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Surgical Management of Strabismus SURGICAL MANAGEMENT OF STRABISMUS EUGENE M. HELVESTON, M.D. Emeritus Professor of Ophthalmology Indiana University School of Medicine Department of Ophthalmology Section of Pediatric Ophthalmology and Strabismus Indianapolis, Indiana FIFTH EDITION With 852 illustrations With love and gratitude to my wife Barbara Preface to the fifth edition The 33 years since the publication of the Atlas of around the world. These patients' consultations were Strabismus Surgery has seen a steady growth in the made possible by ORBIS Telemedicine, Cyber-Sight number of ophthalmologists specializing in the diag- that is supported by the server at Flight Safety in New nosis and treatment of strabismus. Membership in the York and provided through the generosity of Mr. American Association for Pediatric Ophthalmology Albert Ueltschi. By viewing these images and read- and Strabismus has grown to more than 500 mem- ing the discussion that accompanies each, it is my bers and the International Strabismological hope that the reader will by critical analysis along Association boasts 300 members in 25 countries. with comparison of the patients seen in his or her clin- Several journals deal exclusively or largely with the ic hone skills for a more effective personal approach subject of strabismus and several high quality texts to the whole patient leading to better outcome. have been published dealing with strabismus diagno- This book represents the 'full circle' in that it is sis and management. Moreover, an explosion in the based on experience during a professional lifetime in field of information technology has brought people the care of patients with strabismus. It is my hope together and facilitated the distribution of information that what I have learned and then shared here will be in a way not dreamed of when the first edition of this of use to those who follow. book was written. As with any effort like this there are many This fifth edition is renamed Surgical deserving people to thank. First among these is Mrs. Management of Strabismus reflecting the fact that the Lynda Smallwood who more than any person is major emphasis has shifted from a description of sur- responsible for this book being completed. She not gical procedures to a discussion of why and how only typed the manuscript, but also assembled and these procedures are used to treat the patient with formatted the entire book making it ready for the strabismus. There have been relatively few substan- printer by simply submitting it in electronic format tive changes in surgical technique. It is how these ready for duplication. Truly a monumental task! techniques are applied including the 'what' and 'when' Others who worked hard and effectively are Leslie which make up the bulk of this book. Abrams, Michelle Harmon, Gwen Kopecky, Sharon A new concept that has influenced surgical man- Teal who so ably carried on the art work begun by agement during the last decade is that of the pulleys Craig Gosling, and Ann Hammer who read the first associated with the horizontal rectus muscles. Study three chapters. I am grateful to the many Cyber-Sight of these structures made possible in part by new partners who submitted hundreds of cases, and to my imaging techniques, but more importantly by meticu- fellow Cyber-Sight strabismus mentors, especially lous study of anatomic specimens, has helped make Dan Neely who faithfully and expertly responded the management of 'A' and 'V' more logical and effec- when called on. I thank all of my teachers, especial- tive. ly Gunter von Noorden my mentor beginning in 1966 Included in this book are 135 strabismus cases and my friend for life. Most of all, I thank my wife managed by me either in the clinic or by means of Barbara for her unselfish and unfailing support, and consultation carried out by me and other mentors on my two daughters both of whom had the good sense patients sent by dozens of partners from countries to marry outstanding strabismologists. Eugene M. Helveston i From the Preface to the first edition There have been several excellent texts on stra- the vista of strabismus surgery. bismus including strabismus surgery in the past few For these reasons it seems appropriate at this years, but developments have moved rapidly. Recent time to compile an up-to-date atlas of strabismus sur- advances in technique have greatly expanded the gery. This atlas employs schematic drawings options available to the strabismus surgeon. More designed to illustrate at each step only that anatomy accurate diagnostic tests leading to a better under- significant to the step shown for easier orientation of standing of the pathophysiology of strabismus and the reader. Procedures that I have found useful have amblyopia have convinced some surgeons of the need been given emphasis; those that are controversial or for surgery in infants as young as 5 months of age. that I have not found to be particularly helpful have Improved anesthesia and an increasing boldness on been omitted. Some "favorite technique" may be the part of the strabismus surgeon have led to outpa- omitted simply because I prefer an alternative choice; tient extraocular muscle surgery in some instances those that I think should be avoided will be clearly without patch and without ointment or drops. The labeled so. limbal and cul-de-sac (or fornix) extraocular muscle No attempt will be made to give a set of surgical exposure techniques have largely superceded the recipes that will result in a predetermined amount of transconjunctival incision in the interpalpebral space straightening. Instead, general concepts leading to a among younger surgeons. The retinal surgeon has philosophy for strabismus surgery will be presented. opened new dimensions in the degree to which sub- My intent is that this atlas will be of help to the prac- Tenon’s space may be explored. ticing strabismus surgeon and the resident in ophthal- There have been several excellent texts on stra- mology by bringing together in one volume many bismus including strabismus surgery in the past few techniques from a variety of sources for quick and years, but developments have moved rapidly. Recent easy reference. advances in technique have greatly expanded the Several people who assisted significantly in their options available to the strabismus surgeon. More own way to make this atlas possible deserve my sin- accurate diagnostic tests leading to a better under- cere thanks. Dr. Gunter K. von Noorden, teacher, standing of the pathophysiology of strabismus and critic, and friend, introduced me to strabismus and to amblyopia have convinced some surgeons of the need the pursuit of academic ophthalmology. Craig for surgery in infants as young as 5 months of age. Gosling worked with industry and imagination on the Improved anesthesia and an increasing boldness on illustrations, the heart of any atlas. My residents and the part of the strabismus surgeon have led to outpa- many of my colleagues, in particular Drs. Marshall tient extraocular muscle surgery in some instances M. Parks and Phillip Knapp, provided both stimulus without patch and without ointment or drops. and direction. New sutures, adhesives, muscle sleeves, and implantation materials have proved useful innova- tions. Globe fixation sutures, conjunctival recession and relaxation procedures, forced duction and active forced generation tests, as well as topical anesthesia for extraocular muscle surgery, have greatly enlarged Eugene M. Helveston iii Contents Section 1 1 History of strabismus surgery, 1 Anesthesia for strabismus surgery, 67 Preparation of the patient in the operating room, 70 Layout of the operating room and anesthetic 2 Surgical anatomy, 15 apparatus, 72 Patient monitoring, 73 Overview, 15 Magnification in strabismus surgery, 74 Palpebral fissure size, 15 Wearing a mask, 74 Extraocular muscle size, 16 Outpatient surgery: the day of surgery, 75 Pulleys, 18 Postoperative care of the patient, 76 Palpebral fissure shape, 21 Epicanthal folds, 22 Conjunctiva, 23 Section 2 Tenon’s capsule, 24 Surgical anatomy of the rectus muscles, 28 Characteristics of the extraocular muscles, 31 4 Work-up of the strabismus patient, 79 Motor physiology, 31 Design of the surgical procedure, 79 Underaction and “overaction”, 34 Step 1: Patient evaluation, 81 Surgical anatomy of the inferior oblique, 35 Diagnostic considerations for strabismus with Lockwood’s ligament, 37 restrictions, 90 Superior oblique, 38 Differential intraocular pressure test, 98 Whitnall’s ligament, 41 Step 2: Results to be expected from surgery, 108 Trochlea, 42 Summary of steps 1 & 2 in the design of strabismus Anterior segment blood supply, 48 surgery, 117 Vortex veins, 51 Step 3: Guidelines for application of surgical Orbit and extraocular muscle imaging, 52 options, 117 Growth of eye from birth through childhood, 54 Step 4: Surgical technique, 117 Sclera, 56 Step 5: Follow-up of the surgical patient, 120 3 Parasurgical procedures and 5 Diagnostic categories and preparation, 59 classifications of strabismus, 123 Overview, 59 Congenital esotropia, 125 Physical examination, 60 Intermittent exotropia, 142 Consent for strabismus surgery, 60 Brown syndrome, 147 Instruments used in strabismus surgery, 63 Duane syndrome, 149 Sutures and needles for strabismus surgery, 64 Superior oblique palsy, 151 v Contents Section 3 6 Mechanics of surgery, 163 9 Surgery of the obliques, 215 Techniques of exposure, 163 Oblique muscle surgery, 215 Limbal incision, 171 Weakening the inferior oblique, 216 Incisions for exposing the obliques, 174 Strengthening
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