Preservation and Observation of Anterior Ciliary Vessels in Rectus Muscles during Strabismus Surgery

Purpose :To observe the form and number of the anterior ciliary vessels (ACV) in rectus muscles. To train technician in preservation and obsevation of ACV, so preservation can be done in caes with a risk of anterior segment ischemia (ASI). Methods:Curved foreign knife, iris hook, plastic rubber band and standard operating loupes (3x. ) or microscope were used in the surgery on 34 cases of comitant strabismus and 18 cases of paralytic strabismus.Results:The ACVs per muscle in medial, lateral, superior, inferior rectus were 3. 08,3. 26,3. 50 and 3. 50 respectively in 89 muscles of 52 surgical strabismus cases. All ACVs in 16 rectus muscles and 90 out of 220 ACVs in 73 rectus muscles were too small or too short to be dissected. The success rate of ACV preservation was 91. 5% (119/130). 105 out of 130 vessels were saved using loupe magnification and 14 pit pf 130 vessels were saved under operating microscope. Conclusions :The number of ACV in rectus muscles are more than 2 in our observation cases. The ACV     

外直肌和上直肌部分联结术治疗常规手术无效的高度近视眼限制性内下斜视

目的探讨应用外直肌和上直肌部分联结术治疗常规手术无效的高度近视眼限制性内下斜视的效果。 方法收集2012年9月至2017年12月因常规退缩手术治疗无效到厦门大学附属厦门眼科中心再次行斜视矫正手术的高度近视眼限制性内下斜视患者5例(8只眼),男性2例(4只眼),女性3例(4只眼);年龄52.0～73.0岁,平均(61.2±2.4)岁。手术前后,全部患者均进行视力、验光、裂隙灯显微镜、眼底、眼球运动、斜视角、眼轴长度及眼眶冠状位和水平位计算机X射线断层扫描(CT)检查。采用外直肌和上直肌部分联结术进行治疗。 结果全部患者5例(8只眼)患眼处于内下斜位,外转和上转功能受限;CT显示所有患眼存在上直肌向鼻侧移位、外直肌向下方移位、眼球后部向颞上方疝出肌圆锥。2例双眼(4只眼)行外直肌和上直肌部分联结术,1例双眼(2只眼)行外直肌和上直肌部分联结术联合内直肌后徙悬吊术,2例单眼(2只眼)行外直肌和上直肌部分联结术。患者随访超过6个月时,4例(6只眼)患者术后第一眼位正位,1例(2只眼)患者术后远期第一眼位为－15°,CT显示脱位的眼球被还纳回肌圆锥内,眼球的外转和上转功能逐渐恢复。所有患者未出现复视。无并发症发生。 结论外直肌和上直肌部分联结术可有效矫正经常规退缩手术治疗无效的高度近视眼限制性内下斜视,还纳脱出的眼球至肌圆锥内,并改善眼球运动功能。     

A Conjunctival Retractor during Strabismus Surgery

The use of a conjunctival retractor that expands a small incision in the conjunctiva/Tenon’s capsule facilitated the performance of strabismus surgery through a fornix incision. A wide field of exposure revealed the entire area of the muscle insertion. While there is a risk of conjunctival tearing in elderly patients, the use of the retractor is valuable.     

Botulinum Toxin Injection into Extraocular Muscles as an Alternative to Strabismus Surgery

Sixty-seven injections of botulinum A toxin were given to patients for correction of strabismus. No systemic complications of any kind have occurred. The maximum time of paralysis occurs four to five days following the injection, and then gradually diminishes, depending on the dose. The maximum correction of strabismus has been 40 prism diopters. The maximum follow-up following injection is six months. Injection of botulinum A toxin into extraocular muscle to weaken the muscle appears to be a practical adjunct or alternative to surgical correction.     

Adjustable Augmented Rectus Muscle Transposition Surgery with or Without Ciliary Vessel Sparing for Abduction Deficiencies

Background: Vertical rectus transposition (VRT) is useful in abduction deficiencies. Posterior fixation sutures enhance the effect of VRT, but usually preclude the use of adjustable sutures. Augmentation of VRT by resection of the transposed muscles allows for an adjustable technique that can reduce induced vertical deviations and overcorrections.

Methods: We retrospectively reviewed the records of all patients undergoing adjustable partial or full tendon VRT augmented by resection of the transposed muscles. Ciliary vessels were preserved in most of the patients by either splitting the transposed muscle or by dragging the transposed muscle without disrupting the muscle insertion.

Results: Seven patients with abducens palsy and one with esotropic Duane syndrome were included. Both vertical rectus muscles were symmetrically resected by 3–5?mm. Preoperative central gaze esotropia of 30.6?±?12.9Δ (range, 17–50Δ) decreased to 10.6?±?8.8Δ (range, 0–25Δ) at the final visit (p?=?0.003). Three patients required postoperative adjustment by recession of one of the transposed muscles due to an induced vertical deviation (mean 9.3Δ reduced to 0Δ), coupled with overcorrection (mean exotropia 11.3Δ reduced to 0 in two patients and exophoria 2Δ in one patient). At the final follow-up visit 3.8?±?2.6 months postoperatively, one patient had a vertical deviation <4Δ, and none had overcorrection or anterior segment ischemia. Three patients required further surgery for recurrent esotropia.

Conclusions: Augmentation of VRT by resection of the transposed muscles can be performed with adjustable sutures and vessel-sparing technique. This allows for postoperative control of overcorrections and induced vertical deviations as well as less risk of anterior segment ischemia.     

Experimental Study on the Prevention of Anterior Segment Ischemia by Preservation of Anterior Ciliary Vessels

Purpose: To observe the effect of preserving anterior ciliary vessels (ACVs) on anterior segments of rabbit eyes undergoing tenotomy of extraocular muscles. Methods: Thirty-two adult New Zealand white rabbits were divided into four groups. Same procedures were done in both eyes in each group except that left eyes underwent preservation of ACVs. In the first group medial and lateral recti, in the second group, superior and inferior recti, in the third group, medial, lateral and superior or inferior recti and in the fourth group, all four recti, underwent tenotomy. Slit-lamp examination, intraocular pressure (IOP) measurement, total protein and lactic acid quantification in aqueous humor were done in all eyes pre- and post-operatively. By four weeks after operation, the eyes were enucleated for histological examination and electron microscopy. All data were analyzed using SPSS version 10.Results: In the left eyes of both group 1 and group 2, no inflammatory response was observed. In the left eyes of group     

Rectus Muscle Resection for Vertical Strabismus in Thyroid Eye Disease

Purpose: Rectus muscle resection in thyroid eye disease (TED) is generally avoided due to the risk of worsening restriction or reactivating inflammation. However, for some patients with large-angle strabismus or diplopia in primary gaze despite maximum recession surgery, rectus muscle resection may be beneficial. We report our surgical experience with rectus muscle resection in the management of vertical strabismus associated with TED.

Methods: Retrospective review of eight patients with TED and vertical diplopia who underwent vertical rectus muscle resection by a single surgeon (IBM) at a tertiary referral centre in Liverpool, UK, from 2001 to 2013. The goal of surgery was elimination of diplopia in primary and reading position. Vertical deviations were measured in prism dioptres (^?) before and after surgery at one month, four months and final visit by prism alternate cover testing at ? m and 6 m.

Results: The mean ± standard deviation vertical deviation for near and distance reduced significantly from 14.2^? ± 8.4^? and 15.8^? ± 8.8^? pre-operatively to 5.7^? ± 4.9^? and 6.7^? ± 7^? at the four-month visit, respectively (p< 0.05). At the four-month follow-up, five (62.5%) patients achieved binocular single vision in primary and reading position with either no prisms or prisms less than 5^?. Further recession surgery, Harada-Ito procedure, or lateral rectus resection were necessary in four (50%) patients with persistent diplopia. No patient developed recurrence of inflammation or increased muscle restriction.

Conclusions: Vertical rectus resection could be considered as an additional surgical strategy in the management of TED patients with vertical strabismus without adverse sequelae.     

Role of Inferior Rectus Botulinum Toxin Injection in Iatrogenic Vertical Strabismus

Introduction: We describe the uses and effectiveness of botulinum toxin to the inferior rectus muscle in iatrogenic vertical strabismus.

Methods: A retrospective review of our database to identify patients who had undergone inferior rectus botulinum toxin injection between 1982 and 2006 for iatrogenic vertical strabismus.

Results: There were 13 patients, 5 female, with an age range of 14 to 78 years. Eight left eyes were injected. The mean period of follow-up was 3.3 years. Etiologies included post–local anesthetic, post–plaque radiotherapy for malignant melanoma, adherence syndrome after inferior oblique surgery, and post–botulinum toxin to the levator muscle to produce a temporary therapeutic ptosis. Reversal on first injection occurred in 7 patients and occurred in a further 2 patients on second injection. Pre-injection binocularity was not demonstrable in 3 patients; 2 of these patients did have binocular vision demonstrable after botulinum toxin injection. Seven patients had one injection, 3 patients had two, 1 had three, 1 had five, and 1 had six.

Discussion: The data demonstrate the range of indications that can be successfully treated and managed with inferior rectus botulinum toxin injection in iatrogenic vertical strabismus.     

直肌边缘切开联合楔形切除治疗儿童共同性斜视的远期疗效观察

目的 探讨儿童直肌边缘切开联合楔形切除治疗共同性斜视的远期临床效果.方法 回顾性分析477例共同性斜视患者,其中儿童组(年龄≤15岁)247例,成人组(年龄＞15岁)230例.对儿童组和成人组以及儿童组中不同斜视度的治疗效果进行了对比分析,随访时间12个月至5年.结果 儿童组和成人组手术时间为(9.47±1.35)min、(10.42±1.54)min,术后12个月的正位率分别为76.9%、83.9%;术后12个月的残斜视度分别为(15.45±3.52)△、(8.24±3.10)△.两组比较,手术时间差异有统计学意义(P＜0.01).两组相比,获得双眼单视功能的,儿童组所占比例为59.1%,成人组仅为43.5%,差异有统计学意义(P＜0.01).建立立体视觉的,儿童组所占比例为32.8%,成人组仅为18.7%,差异也有统计学意义(P＜0.01).当内外斜视度数小于20度(35△)、介于20度(35△)与30度(53△)之间、高于30度(53△)时,双眼直肌边缘切开的一次手术成功率分别为94.1%、84.7%、12.0%.结论 儿童直肌边缘切开联合楔形切除治疗共同性斜视是一种安全、远期疗效好的方法.儿童组在正位率方面略低于成人组,但在双眼单视功能和立体视觉方面儿童组优于成人组.儿童组中随着斜视度数的增高,双眼直肌边缘切开的一次手术成功率逐渐下降.当斜视度数高于30. (53△)时需联合其他肌肉手术.     

Re-recession of the Medial Rectus Muscles in patients with recurrent esotropia

PURPOSE: Retrospective evaluation of changes in ocular motility after surgical re-recession of the medial rectus (MR) muscles as treatment of recurrent esotropia (ET). METHODS: We describe 115 patients (age, 11 months-77 years; median, 11.1 years; 83 children and 32 adults) with an average amount of non-accommodative ET before surgery of 18.7 PD (SD = 8.8 PD). Preoperative alignment, amount of re-recession, distance from insertion to the limbus, and postoperative alignment and versions were collected. RESULTS: In most cases, MR muscles were re-recessed to a fixed distance of 12 mm from the limbus, with unilateral re-recessions in cases with relatively small ET (typically < 20 PD) and bilateral re-recessions in cases with larger amounts of ET (typically > 20 PD). No clear relation was found between the amount of re-recession and the change in alignment in prism diopters. The success rate (esotropia [ET] < or = 10 PD or exotropia [XT] < or = 8 PD) 4 weeks to 8 months after surgery was 85%, with 4 patients still showing ET and 13 patients showing XT. Incidence of XT was higher for bilateral than for unilateral re- recessions. Significant underaction of the MR muscles was noted in 7% of the patients. None of the undercorrected patients and only 1 of the overcorrected patients were adults. Among adults, incidence of MR underaction was 4%. Long-term follow-up (8-120 months; median, 25 months) data from 59 patients indicated that good stability in alignment can be expected. CONCLUSION: The results support the notion that MR re-recession to 12 mm from the limbus successfully corrects recurrent ET up to 35 PD and that it is particularly effective in adults.     

Polyglycolic Acid Sutures in Strabismus Surgery

S ummary
T he trial of 1·5 metric (4/0) polyglycolic acid suture was conducted in extra-ocular muscle surgery using the patient as his own control in 25 cases. It is suitable for this purpose and has some advantages over the currently available sutures with little disadvantage.     

Oculocardiac Reflex during Strabismus Surgery: Experience from a Tertiary Hospital

Purpose: To evaluate the incidence of the oculocardiac reflex (OCR) and its associated risk factors during strabismus surgery at a tertiary referral center.

Methods: Over a 2-year period, all strabismus surgery candidates were enrolled in the study. OCR was defined as heart rate reduction ≥15% after traction on extraocular muscle(s). The rate of OCR was determined and possible associations were explored. Variables included age, gender, type of strabismus, nature of surgery (weakening versus strengthening), specified extraocular muscle, times of surgery, and the sequence of operated muscles (eg, first, second, or third operated muscle). We avoided the use of atropine pre- and postoperatively.

Results: Seventy-six patients with mean age of 15±12 years were enrolled; 51.3% of subjects were male. OCR occurred in 65 out of 76 (85.5%) patients and with 84 out of 173 (48.6%) operated muscles. OCR was more common in subjects less than 20 years of age; however, it showed a decreasing trend afterwards. OCR was more frequent during operation on cyclovertical muscles than horizontal recti (P=0.02). Moreover, during procedures on horizontal rectus muscles, OCR was more common if baseline heart rate was more than 61 (P=0.008). OCR was not correlated with gender, type of strabismus, nature of surgery, times of the surgery, or the sequence of operated extraocular muscles.

Conclusions: The great majority of patients undergoing strabismus surgery, especially younger subjects, those undergoing operation on cyclovertical muscles, and subjects with higher baseline heart rate, experience OCR during strabismus surgery. During surgery on cyclovertical muscles, the amount of pull is usually more due to more difficult exposure.