to be of congenital or idiopathic etiology. Congenital superior oblique palsies have characteristic signs and symptoms,2 including early (often vague) onset, absence of specific inciting event, torticollis, facial asymmetry, underaction of superior oblique, large vertical fusional amplitudes, and head tilt for longer than 6 months. There was no history of closed head trauma nor evidence of systemic illness—including uncontrolled hy-
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FIG 2. Patients undergoing combined superior oblique tuck and adjustable suture superior rectus recession. Open squares represent operating room alignment immediately after suture adjustment. Closed circles represent 2-week postoperative alignment. Open triangles represent 6-week postoperative alignment. *Patient could not be adjusted to orthophoria and required a second procedure. **Patient unavailable after 2-week measurement.
pertension, diabetes, dysthyroidism, or myasthenia gravis—in any of these patients. One patient had a previous retinal detachment repaired with scleral buckle encircling band, and 1 patient suffered a knife injury to the upper lid with an unrepaired conjunctival laceration in the superonasal quadrant that probably resulted in unrecognized injury to the superior oblique tendon. Other surgical combinations have yielded satisfactory results, but these often require making a second surgical incision or operating on the contralateral eye. An example of this is ipsilateral superior rectus recession or inferior oblique weakening combined with contralateral inferior rectus recession.1 A second example is ipsilateral superior oblique tuck combined with contralateral inferior rectus recession. Either procedure requires operating on the normal eye to correct a problem of the paretic eye. Another possible complication is lower lid retraction, which may result from recessing the inferior rectus. On the other hand, with a superior oblique tuck and simultaneous superior rectus recession, both muscles can be isolated from the same conjunctival incision. The superior oblique tendon is tucked close to its insertion under the superior rectus. An adjustable suture is placed on the superior rectus and adjusted as necessary. With this procedure, the normal (contralateral) eye is not exposed to any risks. Iatrogenic Brown’s syndrome from tucking the superior oblique is a concern, but it rarely persists in patients with
congenital palsy in whom the tendon is usually abnormally lax. The two patients with injury near the superior oblique might be eliminated from this series, but they appear particularly instructive. As mentioned above, patient no. 2 had a postoperative deviation of 12 PD and required a second procedure to correct the diplopia. This patient had had a previous retinal detachment repaired with pars plana vitrectomy, lensectomy, and scleral buckle placement. A significant amount of scar tissue was found during the first strabismus surgery. This patient’s superior rectus was maximally loosened on the adjustable suture. The recession measured 9.0 mm posterior to the original insertion, at which point the sutures holding the muscle became slack, and the muscle would not slide further posterior. This was almost double the second-largest recession required in all other patients. Nevertheless, the patient had a residual hypertropia in the operating room, which only increased at the 2- and 6-week postoperative measurements. A subsequent recession of the ipsilateral inferior oblique decreased the vertical deviation to a phoria of 7 PD and resulted in relief of diplopia. Thus, it would appear that significant scarring around the superior oblique or superior rectus is a poor prognostic sign and may result in a lower success with our treatment strategy. Also, the need to adjust the patient’s intraoperative alignment to orthophoria seems apparent, and any residual
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hypertropia probably indicates a need for additional extraocular muscle surgery. In contrast, patient no. 12 sustained direct injury to the superior oblique but had minimal scarring. This patient adjusted to orthophoria with a more typical 4.0-mm recession of the superior rectus and behaved similarly to the congenital/idiopathic group. Therefore, direct trauma to the superior oblique is not necessarily a contraindication to this treatment strategy.
CONCLUSION
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The need for temporary patching as well as the prolonged discomfort of long suture ends abrading the ocular surface are avoided, and extended time in the recovery room is eliminated. With a high rate of success, the procedure is convenient, comfortable, and includes the flexibility and precision required to achieve satisfactory binocular alignment and relief of diplopia. References
The subset of patients described in this article has a vertical deviation that cannot be corrected by operating on only 1 muscle. Tucking the superior oblique alone would greatly improve the hypertropia in its field of action, but this would not correct the hypertropia/diplopia in ipsilateral side gaze and down gaze caused by the chronic contracture of the superior rectus. Because a second muscle must be manipulated, choosing the ipsilateral superior rectus (1) eliminates risks and potential complications to the opposite eye by avoiding the normal contralateral yoke inferior rectus and (2) makes the surgery technically easier for both the patient and surgeon. Immediate postoperative adjustable suture techniques offer additional practical benefits. While the patient is still in the operating room, sterile conditions are easier to maintain, and ancillary personnel and surgical instruments are readily available.
1. Aseff AJ, Munoz M. Outcome of surgery for superior oblique palsy with contracture of ipsilateral superior rectus treated by superior rectus recession. Binocul Vis Strabismus Q 1998;13:177-80. 2. Flanders M, Draper J. Superior oblique palsy: diagnosis and treatment. Can J Ophthalmol 1990;25:17-24. 3. Helveston EM, Krach D, Plager DA, Ellis FD. A new classification of superior oblique palsy based on congenital variations in the tendon. Ophthalmology 1992;99:1609-15. 4. Jampolsky A, Scott AB. Ocular deviations. Int Ophthalmol Clin 1964; 4:675-701. 5. Knapp P. Classification and treatment of superior oblique palsy. Am Orthopt J 1974;24:18-22. 6. Metz HS, Lerner HL. The adjustable Harada-Ito procedure. Arch Ophthalmol 1981;99:624-6. 7. Noorden GK, Murray E, Wong SY. Superior oblique paralysis. Arch Ophthalmol 1986;104:1771-6. 8. Cogen MS, Guthrie ME, Vinik HR. The immediate postoperative adjustment of sutures in strabismus surgery with comaintenance of anesthesia using propofol and midazolam. J AAPOS 2002;6:241-5.
An Eye on the Arts – The Arts on the Eye
“ ‘O’ ” Lily reads. Then turns to Mercedes. “We’re almost there.” Mercedes knows only that her sister is being guided. She looks down into Lily’s eyes, and Lily feels her back open up like a book on either side of her spine, onto a dark and endless corridor full of something Mercedes craves. This is the look of Reverence. Like the look of Pity, it is frightening. But Lily has learned how to remain Lily while receiving such a look. She holds her eyes the way you might hold your arms when looking up at someone who is in danger of falling from a high place: still, steady, outstretched. This discourages the person from jumping and killing you both, for perhaps they just wanted to know there was someone waiting below to catch them. The way Lily looks when she calmly holds out her eyes in this manner is what the lookers of Pity and Reverence call “beatific”. ——Anne-Marie MacDonald (from Fall on Your Knees)