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Year : 1978  |  Volume : 26  |  Issue : 1  |  Page : 29-33

Total superior rectus transplantation in lateral rectus paralysis


Department of Ophthalmology, Medical College, Amritsar, India

Correspondence Address:
Daljit Singh
Department of Ophthalmology, Medical College, Amritsar
India
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Source of Support: None, Conflict of Interest: None


PMID: 711275

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How to cite this article:
Singh D, Singh M. Total superior rectus transplantation in lateral rectus paralysis. Indian J Ophthalmol 1978;26:29-33

How to cite this URL:
Singh D, Singh M. Total superior rectus transplantation in lateral rectus paralysis. Indian J Ophthalmol [serial online] 1978 [cited 2024 Mar 19];26:29-33. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1978/26/1/29/31454

Though uncommon, congenital or acquired abduction paralysis poses a great problem. The prognosis is influenced by the recovery of lateral rectus force and the development of secondary changes in other muscles.

Hummelsheim[7],[8],[9] laid down some princi­ples of muscle transplantation procedures. Numerous modifications of these procedures have been reported from time to time[1],[3],[11],[14],[16]

Jensen[10] described a new technique based on Hildreth's[5] experiments. In this technique split lateral half of each vertical rectos is sutured to the adjacent half of the similarly split latera rectus, near the equator of the globe. This l method has been followed by Frueh and Hender­son' and Hill[6].

Vesey[10] reported the transplantation of the entire superior rectus muscle in one case of acquired lateral rectus paralysis with the recovery of normal movements.

This paper concerns the results of total superior rectus transplantation in four cases (five eyes) of abduction paralysis.


  Technique of operation Top


The conjunctiva is incised just anterior to the lateral rectus insertion and the incision is extended superiorly in a curvilinear fashion to the medial margin of the superior rectus. Tenon's capsule is also incised and the area of the lateral and superior recti cleared by blunt dissection.

The superior rectus muscle is cleared backwards as far as possible, generally for a little over 2 cms. Two silk sutures are passed through the tendon of the superior rectus muscle and the muscle is severed from its insertion. The muscle is bodily shifted to the direction of the lateral rectus muscle. The tendon of the superior rectus muscle is passed under the tendon of the lateral rectus muscle. The lateral stitch of the superior rectus is tied at the lower edge of the lateral rectus insertion and the medial stitch is tied at the upper edge. The Tenon's capsule and the conjunctiva are closed.


  Case Reports Top


Case No. 1: Miss R, 15 years old developed right lateral rectus paralysis after fever 5 years back. She had consulted a few eye specialists, who had advised her that the condition wv as incurable. The vision in the squinting eve was 6/60. There was esotropia of about 30 degrees in the primary position with 10 degrees of hypertropia. The eye could not be abducted beyond the midline.

Total superior rectus transplantation followed one week later by 5mm recession of the ipsilateral medial reclus was done. As a result the eves were straight in the primary position with no change in the degree of hypertropia. An abduction of about 30 degrees was obtained [Figure - 1],[Figure - 2],[Figure - 3],[Figure - 4].

Case No. 2: Miss J, 18 years old was admitted with right lateral rectus paralysis since early age. Vision in the affected eye was 3/60. Esotropia in the primary position was over 30 degrees and the right eye could be abducted only a little beyond the midline.

Total superior rectus transplantation and 5 mm recession of the right medial rectus was done at the first sitting. One week later, recession of the left medial rectus by 5mm was done. Postoperatively the eyes were straight in the primary position. On dextrover­sion full abduction was obtained in the affected eye. On levoversion, slight retraction of the right eyeball with narrowing of the palpebral fissure was seen [Figure - 5],[Figure - 6],[Figure - 7],[Figure - 8].

Case No. 3: Mr. G.S., 21 years old, had acquired lateral rectus paralysis in the left eye, after prolonged fever at the age of 14 years. Vision in the squinting eye was only 2/60. There was over 30 degree conver­gent squint in the primary position and the affected eye could not be moved beyond the midline.

Total superior rectus transplantation of the left eye and 5mm recession of the left medial rectus were done. He obtained orthophoria in the primary position with full lateral movements [Figure - 9],[Figure - 10],[Figure - 11],[Figure - 12].

Case No. 4: Kaka, 6 years old male child, had congenital bilateral lateral rectus paralysis with crossed fixation. As a result he was very much visually handi­capped and mentally retarded. Visual acuity could not be ascertained. Each eye could not be moved outwards beyond the midline.

Bilateral total superior rectus transplantation combined with 4 mm bimedial recession was performed at one sitting. Postoperatively the right eye was found to be exotropic by 10 degrees. Therefore the right medial rectus was re stitched at the original site on the third day. Orthophoria was obtained in the primary position with the achievement of full lateral movements in both the eyes [Figure - 13],[Figure - 14],[Figure - 15]. Updrift of the right eye on levoversion was noticed [Figure - 13],[Figure - 14],[Figure - 15].


  Comments Top


It has been experimentally demonstrated that the central control of ocular movements is not firmly fixed[2],[12],[13]

Any ocular muscle can either be stimulated or inhibited as a whole at one time. Therefore it can perform only one primary function[20]. Furthermore even to achieve moderate abduction the transplanted strips have to be quit long at least 20 to 22 mms'[15],[17],[18],[19]. Therefore a partial transplantation of small slips of vertical recti do not function to the best of their altered anatomy. The best we could obtain was a good cosmetic appearance in the primary position with an abduction of 10 degrees[20]. Jensen's[10] operation also fails in its maximum effectiveness on this very ground.

Total shift of the superior rectus muscle alone to the site of insertion of paralysed muscle provides a long and a functionally single unit with its action practically in the line of the weak lateral rectus muscle. In the absence of the superior rectus, the inferior oblique muscle gives the eye adequate upward movements[20].

In all our 4 cases (five eyes) the lateral rectus paralysis was of long standing. In every case the eye was markedly esotropic in the primary position and there was gross limitation of abduc­tion. Every case had poor vision in the affected eye (tested in case no. 4) and surgery was undertaken for cosmetic purpose only. In all the cases total transplantation of the superior rectus had to be combined with a recession of one or both medial recti.

In all the four cases (five eyes) orthophoria was achieved in the primary position. Full abduction was obtained in 4 of the 5 eyes. In the fifth eye (case no. 1) an abduction of about 30 degrees was obtained.

None of the operated eyes developed hypo­tropia in spite of the shift of the superior rectus muscle.

In one case (case no. 2) the palpebral fissure became narrow on adduction, thus simulating Duane's syndrome. Postoperative Duane's synd­rome has also been reported by Frueh and Henderson[4] and Hill[6] after Jensen's operation. It could be attributed to the cord like action of the transplanted muscle in the postoperative period.

In one case (case no.4) updrift of the right eye on levoversion was recited, which is difficult to explain.


  Summary Top


The paper describes our experience of four patients (five eyes) with long standing lateral rectus paralysis treated by total transplantation of superior rectus muscle coupled with surgery on medial recti. In all the cases the results have been quite satisfactory.

 
  References Top

1.
Berens C. and Girard, L J.. 1950, Amer. J. Ophthal., 33, 1041.  Back to cited text no. 1
    
2.
Bloomgarden, C.I. and Jampel, R.S., 1963, Amer J. Ophthal., 56, 250.  Back to cited text no. 2
    
3.
Fricdman, B., 1970, Eye, Ear, Nose and Throat Monthly, 49, 245  Back to cited text no. 3
    
4.
Frueh, B.R. and Herderson, J.W., 1971, Arch. Ophthal., 85, 191.  Back to cited text no. 4
    
5.
Hildreth, H.R., 1953, Amer J.Ophthal.,36,1267.   Back to cited text no. 5
    
6.
Hill, K., 1973, Canad. J. Ophthal., 8, 437.  Back to cited text no. 6
    
7.
Hummelscheim, E., 1907, Quoted by Vessey, F.A. 1972, Brit. J. Ophthal. 56, 892.  Back to cited text no. 7
    
8.
Hummelscheim, E., 1907, Quo ed by Vessey, F.A., 1972, Brit. J. Ophthal., 56, 892.  Back to cited text no. 8
    
9.
Hummelscheim, E., 1912, Quoted by Vessey F.A., 1972, Brit. J. Ophthai., 56, 892.  Back to cited text no. 9
    
10.
Jensen, C.D.F., 1964, Trans. Pacif. Coast. Oto­phthal. Soc., 54, 359.  Back to cited text no. 10
    
11.
Krev sop, W.E., 1957, Jour. Internat. Coll. Surg. 27, 731.  Back to cited text no. 11
    
12.
Leinfelder, P. and Black, N.M., 1942, Quoted by Vessey, F.A , 1972, Brit. J. Ophthal., 56, 892.  Back to cited text no. 12
    
13.
Marina, A., 1915, Quoted by Vessey, F.A., 1972, Brit. J. Ophthal., 56, 892.  Back to cited text no. 13
    
14.
O'Conner, R., 1935, Amer. J. Ophthal., 18, 813.  Back to cited text no. 14
    
15.
Quain, R 1929, Quoted by Vessey, F.A., 1972, Brit. J. Ophthal., 56, 892.  Back to cited text no. 15
    
16.
Schillinger, R.J., 1959, Jour. Internat. Coll. Surg., 31, 593.  Back to cited text no. 16
    
17.
Scobes, R.G., 1947, The Oculorotary muscles, 71. Mosby, St. Louis.  Back to cited text no. 17
    
18.
Stallard, H.B., 1950, Eye Surgery 2nd Ed., 315, Willium and Wilkins Baltimore.  Back to cited text no. 18
    
19.
Vessey, F.A., 1967, XX Concilium Ophthat­mologicum Get-mania, 1966, Acta Munich, 12, 938 Int. Congr. Ser. No. 146. Excerpta Medica Foundation, Amsterdam.  Back to cited text no. 19
    
20.
Vessey, F.A., 1972, Brit. J. Ophthal., 56, 892.  Back to cited text no. 20
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14], [Figure - 15]



 

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