Surgical management of Helveston syndrome (triad of A- pattern exotropia, superior oblique overaction and dissociated vertical deviation) using 'Four Oblique' procedure

Purpose: To report the surgical outcomes in six patients of Helveston syndrome using a 揻our oblique� procedure. The popular methods for surgical management include superior rectus recessions alone or combined with superior oblique tenectomy. However, large angle exotropia correction would entail a higher risk of anterior segment ischemia when the superior rectus needs to be operated along with the horizontal recti. Hence, we evaluated the long-term results of this uncommon procedure. Methods: This was a retrospective review of six patients diagnosed to have manifest dissociated vertical deviation (DVD) with A pattern exotropia with bilateral superior oblique over action. All patients underwent horizontal muscle recessions/resections for exotropia along with bilateral posterior tenectomy of the superior oblique with inferior oblique anterior transpositioning. Results: The median age was 10 years (Range 5� years). The mean postoperative follow-up was 26 � 14.02 months (Range 12� months). The mean reduction in exotropia was from 36.5 � 21.06 PD (Range 15� PD) to 6.1 � 3.06 PD (Range 3� PD). The procedure corrected the A pattern from a mean 23 � 7 PD (Range 15� PD) to 7.6 � 3.2 PD (Range 3� PD). The average DVD in the right eye reduced from 14 � 4.3 PD (Range 8� PD) to 5.3 � 1.2 PD and in the left eye from 14.33 � 3.6 PD (Range 10� PD) to 4.1 � 1.1 PD. The DVD asymmetry reduced from 6.33 � 3.4 PD to 1.5 � 1.3 PD. Conclusion:擣our oblique� procedure with horizontal muscle surgery seems to be an effective method for significantly correcting the A pattern as well as reducing the DVD with good long-term outcome in our case series.

Effects of tenectomy of the medial head of the deep digital flexor on the hindlimbs of healthy horses / Efeitos da tenectomia da cabeça medial do tendão flexor digital profundo nos membros posterior de cavalos saudáveis

The tenectomy of the medial head of the deep digital flexor (TMHDDF) is a minimally studied surgery used in cases of dorsal subluxation of the proximal interphalangeal joint of the hindlimb in horses. The TMHDDF was evaluated in six healthy horses by the degree of lameness, perimeter of the surgical site, the angle of the distal articular joints, and the linear and angular measures of the hoof. Thus, TMHDDF of the right hindlimb was performed and the contralateral limb was used as a control. Both, right and left limbs were evaluated before surgery, as well as at 15, 30, and 60 days after surgery aiming to evaluate the effects of the surgical procedure in healthy limbs. Data were compared by analysis of variance regarding days and limbs. Values below the significant level (P< 0.05) were analyzed using the Tukey's test. TMHDDF caused a mild increase of the toe length and the height of lateral heel (0.2cm in both), as well as a decrease of the angle of the proximal interphalangeal joint (2°) when comparing the left hindlimb to the right hindlimb, 30 and 60 days after surgery. Overall, TMHDDF did not cause significant changes in the evaluated variables up to the 60 days of surgery.(AU)

A tenectomia da cabeça medial do flexor digital profundo (TCMFDP) é uma técnica cirúrgica pouco estudada, indicada para equinos com subluxação dorsal da articulação interfalângica proximal do membro pélvico. A TCMFDP foi avaliada em seis equinos hígidos no grau de claudicação; na perimetria da área operada; nos ângulos articulares distais; e nas medidas lineares e angulares de parâmetros dos cascos. Nesse sentido, foi realizada a TCMFDP do membro pélvico direito, permanecendo o esquerdo como controle. Ambos os membros foram avaliados nos momentos pré-operatório (0) e 15, 30 e 60 dias após a cirurgia, sendo objetivo avaliar os efeitos do procedimento cirúrgico em membros hígidos. Para comparação dos dados entre momentos e membros, foi realizada análise de variância. Os valores inferiores ao de significância (P<0,050) foram submetidos ao teste de Tukey. A TCMFDP provocou discreto aumento (0,2cm, em ambos) do comprimento de pinça e da altura do talão lateral e redução no ângulo da articulação interfalângica proximal (2°) na comparação com o membro pélvico esquerdo aos 30 e 60 dias após a cirurgia no contralateral. Em geral, a TCMFDP não causou alterações influentes nos aspectos avaliados até 60 dias do experimento.(AU)

Tenectomy and Posterior Tenectomy of the Superior Oblique for Superior Oblique Overaction

PURPOSE: The authors of the present study compared the effects of tenectomy and posterior tenectomy of the superior oblique for treating superior oblique overaction (SOOA). METHODS: The records of 30 eyes of 19 patients who underwent tenectomy or posterior tenectomy of the superior oblique alone or in combination with surgery on other horizontal rectus muscles from April 2005 through November 2010 were reviewed. The review was performed in 3 patients who underwent unilateral superior oblique tenectomy, 5 patients who underwent unilateral superior oblique posterior tenectomy, 3 patients who underwent bilateral superior oblique tenectomy, 6 patients who underwent bilateral superior oblique posterior tenectomy, and 2 patients who underwent superior oblique posterior tenectomy and tenectomy. RESULTS: The mean age of the patients was 14.2 years, and the mean follow-up period was 20 months. Through superior oblique tenectomy (11 eyes) and superior oblique posterior tenectomy (19 eyes), the amount of SOOA decreased from +2.27 to +0.09 and from +1.84 to +0.93, respectively. Except for 1 out of 11 eyes with superior oblique tenectomy, SOOA was completely corrected, although SOOA remained in 6 eyes after posterior tenectomy. Therefore, the correctional effects of the 2 methods differed; both procedures showed insignificant correctional effects on vertical strabismus. CONCLUSIONS: Superior oblique tenectomy has a superior long-term weakening effect; however, posterior tenectomy showed a comparable effect in the patient with moderate to severe SOOA. Both of these methods had few complications and are considered to be effective superior oblique weakening procedures.

Posterior Tenotomy and Tenectomy of Superior Oblique Muscle in "A" Pattern Strabismus

In 7 patients with "A" pattern strabismus with superior oblique overaction, we performed superior oblique posterior tenotomy and tenectomy(PTT) and horizontal rectus muscle surgery for horizontal strabismus, uni- or bilaterally, and analysed the status in degree of postoperative correction of "A" pattern, horizontal and vertical deviation in the primary position for availability of PTT in correction of superior oblique overaction. The average correction of "A" pattern was 10.4 prism diopter(PD). 6 of 7 patients showed eso- or exotropia under 6 PD in the primary position. Two of four patients in bilateral surgery and 2 of 3 patients in unilateral surgery showed the change of vertical deviation in the primary position but there were no problems cosmetically except one. From these results, we think that posterior tenotomy and tenectomy of superior oblique muscle is one of the useful methods for correction of superior oblique overaction in "A" pattern strabismus.