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Rectus muscle resection in Graves' ophthalmopathy
Letters to the Editor MANAGEMENT OF PERSISTENT DIPLOPIA AFTER SURGICAL REPAIR OF ORBITAL FRACTURES To the Editor: I read with great interest the recent report by Loba and colleagues1 describing management strategies to treat persistent diplopia in patients after surgical repair of orbital fractures. A subset of the study patients had inferior rectus muscle restriction confirmed by forced duction testing (second and fourth groups in the study). I am curious whether these patients had postoperative orbital radiography after their orbital fracture repairs? It is plausible that either the fracture repair was suboptimal with persistent herniation or entrapment of orbital soft tissues into the maxillary sinus or the patient developed iatrogenic entrapment of orbital soft tissues due to the reconstruction implant used to recreate the orbital floor. To rule out these accepted possibilities, these patients should have been evaluated with orbital imaging. If either was confirmed, I would contend that reoperation to remove the orbital implant and replacement with a properly positioned implant would represent the surgical treatment of choice before any strabismus procedure be considered. Roman Shinder, MD SUNY Downstate Medical Center, Brooklyn, New York Reference 1. Loba P, Kozakiewicz M, Nowakowska O, Omulecki W, BroniarczykLoba A. Management of persistent diplopia after surgical repair of orbital fractures. J AAPOS 2012;16:548-53. http://dx.doi.org/10.1016/j.jaapos.2013.03.024 J AAPOS 2013;17:561. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
REPLY To the Editor: We would like to thank Dr. Shinder for his interest in our article,1 in which we present a subgroup of patients with restricted ocular motility that persists after otherwise successful reconstruction surgery for orbital fracture. We agree that in such cases computed tomography and possibly modifying the implant should be the first consideration before eye muscle surgery. Our patients, however, were recruited from those referred to the Strabismus Outpatient Clinic because of diplopia and abnormal ocular motility after surgery. It may not be adequately stressed in the paper, but those patients were disqualified from further maxillofacial procedures. Such decisions are usually facilitated by checking the implant position by means of computed tomography. On the other hand, we do not routinely perform postoperative orbital radiography and reserve it solely for
Journal of AAPOS
cases with no evident improvement after reconstructive surgery. Additionally, it should be noted that improper implant positioning or persistent herniation or entrapment of orbital soft tissues are not always the underlying cause of limited supraduction. Especially in patients with concomitant restriction and paresis of the inferior rectus muscle (group D in our study) ocular motility impairment may result from muscle fibrosis, adhesions or ischemic contracture.2-4 Piotr Loba, MD Department of Ophthalmology, Medical University of Lodz Sienkiewicza 59/4, 90-009 Lodz, Poland References 1. Loba P, Kozakiewicz M, Nowakowska O, Omulecki W, BroniarczykLoba A. Management of persistent diplopia after surgical repair of orbital fractures. J AAPOS 2012;16:548-53. 2. Seiff SR, Good WV. Hypertropia and the posterior blowout fracture: mechanism and management. Ophthalmology 1996;103:152-6. 3. Hosal BM, Beatty RL. Diplopia and enophthalmos after surgical repair of blow-out fracture. Orbit 2002;21:27-33. 4. Smith B, Lisman RD, Simonton J, Della Rocca R. Volkmann’s contracture of the extraocular muscles following blowout fracture. Plast Reconstr Surg 1984;74:200-216. http://dx.doi.org/10.1016/j.jaapos.2013.07.005 J AAPOS 2013;17:561. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
RECTUS MUSCLE RESECTION IN GRAVES’ OPHTHALMOPATHY To the Editor: We thank Yoo and colleagues1 for sharing their experience of rectus muscle resection in Graves’ ophthalmopathy. In this series, 9 patients with Graves’ ophthalmopathy were successfully treated using rectus muscle resections as part of the surgical plan without unusual inflammation, increased restriction, or an overcorrection. However, there was little information about how to approach the resection. We would like to add information on the resection itself. We performed an additional rectus muscle resection for the residual deviation in 12 patients (7 males) with restrictive strabismus associated with Graves’ ophthalmopathy; the result was published in Chinese in 2010.2 The mean age was 47.3 8.0 years (range, 39-64). Of the 12 patients, 10 (83.3%) had a history of orbital decompression. For the involved agonist and antagonist muscles, the preoperative ocular duction ranged from 1 to 3 (using a standard 4-point scale), and the intraoperative passive forced duction test was mild to moderate. Nine patients underwent 1 or more muscle recession surgeries before the resection, and 3 patients underwent resection as part of the first muscle surgery. Seven patients underwent resection of the lateral rectus muscle (3 underwent unilateral surgery and
561
562
Letters to the Editor
4 bilateral surgery); the initial horizontal deviation angle was 51.0 9.6D (range, 38D-64D). Two patients underwent resection and advancement of the medial rectus muscle, and 1 of them underwent resection for a 25D consecutive exotropia. Three other patients underwent resection of the superior rectus muscle. The initial vertical deviation was 40.5 14.5D (range, 30D-62D). Our surgical procedure involved recessing the muscle, the adjacent fibrotic tissue, and the conjunctiva to the position of the passive forced duction test being free (as Del Canto and colleagues3 called the “intraoperative relaxed muscle positioning technique”). We then performed resection of the antagonist muscle for 4–6 mm if the eyeball position was not centralized. The resected muscle was sutured back to the original insertion after confirming the passive forced duction to be free. Adjustable suture was left on the resected muscle, and the adjustment could be performed immediately after the surgery or on the next day. The postoperative medication included topical antibiotics and steroids; no peribulbar or systemic steroids were administered. There was no unusual postoperative inflammation. Mildly decreased rotation was noted in 1 patient, and no increased restriction was observed in the others. The mean follow-up was 28.0 20.1 months (range, 4-66). At the final visit, all except 2 patients achieved fusion with or without prism glasses in the minimal abnormal head posture, which was easily tolerated by the patients. The patient with consecutive exotropia complained of persistent diplopia, which might be due to a 9D residual exotropia immediately after resection and advancement progressed to 20D six months later. The other patient made a satisfactory recovery following right inferior rectus recession and right superior rectus resection until 1 year later, when the right hypertropia (left hypotropia) recurred. Strabismus correction is still challenging in dysthyroid ophthalmopathy in terms of the surgical procedure and dosing. Extraocular muscle recession may successfully correct strabismus in most patients with Graves’ ophthalmopathy. For some patients with residual deviation and mild to moderate muscle fibrosis, additional resection might be beneficial. Meng-Ling Yang, MD Ling-Yuh Kao, MD Department of Ophthalmology, Chung-Gung Memorial Hospital, Tau-Yuan, Taiwan References 1. Yoo SH, Pineles SL, Goldberg RA, Velez FG. Rectus muscle resection in Graves’ ophthalmopathy. J AAPOS 2013;17:9-15. 2. Cheng HC, Lai HC, Kao LY, et al. Extraocular muscle resection for strabismus correction in dysthyroid ophthalmopathy. Acta Soc Ophthalmol Sinicae 2010;49:337-42. 3. Del Canto AJ, Crowe S, Perry JD, Traboulsi EI. Intraoperative relaxed muscle positioning technique for strabismus repair in thyroid eye disease. Ophthalmology 2006;113:2324-30.
Volume 17 Number 5 / October 2013 http://dx.doi.org/10.1016/j.jaapos.2013.03.025 J AAPOS 2013;17:561-562. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
REPLY We thank Dr. Yang and Dr. Kao for their comments on our article. We agree that strabismus surgery for patients with thyroid ophthalmopathy can be challenging, and in some patients extraocular muscle resection may be beneficial to the patient with the precautions discussed in our article. Their results on 12 patients with thyroid-associated strabismus who underwent extraocular muscle resection can be compared with those in our article. In both reports, most patients had undergone orbital decompression before strabismus surgery. In our article, half of the patients had undergone prior strabismus surgery with extraocular muscle recession, whereas in the work by Dr. Yang, most patients had undergone prior extraocular muscle recession and 3 underwent extraocular muscle resection as their first strabismus surgery. The lateral rectus muscle was the most frequently resected in both reports. Our study discussed the resected lateral rectus muscles being of relatively normal size on imaging available for 4 patients possibly being a factor in considering extraocular muscle resection in thyroid ophthalmopathy patients. As the lateral and superior rectus muscles are the least commonly involved muscles, this may also have been a factor in the outcome of the 10 patients who underwent resection of the lateral and superior rectus muscles in the group of Dr. Yang, although the authors did not mention imaging. Dr. Yang and Dr. Kao discussed their surgical technique for thyroid ophthalmopathy patients undergoing extraocular muscle resection. In our study, 4 different strabismus specialists performed the surgeries; thus there were small variations in technique. However, important considerations and concepts of strabismus surgery in thyroid ophthalmopathy patients and in the adjustable suture technique were based on notes from Clinical Strabismus Management: Principles and Surgical Techniques, edited by Dr. Arthur Rosenbaum and Dr. Alvina Santiago.1,2 Overall, the patients of Dr. Yang achieved good results with no unusual postoperative inflammation on topical steroids, mildly decreased rotations in 1 patient, and fusion in 10 patients at the final follow-up visit. Our patients also had no unusual postoperative inflammation and no increased restriction of the resected muscle or unanticipated decreased ocular rotations, with most patients orthotropic at their final follow-up visit. Sylvia H. Yoo, MD Stacy L. Pineles, MD Robert A. Goldberg, MD Federico G. Velez, MD Jules Stein Eye Institute, UCLA, Los Angeles, California
Journal of AAPOS
REPLY To the Editor: We would like to thank Dr. Shinder for his interest in our article,1 in which we present a subgroup of patients with restricted ocular motility that persists after otherwise successful reconstruction surgery for orbital fracture. We agree that in such cases computed tomography and possibly modifying the implant should be the first consideration before eye muscle surgery. Our patients, however, were recruited from those referred to the Strabismus Outpatient Clinic because of diplopia and abnormal ocular motility after surgery. It may not be adequately stressed in the paper, but those patients were disqualified from further maxillofacial procedures. Such decisions are usually facilitated by checking the implant position by means of computed tomography. On the other hand, we do not routinely perform postoperative orbital radiography and reserve it solely for
Journal of AAPOS
cases with no evident improvement after reconstructive surgery. Additionally, it should be noted that improper implant positioning or persistent herniation or entrapment of orbital soft tissues are not always the underlying cause of limited supraduction. Especially in patients with concomitant restriction and paresis of the inferior rectus muscle (group D in our study) ocular motility impairment may result from muscle fibrosis, adhesions or ischemic contracture.2-4 Piotr Loba, MD Department of Ophthalmology, Medical University of Lodz Sienkiewicza 59/4, 90-009 Lodz, Poland References 1. Loba P, Kozakiewicz M, Nowakowska O, Omulecki W, BroniarczykLoba A. Management of persistent diplopia after surgical repair of orbital fractures. J AAPOS 2012;16:548-53. 2. Seiff SR, Good WV. Hypertropia and the posterior blowout fracture: mechanism and management. Ophthalmology 1996;103:152-6. 3. Hosal BM, Beatty RL. Diplopia and enophthalmos after surgical repair of blow-out fracture. Orbit 2002;21:27-33. 4. Smith B, Lisman RD, Simonton J, Della Rocca R. Volkmann’s contracture of the extraocular muscles following blowout fracture. Plast Reconstr Surg 1984;74:200-216. http://dx.doi.org/10.1016/j.jaapos.2013.07.005 J AAPOS 2013;17:561. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
RECTUS MUSCLE RESECTION IN GRAVES’ OPHTHALMOPATHY To the Editor: We thank Yoo and colleagues1 for sharing their experience of rectus muscle resection in Graves’ ophthalmopathy. In this series, 9 patients with Graves’ ophthalmopathy were successfully treated using rectus muscle resections as part of the surgical plan without unusual inflammation, increased restriction, or an overcorrection. However, there was little information about how to approach the resection. We would like to add information on the resection itself. We performed an additional rectus muscle resection for the residual deviation in 12 patients (7 males) with restrictive strabismus associated with Graves’ ophthalmopathy; the result was published in Chinese in 2010.2 The mean age was 47.3 8.0 years (range, 39-64). Of the 12 patients, 10 (83.3%) had a history of orbital decompression. For the involved agonist and antagonist muscles, the preoperative ocular duction ranged from 1 to 3 (using a standard 4-point scale), and the intraoperative passive forced duction test was mild to moderate. Nine patients underwent 1 or more muscle recession surgeries before the resection, and 3 patients underwent resection as part of the first muscle surgery. Seven patients underwent resection of the lateral rectus muscle (3 underwent unilateral surgery and
561
562
Letters to the Editor
4 bilateral surgery); the initial horizontal deviation angle was 51.0 9.6D (range, 38D-64D). Two patients underwent resection and advancement of the medial rectus muscle, and 1 of them underwent resection for a 25D consecutive exotropia. Three other patients underwent resection of the superior rectus muscle. The initial vertical deviation was 40.5 14.5D (range, 30D-62D). Our surgical procedure involved recessing the muscle, the adjacent fibrotic tissue, and the conjunctiva to the position of the passive forced duction test being free (as Del Canto and colleagues3 called the “intraoperative relaxed muscle positioning technique”). We then performed resection of the antagonist muscle for 4–6 mm if the eyeball position was not centralized. The resected muscle was sutured back to the original insertion after confirming the passive forced duction to be free. Adjustable suture was left on the resected muscle, and the adjustment could be performed immediately after the surgery or on the next day. The postoperative medication included topical antibiotics and steroids; no peribulbar or systemic steroids were administered. There was no unusual postoperative inflammation. Mildly decreased rotation was noted in 1 patient, and no increased restriction was observed in the others. The mean follow-up was 28.0 20.1 months (range, 4-66). At the final visit, all except 2 patients achieved fusion with or without prism glasses in the minimal abnormal head posture, which was easily tolerated by the patients. The patient with consecutive exotropia complained of persistent diplopia, which might be due to a 9D residual exotropia immediately after resection and advancement progressed to 20D six months later. The other patient made a satisfactory recovery following right inferior rectus recession and right superior rectus resection until 1 year later, when the right hypertropia (left hypotropia) recurred. Strabismus correction is still challenging in dysthyroid ophthalmopathy in terms of the surgical procedure and dosing. Extraocular muscle recession may successfully correct strabismus in most patients with Graves’ ophthalmopathy. For some patients with residual deviation and mild to moderate muscle fibrosis, additional resection might be beneficial. Meng-Ling Yang, MD Ling-Yuh Kao, MD Department of Ophthalmology, Chung-Gung Memorial Hospital, Tau-Yuan, Taiwan References 1. Yoo SH, Pineles SL, Goldberg RA, Velez FG. Rectus muscle resection in Graves’ ophthalmopathy. J AAPOS 2013;17:9-15. 2. Cheng HC, Lai HC, Kao LY, et al. Extraocular muscle resection for strabismus correction in dysthyroid ophthalmopathy. Acta Soc Ophthalmol Sinicae 2010;49:337-42. 3. Del Canto AJ, Crowe S, Perry JD, Traboulsi EI. Intraoperative relaxed muscle positioning technique for strabismus repair in thyroid eye disease. Ophthalmology 2006;113:2324-30.
Volume 17 Number 5 / October 2013 http://dx.doi.org/10.1016/j.jaapos.2013.03.025 J AAPOS 2013;17:561-562. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
REPLY We thank Dr. Yang and Dr. Kao for their comments on our article. We agree that strabismus surgery for patients with thyroid ophthalmopathy can be challenging, and in some patients extraocular muscle resection may be beneficial to the patient with the precautions discussed in our article. Their results on 12 patients with thyroid-associated strabismus who underwent extraocular muscle resection can be compared with those in our article. In both reports, most patients had undergone orbital decompression before strabismus surgery. In our article, half of the patients had undergone prior strabismus surgery with extraocular muscle recession, whereas in the work by Dr. Yang, most patients had undergone prior extraocular muscle recession and 3 underwent extraocular muscle resection as their first strabismus surgery. The lateral rectus muscle was the most frequently resected in both reports. Our study discussed the resected lateral rectus muscles being of relatively normal size on imaging available for 4 patients possibly being a factor in considering extraocular muscle resection in thyroid ophthalmopathy patients. As the lateral and superior rectus muscles are the least commonly involved muscles, this may also have been a factor in the outcome of the 10 patients who underwent resection of the lateral and superior rectus muscles in the group of Dr. Yang, although the authors did not mention imaging. Dr. Yang and Dr. Kao discussed their surgical technique for thyroid ophthalmopathy patients undergoing extraocular muscle resection. In our study, 4 different strabismus specialists performed the surgeries; thus there were small variations in technique. However, important considerations and concepts of strabismus surgery in thyroid ophthalmopathy patients and in the adjustable suture technique were based on notes from Clinical Strabismus Management: Principles and Surgical Techniques, edited by Dr. Arthur Rosenbaum and Dr. Alvina Santiago.1,2 Overall, the patients of Dr. Yang achieved good results with no unusual postoperative inflammation on topical steroids, mildly decreased rotations in 1 patient, and fusion in 10 patients at the final follow-up visit. Our patients also had no unusual postoperative inflammation and no increased restriction of the resected muscle or unanticipated decreased ocular rotations, with most patients orthotropic at their final follow-up visit. Sylvia H. Yoo, MD Stacy L. Pineles, MD Robert A. Goldberg, MD Federico G. Velez, MD Jules Stein Eye Institute, UCLA, Los Angeles, California
Journal of AAPOS