Vertical rectus transposition procedures for lateral rectus palsy: A systematic review

Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy,” “vertical rectus transposition for abducens palsy,” “superior rectus transposition,” “inferior rectus transposition,” and “Hummelsheim procedure.” References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.

Isolated abscess in superior rectus muscle in a child.

Pyomyositis is a primary bacterial infection of striated muscles nearly always caused by Staphylococcus aureus. Development of the intramuscular abscess involving the extra‑ocular muscles (EOMs) remains an extremely rare process. We herein present a case of isolated EOM pyomyositis involving superior rectus muscle in a 2‑year male child who was referred with complaints of swelling in left eye (LE) and inability to open LE since last 1‑month. Orbital computed tomography (CT) scan showed a well‑defined, hypo‑dense, peripheral rim‑enhancing lesion in relation to left superior rectus muscle suggestive of left superior rectus abscess. The abscess was drained through skin approach. We concluded that pyomyositis of EOM should be considered in any patient presenting with acute onset of orbital inflammation and characteristic CT or magnetic resonance imaging features. Management consists of incision and drainage coupled with antibiotic therapy.

The Effect of Unilateral Superior Rectus Recession for Dissociated Vertical Deviation (DVD)

PURPOSE: This study analyzed the outcome of unilateral superior rectus recession in patients with asymmetrical dissociated vertical deviation (DVD) in terms of effectiveness and influence on the fellow eye. METHODS: Medical records of 40 patients (40 eyes) who had undergone unilateral superior rectus recession for the treatment of asymmetrical DVD were retrospectively reviewed from February 1993 to March 2009. The minimum follow-up period was 1 year after the operation. RESULTS: The overall success rate in the operated eye was 97.5% at 12 months and 90% at the last follow-up. However, a DVD larger than 10 PD developed in the fellow eye in 20% (8) of the patients. In patients who preoperatively had DVD in their fellow eyes, 50% developed DVD postoperatively in their fellow eyes. In patients who preoperatively did not have DVD in their fellow eyes, 14.7% developed DVD postoperatively in their fellow eyes. Furthermore, the angle of the DVD in the fellow eye increased with the surgical dosage. CONCLUSIONS: Unilateral SR recession is effective in patients with asymmetrical DVD. However, a high incidence rate of DVD in the fellow eye should be considered, especially when preoperatively there is a small DVD in the fellow eye or a large DVD angle in the operated eye, whenever monocular superior rectus recession surgery is performed.

Surgical Outcome of Vertical Rectus Muscle Recession in Hypertropia

PURPOSE: To determine the extent of vertical rectus muscle correction in hypertropia showing good prognosis. METHODS: A retrospective study was performed with a total of 16 patients who underwent superior or inferior rectus muscle recession surgery with a follow-up of more than 6 months. Vertical muscle recession of 1 mm per 2.5 to 3.0 prism diopters was performed according to the surgeon's discretion. RESULTS: At 1 week after surgical correction, undercorrection, orthophoria, and overcorrection was observed in 4, 7 and 5 cases, respectively. At the final examination, ocular deviation was decreased in the undercorrected cases and maintained orthophoric except in 1 case where only a small amount of deviation recurred. However, in the cases of postoperative overcorrectionn, ocular deviation increased; 2 cases required surgical correction for consecutive hypertropia. CONCLUSIONS: When performing vertical rectus muscle recession in primary hypertropia, the amount of correction for orthophoria or undercorrection should be determined.

Trypan Blue-Assisted Measurements of Anatomical Positions of the Superior Rectus Muscle and Superior Oblique Muscle in Enucleated Eyes

PURPOSE: To recognize the anatomical positions of the superior oblique muscle in enucleated eyes using trypan blue. METHODS: Twenty-two surgically-enucleated eyes of 11 bodies were studied. The shortest distance from the nasal insertion of superior rectus to the anterior end of the superior oblique tendon, the distance from the temporal insertion of superior rectus to the anterior end of the superior oblique insertion, and the greatest width of superior oblique tendon insertion were measured by caliper 3 consecutive times. The average values in each of the above 3 points were calculated, and values prior to and after trypan blue staining were compared. RESULTS: Prior to staining with trypan blue, the average distance from the nasal insertion of superior rectus to the anterior end of the superior oblique tendon was 4.97 mm and the average distance from the temporal insertion of superior rectus to the anterior end of the superior oblique insertion was 7.57 mm; after staining with trypan blue, the average values were 5.09 mm and 7.65 mm, respectively. There was no statistically meaningful difference in values prior to and after staining (p > 0.05). Prior to staining, the average value of the greatest width of the superior oblique tendon was 10.32 mm, and after staining with trypan blue, the average value increased to 10.76 mm. There was a statistically meaningful difference between the values (p = 0.02). CONCLUSIONS: Trypan blue staining helped to recognize the location and the width of the superior oblique tendon more precisely.

Superior Rectus Muscle Recession for Residual Head Tilt after Inferior Oblique Muscle Weakening in Superior Oblique Palsy

PURPOSE: Residual head tilt has been reported in patients with superior oblique muscle palsy (SOP) after surgery to weaken the inferior oblique (IO) muscle. The treatments for these patients have not received appropriate attention. In this study, we evaluated the superior rectus (SR) muscle recession as a surgical treatment. METHODS: The medical records of 12 patients with SOP were retrospectively reviewed. Each of these patients had unilateral SR muscle recession for residual head tilt after IO muscle weakening due to SOP. The residual torticollis was classified into three groups on the basis of severity: mild, moderate, or severe. Both IO muscle overaction and vertical deviation, features of SOP, were evaluated in all patients. The severity of the preoperative and postoperative torticollis and vertical deviation were compared using a paired t-test and Fisher's exact test. RESULTS: The torticollis improved in nine of 12 (75%) patients after SR muscle recession. The difference between the preoperative and postoperative severity of torticollis was statistically significant (p = 0.0008). After surgery, the mean vertical deviation was significantly reduced from 12.4 prism diopters to 1.3 prism diopters (p = 0.0003). CONCLUSIONS: Unilateral SR muscle recession is an effective method to correct residual head tilt after IO muscle weakening in patients with SOP. This surgical procedure is believed to decrease head tilt by reducing the vertical deviation and thereby the compensatory head tilt.

The Effect of Superior Rectus Re-recession for Dissociated Vertical Deviation

PURPOSE: When recurrent dissociated vertical deviation (DVD) is cosmetically objectionable after superior rectus recession is used to surgically treat DVD, inferior rectus resection or superior rectus re-recession should be considered. The effect of re-recession of the superior rectus was, therefore, evaluated as a treatment of recurrent DVD. METHODS: We retrospectively reviewed the medical records of 9 eyes from 7 patients who had undergone superior rectus re-recession as a second surgery due to recurrence after superior rectus recession for DVD. RESULTS: The mean follow-up period after re-recession of the superior rectus was 32.1 (22~66) months. The preoperative mean deviation was 16.0 prism diopters (PD), and the postoperative mean deviation was 4.9PD. According to the classification of recurrent DVD by Scott, the surgical results of five eyes were excellent (0~4PD), those of 2 eyes were good (10~14PD), and those of 2 eyes were fair. The mean corrected DVD was 4.1PD per 1 mm recession. CONCLUSIONS: Postoperatively, 7 of 9 eyes (77.7%) were aligned within 9PD. In cases of recurrent DVD, superior rectus re-recession yielded satisfactory results with minimum surgery on the superior rectus. The results of this study will be helpful in deciding surgical amount of superior rectus re-recession to be performed.

A Cadaveric Anatomical Study of the Levator Aponeurosis and Whitnall's Ligament

PURPOSE: To identify the anatomy of the levator aponeurosis (LA) and Whitnall's ligament (WL) in Korean subjects using cadavers. METHODS: Orbital exenteration was performed in ten cadavers (20 eyeballs) that had no history of trauma near the eyeball. We observed characteristics of WL (tension, density, and shape) and the relationship between the superior rectus muscle (SR) and the levator palpebrae superioris. We measured the distance from both the eyelid margin and the upper border of the tarsal plate to the insertion of the LA medially, centrally, and laterally. RESULTS: The WLs we observed showed several shapes. In 12 eyes, we saw clear, white fibrotic bands, while in four others, we found thin, less taut bands. In four eyes, we were unable to identify the precise shape of the band. The insertions of the LA showed nasal dehiscence in 13 eyes and parallel attachment in seven eyes. The distances from the eyelid margin to the insertion of the LA medially, centrally, and laterally were 8.31 mm, 5.57 mm, and 5.15 mm, respectively. The distances from the upper border of the tarsal plate to the insertion of the LA medially, centrally, and laterally were 2.75 mm, 4.82 mm, and 4.29 mm, respectively. CONCLUSIONS: This study examined the anatomy of WL and the LA in Korean subjects and may be helpful as a reference in levator muscle surgery.

The Surgical Correction of Vertical Deviation after Superior Rectus Muscle Recession in Patients with Hypertropia

PURPOSE: In general, the amount of vertical rectus surgery is based on achieving 3 prism diopters (PD) of realignment for each millimeter of muscle recession. The study aimed to determine the surgical correction of vertical deviation in patients with hypertropia after superior rectus muscle recession. METHODS: A total of 32 patients with hypertropia underwent 2-8 mm recession of the superior rectus muscle. The average surgical correction for each millimeter of recession was calculated by deducting the post-surgical deviation from the pre-surgical vertical deviation and dividing the remnant by the amount of recession (mm). RESULTS: The average surgical correction was 2.2 +/- 0.7 PD for each millimeter of superior rectus recession. There was no statistical significance in the change in surgical correction in terms of follow-up period, which was categorized as one day, one, two, and six months, and one year (P>0.05). The relationship between surgical correction and age (below and above 11 years old), gender or the amount of recession (below or above 5 mm) was not statistically significant (P>0.05). There was no statistically significant difference in vertical correction between esodeviation and exodeviation (P>0.05). CONCLUSIONS: The study showed an average surgical correction of vertical deviation of 2.2 PD for each millimeter of superior rectus muscle recession. The results suggest that increased recession, within the maximum limit of 8 mm, is an effective approach to prevent undercorrection for children who have hypertropia but cannot undergo adjustable strabismus surgery.

The Effect of 9 mm, 7 mm Bilateral Superior Rectus Recession for Bilateral Dissociated Vertical Deviation

PURPOSE: To evaluate the effect of 9 mm and 7 mm bilateral recession of the superior rectus muscle in patients with bilateral dissociated vertical deviation (DVD) who had a deviation difference between the non-fixing and fixing eyes of less than 8PD. METHODS: The subjects were chosen from the patients who visited our hospital for DVD between January 2001 and November 2003. We reviewed the surgical records of 19 patients who had undergone 9 mm recession of superior rectus muscle in the non-fixing eye and 7 mm in fixing eye, and who had been followed up for at least 6 months. RESULTS: A residual DVD less than 8PD was regarded as successful. The overall success rate was 73.7%. The success rate of 10~14PD preoperative deviation of the non-fixing eye was 80.0%, and that of 15~19PD preoperative deviation of the non-fixing eye was 75.0%. However, the success rate was 66.7% in recession for the deviation over 20PD. CONCLUSIONS: Bilateral recession of 9 mm and 7 mm of the superior rectus muscle was effective for bilateral DVD in which the deviation difference of the non-fixing eye and fixing eyes was less than 8PD.

Tensile Strength of Musculoscleral Insertion after Superior Rectus Recession on Rabbit

PURPOSE: The author performed this experimental study to investigate the changes in the tensile strength of a new insertion following a superior rectus recession in a rabbit's eye. METHODS: Conventional superior rectus muscle recession procedures with the hang-back suture technique were performed on New Zealand white rabbits (body weight 2~3kg), after which the disinsertional force was measured using a digital tension gauge on the 3rd, 5th, and 7th days, and then weekly for up to 8 weeks postoperatively. RESULTS: The postoperative disinsertional forces were as follows: 38.25 +/- 2.75, 165 +/- 31.27, and 167.25 +/- 26.99 g at the 3rd , 5th and 7th days, and 211.00 +/- 25.66, 222.75 +/- 26.66, 255.25 +/- 24.51, 271.50 +/- 38.25, 429.50 +/- 21.14 g at the 2nd, 3rd, 4th, 6th and 8th weeks respectively. The disinsertional forces linearly increased with the postoperative time period and there was a strong correlation with correlation coefficient being 0.903. CONCLUSIONS: We concluded that musculoscleral adhesion with hang-back suture maintained enough strength in early postoperative time period.

A Case of Simultaneous Injury to Ipsilateral Superior Rectus and Superior Oblique Muscle

PURPOSE: Because the ipsilateral superior rectus (SR) and superior oblique (SO) muscles are innervated by two different nerves, it is very rare for these two muscles to be paralyzed while all other extraocular muscles function normally. The authors experienced a case where the patient had a loss of intorsion (action of both SR and SO muscles) and also loss of SO muscle's infraduction and adduction, and SR muscle's supraduction and abduction. The authors studied how such loss of function affects extraocular movement. METHODS: A 63-year-old male patient who had his SR and SO muscles severed by a saw was admitted to the hospital after getting rid of the two exposed muscle which were attached to the eyeball due to failure of reconstruction of two muscle. The patient was followed up for 8 months, and at the end of the follow-up period, the angle of deviation was measured while double Maddox test and fundus examination were also performed. RESULTS: At primary position there was extorsion of 7 degrees as well as esodeviation of 6 PD and hypodeviation of 6 PD on the left eye, and we hereby report the case.

A Case of Surgery for Congenital Superior Oblique Palsy with Intorsion of Nonparalized Eye

PURPOSE: Superior oblique palsy characterizes the abnormal oblique muscle function and excyclotorsion of paralized eye, and facial asymmetry and spread of comitance in long-standing case. We report the clinical aspects and treatment result of a 13-year-old female with congenital superior oblique palsy manifesting nonparalized eye intorsion instead of paralized eye excyclotorsion and intermittent exotropia. METHODS: This patient showed intermittent exotropia and congenital superior oblique palsy characterized by facial asymmetry, ipsilateral superior rectus contracture, abnormal posterior insertion of superior oblique tendon, and contralateral eye incyclotorsion and secondary superior oblique overaction. We operated ipsilateral superior rectus and lateral rectus recession considering these characteristics. RESULTS: There has been no intorsion in nonparalized eye immediately after surgery, and the 9 cardinal gazes have been orthophoric after 2 weeks of surgery. CONCLUSIONS: We report a surgical experience of a congenital superior oblique palsy that has not been reported yet, that showed intorsion of nonparalized eye instead of extorsion.

The Surgical Results According to the Amount of Superior Rectus Recession for Dissociated Vertical DeviationDVD

To evaluate the surgical results of superior rectus recession with different amount according to the degree of eyeball deviation.We reviewed the surgical records of 36 eyes in 23 patients who had undergone superior rectus recession and followed up for at least 6 months.Patients were divided into 3 groups according to the degree of deviation : Group 1[8-10PD, 4.0 mm recession], Group 2[11-20PD, 6.0 mmrecession], Group 3[21PD or greater, 8.0 mmrecession].Five PD or less after operation was regarded as acceptable. The success rate of Group 1 was 86.6%at the 6th month, 87.5% at the 12th month, and 83.8%at the 24th onth, respectively.In group 2 those were 87.5%, 75%, and 80%, respectively.In group 3 those were 60%, 50%, and 50%, respectively.The overall success rate as 83.3%at the 6th month, 75% at the 12th month, 75%at the 24th month.These results indicate that superior rectus recession with the different amount according to the degree of eyeball deviation is effective for the deviation under 20PD but not over 21PD.

Clinical Evaluation of Ptosis after Scleral Buckling

We evaluated the degree of ptosis, the function of levator muscle, and postoperative interval to recovery of ptosis in 20 patients who underwent scleral buckling for retinal detachment. The MRD 1(Margin reflex distance 1), function of levator muscle by Berke method and interpalpebral fissure height were evaluated at preoperative day and 1, 3 days, 1, 2, 4, 6, 8, weeks, and 6 months after surgery. The results were compared according to age, gender, extent of buckling, location of buckle. All patients were reported to develop ptosis at postoperative day one, and 20% of them showed mild ptosis persistent until 8 weeks after surgery. The decrement of MRD 1 was statistically significant until postoperative 2 weeks, but impaired function of levator muscle was statistically significant until postoperative 6 weeks(P<0.05). The postoperative interval to recovery of MRD 1 was delayed in group of old age(order than 40 years), in male and when the buckle was located under the superior rectus muscle(P<0.05). The postoperative interval to recovery of function of levator muscle was delayed in group of female, when the buckle extent was more than 180 degrees and when the buckle was located under the superior rectus muscle(P<0.05).

A Prospective Study of Ptosis following Cataract Surgery

A prospective study was investigated to evaluate the effect of local anesthesla, surgical technique of cataract and superior rectus muscle injury on postoperative ptosis. Preoperative and postoperative measurements of palpebral fissure, margi reflex distance(MRD), margin limbal distance(MLD), levator function and photograph were taken. Two hundreds patients were randomized into four groups to study these effect. Group A received a Van Lint eyelid block and a superior rectus bridle suture. Group B received a Van Lint block and an episcleral retraction suture. Group C received an O'Brien eyeli block and a superior rectus bridle suture. Group D received an O'Brien block and an episcleral retraction suture. Postoperative measurements of palpebral fissure, margin reflex distance(MRD), margin limbal distance(MLD), levator functi and photograph were taken at first day and eight weeks postoperatively and ptosis patients of a drop in the lid margin of a 2mm or more were follow up at six months postoperatively. Ptosis patients of a drop in the lid margin of 2mm or more were found in 20% of group A, 18% of group B, 14% of group C, 4% of group D, and 14% of all cases. Postoperative ptosis was statistically reduced in group D at eight weeks postoperatively(compared with group A and D P=0.0091, group B and D P=0.0042, group C and D P=0.0268). It appears that trauma to the superior retus muscle complex is the most critical factor in postoperative ptosis and we could minimize this effect in group D.

Superior Rectus Recession with Modified Hang-loose Technique in Rabbits

Hang-loose technique(HLT) is a reliable recession method in strabismus surgery. However, the loop length and the parallel of the anterior muscle border may not be sustained when the muscle was recessed behing the equator. This study was designed to assess the postoperative status of the large-recessed superior rectus muscle using the HLT and a modification of HLT(M-HLT) respectively in rabbits. Some of the recessed muscles with both techniques showed forward creeping. The average creeping was 0.5 mm on M-HLT and 1.1 mm on HLT in 7 mm recession group, and the difference was statistically significant(p=0.023). In 8 mm recession group, the average creeping was 1.0 mm on M-HLT and 1.8 mm on HLT. The difference was statistically significant(p=0.012). Although the parallel of the anterior muscle border was better on HLT than on M-HLT, the difference was not significant statistically. According to our result, M-HLT may be an useful alternative method in the cases of large recession with HLT.

The Effect of Superior Rectus Recession for Dissociated Vertical Deviation(DVD)

Dissociated vertical deviation(DVD) is a peculiar clinical entity consisting of an upward and extortional drift of a nonfixating eye. Many different surgical procedures have been advocated for its treatment, but the best approach is still debated. The authors performed superior rectus recession for treatment of DVD in 13 eyes of 8 patients. All patients were followed up for average 15 months after operation. In the vast majority cases, unilateral or bilateral superior rectus recession of graded amounts(7-8 mm) was performed. The amount of preoperative DVD was ranged from 10 to 25 delta and the mean effect of surgery was 11 delta After operation, 46% of the eyes were aligned within good to excellent categories(0-9 prism diopters), and 12 of 13 eyes within fair to excellent results(0-14 prism diopters).

Histopathologic Change Following Injection of Steroid Subconjunctivally in Rabbit: I. Resection or Recession of Superior Rectus

The authors observed histologic changes after subconjunctival injection of steroid (triamcinolone acetonide; TA) around the operated superior rectus muscle to investigative the alteration of subconjunctival collagen and muscle fibers in rabbits. The TA was identified in the subconjunctival tissue as an eosinophilic, foamy deposit with infiltration of macrophages phagocytosing TA particles and a few inflammatory cells The deposit was surrounded by compact collagen fibers that formed a pseudocapsule. The collagen fibers and fibroblasts were altered and fibrolytic in appearance within and margin of the drug deposit. While there was only mild degeneration in the muscle and its surrounding connective tissue. And the collagen fibers and fibroblasts at the site distant from the TA deposit were normal. There was no difference in histologic findings between the resected and recessed muscles. From these observations, it would appear that TA has a local fibrolytic effect. The localized fibrolytic effect within and marign of the drug deposit may explain, in part, the fibrolytic action of macrophages, which contained phagocytosed TA.

The Effect of Superior Rectus Recession for Dissociated Vertical Deviation (DVD)

Dissociated vertical deviation (DVD) is a peculiar clinical entity consisting of an upward and extortional drift of a nonfixating eye. Many different surgical procedures have been advocated for its treatment, but the best approach is still debated. The authors performed superior rectus recession for treatment of DVD in 13 eyes of 8 patients. All patients were followed up for average 15 months after operation. In the vast majority cases, unilateral or bilateral superior rectus recession of graded amounts (7-8mm) was performed. The amount of preoperative DVD was ranged from 10 to 25.6. and the mean effect of surgery was 11 delta. After operation, 46% of the eyes were aligned within good to excellent categories (0-9 prism diopters), and 12 of 13 eyes within fair to excellent results (0-14 prism diopters).