Simulation of complex strabismus surgical procedures on goat eyes.

PURPOSE: To describe the possibility of complex strabismus surgical simulation on goat eyes. METHODS: The goat eyes were procured from local slaughterhouse with retained extra ocular muscle tissues. The obtained eyes were inspected for globe integrity, muscle quality, muscle length, and the surrounding teno-conjunctival layers. The included eyes were then segregated for surgical simulation based on their insertion and orientation (as oblique or recti), and they were mounted on a mannequin head, with a fixation suture at free end to simulate the resting tension. Additionally, as per necessary, extra muscles were also transplanted along desired sites to simulate human extra ocular muscle anatomy. RESULTS: The inferior oblique, superior oblique, and all other four recti were successfully simulated in varying proportions in more than 50 eyes. Primarily, by simulating the lateral rectus, inferior rectus, and the inferior oblique muscle, staged weakening procedures of inferior oblique were successfully practiced (Fink's recession, Park's recession, Elliot and Nankin procedure, total anterior positioning, and antero-nasal trans-position or Stager's procedure). Similarly, by simulating superior rectus, inferior rectus, lateral rectus, and the medial rectus muscles, half width transposition, full width transposition, and other complex procedures were practiced (Knapp's procedure, augmented Knapp's, Nishida's procedure, Faden operation, and Y splitting procedure). Furthermore, by simulating superior oblique and the superior rectus muscles, superior oblique tuck, posterior tenectomy, loop tenotomy, and Harada Ito procedures were successfully practiced. CONCLUSIONS: On goat eyes, the complex strabismus surgical procedures can be successfully simulated and practiced after re-organizing the existing muscles in different patterns.

Transplante autólogo de músculo ocular extrínseco para tratamento cirúrgico de estrabismos sensoriais grandes / Autologous graft of extraocular muscle to treat large angle sensory strabismus

RESUMO Apresenta-se uma série de 13 casos de pacientes com estrabismo sensorial de grande ângulo submetidos à técnica cirúrgica de autotransplante da musculatura ocular extrínseca. Foi realizada a técnica de recuo-ressecção dos músculos retos horizontais, e o retalho retirado do músculo ressecado foi suturado ao músculo enfraquecido como expansor autólogo. Foram avaliadas seis exotropias e sete esotropias, com desvios médios de 75 (70-90) dioptrias prismáticas (DP). Houve melhora significativa dos desvios no pós-operatório, sendo a média pós-operatória de 10,07 dioptrias prismáticas (ortotropia a 35DP). Somente um dos casos evoluiu com inversão do desvio após procedimento cirúrgico.

ABSTRACT We report 13 cases of large angle sensory strabismus treated with autologous graft of extraocular muscle. Recession-resection procedure of the horizontal rectus muscles was performed, and the flap from the resected muscle was sutured to the weakened muscle as an autologous expander. Six cases of exotropia and seven of esotropia, with mean prism diopter deviation of 75 (range of 70-90). There was significant improvement in the postoperative deviation, and mean prism diopter of 10.07 (range of no deviation to 35). Only one patient progressed with inverted misalignment after the surgical procedure.

Muscle Transplantation for Large Angle Horizontal Strabismus.

Large angle sensory strabismus in the form of esotropia and exotropia often calls for bilateral surgery to correct the primary angle deviation. However, considering patients' reluctance to have surgery on the good eye, such large deviations may be managed with true muscle transplantation. The authors present a case series of four patients with large angle esotropia and exotropia who underwent unilateral true muscle transplantation as a single-stage procedure. [J Pediatr Ophthalmol Strabismus. 2020;57:e59-e62.].

Minimal invasive vertical muscle transposition for the treatment of large angle exotropia due to congenital medial rectus hypoplasia: Case Report and Literature Review.

Reports of isolated anomalies of the medial rectus (MR) muscle in literature are sparse. It has been identified as a subtype of congenital cranial dysinnervation disorder that affects the normal development of brainstem motor neurons. Herein, we report a 37-year-old male presented with large-angle exotropia since the birth of right eye with palpebral fissure widening. On examination of ocular movements, there was -6 limitation of adduction. There was no limitation in other ocular movements. In the preoperative CT scan, all extraocular muscles were present. He underwent surgery in right eye. Intraoperatively in the site of medial rectus, we found an empty sheath without muscle fibers indicating medial rectus hypoplasia. The width of muscle insertion was normal. Surgery consisted of lateral rectus muscle recession 10 mm in hang-back method and vertical muscle transposition procedure, by a modification of Nishida technique, in which the vector of superior and inferior recti was transposed medially by inserting non-absorbable sutures at nasal margins of muscles secured to sclera 8 mm posterior to medial rectus site without tenotomy or splitting. The deviation was decreased to less than 10 PD exotropia in primary position. The adduction was improved from -6 to -4. The palpebral fissure asymmetry was also corrected. Here, we also reviewed clinical features of all cases of medial rectus hypoplasia/aplasia in the literature and discussed surgical approaches. For vertical rectus transposition and horizontal muscle weakening, this technique has the advantages of being simpler and less traumatic to ocular tissues and unlike the traditional transposition procedures, there is no need for tenotomy and splitting.

Improved Function of Orbicularis Oculi by Dynamic Transfer of Contralateral Orbicularis Oculi Muscle in Patients with Facial Palsy.

PURPOSE: The purpose of this study is to introduce the results of a new surgical technique in patients with complete facial nerve palsy using the dynamic muscle transfer of orbicularis oculi muscle (OOM) flap from the contralateral side. METHODS: This case series presents a new surgical technique in three patients with complete facial palsy and lagophthalmos who were unresponsive to other modalities. In this technique, a rectangular flap of OOM was dissected from the upper lid of fellow eye and transferred to the affected eye through a subcutaneous tunnel over the nasal bridge. The flap was divided into two halves for upper and lower lids. Each half was incised longitudinally to increase the length of the flap and cover the lateral part of the affected eyelids. RESULTS: Improvement in exposure keratitis, lagophthalmos, and other related symptoms was observed as soon as the 1st week after the surgery. Partial blinking recovered and the operation was uneventful. CONCLUSION: Muscle flap transfer technique using contralateral OOM for complete facial palsy can be considered as a helpful alternative in patients who are still symptomatic despite conventional treatment modalities.

Fascia lata augmented nasal transposition of split lateral rectus in complete oculomotor nerve palsy with a previous failed surgery.

PURPOSE: To report our experience in the management of a complete oculomotor nerve palsy with a previous failed surgery. METHODS: We used a fascia lata augmented nasal transposition of the split lateral rectus in a patient who had complete oculomotor nerve palsy with recurrent exotropia after previous recession-resection surgery. The lateral rectus muscle was split in half, and then joined end-to-end with fascia strips with a 5-0 polyester nonabsorbable suture. The superior and inferior fascia strips were transposed to the adjacent of the superior and inferior corners of the insertion of medial rectus. With the globe being adducted about 10 degrees, the strips were sutured on the globe using fixed 5-0 polyester sutures. RESULTS: The patient showed orthotropic alignment at the primary position at the 5-month post-operation follow-up. CONCLUSION: With adequate preoperative imaging-aided evaluation and meticulous intraoperative exploration, fascia lata augmented nasal transposition of split lateral rectus could be an option of treatment for complete oculomotor nerve palsy after a previous failed surgery.

Inferior oblique belly transposition for V pattern strabismus.

Purpose: Monocular transposition of the inferior oblique muscle belly (IOMBT) effectively weakened mild to moderate inferior oblique overaction and corrected small primary position hypertropia. Now we aim to evaluate the efficacy of inferior oblique muscle belly transposition (IOMBT) in treating V pattern strabismus with upshoot in adduction.Methods: This is a retrospective review of 13 patients with V pattern who underwent IOMBT procedure from January 2017 to December 2018. The inclusion criteria were: the amount of V pattern from 15 to 25 pd; the degree of upshoot in adduction from +1 to +3; no or trace vertical deviation in primary gaze position. Bilateral IOMBT was performed to reduce the V pattern. Horizontal rectus muscle surgery was performed at the same stage to correct the horizontal deviation. The angle of deviation in upgaze and downgaze was measured pre- and postoperatively. The degree of elevation in adduction was graded. The amount of V pattern was the difference in horizontal angle between up- and downgaze. The change in the amount of V pattern was assessed postoperatively.Results: All 13 patients had complete resolution of the V pattern. The amount of V pattern changed from 18.92 ± 4.310 prism diopters to 3.462 ± 1.854 prism diopters postoperatively. The mean grade of upshoot in adduction changed from 1.92 to 0.12 postoperatively. No depression in adduction or consecutive A pattern were found after surgery.Conclusions: IOMBT can successfully eliminate the V pattern in patients with mild V pattern esotropia or exotropia with mild to moderate upshoot in adduction. This procedure appears to be a useful addition to our inferior oblique surgical armamentarium.

Retroauricular myoperiosteal autograft for orbital implant exposure: 11 years of experience.

PURPOSE: To describe our experience with retroauricular myoperiosteal autograft for surgical coverage of exposed orbital implants. METHODS: This was a single-center, retrospective, observational cohort study, in which demographic and clinical data were compiled by reviewing the clinical records of anophthalmic patients with implant exposure treated with an autogenous retroauricular myoperiosteal graft at the Instituto de Microcirugía Ocular (IMO, Barcelona, Spain) over the period January 2007 to December 2017. Main outcome was the long-term coverage of implant after retroauricular myoperiosteal autograft; secondary outcome was the rate of post-surgical complications and management. RESULTS: Over the 11-year period, 27 eyes of 27 patients with implant exposure received a retroauricular myoperiosteal autograft. Mean participant age was 47.3 ± 17.9 years (range 9-78, median 45). Primary surgery was enucleation in 8 eyes (29.6%) and evisceration in 19 (70.4%). Implant materials were porous polyethylene in 17 (63%), hydroxyapatite in 3 (11.1%), and bioceramics in 4 (14.8%). In the remaining three patients (11.1%), the implant material and size were unknown. Implant exposure was diagnosed after a mean of 98 ± 111.7 months. Mean exposure diameter was 5.9 ± 3.1 mm. Mean follow-up duration after graft surgery was 37.5 ± 39 months. In four patients (14.8%), implant re-exposure was recorded and in two of these patients a re-graft using the same technique was performed. In the last follow-up session, all patients showed good implant coverage. CONCLUSIONS: Myoperiosteal graft could be a valid option for the long-term management of implant exposure irrespective of primary surgery, exposed area, and implant material.

A new application of modified Nishida muscle transposition procedure for medial rectus muscle transection following endoscopic sinus surgery without tenotomy or splitting muscles.

The modified Nishida muscle transposition procedure, in which the one-third of the vertical rectus muscle bellies are sutured onto the sclera in the infero- and superotemporal quadrants without either tenotomy of the vertical rectus muscles or splitting of the vertical rectus muscle is an effective treatment for abducens nerve palsy. We report 2 cases of large-angle exotropia caused by medial rectus transection following the endoscopic sinus surgery treated using the modified Nishida procedure to transpose both vertical rectus muscles nasally, combined with lateral rectus muscle recession.

Unilateral inferior oblique anterior transposition for markedly asymmetric dissociated vertical deviation with unilateral inferior oblique over-action.

BACKGROUND: To evaluate the results of unilateral inferior oblique anterior transposition (IOAT) for markedly asymmetric dissociated vertical deviation (DVD) combined with inferior oblique over-action (IOOA). METHODS: Retrospective chart review of the records of all patients with asymmetric DVD combined with unilateral IOOA in the non-dominant eye who received unilateral IOAT on the non-dominant eye. No other muscles were operated on simultaneously. The amount of DVD and IOOA were measured before and after the operation and statistically analysed. RESULTS: Seventeen patients were included. The mean age at surgery was 23.5 ± 8.4 (range 12-38) years old. The mean postoperative follow-up period was 15.7 ± 7.2 (range 6-32) months. The primary position DVD was 19.6 ± 5.4 (range 14-36) PD preoperatively and decreased significantly to 2.9 ± 2.0 (range 0-8) PD postoperatively (P < 0.01). Preoperatively, there were 2, 7, and 8 patients with + 1, + 2, and + 3 IOOA, respectively, and these were reduced from 2.4 ± 0.7 to 0.3 ± 0.4 postoperatively (P < 0.01). None of the patients were complicated obvious hypotropia, anti-elevation syndrome or IOOA in the contralateral eye. CONCLUSIONS: Unilateral IOAT was recommended in patients with asymmetric DVD coexists with unilateral IOOA.

[Corrective Surgery of Severe Esotropia after Decompression in Patients with Graves' Orbitopathy - Comparison of Tendon Elongation and Recession of the Medial Rectus Muscle]. / Korrektur horizontaler Schielwinkel nach Dekompressionsoperation bei Patienten mit endokriner Orbitopathie ­ Vergleich von Sehnenverlängerung und einfacher Rücklagerung des M. rectus medialis.

BACKGROUND: Patients with Graves' orbitopathy (GO) often show severe esotropia after decompression surgery, especially in cases with severe enlargement of muscles before decompression. In severely afflicted patients, simple recessions of the medial rectus muscle are not sufficient. In these patients, tendon elongation with bovine pericardium (Tutopatch®) is an alternative for simultaneous resection of the lateral rectus muscle. We retrospectively analysed our clinical data of patients who underwent corrective surgery of the medial rectus following three-wall decompression surgery. METHODS: Patients who underwent classical uni- or bilateral medial recession (MR, BMR; n = 87) or bilateral medial recessions combined with tendon elongation with a graft at one or both muscles (n = 60), were analysed for surgical success (≤ 10 Δ esotropia, central 20° field of binocular single vision), dose effect (° per mm recession/elongation distance) and postoperative ductions. Clinical data directly after surgery and 3 and 12 months later were evaluated in a retrospective manner. RESULTS: All patients showed lower dose effects compared to medial recessions without prior decompression: Unilateral recession 1.2 ± 0.4°/mm, bilateral 1.0 ± 0.3°/mm, unilateral tendon elongation with contralateral simple recession 0.92 ± 0.3°/mm and bilateral tendon elongation 0.87 ± 0.3°/mm. Because of a preoperatively overestimated dose effect, some patients showed undercorrections after surgery. Under consideration of the actual dose effect, surgical success could often be achieved in these severely afflicted GO patients: After simple recessions in 90% and after tendon elongations in 70% of patients. CONCLUSIONS: In patients following three-wall decompression, higher dosages have to be used for medial recessions and recessions with tendon elongation than with patients without prior decompression. Simple recessions are therefore only to be recommended up to 15° esotropia. In more severe cases up to 25°, tendon elongation can be used.

A modified vertical muscle transposition for the treatment of large-angle esotropia due to sixth nerve palsy.

INTRODUCTION: Multiple different procedures have been proposed to address complete sixth nerve palsy with severe abduction limitation. In this study, we report a modification of the Hummelsheim's procedure. It is in fact muscle pulley transposition that obviates the need for tenotomy or muscle splitting. For the first time, Muraki and Nishida proposed this technique. MATERIALS AND METHODS: Patients with large angle esotropia and abduction limitation of minus four or greater were enrolled. The surgery involved insertion of a polyester monofilament fiber suture through the temporal muscular margin of each vertical rectus muscle at approximately one-third of the width from the edge at 10 mm behind the muscle insertion. We tried to insert sutures away from the vessels of vertical muscles. Then, the vertical muscles were transposed without any tenotomy or splitting and the sutures were secured to the sclera 16 mm from the limbus in supratemporal and infratemporal quadrants. In all of the patients, this transposition was combined with medial rectus recession. RESULTS: A total of 10 patients were included; all of them had an esotropia with profound abduction deficit (-4 or more). The mean age of patients was 44.2 ± 9.2 years (mean ± standard deviation) (range: 28-57). The mean preoperative deviation was 49.5 ± 9 PD prism diopters (PD) (range: 40-65 PD). The mean preoperative abduction limitation was -4.8 ± 0.8. The patients were followed for at least 6 months. Postoperative deviation ranged from orthotropia to 12 PD of esotropia and all the patients obtained abduction at least beyond the midline. No vertical ductional disturbances or deviations were developed. The adduction was not compromised in any patient. Anterior segment ischemia did not occur in any patients. CONCLUSION: This procedure is comparable to traditional procedures with the advantages of no need to tenotomy or splitting and can be a good alternative to conventional Hummelsheim's procedure.

[Foster Modification of Full Tendon Transposition of Vertical Rectus Muscles for Sixth Nerve Palsy]. / Komplette vertikale Transposition der Vertikalmotoren modifiziert nach Foster als Operationstechnik für Abduzensparese.

INTRODUCTION: Since 1907 a variety of muscle transposition procedures for the treatment of abducens nerve palsy has been established internationally. Full tendon transposition of the vertical rectus muscle was initially described by O'Connor 1935 and then augmented by Foster 1997 with addition of posterior fixation sutures on the vertical rectus muscle. Full tendon transposition augmented by Foster belongs to the group of the most powerful surgical techniques to improve the abduction. Purpose of this study was to evaluate the results of full tendon vertical rectus transposition augmented with lateral fixation suture for patients with abducens nerve palsy. METHODS AND RESULTS: Full tendon transpositions of vertical rectus muscles augmented with posterior fixation suture was performed in 2014 on five patients with abducens nerve palsy. Two of the patients received Botox injections in the medial rectus muscle: one of them three months after the surgery and another during the surgery. One of the patients had a combined surgery of the horizontal muscles one year before. On three of the patients, who received a pure transposition surgery, the preoperative deviation at the distance (mean: + 56.6 pd; range: + 40 to + 80 pd) was reduced by a mean of 39.6 pd (range 34 to 50 pd), the abduction was improved by a mean of 3 mm (range 2 to 4 mm). The other two patients, who received besides the transposition procedure additional surgeries of the horizontal muscles, the preoperative deviation at the distance (+ 25 and + 126 pd respectively) was reduced by 20 and 81 pd respectively. The abduction was improved by 4 and 8 mm respectively. After surgery two patients developed a vertical deviation with a maximum of 4 pd. None of the patients had complications or signs of anterior segment ischemia. The elevation and/or depression was only marginally affected. There was no diplopia in up- or downgaze. CONCLUSIONS: Full tendon transposition of vertical rectus muscles, augmented with lateral posterior fixation suture is a safe and effective treatment method for abducens nerve palsy and in most cases recession of the medial rectus can be avoided. Upgaze and downgaze are affected very slightly. Diverse studies have shown that the risk of anterior segment ischemia is low.

Combined lateral rectus augmented transposition and inferior rectus recession for monocular elevation deficiency.

We report the case of a 21-year-old woman who presented with a drooping right upper eyelid and smaller-appearing right eye, evident since birth. Her visual acuity was 20/30 in the right eye and 20/20 in the left eye. In primary gaze she had a hypotropia of 25Δ, with a marked elevation limitation and associated true upper lid ptosis of 3 mm. Under local anesthesia, the lateral rectus muscle was transposed to the superior rectus muscle and was augmented by a nonabsorbable suture attaching the superior rectus muscle and lateral rectus muscle 8 mm posterior to the insertion, accompanied by an inferior rectus recession. One year after surgery she was orthophoric in primary position and showed improvement in elevation. The surgical procedure can be performed at the same time as the inferior rectus recession and reduces the risk of anterior segment ischemia.

Augmented superior rectus transposition procedure in Duane retraction syndrome compared with sixth nerve palsy.

PURPOSE: Superior rectus transposition (SRT) with medial rectus recession has been used for the treatment of sixth nerve palsy and esotropic Duane retraction syndrome (DRS). The purpose of this study was to compare the results of augmented SRT (with scleral fixation) without medial rectus recession in DRS and sixth nerve palsy. METHODS: Patients with unilateral esotropic DRS (DRS group) and sixth nerve palsy were included in this prospective, comparative study and underwent SRT. Preoperative forced duction testing was negative or slightly positive in both groups. Prospective measurements were compared between the two groups. RESULTS: There were 11 patients in the DRS group and 11 patients in the sixth nerve palsy group. The mean preoperative esotropia decreased from 20.9 ± 6.0 prism diopter (PD) at far to 13.2 ± 5.8 PD in the DRS group (P = 0.003). The same measurement improved from 28.0 ± 8.5 PD to 8.4 ± 7.3 PD in the sixth nerve palsy group (P = 0.003). In the sixth nerve palsy group, the improvement in primary gaze esotropia and abnormal head posture was more than the DRS group (Both P < 0.001).The average dose effect for SRT was 7.8 ± 2.2 PD in the DRS group and 19.2 ± 4.6 PD in the sixth nerve palsy group. Although objective intorsion was significantly induced after SRT, subjective torsion was not significant after surgery in both groups. CONCLUSION: SRT appears to be more effective in improving primary gaze deviation and head posture in sixth nerve palsy compared with DRS. Subjective torsional and vertical diplopia were rare in both groups.

[Efficacy of Vertical Muscle Transpositions with and without Simultaneous Rectus Muscle Recession for Unilateral Sixth Nerve Palsy]. / Effekt von Muskeltranspositionen nach dem Hummelsheim-Prinzip mit und ohne zeitgleiche Rücklagerung des M. rectus internus.

BACKGROUND: We report results of a modified vertical muscle transposition procedure according to the Hummelsheim principle - with and without simultaneous rectus muscle recession - for unilateral sixth nerve palsy. We examine the influence of the duration of the palsy, preoperative angle of squint and preoperative abductive capacity on surgical results of the procedures. PATIENTS AND METHODS: Retrospective study of 29 consecutive patients with unilateral abducens nerve palsy who underwent surgery between 2001 and 2012. 21 patients had a modified vertical rectus muscle transposition according to the Hummelsheim principle (HUM); 8 patients had this operation combined with simultaneous medial rectus muscle recession (HUM+I). Surgery was performed at least 9 months after onset of the palsy (HUM: 9 to 98, median 19, mean 30 months; HUM+I: 12 to 65, median 25, mean 29 months). RESULTS: The median preoperative angle of squint (far distance) for the HUM group was 27.0° (20.0 to 45.0; mean 28.1°), and for the HUM+I group 30.5° (21.8 to 50.0; mean 33.4°). The median preoperative abductive capacity was for - 1,6 mm before midline (- 8.0 to + 1.2; mean - 1.8 mm) for the HUM group, and - 3.0 mm before midline (- 10.0 to - 1.0; mean - 4.1 mm) for the HUM+I group. The median postoperative angle of squint (far distance) was 0° (- 11.3 to + 20.0; mean 0.1°) for the HUM group, and - 2.3° (- 11.3 to + 12.0; mean - 2.1°) for the HUM+I group. The median postoperative abductive capacity was 1.0 mm (0 to + 3.0; mean + 1.1 mm) for the HUM group, and 1.1 mm (- 1.2 to + 3.0; mean + 0.9 mm) for the HUM+I group. The median reduction of squint angle was 27.0° (9.1 to 45.0; mean 28.0°) for the HUM group, and 36.8° (25.2 to 41.4; mean 35.5°) for the HUM+I group. The median effect on abductive capacity was 2.5 mm (0 to 11.0; mean + 2.9 mm) for the HUM group, and 4.6 mm (2.4 to 8.8; mean + 5.0 mm) for the HUM+I group. In the HUM group, the effect on squint angle reduced with the duration of the palsy, whereas, in the HUM+I group, the effect improved with the duration of the palsy. CONCLUSIONS: For patients with unilateral sixth nerve palsy, simultaneous medial rectus recession increases the effect of modified vertical rectus muscle surgery according to the Hummelsheim principle. The duration of the palsy is a relevant parameter for the selection of a sole or combined intervention with medial rectus recession.

[Autologous tissue reconstruction of tarsal plate combined with temporal flap in repairing full-thickness lower eyelid defect].

OBJECTIVE: To evaluate the clinical effect of combination of autologous tissue reconstruction of tarsal plate with temporal flap on repair of full-thickness lower eyelid defect. 
 Methods: Eleven patients (11 eyes) underwent hard palate mucosa or ear cartilage combined the emporal flap with the orbicularis oculi muscle to repair full-thickness defect of palpebra inferior. Of the 11 patients, 6 had more than 75% eyelid defect area, and 5 had more than 50% eyelid defect area. 
 Results: All 11 eyes closed completely, with no entropion or ectropion, and returned to normal basically. Postoperative follow-up was performed for 6 months to 5 years, 3 years and 4 months on average. The function and form of eyelid remained stable. Infection, leakage or contracture was not found on reconstruction tarsus. 
 Conclusion: Reconstruction of eyelid with autogenous hard palate mucosa or ear cartilage combined the emporal flap with the orbicularis oculi muscle is a simple, convenient and effective method.

Stability and effects of muscle transplantation for very large angle esotropia: A study of 22 patients.

PURPOSE: A very large angle esotropia is characterized by an angle more than 80 prism diopters (pd). A single eye surgery would not correct such a large angle. Supramaximal recessions and resection would lead to restriction of ocular motility. We present a series of 22 patients with large angle esotropia treated with muscle transplantation. METHODS: A total of 22 patients (14 males and 8 females) were included in the study. All the patients had a minimum of 80 base out deviation in primary position. All patients underwent thorough preoperative orthoptic checkup and refraction. The patients were followed up on day 1, day 30, at 6 months, at 1 year, and 2 years. All the patients underwent standard muscle transplantation, where the resected extra stump of lateral rectus was transplanted to the medial rectus using 6-0 prolene which was recessed by a standard recession technique. RESULTS: The mean age of the 22 patients was 32.21 ± 13.1 years. The mean preoperative angle was 92.4 ± 13.5 pd base out. The mean postoperative angle at 2-year follow-up was 12.3 ± 9.9 pd. The average correction achieved per mm was 4.1 ± 0.3 pd. The adduction restriction was <1 in all the patients at the end of 2 years except one patient. The abduction was normal in all the patients. CONCLUSION: The true muscle transplantation is a safe alternate option for large angle esotropia when uniocular surgery is desired. The surgical results are stable in long-term and therefore a viable option.

Anterior and nasal transposition of inferior oblique muscle in cases of superior oblique palsy.

PURPOSE: To report long-term outcome of inferior oblique anterior and nasal transposition in superior oblique palsy. METHODS: The medical records of patients with superior oblique palsy who underwent inferior oblique anterior nasal transposition were reviewed retrospectively. A comprehensive ophthalmic evaluation, including prism bar cover test and measurement of torsion, was performed for all cases. One-year postoperative results were evaluated for alignment in primary gaze, contralateral gaze, and upgaze; reduction in inferior oblique overaction and changes in fundus torsion to assess long-term outcome of the procedure. RESULTS: A total of 12 patients were included. Three cases also underwent horizontal muscle surgery. Mean age at the time of surgery was 20.6 years. The median preoperative hypertropia was 21.5Δ (range, 12Δ-36Δ), corrected to 4.5Δ (range, 2Δ-10Δ) at 12 months postoperatively (P = 0.002). Median inferior oblique overaction decreased from +3 (range, +1 to +4) to 0 (range, -1 to +1). Preoperative fundus extorsion was 19.2° ± 6.7°; postoperative, 0.58° ± 1.8° (P < 0.001). No consecutive hypotropia or underaction in elevation was observed in 10patients; 1 patient complained of torsional diplopia in upgaze. Extorsion was eliminated and head tilt improved in all patients. CONCLUSIONS: Inferior oblique anterior and nasal transposition resulted in good long-term outcomes in our patients with superior oblique palsy presenting with hypertropia, inferior oblique overaction, and extorsion in primary gaze.