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 expe- rienced 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 or- bital 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. ARCH OPHTHALMOL / VOL 118, MAR 2000 WWW.ARCHOPHTHALMOL.COM 431 ©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 ap- proach, the dissection must follow the plane of the Horner muscle to the pos- terior 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 de- signed 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 medi- ally) 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 ($1 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 ex- posed by dissecting the Tenon cap- sule anteriorly. Blunt scissors and then a fine hemostat are pushed through the orbital fat just poste- rior 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 sub- periosteal 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 ARCH OPHTHALMOL / VOL 118, MAR 2000 WWW.ARCHOPHTHALMOL.COM 432 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Anterior Ethmoidal Artery 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. ARCH OPHTHALMOL / VOL 118, MAR 2000 WWW.ARCHOPHTHALMOL.COM 433 ©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 in- jection (such as triamcinolone acetate) is given at the end of the procedure. REPORT OF CASES Five patients were evaluated and underwent the periosteal flap proce- dure. Presented are their preopera- tive and postoperative histories, in- cluding 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 examina- tion. 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 addi- tional 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.