Special types of muscle anomalies associated with Graves' disease

This paper discusses two cases of superior oblique paresis, two cases of cyclic hypertropias, and ten cases of large angle esotropia with high myopia. The association with Graves' disease, the treatment, and favorable prognosis in all cases is presented.     

Pediatric orbital floor fracture : direct extraocular muscle involvement

OBJECTIVE: To study the clinical presentation, operative findings, and postoperative results of a surgical series of isolated orbital floor fractures in children. DESIGN: Noncomparative, retrospective, consecutive case series. PARTICIPANTS: Thirty-four patients (34 orbits) less than 18 years of age with isolated orbital floor fractures. Indications for surgery were severe limitation of extraocular ductions, 22 of 34; enophthalmos, 8 of 34: or both, 4 of 34. INTERVENTION: Surgical repair. MAIN OUTCOME MEASURES: Cause of fracture, symptoms, clinical signs, radiographic data, operative findings, postoperative results, and complications. RESULTS: Children older than 12 years of age were more likely to sustain an orbital floor fracture as a result of interpersonal violence than were children less than 12 years of age (P: = 0.020). Sixty-two percent of patients (21 of 34) exhibited pain with eye movements and/or nausea and vomiting. Most had a trapdoor type fracture (21 of 34). The inferior rectus muscle was entrapped in the orbital floor fracture in 69% (18 of 26) of patients with a severe limitation of ocular ductions. Preoperative nausea and vomiting were immediately relieved after surgery. The median time for improvement of preoperative duction deficits and diplopia was 4 days for patients receiving surgery within 7 days and 10.5 days for those undergoing surgery after 14 days (P: = 0.030). Resolution of duction deficits or diplopia was not dependent on time of surgery if performed within 1 month of injury. Loss of vision, worsening of motility, or implant complications did not occur. CONCLUSIONS: Pediatric patients with isolated orbital floor fractures who had pain, nausea, vomiting, and severe limitation of extraocular motility often have direct entrapment of the inferior rectus muscle into the fracture site. Surgical repair rapidly relieved preoperative pain, nausea, and vomiting. For patients with severe limitation of ductions, early surgical repair within 7 days of injury resulted in more rapid improvement of ductions and diplopia than surgery performed later.     

Superior tarsal muscle resection to correct blepharoptosis.

Resection of the superior tarsal muscle (STM) is effective in correcting congenital or acquired blepharoptosis in patients who have satisfactory elevation of the eyelid with a preoperative phenylephrine eye drops test. Advantages of this procedure are that only the STM is resected, the conjunctiva and basic lacrimal secretors are preserved, tarsal stability is maintained, no special instruments are required, and the preoperative phenylephrine eye drops test reliably predicts the postoperative result.     

Three horizontal muscle squint surgery for large angle infantile esotropia

BACKGROUND: To report the long-term outcome of a series of 49 patients who underwent three horizontal muscle squint surgery for large angle infantile esotropia. METHODS; The patient records were retrospectively reviewed of 49 (24 girls [49%], 25 boys) consecutive patients with infantile esotropia of angle > or =60 Delta, who had undergone three horizontal muscle surgery performed by one surgeon (author GG). Surgery consisted of bilateral medial rectus recession combined with graded unilateral lateral rectus resection. Surgeries were carried out over a 6-year period with a mean follow-up period of 32.9 months (3.7-71.8 months). RESULTS: Using Kaplan-Meier life-table analysis, cumulative surgical success (orthotropia +/-10 Delta) was 93.9% at 1 week, 91.8% at 2 and 6 months, 87.7% at 12 and 18 months, 79.9% at 2 years, 77.1% at 3, 4 and 5 years, and 70.6% at 6 years. The mean preoperative deviation was 68.7 Delta. The mean age at surgery was 12.9 months. The failure rate was independent of preoperative deviation. Prevalence of residual esotropia (>10 Delta) varied from 2.0% at 1 week to 17.0% at 6 years. Similarly the prevalence of consecutive exotropia (>10 Delta) varied from 4.0% at 1 week to 12.4% at 6 years. CONCLUSION; Operating in a graded fashion on three horizontal muscles in children with large angle infantile esotropia has a high success rate, even over long-term follow up. Based on the study's results, amounts of surgery for a given angle of strabismus are proposed.     

上睑下垂"W"型异体阔筋膜悬吊术的探讨

目的探讨“W”型异体阔筋膜额肌悬吊术治疗重度上睑下垂的效果。方法对58例(69眼)上睑提肌力量小于4mm的重度上睑下垂施行“W”型异体阔筋膜额肌悬吊术治疗,随访半年至5年,观察其效果。结果最后随访,Ⅰ级效果58眼,Ⅱ级效果10眼,Ⅲ级效果1眼,术后无任何并发症发生。结论“W”型异体阔筋膜额肌悬吊术创伤小、疗效好、并发症少,是目前治疗重度上睑下垂的较理想术式之一。     

Lengthening extraocular muscle with autologous muscle transplants

Increasing extraocular muscle length by regenerative growth has been proposed as a potentially useful means of treating patients with paralytic or multiple re-operation strabismus. This study evaluates the viability and pattern of regeneration of fresh, autologous extraocular muscle and temporalis muscle transplants in the canine orbit. Bilateral grafts of either inferior oblique or temporalis muscle were sewn between host lateral rectus muscles and the globe. Grafts were biopsied and examined by light and electron microscopy at survival times to 56 days. Functional responses to abducens nucleus stimulation were examined in one extraocular muscle and one temporalis muscle graft at 15 weeks post-operatively. During the first week, both graft types were characterized by loss of pre-terminal nerve from neuromuscular junctions, muscle fiber necrosis that spared the central fibers, and inflammatory cell infiltrate. Myoblasts migrated into and fused within the existing basal laminae of degenerating fibers. By 14 days, grafts were populated by immature myofibers. Neuromuscular junctions were seen by 56 days, coinciding with muscle fiber differentiation as seen by enzyme histochemistry. Only two grafts failed to show regeneration. At 15 weeks survival, both types of grafts contracted in response to abducens nucleus stimulation. Free skeletal muscle grafts to extraocular muscle survive and mature with clear evidence of contractility by 15 weeks. These data suggest that muscle graft procedures could be useful in the management of certain types of strabismus where greater muscle length is needed.     

Extraocular muscle regeneration in freeze-treated extraocular muscle autografts

New growth of extraocular muscle has been demonstrated in degenerating peripheral nerve autografts implanted between two extraocular muscles. This suggests that extraocular muscle may be lengthened for therapeutic purposes if a suitable matrix can be found to support this new growth. Investigators of peripheral nerve regeneration have found that the basal lamina of freeze-killed skeletal muscle remains intact and supports axonal regeneration. This study was designed to investigate the feasibility of inducing regenerative growth of extraocular muscle in freeze-treated extraocular muscle autografts. In six beagles the inferior oblique muscle was removed from both orbits, frozen in liquid nitrogen, and allowed to thaw at room temperature. The freeze-thaw cycle was repeated. The freeze-treated grafts were then sewn in an end-to-end fashion between the cut end of the lateral rectus and the globe. At both 4 and 8 weeks postoperatively, three dogs were killed, and the grafts were removed from both orbits. These were prepared for light and electron microscopic examination. This revealed robust growth of mature-appearing, innervated muscle fibers in the proximal graft that could be differentiated by adenosine triphosphatase histochemistry. Rare, immature fibers were seen in the distal graft. These results demonstrate that freeze-treated extraocular muscle autografts support regenerative growth of extraocular muscle.     

Accessory levator muscle slips of the levator palpebrae superioris muscle

Background:  Accessory levator muscle slips may be associated with congenital eyelid retraction or blepharoptosis. Nevertheless, congenital retraction of the upper eyelid is a poorly defined entity about which little is known. Because of the clinical importance of the accessory levator muscle slip of the levator palpebrae superioris muscle, this study aimed to describe the morphological appearance of this variation in human adult orbits.
Methods:  This study was undertaken in 60 orbits of 30 embalmed adult human cadavers, 17 men and 13 women, between the ages of 38 and 87 years at death. All cadavers were embalmed in 4% formalin solution.
Results:  Three accessory levator muscle slips of the levator palpebrae superioris muscle were identified. One of these arose laterally from the origin of the levator palpebrae superioris muscle. At its anterior end, it divided into two parts, the main superior and a smaller inferior accessory. The second had an accessory levator fibromuscular slip. It arose medially from the origin of the levator palpebrae superioris and lost its muscular character after a short course. The third arose from the origin of the levator palpebrae superioris as a thin flat muscle.
Conclusions:  Although many variations of the levator palpebrae superioris muscle have been reported in fetuses, investigation and demonstration of these may be more important in children and adults for ophthalmic surgery. We believe that detailed knowledge regarding the morphological appearance of an accessory levator muscle slip of the levator palpebrae superioris muscle may be useful for successful outcomes in ophthalmic surgery.     

Anteriorization of inferior oblique muscle and downward transposition of medial rectus muscle for lost inferior rectus muscle

A 6-year-old boy who had been treated with bilateral medial rectus muscle recessions 3 years earlier for congenital esotropia was undergoing bilateral inferior oblique muscle recessions to correct inferior oblique muscle overaction. The right inferior rectus muscle was inadvertently cut during this surgery and was irretrievable. To manage this complication, the medial rectus muscle was transposed toward the inferior rectus insertion and the inferior oblique muscle was anteriorized. At the 1 year follow-up visit, no infraduction deficit was present on downgaze and only 8(delta) of left hypertropia was present in primary position.     

Effects of oblique muscle surgery on the rectus muscle pulley

Purpose  

To determine the position of rectus muscle pulleys in Japanese eyes and to evaluate the effect of oblique muscle surgery on rectus muscle pulleys.     

Extraocular muscle enlargement

Graefe's Archive for Clinical and Experimental Ophthalmology - Extraocular muscle enlargement can occur secondary to a range of orbital and systemic diseases. Although the most common cause of...