Adjustable Vertical Muscle Surgery in Incomitant Squint

Dr Madhu Karna MS, FMRF

Pediatric ophthalmologistCentre for Sight Safdarjung Enclave

Abnormal Head Posture 43 year old female C/o squint and Diplopia Onset of myasthenia gravis at

10 yrs of age Thymectomy done at 20 yrs of

age MG now in remission Right face turn, chin up, left

head tilt BCVA BE 6/6 Right hypertropia with exotropia

Cover Test

RE fixing-15pd R/L and15pd RXT, LE fixing- 20pd R/L and15pd RXT- for distance and near

Extraocular movements

•RE – limitation of depression in abduction, LE – limitation of elevation in adduction

Nine gaze measurements

35pd R/L

12pd RXT

15pd R/L

12pd RXT

4pd R/L

12pd RXT

30pd R/L

15pd RXT

20pd R/L

15 RXT

15pd R/L

15pd RXT

30pd R/L

20pdRXT

15pd R/L

20pd RXT

15pd R/L

20pd RXT

Head Tilt

25 pd R/L 20 pd R/L

Diplopia charting – Maximum separation of images in detroelevation with the right eye image crossed and depressed.

Double Maddox Rod Test

LE Intorsion 25 deg

FDT (LE foll by RE)

INVESTIGATIONS

Neostigmine test – Negative Thyroid status – Within normal limits TPHA (for syphilis)-Negative Serum ACE and Calcium - Within normal

limits MRI scan brain and orbit with contrast –

Within normal limits

SURGICAL PLAN

LE- SO recession RE-SR recession on adjustable suture

under LA

Cuffed superior limbal incision

LE SO Recession

RE – SR Recession

POSTOP-6 HOURS

POST OP WEEK 1

POST OP WEEK 1

AHP DISSOLVED- 6 WEEKS

Postop 9 gaze measurements at 6 weeks

20pd R/L 4pd R/L 4pd L/R

12pd R/L 3pd R/L ortho

8pd R/L ortho 4pd R/L

POST OP 6 WEEKS

POST OP 8 WEEKS

References Strabismus surgery in patients with myasthenia. Davidson JL, Rosenbaum

AL, McCall LC ; J Pediatr Ophthalmol Strabismus. 1993 Sep-Oct;30(5):292-5

The pattern of extra-ocular muscle involvement in ocular myasthenia. Cleary M, Williams GJ, Metcalfe RA; Strabismus.2008 Jan-Mar 16(1):11-8

Postoperative results in inferior oblique palsy.Kutschke PJ, Scott WE : J Pediatr Ophthalmol Strabismus. 1996 Mar-Apr;33(2):72-8.

Isolated inferior oblique paresis. Scott WE, Nankin SJ. Arch Ophthalmol. 1977 Sep;95(9):1586-93

Oblique muscle palsies fixating with the paretic eye. Dickie, Scott. Survey Ophthalmol, 1988;33:97-107.

Clinical characteristics and treatment of isolated inferior rectus paralysis.Von Noorden GK , Hansell R. Ophthalmology. 1991 Feb;98(2):253-7

Recession of superior oblique tendon for inferior oblique palsy and Brown’s syndrome. WFAstle, Cornock, Drummond. Can J Ophthalmol. 1993 vol 28 (5) 207-212.

Adjustable suture strabismus surgery for acquired vertical deviations. Keech,Heckert: J Pediatr Ophthalmol Strabismus 1988;25:159

Preop Exam IO PALSY IR PALSYAHP + -

EOM Limitation + +

Cover test-rht,xt + +

Park 3 step test + -

9 Gaze measur + +

Diplopia chart + -

Postop ExamEOM + -

Park 3 step test + -

9 Gaze measur + -

Diplopia chart + -

Elevators in MG + -