Particular surgical aspects in strabismus surgery. Vincent Paris

Transcription

1 Particular surgical aspects in strabismus surgery Vincent Paris Spring meeting BSA 2009

2 Plan of the presentation Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

3 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

4 In case of total III nerve palsy : use of residual functional muscle Kaufmann

5 In case of partial III nerve palsy Transposition of the two adjacent sound recti in the direction of the maximal palsy position ( Kaufmann ) See book of Roth & Speeg-Schatz : La chirurgie oculomotrice 1995 Masson Ed

6 III nerve palsy

7 Displacement of the inferior oblique Supply of Inferior Rectus function Supply of Superior Oblique function With resection

8 Supply of IR : displacement of the IO at the tendon of the IR Olitsky JPOS 2000, 2005, Gamio BV 2002 resection with

9 Here : efficacy of a standard method

10 Variation of the technique Simultaneous downward transposition of the medial rectus for lost inferior rectus Asadi & Falavarjani J AAPOS 2006;10;6: Better control of the deviation on downgaze that classical inversed Knapp procedure

11 MR LR IO

12 Supply of the SO Stager transposition in the nasal quadrant BV 2001;16 (1) ; Independantly performed by Annie Putteman in a case of rupture of the SO in 2004 another belgian story..

13 Right absence of SO Excyclo 20 in downgaze.

14 IO resection ( 5mm ) and displacement 5 mm behind the inferior part of the MR IO MR Suppression of diplopia..!

15 RESULT Excyclo 6 in downgaze No more diplopia in daily life conditions? Drives again, lives again : patient HAPPY

16 Apert syndrome with absence of both IR and SO on the right eye

17 After a simple transposition and a 8mm resection of the IO..

18 Just a look for compensation of macular rotation

19 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

20 Available techniques Oblique slipping of the superior or inferior part of the muscle ( slanting ) Roth A, Speeg-Schatz C, la chirurgie oculo-motrice, Masson 1995,

21 Available Techniques Vertical slipping ( Costenbader-Knapp 1959)

22 Medial rectus is moved to OPEN the alphabetic pattern : Up for A / Down for V Lateral Rectus is moved to CLOSE the alphabetic pattern : Down for A / Up for A Along the spiral of Tillaux

23 Efficiency of vertical slipping Bietti, Boyd ( ) : D ( A ) Biedner ( 1994 ) : V éso D Garrido ( 2004 ) : 11.4 ( A eso ) Gravier ( 2006 ) : D efficacy of monolateral surgery in intermittent exotropia «mean efficiency : 3D / mm slipping» (Roth)

24 Efficiency of vertical slanting Ohba ( 2004 ) : 10 D ( V exo ) 20 D ( A ) Exemple of slanting resection

25 Consequences When treating more than 15 D of incomitance Slipping of four horizontal muscles Association of both slipping and slanting

26 Result after 2 successive steps for V exo with 40 D of incomitance! Step 1 : slipping 5 mm + resection 7.5 mm of both MR Step 2 : slipping 5 mm + recession 7 mm of both LR X 10 up gaze 0 to E 2 downgaze

27 Particular cases V Eso Normosenrial only in 20 upgaze 30 D of incomitance

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29 Slipping + Slanting techniques : displacement of 3 mm «Stairs Technique»

30 Perfect Result

31 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

32 Goal of the technique Treating the incomitance Without using Faden Operation Easy to perform Easy to re operate!

33 History Alan B Scott 1994 VII th ISA congress posterior fixation : adjustable without posterior suture..based on a large resection associated with a larger recession Based on mathematic model from Miller!! 3 cases in horizontal incomitance

34 Bock, Buckley and Freedman 1999 J AAPOS Application of Scott s technique also in vertical surgery 3 5 mm resection 6 10 mm recession ( adjustable ) Thacker, Velez and Rosenbaum 2005 J AAPOS

35 Other applications John Lee et al 2007 J AAPOS - 22 patients : 12 LR, 7 IR, 3 MR, 3 SR - resection : 5 6 mm ( 7 for LR ) - recession : adjustable - improvement in gaze incomitance in all but one Cordonnier 2007 BSA - 2 patients : resection 5 recession 10 adjustable - good result after failure of myopexia on IR - good result in Brown syndr

36 Other application Ramasamy et al J AAPOS patients for convergence excess - bilat recess/resec in MR ( +/- equal ) - non adjustable Our experience - 5 patients for overcorrection : 3 exo, 1 hypo, 1 eso - perfect result with 4-5 mm resection on site

37 Incomitant overcorrection after IR recession Lack of binocular vision in lateral gaze

38 Perfect result after 4 mm IR resection and 1mm advancement

39 New idea but old practice Our experience in adjustable suture since many years In very unpredictable cases, we perform resection of 3 5 mm associated with hang back suture

40 One rectus muscle recess/ resec Take place beside/ in place to myopexia Efficient in muscles where myopexia is less effective : IR and LR Simple to perform in complicate cases as primary or secondary procedure But myopexia still remains! Elongation test could also lead to associated plication

41 Resection and myopexia ( personal experience ) In case of laxity of the rectus ( elongation test ) In case of inverse deviation ( from near to distance ) - primary - secondary Variation : myopexia in MR and recession of LR Alain Spielmann 2005 JFO

42 Particular case Consecutive exotropia and residual convergence excess Advancement of the MR associated with myopexia

43 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

44 In non-accommodative convergence excess / fixation-linked Large MR recession combined with smaller LR recession Alternative to myopexia De Clippeleire, Apers, Van Eecckoute,Van Lammeren, Janssens 1992 ESA

45 In important nystagmus without null point position Large recession of 8 10 mm Helveston, Spielmann, Gomez de Liano Better vision in some desperate cases. Sometime post op torticollis

46 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

47 IR recession : risk of overcorrection Associated with its anatomy Dual insertion : to the globe and to the tarsus through its capsulo-palpebral head Postop progressive traction

48 Particular aspect of IR surgery Fixed suspension of the capsulo-palpebral head ( Jampolsky 1986, Spielmann 1993) Semi-adjustable suture ( Campos 1990 ) ( only adjustment in the middle of the muscle ) Use of non absorbable suture (Parsa, Guyton ESA 2004) Recession of 90% of posterior fibers! ( Gokygit et al ISA 2006 ) Self adjustment of small amount of recession in thyroid-associated retinopathy ( Evens, Godts IOA 2008 )

49 Left IR fibrosis

50 Overcorrection in spite of Fixed with nonabsorbable suture Let undercorrected

51 Stable result after repositioning ( F up 1 year )

52 Consequences Avoid to perform IR recession if possible If IR recession is necessary : Prefer non-absorbable suture Limit the dosage to 4 mm

53 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

54 Rectus muscle and torsion Useful when oblique surgery is limited rectus muscles can be transposed Nasal transposition of IR in case of residual excyclo in downgaze Vertical recti splitting for large head tilt associated with nystagmus ( Von Noorden 1991 )

55 Spielmann technique Partial recession technique of Spielmann for head tilt and nystagmus

56 New deal in macula translocation: De Clippeleir technique

57 Rectus muscle in case of IV nerve complete palsy Logical ( no oblique innervation ) Rare High dosage is necessary Lack of learning curve Better after performing surgery for macular rotation

58 Right pareusis and left real IV nerve palsy Maximal surgery on obliques + lateral transposition of SR and IR ( still undercorrected )

59 7 steps of surgery for right pareusis and left real IV nerve palsy OS : IR moved nasally, MR moved up, scarring tissue moved from the temporal to the nasal quadrant!!! ( Spielmann copyright ) 3 cases published

60 Preop : residual subjective excyclo 16 Incyclo / 0 subj

61 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

62 Idea : when one muscle creates excessive restriction it has to be Alan B Scott again!! : muscle attachment to the orbital wall

63 Application to Duane with vertical deviation of mechanical type ( with transposition ) Parsa ISA 2006 Good result in 3 cases Ozkan ESA 2008 Residual retraction in 3 cases ( < transposition? )

64 Persistance of vertical deviation after recession of both Medial and

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66 Other application IO periostic fixation for recurrent IOOA LR periostic fixation in a case mitochondrial myopathy operated 3 times with maximal surgery

67 Hard surgery for small result but better than before

68 Different supply technique Alphabetic syndrome and normal oblique function Simultaneous resection and recession Both recession of horizontal recti Particular aspects of inferior rectus surgery Rectus surgery for torsion Periostic fixation Yokoyama technique in high myopia

69 New theory of heavy eye syndrome 2000 Yokoyama and coworkers Myopic staphyloma dislocates the eyeball out of the muscle cone in the superotemporal quadrant, pushing aside the SR and LR muscle

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71 Pushing the globe during the movement to the left : the left eye became capable to pass the midline Still hypo and eso when pushing in primary position

72 New surgical technique Principle of replacing the globe into the muscle cone By means of non absorbable sutures put like a bridge between the SR and the LR ( 11 mm from the insertion ) + 8 mm MR recession

73 Perfect result : straight eyes in PP and normalization of abduction It remains to determine when associated MR is necessary

74 To mention A few words about the dictatorship of Demer and his MRI patients with V and IOOA have to receive a MRI before surgery recession of IR in SO palsy is a physiologic therapy. 2008

75 Of course, some rare motility disorder can be explained by the asymmetric situations of the pulleys and offer some particular applications..

76 From a clinical point of view Some pulleys disorders can be investigated during surgery Heavy eye syndrome is not completely explained by the pulleys Cases resolved only by MRI are rare!

77 A last remark about traction suture In some recurrent case Non-absorbable material fixed between the sclera and the lid In the direction opposed to the deviation Ozkan J AAPOS 2006 : use of Botox in large angle exotropia with conventional resec/resess chemical traction suture

78 You must have Surgical management of strabismus EM HELVESTON The 5th edition just arrives!! Clear! Cases report La chirurgie oculo-motrice A ROTH C SPEEG- SCHATZ International literature! Complete

79 Thank you for your attention..