Use of Apically Based Periosteal Flaps As Globe Tethers in Severe Paretic Strabismus

SURGICAL TECHNIQUE Use of Apically Based Periosteal Flaps as Globe Tethers in Severe Paretic Strabismus

Robert A. Goldberg, MD; Arthur L. Rosenbaum, MD; John T. Tong, MD

Objective: To evaluate the technique of using an in- operative measurements. Greater early postoperative tact autogenous periosteal flap for tethering of the globe swelling was noted after this procedure than with the stan- in patients with severe paretic strabismus. dard strabismus surgery. No complications were experienced during or after surgery. Two patients required a Methods: We performed a periosteal flap procedure on second operation for adjustment of the periosteal flap for 5 patients and followed their postoperative course. The adequate alignment. flap was created from the medial, lateral, or superior orbital walls. A description of the harvesting and manipu- Conclusions: The vascularized periosteal flap tech- lation of the flap and the initial postoperative findings nique provides an excellent tether for the globe. Early are presented. and late stability has been favorable.

Results: All patients showed marked reduction in their postoperative strabismic deviation compared with pre- Arch Ophthalmol. 2000;118:431-437

CCASIONALLY, severe tendency with time for late drift and paretic and restrictive failure. We were therefore motivated to strabismus problems find a more substantial tissue to use for require globe fixation in globe tethering in complex paretic or the primary position restrictive strabismus. This led to our Obecause of the presence of only one use of orbital periosteal flaps. Periosteal active extraocular muscle. In these cases, flaps are not only autogenous but have the one rectus muscle is completely pal- the substantial advantage of being vas- sied or not functioning, and even supra- cularized and based ideally at the orbital maximal recession of its antagonist will apex, in the same area as the origin of almost always result in recurrence of the the extraocular muscle whose function strabismus. Thus, passive globe fixation the periosteal flap is designed to in the primary position is needed to pre- replace. Creating the flaps and manipu- vent recurrence. Classic examples of this lating them within the orbit uses tech- type of problem are complete third nerve niques and takes advantage of anatomi- palsy and severe ocular fibrosis syn- cal features that should be familiar to drome. A variety of techniques are avail- the orbital surgeon. able to accomplish this task, including In this article, we describe the surgi- use of various alloplastic and autogenous cal technique for harvesting and manipu- materials.1-5 lating periosteal flaps and our initial ex- In our evolution of treatment of this perience with 5 patients. problem, we have used permanent suture material and autogenous fascia SURGICAL TECHNIQUE such as temporalis fascia attached to the remnant muscle. Transposition of the We created periosteal flaps from the From the Jules Stein Eye superior oblique muscle with and with- superior, lateral, and medial orbital Institute, University of Figure 1 California–Los Angeles School out removal of the tendon from the walls ( ). The lateral wall, of Medicine. The authors have trochlea has also been described to floor, and medial wall can be accessed no proprietary interest in the achieve medial fixation. Although these through conjunctival incisions. The roof products described in this materials were sometimes successful in is best accessed through an eyelid crease article. initially tethering the globe, there was a incision.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 the floor and orbital rim. To create a medial flap, the incision is located at 6,7 15-20 mm the lateral edge of the caruncle. In the caruncular conjunctival approach, the dissection must follow the plane of the Horner muscle to the posterior lacrimal crest to avoid injury to 8-10 mm the lacrimal sac and canaliculi (Figure 2). In all patients, once the rim is achieved, the fat is cleared from the periosteum. A periosteal flap is designed approximately 1 cm in width and incised with a sharp-tipped mo- nopolar cautery. The flap should be

A started anteriorly as close to the rim (or posterior lacrimal crest medially) as possible and can include the arcus marginalis at the anterior rim as its anterior leading edge. It is easy to trim the edge of the flap if it is too long but impossible to lengthen it if it is too short. Once the periosteum in the desired quadrant is exposed and the flap is designed, the margins of the flap are sharply dissected and the flap is elevated from the under- lying bone using a sharp periosteal elevator (Figure 2). The periosteum is often somewhat thin and friable, and careful dissection is required to avoid transecting the flap. The flap should be based as widely as pos- B sible at the apex (Ն1 cm wide) to minimize the chance of flap tran- section. The flap does not have to be taken back all the way to the apex. Dissection approximately midway into the orbit is usually sufficient to adequately mobilize the flap. After the flap is created, it is fixated with a double-armed suture through its tip (Figure 3). The muscle insertion is then exposed by dissecting the Tenon cap- sule anteriorly. Blunt scissors and then a fine hemostat are pushed through the orbital fat just posterior to the intramuscular septum and visualized in the extraperiosteal C plane. Both arms of the preplaced suture can be grasped with the he- Figure 1. A, Design of a medial periosteal flap, accessed through a caruncular conjunctival incision. B, Design of an inferior periosteal flap, accessed through an inferior fornix incision. C, Design of a lateral mostat and pulled back into the subperiosteal flap, accessed through a lateral forniceal incision, and design of a superior periosteal flap, Tenon plane. This allows the peri- accessed through an eyelid crease incision. Copyright 1998 Regents of the University of California, osteal flap to travel from the reprinted with permission. extraconal space into the periconal space (Figure 4). The conjunctival incision is per- through the orbital fat to the lateral The periosteal flap can then be formed in the fornix overlying the pa- rim. To create an inferior periosteal attached to the extraocular mus- retic muscle. To create a lateral peri- flap, the dissection follows the plane cle’s insertion point under appro- osteal flap, the dissection is carried out of the lower eyelid retractors down to priate tension to position the globe

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Horner Muscle

Figure 2. The medial orbital wall is approached through a caruncular incision. The plane of the Horner muscle is followed to the posterior lacrimal crest. A lacrimal rake is used to retract the medial cut edge of conjunctiva, and a thin malleable retractor is used to hold back the orbital fat. Copyright 1998 Regents of the University of California, reprinted with permission.

Lacrimal Sac

Figure 3. A permanent suture such as 5-0 Mersilene on a spatulated double-armed needle is passed through the edge of the periosteal flap. Copyright 1998 Regents of the University of California, reprinted with permission.

Figure 4. Axial section. A fine hemostat is passed by blunt dissection from the periconal space to the periosteal space, and the sutures are grasped. Copyright 1998 Regents of the University of California, reprinted with permission.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 The conjunctiva is closed using interrupted absorbable sutures. To decrease postoperative inflammation and chemosis after this extensive, multiplane orbital dissection, a corticosteroid injection (such as triamcinolone acetate) is given at the end of the procedure.

REPORT OF CASES

Five patients were evaluated and underwent the periosteal flap procedure. Presented are their preopera- tive and postoperative histories, including strabismic measurements and any previous or subsequent eye A muscle operations.

CASE 1

A 9-month-old girl had a left face turn and a dilated right pupil for 4 months before our initial examination. She had 45 PD of exotropia (XT) at distance and near, with limitation of elevation, depression, and adduction of the right eye. The right pupil was 4 mm and the left pupil was 2 mm. Although there was no ptosis, the findings indi- cated a right third cranial nerve palsy. At another institution 1 month later, she underwent an 8-mm recession of the right lateral rectus muscle and a 6-mm resec- tion of the right medial rectus, B both with superior transposition. Examination 21⁄2 years later Figure 5. The flap is attached to the muscle insertion and surrounding sclera using the preplaced double-armed suture. A, Axial section. B, Idealized surgical view. In reality, the knot is tied “in the hole” revealed a 30-PD XT at distance within the orbit. Copyright 1998 Regents of the University of California, reprinted with permission. and near (Figure 6, A). At age 31⁄2 years, she underwent an additional 4-mm recession of her right lateral rectus and a right medial to approximately 5- to 10-prism diop- access to the superior orbital rim. periosteal flap procedure to tether ter (PD) overcorrection (Figure 5), The superior flap is harvested lat- the XT eye in the primary position. recognizing that undercorrections are eral to the supraorbital neurovascu- Although she was orthophoric 3 more frequent than are overcorrec- lar bundle to avoid injury to the fron- months after surgery (Figure 6, B), tions in these patients. It is necessary tal nerve (Figure 1, C), but the flap 5 months after surgery she had 5 to to tie the suture “in the hole,” pass- can then be slightly curved medi- 10 PD of XT (Figure 6, B); 14 ing one end back into the orbit as the ally if desired as it is dissected back months after surgery she had 5 to knot is tied, to avoid pulling the su- to the apex so that the flap actually 10 PD of XT with 5 to 10 PD of ture out of the periosteal flap. crosses over the nerve. Working right hypertropia. To harvest a periosteal flap in through a separate conjunctival in- the superior orbit (to tether the globe cision over the superior rectus in- CASE 2 against an unopposed inferior rec- sertion, the flap can then be brought tus muscle), the orbital rim is best from the extraconal to the peri- A 4-month-old girl had limited ab- approached through an eyelid crease conal space using a hemostat, as de- duction of the right eye for 2 months. incision, working superior to the le- scribed above. The flap is passed On examination, she had 30 PD of vator aponeurosis and muscle. An around the lateral edge of the leva- esotropia (ET) with minimal ab- eyelid crease incision provides rapid tor muscle. duction in the right eye. She also had

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 reduction of elevation and depression in the right eye. At age 11 months, shortly before surgery, she had 40 PD of ET with 5 PD of right hypertropia. Passive forced duction testing of the right eye under anesthesia revealed severe restriction in all directions consistent with ocular fibrosis syndrome. She underwent a right lateral periosteal flap procedure and 7-mm recession of the right medial rectus. The right superior rectus was tight and severely na- sally displaced and therefore was recessed 7 mm; it was believed that the nasal displacement was contribut- ing to the abduction restriction. A Therefore, the right superior rectus was recessed. Six weeks after surgery she had a residual ET of 15 PD. Eight months after surgery there was 15 to 20 PD of ET with a right hypotropia of 15 to 20 PD. Nine months after surgery a revision of the lateral periosteal flap with tighten- ing, an additional 6-mm recession of the right medial rectus muscle, and a 10-mm recession of the right inferior rectus muscle were performed. Six months later, no horizontal deviation occurred and left hypertropia was 20 PD.

CASE 3 B A 4-year-old boy with bilateral ocular fibrosis syndrome had no abil- Figure 6. Case 1. Right third cranial nerve palsy before surgery (A) and 5 months after surgery (B). ity to rotate either eye above the midline and severe restriction of adduction bilaterally. Years before our examination he had undergone the superior periosteal flap was per- months after surgery she was ortho- bilateral large inferior rectus muscle formed. Eight months after the re- phoric at distance and had a 6-PD recessions for a large chin-up posi- vision he had a 10° chin-up posi- XT near. Sixteen months after sur- tion because of the inability to el- tion with a left hypertropia of 5 PD gery she had an 8-PD XT at dis- evate either eye. However, both eyes and an XT of 10 PD. tance and near (Figure 7, B). were still “fixed” in downgaze with a compensating chin-up position, CASE 4 CASE 5 and the child could not elevate either eye to the horizontal position. A 79-year-old woman sustained a ce- A 3-year-old girl had congenital The left inferior rectus muscle was rebrovascular accident 1 year be- cerebral palsy associated with again recessed to a distance of 15 fore our evaluation and had a result- facial diplegia. On our initial mm posterior to the limbus, accom- ant left third cranial nerve palsy. She evaluation she had a 70-PD XT panied by a superior orbital perios- had a 65-PD XT with a left hyper- with poor supraduction, infra- teal flap in an effort to stabilize the tropia of 10 PD (Figure 7, A). She duction, and adduction of both left eye in the primary position and had marked reduction of elevation, eyes. She had undergone bilateral prevent recurrence of the left infe- depression, and adduction of the left ptosis repair at 2 years of age. Pas- rior rectus contracture. Six weeks af- eye. The patient underwent a me- sive forced duction testing under ter surgery both eyes were near the dial periosteal flap procedure with anesthesia revealed marked horizontal midline with little or no an 18-mm recession of her left lat- restriction of the elevation and chin-up position. Three months later eral rectus muscle on an adjustable depression and moderate restric- a left hypotropia and chin-up posi- suture and a 9-mm recession of the tion of adduction of both eyes, tion had recurred, and a revision of left superior rectus muscle. Three consistent with ocular fibrosis

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 of a sixth cranial nerve palsy cre- ates an imbalance between the medial and lateral rectus muscles in one eye, with a resultant ET. The treatment is based on either resect- ing a paretic lateral rectus to reestablish the equilibrium of forces between the medial and lateral recti or performing some type of muscle transposition procedure of the ver- tical recti laterally to create a new lateral force to balance the unopposed normal medial rectus force. In restrictive strabismus, the stron- ger or more restrictive force is usually weakened by recessing a rectus muscle, as in a patient with Graves disease with a hypotropia, with a A restriction of upward rotation. In this situation, the inferior rectus muscle is recessed to reestablish a balance of force between the inferior and superior recti. This treatment strategy works well in situations in which the antagonist is capable of generating sufficient muscle strength or in which transposed muscles can establish an opposing force. However, in some complicated situations, the rebalancing of forces is not possible. For instance, in a patient with a complete third cranial nerve palsy, the normal lateral rectus muscle is es- sentially unopposed by any mean- ingful adduction force. Conse- quently, conventional strabismus B surgical procedures are not effec- tive, and XT will usually recur, even Figure 7. Case 4. Left third cranial nerve palsy before surgery (A) and 16 months after surgery (B). with aggressive lateral rectus recession. In this type of situation, it syndrome. She underwent a right marked reduction of their preop- might be desirable to create an ef- medial periosteal flap and a 9-mm erative deviations at the 6-week fective restriction medially that will recession of her right lateral rectus postoperative measurements. The result in alignment in the primary muscle. Forced duction testing average postoperative week 6 mea- position and prevent recurrent XT under anesthesia 4 weeks after surement was 6 PD of deviation by creating an opposing mechani- surgery demonstrated a slight (range, 0-15 PD), with an average cal restriction to balance active lat- release of the periosteal flap pro- reduction of 36 PD (range, 5-65 eral rectus contraction. Similarly, in cedure but continued good tether- PD). This translates to an average ocular fibrosis syndrome, it might be ing effect. Postoperative week 7 correction of 88% from orthopho- necessary to tether the globe against measurements showed an XT of ria (range, 63%-100%). Both the unopposed action of an antago- 15 PD. patients who underwent revision nist muscle. The Table summarizes the of the periosteal flap had ocular Multiple attempts have been characteristics and outcomes of the fibrosis syndrome. made to create such a tethering ef- patients. Four of the 5 patients fect using various materials. We and were children. Three patients had COMMENT other investigators have evaluated al- ocular fibrosis syndrome and 2 had loplastic materials such as silicon third cranial nerve palsies. Preop- The management of paralytic and bands and permanent sutures.3-5 erative deviations ranged from 6 to restrictive strabismus is based on With silicon bands, some authors 70 PD in the plane of the periosteal the principle of rebalancing have tried to regulate the amount of flap, with an average deviation of unequal forces of antagonist elastic tension provided by the 42 PD. All patients experienced muscles. For instance, the presence band.3,4

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 To treat difficult paretic strabis- Patient Characteristics and Outcomes* muswhenotheroptionswerelimited, we used a vascularized periosteal flap Final Examination based at the apex, tunneled from the Deviation, PD Patient Age†/ Deviation, periosteal space to the periconal space No. Sex Diagnosis Flap Preop POW 6 Reop Months PD and attached to the rectus muscle in- 1 3.5 y/F Third nerve palsy Medial XT 30 Orthophoric None 14 XT 5-10 sertion to fixate and tether the globe. RHT 5-10 The exposure of the periosteum 2 11 mo/F Fibrosis syndrome Lateral ET 40 ET 15 POM 9 15 LHT 20 through conjunctival incisions later- RHT 5 ally, inferiorly, or medially is difficult, 3 6 y/M Fibrosis syndrome Superior RHT 6 Orthophoric POM 3 8 XT 10 but with good illumination and as- XT 5 LHT 5 4 79 y/F Third nerve palsy Medial XT 65 Orthophoric None 16 XT 8 sistance it is well within the techni- LHT 12 cal capability of a surgeon versed in 5 3 y/F Fibrosis syndrome Medial XT 70 XT 15 None 2 XT 15 orbital anatomy and approaches. Su- periorly, an eyelid crease approach *PD indicates prism diopters; Preop, preoperation; POW 6, postoperative week 6; Reop, reoperation; XT, provides wide visualization of the exotropia; ET, esotropia; POM, postoperative month; RHT, right hypertropia; and LHT, left hypertropia. †Age at time of periosteal flap surgery. periorbita. Although we had to adjust the position of the tether in 2 patients, We and other authors have also to shift the affected globe into an we have been pleased with the early used autogenous materials as tether- orthophoric position in primary and late stability of the tethering ef- ing agents, including fascia lata and gaze. No active movement genera- fect. Aside from increased early post- temporalis fascia.1,2 The amount of tion is expected from the flap, and operative swelling compared with fascia lata harvested as described by the patients or their parents were standard muscle procedures, we have the authors is a 1 ϫ 5-cm strip.2 How- advised of this. noted no complications related to the ever, the limitation of the fascia lata More postoperative edema was harvesting or fixation of the flap. In is that a sufficient amount cannot be noted after the procedure com- our anecdotal experience, the vascu- harvested in very young children.2 pared with after standard strabis- larized periosteal flap provides supe- The periosteal flap has several mus surgery, which was expected rior globe tethering compared with distinct advantages. The tissue itself given the greater extent of dissec- alloplastic or autogenous nonvascu- is autogenous and therefore elimi- tion necessary for the creation of larized tethers. nates the problems associated with al- the periosteal flap. It is recom- loplastic materials, such as extru- mended that a sub-Tenon cortico- Accepted for publication October 29, sion, inflammatory reactions, and steroid injection be given at the 1999. resorption. The periosteal flap is also end of the surgery. Reprints: Robert A. Goldberg, well vascularized because it is a tis- The end point for intraopera- MD, Jules Stein Eye Institute, Univer- sue flap compared with free grafts har- tive alignment was a small overcor- sity of California–Los Angeles School vested from other parts of the body, rection (approximately 5-10 PD) of Medicine, 100 Stein Plaza, Los An- such as the temporalis fascia and fas- based on the eye position in the or- geles, CA 90095. cia lata. Because the periosteal flap has bit. The creation of the periosteal flap its base at the orbital apex, it origi- was performed in conjunction with nates from the same area as the ex- the recession of the active antago- REFERENCES traocular muscles, allowing the flap nistic muscle to decrease the ten- to follow a course through the orbit sion experienced by the flap. Two 1. Awad AH, Shin GS, Rosenbaum AL, Goldberg RL. similar to that of the rectus muscle it patients required revision of the flap, Autogenous fascia augmentation of a partially ex- was designed to replace. In addition, as can be expected from the com- tirpated muscle with a subperiosteal medial or- bitotomy approach. J Am Assoc Pediatr Ophthal- the procedure reduces the number of plex nature of their strabismus. The mol Strabismus. 1997;1:138-142. rectus muscles operated on to achieve recurrence of the deviation might be 2. Salazar-Leon JA, Ramirez-Ortiz MA, Salas- the desired alignment, thus decreas- caused by the opposing force of the Vargas M. The surgical correction of paralytic stra- ing the possibility of anterior seg- antagonistic muscle at the time of bismus using fascia lata. J Pediatr Ophthalmol ment ischemia. flap-scleral adhesion formation. Strabismus. 1998;35:27-32. 3. Scott AB, Miller JM, Collins CC. Eye muscle pros- Our initial experience with 5 Botulinum toxin injection of the an- thesis. J Pediatr Ophthalmol Strabismus. 1992; patients has allowed us to evaluate tagonistic muscle to temporarily cre- 29:216-218. the creation of the periosteal flap ate a palsy of this muscle might be 4. Collins CC, Jampolsky A, Scott AB. Artificial from the medial, lateral, and supe- beneficial to reduce the tension at the muscles for extraocular implantation. Invest Oph- rior orbital walls. The basic proce- wound interface, although we have thalmol Vis Sci. 1985;26(suppl):80. 5. Bicas HEA. A surgically implanted elastic band to dure is similar for all, although a not yet added this modification. Su- restore paralyzed ocular rotations. J Pediatr Oph- transconjunctival approach was turing the antagonist muscle inser- thalmol Strabismus. 1991;28:10-13. used for the lateral and medial wall tion to the periosteum might be 6. Garcia G, Goldberg RA, Shorr N. The transcarun- and an eyelid crease incision was helpful by totally reducing its op- cular approach in repair of orbital fractures. J Cra- niofac Trauma. 1998;4:7-12. used for the roof of the orbit. The posing effect and also decreasing the 7. Rootman J, Stewart B, Goldberg RA. Orbital Sur- purpose of the periosteal flap, as periosteal-scleral wound interface gery: A Conceptual Approach. Philadelphia, Pa: JB with other tethering techniques, is tension. Lippincott; 1995:258-259.

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