Adjustable Augmented Rectus Muscle Transposition Surgery with or Without Ciliary Vessel Sparing for Abduction Deficiencies

Abstract

Background Vertical rectus transposition (VRT) is useful in abduction deficiencies. Posterior fixation sutures enhance the effect of VRT, but usually preclude the use of adjustable sutures. Augmentation of VRT by resection of the transposed muscles allows for an adjustable technique that can reduce induced vertical deviations and overcorrections. Methods We retrospectively reviewed the records of all patients undergoing adjustable partial or full tendon VRT augmented by resection of the transposed muscles. Ciliary vessels were preserved in most of the patients by either splitting the transposed muscle or by dragging the transposed muscle without disrupting the muscle insertion. Results Seven patients with abducens palsy and one with esotropic Duane syndrome were included. Both vertical rectus muscles were symmetrically resected by 3–5 mm. Preoperative central gaze esotropia of 30.6 ± 12.9Δ (range, 17–50Δ) decreased to 10.6 ± 8.8Δ (range, 0–25Δ) at the final visit (p = 0.003). Three patients required postoperative adjustment by recession of one of the transposed muscles due to an induced vertical deviation (mean 9.3Δ reduced to 0Δ), coupled with overcorrection (mean exotropia 11.3Δ reduced to 0 in two patients and exophoria 2Δ in one patient). At the final follow-up visit 3.8 ± 2.6 months postoperatively, one patient had a vertical deviation <4Δ, and none had overcorrection or anterior segment ischemia. Three patients required further surgery for recurrent esotropia. Conclusions Augmentation of VRT by resection of the transposed muscles can be performed with adjustable sutures and vessel-sparing technique. This allows for postoperative control of overcorrections and induced vertical deviations as well as less risk of anterior segment ischemia.

Transposition procedures in Duane retraction syndrome

“…Published data are insufficient to document the relative efficacy of this approach. Furthermore, as described, 12 the small transverse incision in each vertical rectus muscle just anterior to where the suture is placed could still endanger the anterior ciliary supply.…”

“…F, "Full" VRT with ciliary-sparing partial resection of the vertical rectus muscles, as proposed by Hendler and colleauges. 12 An incision of approximately 2.5 mm is made perpendicular to the path of the superior rectus muscle on its temporal side at a predetermined distance (3-4 mm) the muscle insertion. An absorbable suture is woven through the posterior part of the transected portion of the muscle and used to transpose the entire muscle by reattaching it to sclera at the superior border of the lateral rectus muscle insertion along the spiral of Tillaux.…”

“…7,9 Resection does offer some advantages over augmentation sutures, including avoidance of additional scleral passes, the opportunity to perform the transposition in a quantitatively graded manner (although validated dose-response curves do not yet exist), the ability to correct a preexisting vertical tropia by differential resection of the two vertical muscles, and compatibility with adjustable sutures. 12 Whether this approach proves to be a useful addition to our surgical armamentarium for DS remains to be determined.…”

“…They are then attached to the sclera along the spiral of Tillaux using an adjustable suture ( Figure 1F). 12 Proponents of the technique argue that it redirects the force of the entire vertical rectus muscle as opposed to just part of it (in contrast to split-muscle tech-niques), permits adjustment, and spares the anterior ciliary arteries of all of the rectus muscles. Published data are insufficient to document the relative efficacy of this approach.…”

Anterior Segment Ischemia after Strabismus Surgery

“…Many surgeons prefer this technique because it preserves the vasculature. 13 In 2001, Brooks et al 14 proposed an adapted version of the Hummelsheim procedure in which the vertical rectus muscle is resected 4-5 mm prior to transposition (augmented Hummelsheim procedure). Couser et al 15 performed medial rectus recession with the augmented Hummelsheim procedure in 9 patients and reported achieving orthophoria in primary position and improved abduction.…”