Tendon elongation with bovine pericardium in strabismus surgery—indications beyond Graves’ orbitopathy

Abstract

Background For some patients with complex ocular motility disorders, conventional strabismus surgery is insufficient. Surgery with tendon elongation allows correction of larger angles and maintains a sufficient arc of contact for rectus muscles. This study reports results for tendon elongation with bovine pericardium (Tutopatch®) in indications other than Graves’ orbitopathy in which it is already widely used. Methods We reviewed the records of all patients who underwent surgery with Tutopatch® in our institution. Angles of squint and head postures were analyzed preoperatively, on the first postoperative day, and in the long term (median 9 weeks after the operation). Patients with Graves’ orbitopathy were excluded. Results From 2011 to 2018, the procedures on 58 eyes of 54 patients (35 females, median age 35 years (3–75)) met the inclusion criteria. Horizontal rectus muscle surgery (53 eyes) was conducted on patients with residual strabismus (13), Duane’s retraction syndrome with eso- (type I: 16)/exodeviation (type II: 2, type III: 1), 6th (7)/3rd nerve palsy (7), Möbius syndrome (2), congenital fibrosis of the extraocular muscles type 3A (CFEOM3A, TUBB3 mutation) (4), and orbital apex syndrome (1). Vertical rectus muscle surgery (5 eyes) was conducted on patients with myasthenia (1), vertical tropia after orbital floor fracture (1), CFEOM1 (2), and Parry-Romberg syndrome (1). 42 eyes had prior eye muscle surgery (1–5 procedures, median 1). Out of 45 patients with postoperative long-term data, 43 showed an angle reduction. Fifty-one percent had an angle of 10Δ (prism diopter) or less, one had a significant over-effect, and 10 had revision surgery. For the heterogeneous group of residual eso- and exotropias, the median absolute horizontal angle was reduced from 35Δ (16 to 45Δ) to 9Δ (0 to 40Δ), for Duane’s retraction syndrome from 27.5Δ (9 to 40Δ) to 7Δ (0 to 40Δ), and for sixth and third nerve palsies from 43Δ (20 to 75Δ) to 18Δ (4 to 40Δ). For 3 patients with vertical rectus muscle surgery, the median absolute vertical angle was reduced from 30Δ (20 to 45Δ) to 4Δ (1 to 22Δ). The motility range was shifted in the direction contrary to the elongated muscle in all subgroups. A considerable reduction of the excursion into the field of action of the elongated muscle had to be registered. Conclusions Strabismus surgery with bovine pericardium introduces new surgical options for complicated revisions and for rare and complex oculomotor dysfunctions. Yet, it has to be recognized that this type of surgery aiming at maximum effects, despite preservation or restitution of the arc of contact, leads to reduction of the excursion into the field of action of the elongated muscle. Furthermore, dose finding can be difficult depending on the underlying pathology and more than one intervention might be necessary for optimal results.

Update on the surgical management of Graves’ orbitopathy

“…Other groups have also reported satisfactory results ( 140 , 141 ). To reduce IR muscle restriction, tendon elongation uses homologous scleral grafts, polytetrafluoroethylene (Goretex), silicone, bovine pericardium, ( 142 ), or fascia lata ( 143 ). Jefferis et al ( 127 ) reported favorable outcomes after prioritizing downgaze alignment (rather than primary gaze alignment) to avoid downgaze diplopia.…”

Congenital Fibrosis of the Extraocular Muscles: An Overview from Genetics to Management

“…Therefore, conventional strabismus surgery is commonly insufficient in cases with a large-angle deviation. To maximize the weakening effects, Hedergott et al suggested tendon elongation techniques using bovine pericardium [ 77 ].…”

Human pericardial extracellular matrix: An implantation platform for cardiac tissue engineering

“…In brief, pericardium grafts have been applied to correct intracardiac and diaphragm defects (Ricci et al, 2014;Yaliniz et al, 2014;Ascaso et al, 2021), as well as ischemic ventricular septal defect after acute MI (Mihalj et al, 2022). On the other hand, non-cardiac pericardium-based applications include replacement of brain dura mater (Sun et al, 2018), bleb repair, conjunctival reconstruction, cover of severe corneal wound or tendon elongation in the eye (Niegowski et al, 2020;Ashena et al, 2021;Hedergott et al, 2021;Chen et al, 2022), odontology (Solakoğlu et al, 2022) and eardrum reconstruction (de Dorldodot et al, 2013;Sainsbury et al, 2022). Furthermore it has been employed to generate a variety of bioprostheses such as vascular grafts, patches for abdominal or vaginal wall reconstruction and heart valves (Rémi et al, 2010).…”