Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 7646
  • Home
  • Print this page
  • Email this page

   Table of Contents      
ORIGINAL ARTICLE
Year : 2016  |  Volume : 64  |  Issue : 1  |  Page : 33-37

The effect of anterior transposition of the inferior oblique muscle on eyelid configuration and function


Department of Ophthalmology, School of Medicine, Harran University, Sanliurfa, Turkey

Date of Submission04-Feb-2015
Date of Acceptance12-Dec-2015
Date of Web Publication7-Mar-2016

Correspondence Address:
Tugba Goncu
Department of Ophthalmology, School of Medicine, Harran University, 63100 Sanliurfa
Turkey
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.178138

Rights and Permissions
  Abstract 

Purpose: To evaluate the alteration of lower lid configuration and function with anterior transposition surgery of the inferior oblique (IO) muscle. Patients and Methods: A prospective clinical trial was conducted on a consecutive series of patients underwent anterior transposition of the IO as a sole operation. All patients received a thorough ophthalmic examination 1 day before and 3 months after surgery. Output parameters were consisted of palpebral fissure, margin reflex distance 1–2, lower lid function, hertel value, and lower lid crease. The differences of the collected data were calculated for statistical significance by using the Wilcoxon test. Results: A total of 19 eyes of 16 consecutive patients were included. The median preoperative grade of IO overaction was 3.5 (ranging from 3 to 4), which decreased to 0 (ranging from 0 to 2) postoperatively (P < 0.05). No significant change was observed in all parameters 3 months postoperatively (P > 0.05). Conclusion: In this study, no significant effect on lower lid configuration and function was observed following IO anterior transposition in which the disinserted muscle was placed posterior to inferior rectus insertion.

Keywords: Inferior eyelid function, inferior oblique anterior transposition, lower lid crease, palpebral fissure


How to cite this article:
Goncu T, Cakmak S, Akal A, Oguz H. The effect of anterior transposition of the inferior oblique muscle on eyelid configuration and function. Indian J Ophthalmol 2016;64:33-7

How to cite this URL:
Goncu T, Cakmak S, Akal A, Oguz H. The effect of anterior transposition of the inferior oblique muscle on eyelid configuration and function. Indian J Ophthalmol [serial online] 2016 [cited 2020 May 26];64:33-7. Available from: http://www.ijo.in/text.asp?2016/64/1/33/178138

Inferior oblique (IO) muscle weakening is the procedure of choice in treatment of the primary IO overaction or secondary overaction due to superior oblique palsy.[1],[2],[3] For increasing the weakening effect, anterior transposition of the IO was first suggested by a theoretical work of Scott.[4] This procedure was widely accepted for treatment of dissociative vertical deviation (DVD) associated with IO overaction.[5],[6],[7] Furthermore, anterior transposition of the IO was found to be effective for correction of primary IO overaction and secondary overaction due to superior oblique palsy.[1],[8],[9],[10],[11],[12],[13],[14]

Anatomically, the inferior rectus muscle, inferior IO, and the lower lid have a unique relationship, as they are interconnected to capsulopalpebral fascia and lower eyelid retractors. The capsulopalpebral fascia arises from the inferior rectus muscle posterior to the IO, courses anteriorly to envelope the IO, then continues anteriorly to insert into the tarsal plate. On the basis of these relationships, inferior rectus surgery affects dramatically the lower eyelid position, however, it is not well documented for IO surgery.[15],[16] Compatible to this fact, narrowing of the palpebral fissure (PF) has been observed following anterior transposition of the IO.[7],[8],[9],[10] Kushner reported a significant narrowing of the PF and fullness of lower eyelid on upgaze.[7] However, all these findings observed in patients in whom the muscle is reattached at temporal border of the inferior rectus muscle or further anterior. The effect of anterior transposition surgery in which IO was placed posterior to inferior rectus insertion not known very well. As well as, no data were available about the effect of this procedure on functioning and other parameters of lower eyelid structures.

The aim of this study was to evaluate the alteration of lower lid configuration and function parameters with anterior transposition of the inferior IO surgery in which the scleral attachment was posterior to insertion of inferior rectus muscle.


  Patients and Methods Top


A prospective clinical trial was conducted on a consecutive series of the patients with primary IO overaction or secondary overaction due to superior oblique palsy. The patients underwent anterior transposition of the IO as a sole operation was included. The study was done between March 2013 and March 2014. Institutional Review Board approval was obtained and signed informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

Exclusion criteria included presence of DVD, history of simultaneous or previous strabismus and/or ocular surgery, inadequate follow–up, and concurrent conditions that might influence results such as eyelid anomalies and orbital disease. The patients who did not cooperate enough for taking measurements were also excluded such as small children and the patients with low vision who could not fixate properly.

All patients received a thorough ophthalmic examination 1 day before surgery and 3 months thereafter. Overaction of IO was determined as overelevation in adduction and graded by a scale ranging from 0 to + 4.[17] Output measurements were consisted of PF, margin reflex distance (MRD) 1–2, lower lid function (LLF), hertel value, and lower lid crease (LLC). PF was measured by assessing the distance between the upper and lower eyelid margin at the point that bisected the light reflex on the cornea. MRD-1 represented the distance from the corneal light reflex to the upper eyelid margin whereas MRD-2 represented the distance to lower eyelid margin. LLF was assessed by measuring eyelid excursion from extreme upgaze to extreme downgaze while holding the head still. Hertel mirror exophthalmometer was used to measure the protrusion of the glob from the lateral orbital rim. LLF was the distance between lower eyelid margin and LLF. All the stable measurements were taken by a handheld ruler while the patient sitting upright and fixating with that eye to a penlight held at 50 cm in front of the patient. All preoperative and postoperative measurements were always performed by the same examiner, who did not know the details of patients. To increase the reliability of the measurements, all were taken twice and the average value used, if there was any inconsistency a third measurement was considered.

The hyperdeviation was measured with prism and cover test or with Krimsky test if corrected visual acuity was inadequate for prism and cover test. Abnormal head posture was also recorded. Postoperative change in head posture was assessed by comparing preoperative and postoperative angles. All preoperative and postoperative examinations and measurements were made by the same observer, who was not masked to the data.

Surgical technique

All surgeries were done using a similar technique which was first described by Elliot and Nankin.[1] In this original procedure, IO was sutured just anterior to the insertion of the inferior rectus muscle; however, we sutured the IO posterior to the inferior rectus insertion. In brief, a lid speculum was inserted and the globe was maximally elevated and adducted. A conjunctival incision was made inferotemporally approximately 8 mm posterior to the limbus. After careful dissection, the IO was hooked under direct visualization. Polyglactin 6-0 sutures were placed in the IO near its insertion, with locking bites on either edge. Then, the muscle was freed and the anterior arm of the suture was placed posterior to the temporal edge of the inferior rectus muscle insertion. The muscle placed 1–2 mm posterior to inferior rectus insertion. The posterior arm was placed temporally and posteriorly within 2–3 mm [Figure 1]. Hence, the new direction of the IO insertion was also different from the original procedure of Elliot and Nankin. In original technique, the new IO insertion should be just anterior but parallel to the inferior rectus insertion.[1] Finally, the conjunctiva was closed with 8–0 polyglactin suture. All surgery was performed by one of the authors (Tuğba Göncü).
Figure 1: The anterior arm of disinserted inferior oblique muscle placed 1–2 mm posterior to lateral edge of inferior rectus insertion. The posterior arm was placed temporally and posteriorly within 2–3 mm to anterior arm

Click here to view


Statistical analysis

The differences of the collected data were calculated for statistical significance using the Wilcoxontest. Statistical analysis was conducted using the PASW Statistics for Windows, Version 18.0. (SPSS Inc., Chicago, IL, USA), and P < 0.05 was considered significant.


  Results Top


A total of 19 eyes of 16 consecutive patients who met the criteria were included. The mean age of the patients was 8.7 ± 7.1 years, with a range of 2–23 years. There were 9 males and 7 female patients. Seven eyes (36.8%) of 4 cases had primary IO overaction, while 12 eyes (63.2%) of 12 cases had secondary overaction due to superior oblique palsy. The surgery was performed unilaterally for one case with bilateral asymmetric primary IO overaction because this case had severe amblyopia in that eye. The median preoperative grade of IO overaction was 3.5 (ranging from 3 to 4), which decreased to 0 (ranging from 0 to 2) (P < 0.05) 3 months postoperatively. All of the eyes underwent anterior transposition of IO placed 1–2 mm posterior to inferior rectus insertion. The mean preoperative hypertropia in the primary position was 14.1 ± 5.9 prism diopters (PDs) and the mean postoperative hypertropia was 2.4 ± 4.5 PD at the 3-month follow-up visit (P = 0.005). The mean reduction of hypertropia obtained by surgery was 11.2 ± 6.6 PD. No hypotropia was observed in the operated eyes postoperatively. Among eyes, 84.2% had hypertropia of 5 PD or less postoperatively. [Table 1] shows the clinical details of the patients.

The mean preoperative PF was 10.2 ± 1.3 mm in which no change was observed and it was 10.2 ± 0.9 mm postoperatively (P = 0.79). The mean preoperative MRD-1 was 4.7 ± 0.7 mm, which decreased postoperatively to 4.2 ± 0.6 mm (P = 0.08). The mean preoperative MRD-2 was 5.6 ± 0.8 mm, which increased postoperatively to 5.8 ± 0.5 mm (P = 0.25). The mean preoperative hertel value was 15.4 ± 2.2 mm which decreased postoperatively to 15.0 ± 2.8 mm (P = 0.48). The mean preoperative LLF was 5.4 ± 1.4 mm, which increased postoperatively to 5.6 ± 1.2 mm (P = 0.21). The mean preoperative LLC was 4.6 ± 1.2 mm which decreased postoperatively to 4.4 ± 1.3 mm (P = 0.41) [Table 2].
Table 1: Demographic and operative data for patients who underwent anterior transposition of the inferior oblique

Click here to view
Table 2: Preoperative and postoperative values of output measures

Click here to view


Abnormal head posture was observed in 12 patients and all of them had unilateral superior oblique palsy. The abnormal head posture was not noticable in 7 (58.3%) of these patients and the angle of head tilt reduced in 5 patients (41.7%) at the 3-month postoperative visit.


  Discussion Top


Within the orbit, a complex musculofibroelastic structure suspends the globe, interrelates with the eyelids, and other orbital elements. The capsulopalpebral fascia which is analogs to the levator aponeurosis in the upper lid is a major component of lower lid retractors. It originates from the belly of the inferior rectus muscle; there are firm adhesions between capsulopalpebral fascia and inferior rectus. The capsulopalpebral fascia splits open and forms a anterior layer and a posterior layer which wrapping around the IO.[18],[19] Any procedure on IO as well as anterior transposition surgery might have effect on lower lid retractors and therefore might influence lower lid configuration and functioning.

Anterior transposition of the inferior IO, introduced by Elliott and Nankin, was highly effective in the treatment of DVD, primary inferior IO overaction and secondary overaction due to superior oblique palsy.[1],[5],[6],[7],[8],[9],[10],[11],[12] We also observed clinically and statistically significant decrease in the preoperative hypertropia after this procedure and 68.4% of the patients achieved a hypertropia of 5 PD or less postoperatively. Anterior transposition has been shown to work in part by converting the IO from an elevator to a depressor of the globe because the neurovascular bundle became a new origin for the temporal portion of the IO.[20] Elliott and Nankin also found that anterior transposition of IO was advantageous when compared to standard recession surgery and also was devoid of difficulties and complications related to reinserting the muscle.[1] Guemes and Wright reported a modified anterior transposition technique called “graded anterior transposition” to reduce the complication of limited elevation. In this procedure, the amount of anterior transposition was titrated to the amount of IO overaction.[13] Farvardin et al., reported combined resection and anterior transposition of IO in the treatment of IO overaction secondary to superior oblique palsy with successful results.[8] Fard described anterior and nasal transposition of IO for the treatment of DVD associated with IO overaction.[21] Limitation of elevation in abduction and/or adduction and hypotropia in primary position are known complications of anterior transposition surgery of IO.[7],[9],[10],[12],[22],[23] Functionally, less significant complications such as PF alteration, PF asymmetry, lower lid fullness, were noted in a few study.[7],[8],[9],[10]

In the present study, we prospectively evaluated the alteration of the PF, lower lid contour, and function parameters with anterior transposition of the inferior IO surgery. For this purpose, the PF, MRD-1, MRD-2, hertel value, LLF, and LLC were evaluated however, none of them revealed significant change postoperatively (P > 0.05). Comparable to our results, no postoperative PF asymmetry has been reported by Goldchmit et al., after IO anterior transposition in patients with unilateral IO overaction. In their technique, the disinserted IO was sutured adjacent to the lateral end of inferior rectus insertion bunched with one suture. They noted slight lower lid curvature deformity on forced upgaze in four of ten patients.[12] Farvardin and Nazarpoor have observed mild fullness in 25% of the patients with superior oblique palsy following anterior transposition surgery in which the disinserted IO was sutured just anterior to the lateral of inferior rectus insertion.[9] However, they did not reported any elevation of lower lid on upgaze in their patients. However, Kushner has mentioned that anterior transposition of the inferior IO caused a narrowing of the PF and this could be cosmetically noticeable. He compared postoperative PF of patients who underwent IO transposition surgery with control group who underwent standard recession without transposition. In this work, the outcomes of transposition surgery were evaluated in two separate groups in first group the IO was placed at the level of inferior rectus insertion and in second group the IO was placed 2 mm anterior to inferior rectus insertion. Compared with the control both groups showed significant decrease in PF and second group resulted in a greater decrease.[7] González and Cinciripini reported elevation deficiency, elevation of lower lid on upgaze and reduced inferior scleral show in the eyes following anterior transposition in which IO reinserted 3 mm posterior from the limbus in the line of lateral edge of inferior rectus insertion. They speculated that the reason for lower lid elevation to be the advancement of the capsulopalpebral fascia extending to inferior rectus.[10]

Some studies have reported that IO transposition of 1 mm or more anterior to the inferior rectus muscle insertion as well as the lateral spreading of the posterior fibers more than 2 mm at the new insertion are risk factors for complications of this surgery such as anti-elevation syndrome and hypotropia.[22],[23],[24] The lower lid elevation and fullness in lower lid on upgaze also noted more in this augmented anteriorization procedures.[7],[8],[9],[10] Kushner demonstrated that if the posterior fibers of IO are inserted more distant from the lateral extremity of the inferior rectus insertion, the effect on limitation of elevation would be greater, because these new fibers become more stretched.[23] Those cases cannot be compared with ours because we performed anteriorization surgery in which IO was placed posterior to the lateral end of the inferior rectus insertion thus, the posterior fibers had minor anteriorization. Postoperatively no significant change on lower lid configuration and function parameters were observed in our patients.

The small sample size and the parameters depending on patients' cooperation such as PF, LLF are main limitations of this study. We tried to overcome this issue by including only cooperative patients and using the average of two compatible measurements.


  Conclusion Top


Due to close anatomic relationship of IO with lower lid retractors, it is rational to expect an alteration of lower lid configuration and functioning with IO surgery. In this study, we did not observe any significant effect on lower lid parameters with IO anterior transposition in which we placed the IO posterior to inferior rectus insertion. However, the alteration of these parameters might be more noticeable particularly in patients with greater degrees of anterior transpositions in which IO placed anterior to inferior rectus insertion. Placing the IO posterior to the inferior rectus insertion avoiding further anterior transposition may enable successful surgical outcomes without any effect on eyelid configuration and functioning. Further observations should also be done on a larger number of patients to confirm the effect of IO anterior transposition on the eyelid tissues.

Acknowledgments

The authors would like to thank Dr. Reşit Çiftçi and İbrahim Çiftçi for their technical assistance on drawing illustrations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Elliott RL, Nankin SJ. Anterior transposition of the inferior oblique. J Pediatr Ophthalmol Strabismus 1981;18:35-8.  Back to cited text no. 1
    
2.
Burke MJ, Hutchison JD. Diagnosis and management of superior oblique palsy. Ophthalmol Clin North Am 1992;5:31-8.  Back to cited text no. 2
    
3.
Moon K, Lee SY. The effect of graded recession and anteriorization on unilateral superior oblique palsy. Korean J Ophthalmol 2006;20:188-91.  Back to cited text no. 3
    
4.
Scott A. Planning inferior oblique muscle surgery. In: Reinecke R, editor. Strabismus. New York: Grune and Stratton; 1978. p. 347-54.  Back to cited text no. 4
    
5.
Burke JP, Scott WE, Kutshke PJ. Anterior transposition of the inferior oblique muscle for dissociated vertical deviation. Ophthalmology 1993;100:245-50.  Back to cited text no. 5
    
6.
Nabie R, Anvari F, Azadeh M, Ameri A, Jafari AK. Evaluation of the effectiveness of anterior transposition of the inferior oblique muscle in dissociated vertical deviation with or without inferior oblique overaction. J Pediatr Ophthalmol Strabismus 2007;44:158-62.  Back to cited text no. 6
    
7.
Kushner BJ. The effect of anterior transposition of the inferior oblique muscle on the palpebral fissure. Arch Ophthalmol 2000;118:1542-6.  Back to cited text no. 7
    
8.
Farvardin M, Bagheri M, Pakdel S. Combined resection and anterior transposition of the inferior oblique muscle for treatment of large primary position hypertropia caused by unilateral superior oblique muscle palsy. J AAPOS 2013;17:378-80.  Back to cited text no. 8
    
9.
Farvardin M, Nazarpoor S. Anterior transposition of the inferior oblique muscle for treatment of superior oblique palsy. J Pediatr Ophthalmol Strabismus 2002;39:100-4.  Back to cited text no. 9
    
10.
González C, Cinciripini G. Anterior transposition of the inferior oblique in the treatment of unilateral superior oblique palsy. J Pediatr Ophthalmol Strabismus 1995;32:107-13.  Back to cited text no. 10
    
11.
Keskinbora KH. Anterior transposition of the inferior oblique muscle in the treatment of unilateral superior oblique palsy. J Pediatr Ophthalmol Strabismus 2010;47:301-7.  Back to cited text no. 11
    
12.
Goldchmit M, Felberg S, Souza-Dias C. Unilateral anterior transposition of the inferior oblique muscle for correction of hypertropia in primary position. J AAPOS 2003;7:241-3.  Back to cited text no. 12
    
13.
Guemes A, Wright KW. Effect of graded anterior transposition of the inferior oblique muscle on versions and vertical deviation in primary position. J AAPOS 1998;2:201-6.  Back to cited text no. 13
    
14.
Wright KW, editor. Inferior oblique surgery. In: Color Atlas of Ophthalmic Surgery: Strabismus. Philadelphia: Lippincott; 1991. p. 173-99.  Back to cited text no. 14
    
15.
Kushner BJ. A surgical procedure to minimize lower-eyelid retraction with inferior rectus recession. Arch Ophthalmol 1992;110:1011-4.  Back to cited text no. 15
    
16.
Kim DB, Meyer DR, Simon JW. Retractor lysis as prophylaxis for lower lid retraction following inferior rectus recession. J Pediatr Ophthalmol Strabismus 2002;39:198-202.  Back to cited text no. 16
    
17.
Del Monte MA, Parks MM. Denervation and extirpation of the inferior oblique. An improved weakening procedure for marked overaction. Ophthalmology 1983;90:1178-85.  Back to cited text no. 17
    
18.
Nam YS, Han SH, Shin SY. Detailed anatomy of the capsulopalpebral fascia. Clin Anat 2012;25:709-13.  Back to cited text no. 18
    
19.
Kakizaki H, Malhotra R, Madge SN, Selva D. Lower eyelid anatomy: An update. Ann Plast Surg 2009;63:344-51.  Back to cited text no. 19
    
20.
Stager DR, Weakley DR Jr., Stager D. Anterior transposition of the inferior oblique. Anatomic assessment of the neurovascular bundle. Arch Ophthalmol 1992;110:360-2.  Back to cited text no. 20
    
21.
Fard MA. Anterior and nasal transposition of the inferior oblique muscle for dissociated vertical deviation associated with inferior oblique muscle overaction. J AAPOS 2010;14:35-8.  Back to cited text no. 21
    
22.
Bremer DL, Rogers GL, Quick LD. Primary-position hypotropia after anterior transposition of the inferior oblique. Arch Ophthalmol 1986;104:229-32.  Back to cited text no. 22
    
23.
Kushner BJ. Restriction of elevation in abduction after inferior oblique anteriorization. J AAPOS 1997;1:55-62.  Back to cited text no. 23
    
24.
Ziffer AJ, Isenberg SJ, Elliott RL, Apt L. The effect of anterior transposition of the inferior oblique muscle. Am J Ophthalmol 1993;116:224-7.  Back to cited text no. 24
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed1280    
    Printed5    
    Emailed0    
    PDF Downloaded221    
    Comments [Add]    

Recommend this journal