Advancement into No Man’s Land: Primary Advancement of the Superior Rectus Muscle for Large Angle Vertical Strabismus and Upper Eyelid Retraction in Patients with Thyroid Eye Disease.
Author: Omaya Youssef
Base Hospital / Institution: Mid-Atlantic Permanente Medical Group
ePoster presentation
Abstract ID: 24-383
Purpose
Strabismus surgery for hypotropia (HoT) in thyroid eye disease (TED) commonly involves recession of the affected muscles. With large angle deviations (≥ 25 prism diopters (PD)), additional techniques such as recession of contralateral antagonist muscles, and less frequently, resection of ipsilateral antagonist muscles have been performed. In addition, correction of vertical strabismus is challenging as large recessions commonly result in postoperative upper and/or lower eyelid retraction.
Methods
The author describes a novel approach where primary advancement of the superior rectus (SR) muscle beyond its insertion, following ipsilateral inferior rectus (IR) muscle recession, successfully corrected 40 PD of left HoT and upper eyelid retraction in a patient with asymmetric TED.
Results
At 6 months postop, the patient was orthotropic at distance, near, and in all fields of gaze except for 14 PD of left hypertropia (LHT) in downgaze. Upper eyelid retraction had resolved, however, the patient developed lower eyelid retraction that was successfully repaired with an allograft. At 18 months follow-up, the patient remained orthotropic at distance and near, with 6 PD LHT in downgaze that continued to resolve.
Conclusion
Primary advancement of the SR muscle anterior to its insertion site following standard IR muscle recession appears to preserve the anatomic relationship between the vertical recti insertions. As a result, the globe is rotated superiorly along its vertical axis while preserving motility that is achieved through the vertical recti muscles’ arcs of contact with the globe. The recession-advancement (‘R&A’) procedure appears to be an effective method to correct large angle vertical deviations in asymmetric/unilateral TED, achieving the triple aim of orthotropia, preserving motility, and correcting upper eyelid retraction.
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