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Temporal Transplantation Of The Inferior Rectus Muscle In V-Esotropia*
TRAUMA AND RETINAL DETACHMENT
919
REFERENCES
1. Duke-Elder, S.: Textbook of Ophthalmology. London, Kimpton, 1954, v. 6, p. 58S7. 2. Gros: Dissertation. Giessen, 1903. 3. Casey, W.: A System of Ophthalmic Operations. Chicago, Cleveland Press, 1911. 4. Herrmann: Dissertation. Leipzig, 1906. 5. Knapp, A.: Retinal detachment and trauma. Arch. Ophth., 30:770, 1943. 6. Gonin, J.: Le décollement de la rétine. Arch, ophtal., 51:426, 1934. 7. Shapland: Tr. Ophth. Soc. U. Kingdom, 54:176, 1934. 8. Leber, T.: Die Krankheiten der Netzhaut. In Graefe-Saemisch Handb. Augenh., Leipzig, 1916, v. 7, pt. 2, p. 1374. 9. Dunnington, J. H., and Macnie, J. P.: Detachment of the retina; operative results in ISO cases. Arch. Ophth., 13:191, 1935. 10. Arruga, H. : Reports Internat. Cong. Ophth. Madrid, 1933, v. 2, p. 5. 11. Fanta, H.: Detachment of the retina and trauma. Klin. Monatsbl. Augenh., 105:30, 1940. 12. Gastheiger, H.: Retinal detachment and trauma, Klin. Monatsbl. Augenh., 126:513, 1955. 13. Teng, C. C, and Chi, H. H.: Vitreous changes and the mechanism of retinal detachment. Am. J. Ophth, 44:335, 1957. 14. Sedan, J.: Traumatic detachments and myopia. Ann. Ocul., 33:175, 1959. 15. Dreifus, M., et al.: Post-traumatic retinal detachment treated at the 2nd. Eye Clinic of Charles University in Prague in the period 1945-1957. Cheko. Oftal. Praha, 62:221, 1959.
TEMPORAL TRANSPLANTATION OF THE INFERIOR RECTUS MUSCLE IN V-ESOTROPIA* G U N T E R K.
VON NOORDEN,
M.D.
Baltimore, Maryland The ophthalmologist has become increas ingly aware of the occurrence of vertical incomitancies. Measurement of ocular devia tions in the straight up and downward posi tions of gaze should be incorporated into the diagnostic evaluation of a strabismic patient. However, once the diagnosis of a vertical incomitancy has been established confusion exists as to which muscle or muscle group should be attacked surgically. This confu sion is by no means lessened by the recom mendations from three schools of thought regarding the etiology of A and V syn dromes, each group of authors attaching the blame to a different group of muscles, and accordingly, suggesting a different surgical approach. It would seem that each method of sur* From the Department of Ophthalmology, Col lege of Medicine, State University of Iowa. This study was supported by a Public Health Service Research Career Development Award (NB-K316108) from the National Institute of Neurological Diseases and Blindness.
gical management, whether it consists of sur gery on the horizontal, 1 vertical, 2 or oblique 3 muscles, may have its merits in a particular situation, and I would disagree only with too rigid an application of one surgical prin ciple to all cases presenting one of the ver tical incomitance syndromes. In V-esotropia with marked overaction of the inferior oblique muscles, a weakening procedure on the latter has in our experience . frequently resulted in an increase of the de viation in upward gaze, thus restoring ver tical comitance, and rendering the condition amenable to subsequent horizontal surgery. Little is gained, however, from weakening the inferior oblique muscles when overaction is only slight, or not demonstrable at all, and a different surgical approach seems advisa ble. Miller 4 demonstrated that lateral trans plantation of the inferior rectus muscles aug ments abduction in downward gaze. W e have employed this technique in nine cases
GUNTER K. VON NOORDEN
920
with V-esotropia without significant overaction of the inferior obliques and the results are reported in this paper. TECHNIQUE
The operation was performed on both eyes. After exposure of the inferior rectus tendon, two single armed 4-0 mild chromic catgut sutures were placed and locked at the medial and lateral edge of the tendon, close to its scierai insertion. After detachment of the tendon from the globe its medial edge was attached to the sciera near the lateral aspect of the original insertion. T h e lateral edge of the tendon was sutured to the sciera 9.0 to 10 mm. further laterally, which is ap proximately one breadth of its normal in sertion. The distance between the medial and lateral edges of the tendon and the limbus was measured prior to detachment, and spe cial care was taken to perform reattachment according to these measurements, since the lateral end of the insertion was always found to be farther from the limbus than the medial one. In Case 2 this procedure was combined with a two-mm. advancement of the inferior rectus muscle in the right, and a one-mm. recession in the left eye, to coun teract a right hypertropia. In Case 8 the in ferior rectus muscle of the right eye was recessed two mm. for a left hypertropia. MATERIAL
The patients were between five and 12 years of age. All had a V-esotropia. The difference between measurements in straight up and downward positions ranged between 16 and 50 prism diopters. Measurements were obtained with either eye fixing by the prism and cover test at 33 cm. in the pri mary position, and in the positions of 35degrees elevation and 40-degrees depression. If glasses reduced the angle of squint sig nificantly the pre- and postoperative measure ments were obtained with correction. Distant measurements were never less and, in all but one case, more than 16 prism diopters of esotropia in the primary position. Only one
patient (Case 9) had previous surgery. This girl was originally exotropic and had a re section of the medial and a recession of the lateral rectus muscle in one eye. Subse quently the child developed a V-esotropia. T h e procedure was limited to a group of patients who had little or no overaction of the inferior oblique muscles. T h e purpose was to affect and reduce the deviation main ly in the downward position of gaze, rather than to make the patient more esotropic in up ward gaze by a weakening procedure on the obliques. Another indication was a small an gle esotropia, or no shift in upward gaze, and a relatively large deviation in primary position and downward gaze (Cases 1, 6, 8 and 9 ) . It was felt that horizontal surgery in such a situation may have fostered the danger of overcorrection in upward gaze, and in the instance of Case 9, also in pri mary position, while a reduction of the an gle in downward gaze would increase the chances for binocularity. R E S U L T S AND C O M M E N T S
T h e postoperative results demonstrate a significant reduction of the horizontal devia tion in downward gaze in all patients (fig. 1 ) . T h e improvement was at least 10 prism diopters, amounted to more in most in stances, and measured maximally 31 prism diopters (Case 5 ) . It is of particular interest that in all ex cept one patient (Case 7 ) , the primary posi tion was also favorably influenced by sur gery, and that in three examples (Cases 3, 5 and 9) the esotropia was reduced at least 10 prism diopters in upward gaze. Case 3 is exceptional, inasmuch as the deviation im proved more in the primary position than in downward gaze. An increase of esotropia in upward gaze was noted in three patients (Cases 1, 4 and 7 ) . All but one patient (Case 4 ) were cosmetically improved. Al terations in the size of the lid fissures were not observed. Functional improvement, con sisting of momentary fusion at near and amplitudes with peripheral ( G r a d e 2) tar-
TRANSPLANTATION OF INFERIOR RECTUS MUSCLE
921
MEASUREMENTS OF DEVIATION BEFORE AND AFTER SURGERY
Case 1
Up: Prim. Pos.: Down:
Pre-op
Post-op
Change in ET
Mos. after Surgery
no shift 35 ET 50 ET
14 ET, 3 LHT 16 ET, 4 LHT 32 ET
+14 -19 -18
9
Il ET 20 ET 40 ET, 5 RHT
10 ET 14 ET 18 ET
-1 -6 -22
4
20 ET, 9 LHT 35 ET 40 ET, 4 LHT
9 ET, 10 LHT 14 ET, 9 LHT 30 ET, 10 LHT
-Il -21 -10
12
16 ET, 3 LHT 36 ET, 5 RHT 50 ET
20 ET, 9 RHT 25 ET, 6 RHT 40 ET, 5 RHT
+4 -Il -10
4
18 ET 30 ET, 3 LHT 38 ET
3 LH 12 ET, 4 LHT 7 ET
-18 -18 -31
2.5
8 ET 24 ET 36 ET
no shift 8 ET
3
8ET
-8 -16 -28
10 ET, 5 RHT 16 ET, 6 RHT 45 ET
16 ET 18 ET 30 ET
+6 +2 -15
16
9 ET 18 ET, 3 LHT 25 ET
5E 9 ET, 2 LH 10 ET, 4 LH
-4 -9 -15
12
no shift 10 ET, 3 RHT 16 ET, 2 RHT
10 X 7 X , 4 LH 8 X , 10 LH
-10 -17 -24
3
Case 2
Up: Prim. Pos.: Down: Case 3
Up: Prim. Pos.: Down: Case 4
Up: Prim. Pos.: Down: Case 5
Up: Prim. Pos.: Down: Case 6
Up: Prim. Pos.: Down: Case 7
Up: Prim. Pos.: Down: Case 8
Up: Prim. Pos.: Down: Case 9 .
Up: Prim. Pos.: Down:
Fig. 1 (von Noorden). Measurements of deviation before and after surgery.
gets, was achieved in two (Cases 2 and 8 ) , and functional cure with full binocularity and stereopsis in one instance (Case 9). When, as in Cases 2 and 8 the temporal
transplantation of the inferior rectus mus cles was combined with a recession and ad vancement for hypertropia, the vertical de viation was eliminated (Case 2) or im-
922
GUNTER K. VON NOORDEN
proved (Case 8 ) . A number of patients will have, or have had additional surgery on the horizontal rectus or oblique muscles for functional reasons. Miller 4 advocates combined vertical and horizontal rectus surgery, and states that the effect of temporal transplantation of the in ferior rectus muscles would be enhanced by a simultaneously performed weakening or strengthening procedure on the horizontal adductors and abductors. Be this as it may, we have not followed this advice because we were primarily interested to learn what ef fect the isolated procedure may have, rather than to obscure the result by additional sur gery to which all, or none of the results may be ascribed. While the data presented in this study may not demonstrate perfect results in all
cases, the improvement is, nevertheless, sig nificant. It is quite possible that more effec tive surgical approaches to V-esotropia will be developed. Time and comparison of re sults will eventually indicate which is the best procedure for a given situation in this confusing entity. SUMMARY
Temporal transplantation of the inferior rectus muscles was performed in nine pa tients with V-esotropia. The operation is effective in significantly reducing the verti cal incomitancy in this condition, and may also improve esotropia in the primary posi tion and upward gaze. Wihner Institute, Johns Hopkins Hospital
(5).
REFERENCES
1. Urist, M. J.: Horizontal squint with secondary vertical deviations. AMA Arch. Ophth., 46:245-267, 1951. 2. Brown, H. W.: Cited in Strabismus Ophthalmic Symposium. (Edited by J. H. Allen.) St. Louis, Mosby, 1950, v. 2, p. 241-243. 3. Jampolsky, A.: Bilateral anomalies of the oblique muscles. Tr. Am. Acad. Ophth., 61:689-700, 1957. 4. Miller, J. E.: Vertical recti transplantation in the A and V syndromes. AMA Arch. Ophth., 64:175179, 1960.
S E P A R A T I O N D I F F I C U L T Y IN G I O V A N N I M A R A I N I , M.D.,
L U I G I P A S I N O , M.D.,
AMBLYOPIA* AND SERGIO P E R A L T A ,
M.D.
Parma, Italy The crowding phenomenon, known as separation difficulty in the European litera ture, is one of the most typical symptoms of strabismic amblyopia and has been univer sally accepted since the early work of Bangerter 1 and Müller. 2 One could in effect consider the amblyopic eye as having two different visual acuities when tested with single letters or when examined on a row of symbols. A better understanding of this peculiar phenomenon may improve further our knowledge of the basic physiopathology * From the University Eye Clinic (Director: Prof. Dr. P. Matteucci).
of strabismic amblyopia. Separation diffi culty is an important and interesting aspect of this disease. Several points regarding it are still unsolved: 1. Whether it is a symptom peculiar to strabismic amblyopia (Müller 2 ) or whether it is present also in normal persons (Adler, 3 Ehlers, 4 De Jaeger, 5 Thomas-Decortis, 6 Stu art and Burian 7 ) and in other types of func tional amblyopia (Bagolini 8 ). 2. Whether this phenomenon is limited to about 50 percent of the cases (Erich 9 Mackensen 1 0 ) and particularly to those with eccentric fixation ( C u p p e r s 1 1 ) , or whether
919
REFERENCES
1. Duke-Elder, S.: Textbook of Ophthalmology. London, Kimpton, 1954, v. 6, p. 58S7. 2. Gros: Dissertation. Giessen, 1903. 3. Casey, W.: A System of Ophthalmic Operations. Chicago, Cleveland Press, 1911. 4. Herrmann: Dissertation. Leipzig, 1906. 5. Knapp, A.: Retinal detachment and trauma. Arch. Ophth., 30:770, 1943. 6. Gonin, J.: Le décollement de la rétine. Arch, ophtal., 51:426, 1934. 7. Shapland: Tr. Ophth. Soc. U. Kingdom, 54:176, 1934. 8. Leber, T.: Die Krankheiten der Netzhaut. In Graefe-Saemisch Handb. Augenh., Leipzig, 1916, v. 7, pt. 2, p. 1374. 9. Dunnington, J. H., and Macnie, J. P.: Detachment of the retina; operative results in ISO cases. Arch. Ophth., 13:191, 1935. 10. Arruga, H. : Reports Internat. Cong. Ophth. Madrid, 1933, v. 2, p. 5. 11. Fanta, H.: Detachment of the retina and trauma. Klin. Monatsbl. Augenh., 105:30, 1940. 12. Gastheiger, H.: Retinal detachment and trauma, Klin. Monatsbl. Augenh., 126:513, 1955. 13. Teng, C. C, and Chi, H. H.: Vitreous changes and the mechanism of retinal detachment. Am. J. Ophth, 44:335, 1957. 14. Sedan, J.: Traumatic detachments and myopia. Ann. Ocul., 33:175, 1959. 15. Dreifus, M., et al.: Post-traumatic retinal detachment treated at the 2nd. Eye Clinic of Charles University in Prague in the period 1945-1957. Cheko. Oftal. Praha, 62:221, 1959.
TEMPORAL TRANSPLANTATION OF THE INFERIOR RECTUS MUSCLE IN V-ESOTROPIA* G U N T E R K.
VON NOORDEN,
M.D.
Baltimore, Maryland The ophthalmologist has become increas ingly aware of the occurrence of vertical incomitancies. Measurement of ocular devia tions in the straight up and downward posi tions of gaze should be incorporated into the diagnostic evaluation of a strabismic patient. However, once the diagnosis of a vertical incomitancy has been established confusion exists as to which muscle or muscle group should be attacked surgically. This confu sion is by no means lessened by the recom mendations from three schools of thought regarding the etiology of A and V syn dromes, each group of authors attaching the blame to a different group of muscles, and accordingly, suggesting a different surgical approach. It would seem that each method of sur* From the Department of Ophthalmology, Col lege of Medicine, State University of Iowa. This study was supported by a Public Health Service Research Career Development Award (NB-K316108) from the National Institute of Neurological Diseases and Blindness.
gical management, whether it consists of sur gery on the horizontal, 1 vertical, 2 or oblique 3 muscles, may have its merits in a particular situation, and I would disagree only with too rigid an application of one surgical prin ciple to all cases presenting one of the ver tical incomitance syndromes. In V-esotropia with marked overaction of the inferior oblique muscles, a weakening procedure on the latter has in our experience . frequently resulted in an increase of the de viation in upward gaze, thus restoring ver tical comitance, and rendering the condition amenable to subsequent horizontal surgery. Little is gained, however, from weakening the inferior oblique muscles when overaction is only slight, or not demonstrable at all, and a different surgical approach seems advisa ble. Miller 4 demonstrated that lateral trans plantation of the inferior rectus muscles aug ments abduction in downward gaze. W e have employed this technique in nine cases
GUNTER K. VON NOORDEN
920
with V-esotropia without significant overaction of the inferior obliques and the results are reported in this paper. TECHNIQUE
The operation was performed on both eyes. After exposure of the inferior rectus tendon, two single armed 4-0 mild chromic catgut sutures were placed and locked at the medial and lateral edge of the tendon, close to its scierai insertion. After detachment of the tendon from the globe its medial edge was attached to the sciera near the lateral aspect of the original insertion. T h e lateral edge of the tendon was sutured to the sciera 9.0 to 10 mm. further laterally, which is ap proximately one breadth of its normal in sertion. The distance between the medial and lateral edges of the tendon and the limbus was measured prior to detachment, and spe cial care was taken to perform reattachment according to these measurements, since the lateral end of the insertion was always found to be farther from the limbus than the medial one. In Case 2 this procedure was combined with a two-mm. advancement of the inferior rectus muscle in the right, and a one-mm. recession in the left eye, to coun teract a right hypertropia. In Case 8 the in ferior rectus muscle of the right eye was recessed two mm. for a left hypertropia. MATERIAL
The patients were between five and 12 years of age. All had a V-esotropia. The difference between measurements in straight up and downward positions ranged between 16 and 50 prism diopters. Measurements were obtained with either eye fixing by the prism and cover test at 33 cm. in the pri mary position, and in the positions of 35degrees elevation and 40-degrees depression. If glasses reduced the angle of squint sig nificantly the pre- and postoperative measure ments were obtained with correction. Distant measurements were never less and, in all but one case, more than 16 prism diopters of esotropia in the primary position. Only one
patient (Case 9) had previous surgery. This girl was originally exotropic and had a re section of the medial and a recession of the lateral rectus muscle in one eye. Subse quently the child developed a V-esotropia. T h e procedure was limited to a group of patients who had little or no overaction of the inferior oblique muscles. T h e purpose was to affect and reduce the deviation main ly in the downward position of gaze, rather than to make the patient more esotropic in up ward gaze by a weakening procedure on the obliques. Another indication was a small an gle esotropia, or no shift in upward gaze, and a relatively large deviation in primary position and downward gaze (Cases 1, 6, 8 and 9 ) . It was felt that horizontal surgery in such a situation may have fostered the danger of overcorrection in upward gaze, and in the instance of Case 9, also in pri mary position, while a reduction of the an gle in downward gaze would increase the chances for binocularity. R E S U L T S AND C O M M E N T S
T h e postoperative results demonstrate a significant reduction of the horizontal devia tion in downward gaze in all patients (fig. 1 ) . T h e improvement was at least 10 prism diopters, amounted to more in most in stances, and measured maximally 31 prism diopters (Case 5 ) . It is of particular interest that in all ex cept one patient (Case 7 ) , the primary posi tion was also favorably influenced by sur gery, and that in three examples (Cases 3, 5 and 9) the esotropia was reduced at least 10 prism diopters in upward gaze. Case 3 is exceptional, inasmuch as the deviation im proved more in the primary position than in downward gaze. An increase of esotropia in upward gaze was noted in three patients (Cases 1, 4 and 7 ) . All but one patient (Case 4 ) were cosmetically improved. Al terations in the size of the lid fissures were not observed. Functional improvement, con sisting of momentary fusion at near and amplitudes with peripheral ( G r a d e 2) tar-
TRANSPLANTATION OF INFERIOR RECTUS MUSCLE
921
MEASUREMENTS OF DEVIATION BEFORE AND AFTER SURGERY
Case 1
Up: Prim. Pos.: Down:
Pre-op
Post-op
Change in ET
Mos. after Surgery
no shift 35 ET 50 ET
14 ET, 3 LHT 16 ET, 4 LHT 32 ET
+14 -19 -18
9
Il ET 20 ET 40 ET, 5 RHT
10 ET 14 ET 18 ET
-1 -6 -22
4
20 ET, 9 LHT 35 ET 40 ET, 4 LHT
9 ET, 10 LHT 14 ET, 9 LHT 30 ET, 10 LHT
-Il -21 -10
12
16 ET, 3 LHT 36 ET, 5 RHT 50 ET
20 ET, 9 RHT 25 ET, 6 RHT 40 ET, 5 RHT
+4 -Il -10
4
18 ET 30 ET, 3 LHT 38 ET
3 LH 12 ET, 4 LHT 7 ET
-18 -18 -31
2.5
8 ET 24 ET 36 ET
no shift 8 ET
3
8ET
-8 -16 -28
10 ET, 5 RHT 16 ET, 6 RHT 45 ET
16 ET 18 ET 30 ET
+6 +2 -15
16
9 ET 18 ET, 3 LHT 25 ET
5E 9 ET, 2 LH 10 ET, 4 LH
-4 -9 -15
12
no shift 10 ET, 3 RHT 16 ET, 2 RHT
10 X 7 X , 4 LH 8 X , 10 LH
-10 -17 -24
3
Case 2
Up: Prim. Pos.: Down: Case 3
Up: Prim. Pos.: Down: Case 4
Up: Prim. Pos.: Down: Case 5
Up: Prim. Pos.: Down: Case 6
Up: Prim. Pos.: Down: Case 7
Up: Prim. Pos.: Down: Case 8
Up: Prim. Pos.: Down: Case 9 .
Up: Prim. Pos.: Down:
Fig. 1 (von Noorden). Measurements of deviation before and after surgery.
gets, was achieved in two (Cases 2 and 8 ) , and functional cure with full binocularity and stereopsis in one instance (Case 9). When, as in Cases 2 and 8 the temporal
transplantation of the inferior rectus mus cles was combined with a recession and ad vancement for hypertropia, the vertical de viation was eliminated (Case 2) or im-
922
GUNTER K. VON NOORDEN
proved (Case 8 ) . A number of patients will have, or have had additional surgery on the horizontal rectus or oblique muscles for functional reasons. Miller 4 advocates combined vertical and horizontal rectus surgery, and states that the effect of temporal transplantation of the in ferior rectus muscles would be enhanced by a simultaneously performed weakening or strengthening procedure on the horizontal adductors and abductors. Be this as it may, we have not followed this advice because we were primarily interested to learn what ef fect the isolated procedure may have, rather than to obscure the result by additional sur gery to which all, or none of the results may be ascribed. While the data presented in this study may not demonstrate perfect results in all
cases, the improvement is, nevertheless, sig nificant. It is quite possible that more effec tive surgical approaches to V-esotropia will be developed. Time and comparison of re sults will eventually indicate which is the best procedure for a given situation in this confusing entity. SUMMARY
Temporal transplantation of the inferior rectus muscles was performed in nine pa tients with V-esotropia. The operation is effective in significantly reducing the verti cal incomitancy in this condition, and may also improve esotropia in the primary posi tion and upward gaze. Wihner Institute, Johns Hopkins Hospital
(5).
REFERENCES
1. Urist, M. J.: Horizontal squint with secondary vertical deviations. AMA Arch. Ophth., 46:245-267, 1951. 2. Brown, H. W.: Cited in Strabismus Ophthalmic Symposium. (Edited by J. H. Allen.) St. Louis, Mosby, 1950, v. 2, p. 241-243. 3. Jampolsky, A.: Bilateral anomalies of the oblique muscles. Tr. Am. Acad. Ophth., 61:689-700, 1957. 4. Miller, J. E.: Vertical recti transplantation in the A and V syndromes. AMA Arch. Ophth., 64:175179, 1960.
S E P A R A T I O N D I F F I C U L T Y IN G I O V A N N I M A R A I N I , M.D.,
L U I G I P A S I N O , M.D.,
AMBLYOPIA* AND SERGIO P E R A L T A ,
M.D.
Parma, Italy The crowding phenomenon, known as separation difficulty in the European litera ture, is one of the most typical symptoms of strabismic amblyopia and has been univer sally accepted since the early work of Bangerter 1 and Müller. 2 One could in effect consider the amblyopic eye as having two different visual acuities when tested with single letters or when examined on a row of symbols. A better understanding of this peculiar phenomenon may improve further our knowledge of the basic physiopathology * From the University Eye Clinic (Director: Prof. Dr. P. Matteucci).
of strabismic amblyopia. Separation diffi culty is an important and interesting aspect of this disease. Several points regarding it are still unsolved: 1. Whether it is a symptom peculiar to strabismic amblyopia (Müller 2 ) or whether it is present also in normal persons (Adler, 3 Ehlers, 4 De Jaeger, 5 Thomas-Decortis, 6 Stu art and Burian 7 ) and in other types of func tional amblyopia (Bagolini 8 ). 2. Whether this phenomenon is limited to about 50 percent of the cases (Erich 9 Mackensen 1 0 ) and particularly to those with eccentric fixation ( C u p p e r s 1 1 ) , or whether