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Horizontal Transposition of the Vertical Rectus Muscles for Cyclotropia

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Horizontal Transposition of the Vertical Rectus Muscles for Cyclotropia GUNTER K. VON NOORDEN, MD., RACHAEL H. JENKINS, D.B.O., CO., AND MILTON W. CHU, M.D. • PURPOSE: We studied the effect of horizontal don. It becomes the procedure of choice when transposition of the vertical rectus muscles on surgery on the superior oblique tendon is preclud­ incyclotropia and excyclotropia in terms of the ed, either by the tendon's congenital absence or by amount of correction obtained and the stability of previous surgery on the tendon. Nasal transposi­ the outcome. tion of the superior rectus muscle or temporal • METHOD: Preoperative measurements for cyclo­ transposition of the inferior rectus muscle is ideally tropia were compared in 11 patients with measure­ suited for incyclotropia. No comparably effective ments during the immediate postoperative period operation exists. and last follow-up. Excyclotropia was treated with nasal transposition of the inferior rectus muscle E DEFINE CYCLOTROPIA AS A MANIFEST DE- and incyclotropia with nasal transposition of the viation of one or both eyes around the superior rectus muscle, to which we added tempor­ anteroposterior axis of the globe or al transposition to the inferior rectus muscle in globes. This condition occurs frequently in cycloverti­ one patient to enhance the effect. cal strabismus and usually accompanies any dysfunc­ • RESULTS: Fusion in all gaze positions was re­ tion of one of the oblique muscles. Unless the stored in six patients and functional improvement cyclotropia is of recent onset,1 patients are rarely occurred in five. The average effect of horizontal aware of image torsion because the ocular misalign­ transposition of one vertical rectus muscle for ment is kept latent by cyclofusion or because sensory cyclotropia was a correction of 7 degrees in pri­ or psychological adaptive mechanisms2,3 have devel­ mary position and of 11 degrees in depression. oped. However, once a patient becomes aware of This effect remained stable after a mean follow-up torsional diplopia, the symptoms are rarely tolerated of 17 months, and additional improvement oc­ and surgery is usually indicated. Several approaches curred in one patient. One patient developed a are available. Anterior and lateral displacement of the hypertropia, eliminated by an additional opera­ anterior portion of the superior oblique tendon, tion, in the treated eye. according to Harada and Ito,4 has become an accept­ • CONCLUSIONS: For excyclotropia, nasal trans­ ed mode of treatment for excyclotropia, although this operation cannot be performed when the superior position of the inferior rectus muscle is a viable oblique muscle is congenitally absent or when its alternative to lateral and anterior transposition of tendon has been previously cut. Moreover, no surgical the anterior portion of the superior oblique ten- technique exists for treating incyclotropia that can be performed with equal facility on the inferior oblique Accepted for publication March 4, 1996. muscle. From the Cullen Eye Institute, Baylor College of Medicine, Houston, Texas; and the Ophthalmology Service, Texas Children's Hospital, We have shown that horizontal transposition of Houston, Texas (Dr. von Noorden and Ms. Jenkins). Dr. Chu is in the vertical rectus muscles5 reduces cyclotropia and private practice in Camarillo, California. Reprint requests to Rachael H. Jenkins, CO., Ophthalmology Serv­ that artificial cyclorotation of the eyes created by this ice, Texas Children's Hospital, MC-3-2700, Houston, TX 77030; fax: method benefits patients with congenital nystagmus (713) 796-8110. VOL.122, NO. 3 © AMERICAN JOURNAL OF OPHTHALMOLOGY 1996;122:325-330 325 who have a compensatory head tilt to one shoulder.6 eye while the patient looked at a fixation light held at However, no data are available on the stability of the a 33-cm fixation distance in primary position and a surgical result or on the quantitative effect of this 20-degree depression. A 10-prism diopter prism was operation for cyclotropia. We address these points in inserted base down behind the red Maddox rod to this article and report a complication and its success­ separate the red and white horizontal line seen by the ful management. patient. In three patients, the cyclotropia was also determined in a 20-degree upward gaze. Special care was taken to align the direction of the rods precisely PATIENTS AND METHODS with the 90-degree mark on the trial frame. A scratch mark on the metal frame of the Maddox rods THIS STUDY INCLUDES ALL 11 PATIENTS OPERATED FOR facilitated this alignment. During measurement of the cyclotropia with horizontal transposition of the verti' cyclotropia, with the eyes in depression and elevation, cal rectus muscle since we began employing this the trial frame had to be lifted up or was allowed to procedure in 1989. We have not included one addi­ slide a small distance down the nasal bridge. Compar­ tional patient whose surgical results have been pub­ ing the measurements, often performed by a different lished.5 One of us (G. K. v. N.) operated on Patients orthoptist on subsequent visits, revealed satisfactory 1, 2, 5, and 7 through 10; another (M.W.C.) operated consistency. on Patients 3, 4, and 6. Both used an identical The patients were reexamined on several occasions surgical technique. before surgery, during the immediate postoperative Patients ranged in age from 19 to 68 years. Causes period of six weeks, and at the last follow-up visit, of cyclotropia included unilateral or bilateral superior which occurred at an average of 17 months after oblique muscle paralysis, orbital fractures, myasthenia surgery (range, three to 30 months). Only three gravis, and incomplete tenectomy of one superior patients had a follow-up of less than one year. oblique tendon during bilateral superior oblique te­ All patients complained of torsional diplopia. Di­ nectomy for an A-pattern exotropia, following two plopia was recorded according to whether it was surgical attempts to complete that muscle's tenecto­ limited to downward gaze, present in downward gaze my. Seven patients had undergone previous muscle and primary position, or present in all positions of surgery on one or both eyes: five had had operations gaze. on the superior oblique muscle (tuck, tenectomy, or For excyclotropia, the inferior rectus muscle was Harada-Ito procedure), one had had horizontal mus­ transposed nasally. Incyclotropia was treated with cle surgery, and one had had advancement of a nasal transposition of the superior rectus muscle, previously recessed inferior rectus muscle. temporal transposition of the inferior rectus muscle, During the initial visit, each patient had a com­ or a combination of both (Patient 1). Patient 7, with plete eye examination including visual acuity deter­ incyclotropia of the right eye, had a coexisting right mination, cycloplegic refraction, ocular motility anal­ hypertropia for which the right superior rectus muscle ysis, and a fundus examination. The ocular motility was recessed and nasally transposed. Patient 8 had a examination was performed by an orthoptist and left incyclotropia associated with a left hypertropia, repeated by an ophthalmologist. It consisted of mea­ for which the inferior rectus muscle was resected and suring the deviation with the prism-and-cover test at advanced 2 mm in addition to being transposed a 6-m fixation distance and in the nine diagnostic temporally. The muscle insertions were transposed positions at a 33-cm fixation distance while accom­ one full muscle width in all patients. The width of the modation was controlled. Ductions and versions were insertion and the distance of the nasal and temporal examined, and overacting and underacting muscles edge of the insertion from the limbus were measured graded from —4 (underaction) to +4 (overaction). before detaching the muscle. Special care was taken Cyclotropia was measured with the Maddox double to reattach the temporal and nasal edges of the rod test, as illustrated by one of us (G. K. v. N.),7 by insertion according to these measurements, as illus­ placing the red Maddox rods in a trial frame in front trated by von Noorden, Jenkins, and Rosenbaum6 in a of the right eye and the white rods in front of the left previous publication. In three patients, surgery was 326 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 1996 TABLE 1 SUMMARY OF PREOPERATtVE AND POSTOPERATIVE DATA PREOP TORSION POSTOP TORSION CORRECTION FOLLOW- (IN DEGREES) (IN DEGREES) (IN DEGREES) PATIENT SURGICAL UP NO. DIAGNOSIS UP PP DOWN PROCEDURE (MOS) UP PP DOWN UP PP DOWN 1 Multiple right orbital 15 in 20 in 20in RSR ree 5 mm nasal 3 0 0 0 15 20 20 fractures transp., RIR res 4 mm temporal transp., LIR ree 6 mm (adj) 2 Traumatic bilateral 4 ex 8 ex 11 ex RIR nasal transp. 16 0 5 ex 8 ex 4 3 3 SO palsy 3 Orbital floor n.m. 5 ex 10 ex RIR nasal transp., 24 n.m. 0 0 n.m. 5 10 fracture RMR res 4 mm, RLR ree 5 mm 4 Traumatic LSO palsy n.m. 10 ex 10 ex LIR nasal transp. 30 n.m. 0 0 n.m. 10 10 5 Traumatic bilateral n.m. 5 ex 11 ex RIR nasal transp. 15 n.m. 0 0 n.m. 5 11 SO palsy 6 Traumatic RSO palsy 10 ex 10 ex 15 ex RIR nasal transp. 30 0 0 0 10 10 15 7 Ocular myasthenia n.m. 20 in 23 in RSR ree 4 mm nasal 14 n.m. 4 in 6 in n.m. 16 17 transp., LLR ree 5 mm, LMR res 4 mm 8 Blowout fracture h.m. 11 in 14 in LIR temporal transp. 7 n.m. 0 0 n.m. 11 14 of right orbit and 2-mm advancement and resection 9 XT with A pattern n.m. 5 ex 21 ex RIR nasal transp.
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