The authors developed a new surgical procedure for use in treating pure cyclodeviation. This procedure was accomplished by a simple muscle transposition technique without tenotomy. Satisfactory postoperative results were achieved without postoperative complications. This procedure may be useful for treating cyclodeviations, with minimal risk of surgical complications, particularly anterior segment ischemia.
From the Department of Ophthalmology, Shiga University of Medical Science, Otsu, Japan.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Sanae Muraki, MD, Department of Ophthalmology, Shiga University of Medical Science, Seta-tsukinowacho, 520-2192, Otsu, Japan.
Received: December 04, 2007
Accepted: August 08, 2008
Posted Online: May 21, 2010
Horizontal transposition of the vertical rectus muscles is performed to treat cyclodeviation associated with congenital absence of the superior oblique muscle or to treat residual cyclodeviation after oblique muscle surgery. However, vertical muscle tenotomy that increases the frequency of anterior segment ischemia is necessary in the process of transposition of the vertical rectus muscles.1–4 Therefore, the authors developed a new muscle transposition procedure to treat pure cyclodeviation in which all of the rectus muscles are anchored with sutures to the sclera without tenotomy.
A 75-year-old man had torsional diplopia after undergoing macular translocation in the left eye to treat age-related macular degeneration. Postoperative corrected visual acuity was 1.00 in the right eye and 0.20 in the left eye. Fundus examination showed incyclodeviation in the left eye. Synoptophore testing showed 12.5° incyclotropia; no associated horizontal or vertical deviation was found in primary gaze. The left vertical muscle bellies were transposed without muscle tenotomy to rotate the eye around the sagittal axes in the direction of excycloduction.
The surgical principle is shown in Figure 1. A 6-0 polypropylene monofilament suture was inserted and knotted at one-third of the muscle width and at the nasal margin of the superior rectus muscle 6 mm posterior to the insertion. The 6-0 polypropylene monofilaments were secured at the sclera 6 mm nasal to the margin of the superior rectus muscle. The inferior rectus muscle was transposed temporally without tenotomy using the same technique. Consequently, the eye was rotated around the sagittal axis in the direction of excycloduction. Postoperatively, synoptophore testing showed 3° incyclotropia; no associated horizontal or vertical deviation was found in primary gaze. Therefore, the corrected amount of incyclotropia on synoptophore testing was 9.5°.
Figure 1. Nasal Transposition of the Superior Rectus Muscle with Temporal Transposition of the Inferior Rectus Muscle Causes Excycloduction of the Left Eye. SR = Superior Rectus Muscle; LR = Lateral Rectus Muscle; IR = Inferior Rectus Muscle; MR = Medial Rectus Muscle.
The patient had torsional diplopia as a result of residual cyclodeviation. In addition to residual cyclodeviation, there was partial regression of the torsional effect postoperatively. Synoptophore testing showed 7° incyclotropia 4 months after the first operation. A second surgical procedure was planned 5 months after the first operation to transpose the left horizontal muscle bellies without tenotomy. The surgical procedure is shown in Figure 2. A 6-0 polypropylene monofilament suture was inserted and knotted at one-third of the muscle width and at the inferior margin of the medial rectus muscle 6 mm posterior to the insertion. The suture was secured to the sclera 6 mm below the margin of the medial rectus muscle without tenotomy. Then the inferior margin of the medial rectus muscle was transposed. The lateral rectus muscle was transposed upward without tenotomy using a similar technique. Postoperatively, synoptophore testing showed 3° incyclotropia; no associated horizontal or vertical deviation was found in primary gaze. Therefore, the corrected amount of incyclotropia on synoptophore testing was 4°. When the patient was examined 2 months after the second operation, synoptophore testing showed 3.5° incyclotropia without associated horizontal or vertical deviation in primary gaze. The patient did not complain of torsional diplopia.
Figure 2. Downward Transposition of the Medial Rectus Muscle with Upward Transposition of the Lateral Rectus Muscle Causes Excycloduction of the Left Eye. Sr = Superior Rectus Muscle; LR = Lateral Rectus Muscle; IR = Inferior Rectus Muscle; MR = Medial Rectus Muscle.
The authors developed a new muscle transposition procedure for abducens palsy without tenotomy.5 During this procedure, the superior and inferior rectus muscles are transposed symmetrically without tenotomy or muscle splitting toward the paralytic lateral rectus muscle. Because of the symmetric transposition of the vertical rectus muscles, horizontal duction is increased. However, one consideration is that the procedure can cause cycloduction if the rectus muscles are transposed rotationally. Therefore, the authors developed a new procedure of rotational transposition of the rectus muscles without tenotomy to correct cyclodeviation.
Macular translocation has been performed to treat exudative age-related macular degeneration,6–8 but the procedure resulted in large-angle cyclodeviation that had not been seen previously. Torsional surgery of the oblique muscles, alone or in combination with surgical treatment of two or four rectus muscles, has been performed to treat large cyclodeviations after macular translocation.8,9 Although these procedures are adequate for the treatment of large-angle cyclodeviations of 15° to 50°, they might be unsuitable for correction of small-angle cyclodeviations.8,9 However, the new procedure may achieve cyclodeviation of 15° or less.
Some procedures for the treatment of small-angle cyclodeviation have been reported. Von Noorden et al.10 reported that the average effect of horizontal transposition of one vertical rectus muscle for cyclotropia was a 7° correction in primary gaze. Ohmi et al.11 reported an average 8° correction by unilateral horizontal transposition of one-half the tendon width. However, vertical muscle tenotomy is necessary in these surgical procedures.
In contrast, because tenotomy is unnecessary with the current procedure, it is easier and safer. The new procedure is especially useful during a second surgical procedure after tenotomy because it reduces the surgical damage to the eye and avoids severe complications, such as anterior segment ischemia. Furthermore, the release of cyclorotation was achieved easily by cutting the anchoring suture. It may be possible to correct more cyclodeviation by changing the insertion position at the rectus muscle from one-third the width to one-half the width and changing the anchored position to the scleral point from 6 mm to more than 6 mm. The new technique is an easy and safe method for correcting relatively small amounts of cyclodeviation.
- Girard LJ, Beltranena F. Early and late complications of extensive muscle surgery. Arch Ophthalmol. 1960;64:576–584.
- McNeer KW. Three complications of strabismus surgery. Ann Ophthalmol. 1975;7:441–446.
- Hiatt RL. Production of anterior segment ischemia. J Pediatr Ophthalmol Strabismus. 1978;15:197–204.
- Saunders RA, Sandall GS. Anterior segment ischemia syndrome following rectus muscle transposition. Am J Ophthalmol. 1982;93:34–38.
- Nishida Y, Hayashi O, Oda S, et al. A simple muscle transposition procedure for abducens palsy without tenotomy or splitting muscles. Jpn J Ophthalmol. 2005;49:179–180. doi:10.1007/s10384-004-0151-2 [CrossRef]
- Machemer R, Steinhorst UH. Retinal separation, retinotomy, and macular relocation: II. A surgical approach for age-related macular degeneration?Graefes Arch Clin Exp Ophthalmol. 1993;231:635–641. doi:10.1007/BF00921957 [CrossRef]
- Ohji M, Fujikado T, Kusaka S, et al. Comparison of three techniques of foveal translocation in patients with subfoveal choroidal neovascularization resulting from age-related macular degeneration. Am J Ophthalmol. 2001;132:888–896. doi:10.1016/S0002-9394(01)01255-7 [CrossRef]
- Eckardt C, Eckardt U, Conrad HG. Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol. 1999;237:313–325. doi:10.1007/s004170050239 [CrossRef]
- Fujikado T, Shimojyo H, Hosohata J, et al. Effect of simultaneous oblique muscle surgery in foveal translocation by 360 retinotomy. Graefes Arch Clin Exp Ophthalmol. 2002;240:21–30. doi:10.1007/s00417-001-0401-7 [CrossRef]
- Von Noorden GK, Jenkins RH, Chu MW. Horizontal transposition of the vertical rectus muscles for cyclotropia. Am J Ophthalmol. 1996;122:325–330.
- Ohmi G, Fujikado T, Ohji M, Saito Y, Tano Y. Horizontal transposition of vertical rectus muscles for treatment of excyclotropia. Graefes Arch Clin Exp Ophthalmol. 1997;235:1–4. doi:10.1007/BF01007829 [CrossRef]