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When and How to Strengthen the Superior Oblique Muscle

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When and How to Strengthen the Superior Oblique Muscle Costenbader Lecture When and how to strengthen the superior oblique muscle Richard A. Saunders, MD PURPOSE To review the history of procedures used to strengthen the action of the superior oblique (SO) muscle and methods of quantifying surgical dosage and to determine the relationship between congenital onset and tendon laxity measured at the time of surgery. METHODS We reviewed medical records over a 10-year period of 30 patients who had undergone SO tendon tuck for SO muscle palsy using intraoperative assessment of forced ductions to de- termine surgical dosage. We also designed and tested a modified Bishop tucker, which can simultaneously measure tendon shortening and the force required. This allowed develop- ment of length tension curves between 0 and 200 g for individual SO tendons in patients with and without evidence of muscle palsy. RESULTS In distinction to most other procedures on the extraocular muscles, intraoperative forced ductions are used to determine appropriate surgical dosage. Patients undergoing SO ten- don tuck using a uniform and repeatable forced duction method receive a greater amount of tuck (mean, 3 mm) when there is known congenital onset. Patients with congenital SO muscle palsy received a mean tuck of 10.8 mm (range, 8-16 mm), whereas patients with equivocal or known adult-onset SO palsy received a mean of 7.8 mm (range, 4-12 mm; p 5 0.002). CONCLUSIONS Patients with congenital SO muscle palsy have increased tendon laxity when measured di- rectly during SO tendon tuck. The excursion of presumed normal SO tendons through the trochlea is variable and may be less than previously thought. Modifying the Bishop tucker to provide length and tension data provides information that may be useful in determining surgical dosage. ( J AAPOS 2009;13:430-437) urgery to weaken or strengthen the action of the su- Strengthening procedures have multiple effects on ocular perior oblique (SO) muscle has been performed rou- rotations which can be modified depending on exactly S tinely for nearly 50 years and remains one of the more how the SO tendon is repositioned. Finally, shortening difficult and controversial aspects of strabismus surgery. the SO tendon may produce an unacceptable limitation of There are several reported methods of strengthening the elevation in adduction (iatrogenic Brown syndrome) in SO muscle, all of which rely on operating on the reflected a substantial proportion of cases.1,2 For this reason many tendon (e-Supplement 1, available at jaapos.org). Because surgeons have avoided SO tendon strengthening procedures of the orientation of the trochlea medial and anterior to altogether. It is this unusual anatomy, complex physiology, the SO tendon insertion, the relative proportion of vertical, and unpredictable surgical outcome that undoubtedly led torsional, and horizontal forces induced on the globe are von Graefe to his famous and often repeated admonition complex and depend greatly on the direction of gaze. (‘‘Noli me tangere’’) that surgery on the SO muscle should not be attempted.3 Even as late as 1928, Banister4 stated, ‘‘Owing to the an- Author affiliations: Department of Ophthalmology, Medical University of South Carolina, atomical relations of the superior and inferior oblique mus- Charleston, South Carolina. Presented at the 35th Annual Meeting of the American Association for Pediatric cles to the eyeball, their deep location in the orbit, and their Ophthalmology and Strabismus, San Francisco, California, April 17-20, 2009. attachments to the globe in the neighborhood of the equa- Supported in part by NIH/NEI EY14793 (vision core); and an unrestricted grant to tor. advancement or shortening by tucking, is out of the MUSC, Storm Eye Institute, from Research to Prevent Blindness, Inc., New York, New . York. question and the ophthalmic surgeon must make use 2 The authors have no financial or proprietary interest in any product mentioned herein. of other muscles.’’ However, by that time Wheeler had al- Submitted March 24, 2009. ready shown that direct surgery on the SO tendon could be Revision accepted June 24, 2009. Reprint requests: Richard A. Saunders, MD, Medical University of South Carolina, performed to strengthen the action of an underacting SO Storm Eye Institute, Charleston, SC 29425 (email: [email protected]). muscle. Wheeler’s operation, described as a tendon ad- Copyright Ó 2009 by the American Association for Pediatric Ophthalmology and vancement, was actually more of a plication (folding), with Strabismus. 1091-8531/2009/$36.00 1 0 a tendon loop anchored to the sclera temporal and poste- doi:10.1016/j.jaapos.2009.06.009 rior to the insertion, and was performed after disinsertion 430 Journal of AAPOS Volume 13 Number 5 / October 2009 Saunders 431 of the superior rectus (SR) muscle. In 1946 Foster5 re- of South Carolina. These time periods were chosen because of ported a tendon ‘‘reefing’’ procedure, a plication attached the availability of clinical data, which had been lost for the inter- at the tendon insertion, which he suggested was more phys- vening years. Patients with onset of strabismus or torticollis dur- iologic. McLean modified these techniques by sewing the ing early childhood and no apparent cause, or those with tendon to itself as well as the sclera,6 describing what characteristic plagiocephaly33 and later onset of symptoms, were amounts to a combined SO tendon tuck and plication. deemed to be of ‘‘congenital’’ etiology. The remaining patients He importantly advocated a temporal approach to the ten- were classified as either ‘‘posttraumatic’’ or ‘‘undetermined,’’ de- don, thereby avoiding disinsertion of the SR muscle. pending on clinical circumstances. The presence or absence of McGuire reported success using both SO resection and a clinically lax tendon at the time of surgery was not used in as- tuck7,8 but apparently preferred the former procedure.8 signing etiology. The amount of tendon tuck was determined in In 1966 Dyer9 described and illustrated the SO tuck proce- a similar manner is all cases. A Bishop tendon tucker was used dure, essentially as it is performed today, using a single, to shorten the tendon after the entire SO tendon was isolated tem- nonabsorbable suture to fold the tendon near the insertion. poral to the SR on a Stevens muscle hook (e-Supplement 2, avail- Despite the above reports, prior to 1970 about the only able at jaapos.org). Once a provisional tuck was secured using time an ophthalmologist saw the SO tendon was during a 5-0 braided Dacron suture, a silk traction suture was placed an enucleation (Eugene Helveston, personal communica- through the loop for easy retrieval, and the tendon released. tion, October 14, 2008). Forced ductions were then performed in a manner previously As skepticism regarding SO muscle strengthening re- described,12,34 to assess the limitation of elevation in adduction ceded, the role of SO tendon tuck became better estab- generated by the shortened tendon. An adequate tuck was judged lished, at least in certain clinical situations.10-18 The tuck to have been achieved when the first resistance to elevation in ad- has proved to be convenient to perform and generally re- duction was noted as the inferior limbus crossed an imaginary line versible simply by removing the nonabsorbable suture. between the medial and lateral canthus (Figure 1). Tucks judged Most importantly, it leaves the scleral insertion of the SO too tight or too loose were adjusted appropriately (Figure 2). Care tendon unmolested, with the theoretic advantage that any was taken not to retropulse the globe when performing forced increased forces applied to the globe from tendon tucking ductions, because this would put the tendon on stretch and alter would be generated in the same proportion they were lost the result. The final endpoint was sufficient to remove all tendon due to the paresis. Thus the vertical, torsional, and hori- laxity and generate an approximately À2 elevation deficiency zontal correction would occur as needed, and the only (scale, 0 to À4, where 0 5 full elevation and À4 5 no elevation) required decisions would relate to surgical dosing and in adduction, postoperatively. Data were analyzed with regard whether to operate additional extraocular muscles. to amount of tuck, congenital vs noncongenital onset, and preop- SO tendon tuck figured prominently in Knapp’s treat- erative hyperdeviation. ment paradigm in his well-known classification and treat- ment recommendations for SO muscle palsy, presented Studies Involving a Modified Bishop Tucker in 1970 as the First Richard C. Scobee Memorial Lecture, In 2005 we modified a Bishop tucker to allow the addition of an ‘‘Diagnosis and surgical treatment of hypertropia,’’ to the externally mounted strain gauge. The new instrument allowed si- American Association of Certified Orthoptists in Las multaneous determination of the amount of SO tendon shorten- 11 Vegas, NV. Variations have been described by Harada ing and the force required to achieve this shortening. Early 19 20-22 and Ito and others to increase the relative torsional prototypes proved impractical, because of instrument size (Fig- correction by redirecting and advancing the anterior ten- ure 3) and the use of different materials (stainless steel and alumi- don fibers. However, SO tuck performed temporal to the num), which required different methods of sterilization. We SR muscle remains the simplest and most useful operation subsequently enlisted the help of Bausch and Lomb (St. Louis, in the surgeon’s armamentarium to strengthen the action MO), who produced an improved instrument, similar in size to of an underacting SO muscle, particularly in the context a currently marketed Bishop tucker but with an internal strain of SO muscle palsy. Despite better accessibility, tendon gauge that was more practical to use. The final version had strain shortening medial to the SR muscle has not generally gauge calibration between 0 and 200 g, in 50 g increments, which been advocated, perhaps because of proximity to the troch- could be read through a cutout in the center of the shaft (Figure 4).
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