Limits...
Minimally invasive strabismus surgery (MISS) for inferior obliquus recession.

Mojon DS - Graefes Arch. Clin. Exp. Ophthalmol. (2008)

Bottom Line: The vertical deviation, which was measured in 25 degrees of adduction, decreased from preoperatively 12.8 degrees +/- 5.6 degrees to 2.7 degrees +/- 2.2 degrees (p < 0.0001) at 6 months.Binocular vision improved in eight patients, remained unchanged in six patients, and decreased from 30 to 60 arcsec in one patient (p > 0.1).One patient out of 15 (7%) needed repeat surgery because of insufficient reduction of the sursoadduction within the first 6 months.

View Article: PubMed Central - PubMed

Affiliation: Department of Strabismology & Neuro-Ophthalmology, and University of Bern, Kantonsspital St. Gallen, St. Gallen, 9007, Switzerland. daniel.mojon@kssg.ch

ABSTRACT

Purpose: To present a novel, minimally invasive strabismus surgery (MISS) technique for inferior obliquus recessions.

Methods: Graded MISS inferior obliquus recessions were performed in 20 eyes of 15 patients by applying two small conjunctival cuts, one at the insertion of inferior obliquus and another where the scleral anchoring of the muscle occurred.

Results: The amount of recession was 12.2 +/- 2.3 mm (range 6 to 14 mm). The vertical deviation, which was measured in 25 degrees of adduction, decreased from preoperatively 12.8 degrees +/- 5.6 degrees to 2.7 degrees +/- 2.2 degrees (p < 0.0001) at 6 months. LogMAR visual acuity was preoperatively -0.10 +/- 0.17 and at 6 months -0.14 +/- 0.22 (p > 0.1). In one eye (2.5%) the two cuts had to be joined because of excessive bleeding. Binocular vision improved in eight patients, remained unchanged in six patients, and decreased from 30 to 60 arcsec in one patient (p > 0.1). Conjunctival and lid swelling were hardly visible on the first postoperative day in primary gaze position in 10/20 (50%) of eyes. Five of the eyes (25%) had mild and five (25%) moderate visibility of surgery. One patient out of 15 (7%) needed repeat surgery because of insufficient reduction of the sursoadduction within the first 6 months. The dose-effect relationship 6 months postoperatively for an accommodative near target at 25 degrees adduction was 0.83 degrees +/- 0.43 degrees per mm of recession.

Conclusions: This study demonstrates that small-incision, minimal dissection inferior obliquus graded recessions are feasible and effective to improve ocular alignment in patients with strabismus sursoadductorius.

Show MeSH

Related in: MedlinePlus

Schematic representation of the surgical technique for MISS inferior obliquus recession. After applying a limbal traction suture to expose the temporal inferior quadrant of the eye globe, a radial cut is performed over the insertion of the inferior obliquus muscle (a). A second cut is applied where later the reinsertion will be performed. With blunt Wescott scissors the inferior obliquus insertion is separated from the surrounding tissue (b). Then, the insertion is completely detached (c). Now, one single suture is applied to the anterior third of the detached muscle insertion (d). Afterwards, a blunt cannula is passed through the second cut, the reinsertion site opening, and advanced in order to get out through the first cut (e). The needle is gently inserted in the cannula until it is fixed (f). Now, the cannula is retracted (g) and the scleral fixation is performed (h). The surgical procedure is finished by applying single sutures to each of the two small cuts (i). If a better visualization is needed, the two small cuts can be joined to form one large opening (j)
© Copyright Policy
Related In: Results  -  Collection


getmorefigures.php?uid=PMC2697361&req=5

Fig1: Schematic representation of the surgical technique for MISS inferior obliquus recession. After applying a limbal traction suture to expose the temporal inferior quadrant of the eye globe, a radial cut is performed over the insertion of the inferior obliquus muscle (a). A second cut is applied where later the reinsertion will be performed. With blunt Wescott scissors the inferior obliquus insertion is separated from the surrounding tissue (b). Then, the insertion is completely detached (c). Now, one single suture is applied to the anterior third of the detached muscle insertion (d). Afterwards, a blunt cannula is passed through the second cut, the reinsertion site opening, and advanced in order to get out through the first cut (e). The needle is gently inserted in the cannula until it is fixed (f). Now, the cannula is retracted (g) and the scleral fixation is performed (h). The surgical procedure is finished by applying single sutures to each of the two small cuts (i). If a better visualization is needed, the two small cuts can be joined to form one large opening (j)

Mentions: Surgical technique for MISS inferior obliquus recession Surgery is performed using the operating microscope under general anesthesia. All surgical steps can be performed without an assistant. The amount of recession corresponded to the vertical deviation determined in 25° of adduction. For each millimeter of recession an anteralization of 1/3 of a millimeter was performed, which makes it possible to reattach the anterior border along the physiologic course of the muscle. Preoperatively, no eye drops were given. Directly before surgery, the eyelids and the skin surrounding the operative site were disinfected with Betadine® (Iodum 10 mg ut povidonum iodinatum excip. ad solute. pro 1 ml). The conjunctiva was not rinsed. A limbal traction suture (Silkam® 6-0 or Safil® 6-0 BV-1) is applied in order to expose the temporal inferior quadrant of the eye globe. During surgery, a direct contact of the traction suture with the cornea has to be avoided. A 4 mm radial cut is performed over the insertion of the inferior obliquus muscle (Fig. 1a). The anterior margin of the cut is 1 mm anterior of the tendon insertion. In patients with reduced elasticity of the conjuntival tissue, a slightly larger opening will be needed. A second cut is applied where later the reinsertion will be performed. If the reattachment will be next to the lateral border of the inferior rectus muscle, the muscle itself will help as a landmark. If a graded recession of a certain amount is planned, the place is marked using a measure caliper. With blunt Wescott scissors, the inferior obliquus inseration is separated from the surrounding tissue (Fig. 1b). Then, using the same scissors, the insertion is completely detached (Fig. 1c). Now, one single suture (Vicryl® 7-0 GS-8) is applied to the anterior third of the detached muscle insertion (Fig. 1d). In this patient series, only the anterior border was reinserted to the sclera, and therefore no second posterior suture was used. Afterwards, a blunt cannula (Hurricain Medical, 20G x 1 in. Sub-Tenon's Anaesthesia Cannula) is passed through the second cut, the reinsertion site opening, and advanced in order to get out through the first cut (Fig. 1e). The needle is gently inserted in the cannula until it is fixed (Fig. 1f). Now, the cannula is retracted (Fig. 1g). After withdrawal of the needles from the cannula, the scleral fixation is performed (Fig. 1h). After having controlled that all posterior fibers of the inferior obliquus insertion have been properly cut, the surgical procedure is finished by applying single sutures (Vicryl® Rapid 8-0 GS-8) to each of the two small cuts (Fig. 1i). At the end of surgery, TobraDex® ointment (1 mg dexamethasone and 3 mg tobramycin per g, 0.5% chlorobutanol) or Maxitrol® ointment (polymyxin B sulphate 6,000 units, neomycin sulphate 3,500 units, dexamethasone 1.0 mg, methylparaben 0.05%, and propylparaben 0.01%) was applied. There was no need for an eye patch. For the first 2 weeks after surgery the following treatment was prescribed: TobraDex® suspension (1 mg dexamethasone and 3 mg tobramycin per ml, 0.01% benzalkonium chloride) t.i.d. and TobraDex® ointment in the evening or Maxitrol® suspension (polymyxin B sulphate 6,000 units, neomycin sulphate 3,500 units, dexamethasone 1.0 mg, and benzalkonium chloride 0.004%) t.i.d. and Maxitrol® ointment in the evening. If during minimally invasive surgery the operating site needs to be better visualized, e.g. if excessive bleeding occurs, which cannot be stopped with cautery through the small cuts, the two openings can be joined (Fig. 1J).Fig. 1


Minimally invasive strabismus surgery (MISS) for inferior obliquus recession.

Mojon DS - Graefes Arch. Clin. Exp. Ophthalmol. (2008)

Schematic representation of the surgical technique for MISS inferior obliquus recession. After applying a limbal traction suture to expose the temporal inferior quadrant of the eye globe, a radial cut is performed over the insertion of the inferior obliquus muscle (a). A second cut is applied where later the reinsertion will be performed. With blunt Wescott scissors the inferior obliquus insertion is separated from the surrounding tissue (b). Then, the insertion is completely detached (c). Now, one single suture is applied to the anterior third of the detached muscle insertion (d). Afterwards, a blunt cannula is passed through the second cut, the reinsertion site opening, and advanced in order to get out through the first cut (e). The needle is gently inserted in the cannula until it is fixed (f). Now, the cannula is retracted (g) and the scleral fixation is performed (h). The surgical procedure is finished by applying single sutures to each of the two small cuts (i). If a better visualization is needed, the two small cuts can be joined to form one large opening (j)
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2697361&req=5

Fig1: Schematic representation of the surgical technique for MISS inferior obliquus recession. After applying a limbal traction suture to expose the temporal inferior quadrant of the eye globe, a radial cut is performed over the insertion of the inferior obliquus muscle (a). A second cut is applied where later the reinsertion will be performed. With blunt Wescott scissors the inferior obliquus insertion is separated from the surrounding tissue (b). Then, the insertion is completely detached (c). Now, one single suture is applied to the anterior third of the detached muscle insertion (d). Afterwards, a blunt cannula is passed through the second cut, the reinsertion site opening, and advanced in order to get out through the first cut (e). The needle is gently inserted in the cannula until it is fixed (f). Now, the cannula is retracted (g) and the scleral fixation is performed (h). The surgical procedure is finished by applying single sutures to each of the two small cuts (i). If a better visualization is needed, the two small cuts can be joined to form one large opening (j)
Mentions: Surgical technique for MISS inferior obliquus recession Surgery is performed using the operating microscope under general anesthesia. All surgical steps can be performed without an assistant. The amount of recession corresponded to the vertical deviation determined in 25° of adduction. For each millimeter of recession an anteralization of 1/3 of a millimeter was performed, which makes it possible to reattach the anterior border along the physiologic course of the muscle. Preoperatively, no eye drops were given. Directly before surgery, the eyelids and the skin surrounding the operative site were disinfected with Betadine® (Iodum 10 mg ut povidonum iodinatum excip. ad solute. pro 1 ml). The conjunctiva was not rinsed. A limbal traction suture (Silkam® 6-0 or Safil® 6-0 BV-1) is applied in order to expose the temporal inferior quadrant of the eye globe. During surgery, a direct contact of the traction suture with the cornea has to be avoided. A 4 mm radial cut is performed over the insertion of the inferior obliquus muscle (Fig. 1a). The anterior margin of the cut is 1 mm anterior of the tendon insertion. In patients with reduced elasticity of the conjuntival tissue, a slightly larger opening will be needed. A second cut is applied where later the reinsertion will be performed. If the reattachment will be next to the lateral border of the inferior rectus muscle, the muscle itself will help as a landmark. If a graded recession of a certain amount is planned, the place is marked using a measure caliper. With blunt Wescott scissors, the inferior obliquus inseration is separated from the surrounding tissue (Fig. 1b). Then, using the same scissors, the insertion is completely detached (Fig. 1c). Now, one single suture (Vicryl® 7-0 GS-8) is applied to the anterior third of the detached muscle insertion (Fig. 1d). In this patient series, only the anterior border was reinserted to the sclera, and therefore no second posterior suture was used. Afterwards, a blunt cannula (Hurricain Medical, 20G x 1 in. Sub-Tenon's Anaesthesia Cannula) is passed through the second cut, the reinsertion site opening, and advanced in order to get out through the first cut (Fig. 1e). The needle is gently inserted in the cannula until it is fixed (Fig. 1f). Now, the cannula is retracted (Fig. 1g). After withdrawal of the needles from the cannula, the scleral fixation is performed (Fig. 1h). After having controlled that all posterior fibers of the inferior obliquus insertion have been properly cut, the surgical procedure is finished by applying single sutures (Vicryl® Rapid 8-0 GS-8) to each of the two small cuts (Fig. 1i). At the end of surgery, TobraDex® ointment (1 mg dexamethasone and 3 mg tobramycin per g, 0.5% chlorobutanol) or Maxitrol® ointment (polymyxin B sulphate 6,000 units, neomycin sulphate 3,500 units, dexamethasone 1.0 mg, methylparaben 0.05%, and propylparaben 0.01%) was applied. There was no need for an eye patch. For the first 2 weeks after surgery the following treatment was prescribed: TobraDex® suspension (1 mg dexamethasone and 3 mg tobramycin per ml, 0.01% benzalkonium chloride) t.i.d. and TobraDex® ointment in the evening or Maxitrol® suspension (polymyxin B sulphate 6,000 units, neomycin sulphate 3,500 units, dexamethasone 1.0 mg, and benzalkonium chloride 0.004%) t.i.d. and Maxitrol® ointment in the evening. If during minimally invasive surgery the operating site needs to be better visualized, e.g. if excessive bleeding occurs, which cannot be stopped with cautery through the small cuts, the two openings can be joined (Fig. 1J).Fig. 1

Bottom Line: The vertical deviation, which was measured in 25 degrees of adduction, decreased from preoperatively 12.8 degrees +/- 5.6 degrees to 2.7 degrees +/- 2.2 degrees (p < 0.0001) at 6 months.Binocular vision improved in eight patients, remained unchanged in six patients, and decreased from 30 to 60 arcsec in one patient (p > 0.1).One patient out of 15 (7%) needed repeat surgery because of insufficient reduction of the sursoadduction within the first 6 months.

View Article: PubMed Central - PubMed

Affiliation: Department of Strabismology & Neuro-Ophthalmology, and University of Bern, Kantonsspital St. Gallen, St. Gallen, 9007, Switzerland. daniel.mojon@kssg.ch

ABSTRACT

Purpose: To present a novel, minimally invasive strabismus surgery (MISS) technique for inferior obliquus recessions.

Methods: Graded MISS inferior obliquus recessions were performed in 20 eyes of 15 patients by applying two small conjunctival cuts, one at the insertion of inferior obliquus and another where the scleral anchoring of the muscle occurred.

Results: The amount of recession was 12.2 +/- 2.3 mm (range 6 to 14 mm). The vertical deviation, which was measured in 25 degrees of adduction, decreased from preoperatively 12.8 degrees +/- 5.6 degrees to 2.7 degrees +/- 2.2 degrees (p < 0.0001) at 6 months. LogMAR visual acuity was preoperatively -0.10 +/- 0.17 and at 6 months -0.14 +/- 0.22 (p > 0.1). In one eye (2.5%) the two cuts had to be joined because of excessive bleeding. Binocular vision improved in eight patients, remained unchanged in six patients, and decreased from 30 to 60 arcsec in one patient (p > 0.1). Conjunctival and lid swelling were hardly visible on the first postoperative day in primary gaze position in 10/20 (50%) of eyes. Five of the eyes (25%) had mild and five (25%) moderate visibility of surgery. One patient out of 15 (7%) needed repeat surgery because of insufficient reduction of the sursoadduction within the first 6 months. The dose-effect relationship 6 months postoperatively for an accommodative near target at 25 degrees adduction was 0.83 degrees +/- 0.43 degrees per mm of recession.

Conclusions: This study demonstrates that small-incision, minimal dissection inferior obliquus graded recessions are feasible and effective to improve ocular alignment in patients with strabismus sursoadductorius.

Show MeSH
Related in: MedlinePlus