Ординатура / Офтальмология / Английские материалы / Strabismus Surgery and Its Complications_Coats, Olitsky_2007

found an incidence of almost 50% in a series of patients with persistent strabismus following retinal surgery. Fat adherence syndrome has also been reported following blepharoplasty and orbital trauma [6]. The common feature in all of these cases is trauma to posterior Tenon’s capsule with prolapse of and damage to extraconal fat.

25.3 Prevention

The best method to prevent the development of fat adherence syndrome is to avoid damage to posterior Tenon’s capsule during strabismus surgery. This is especially true during inferior oblique surgery, where damage to posterior Tenon’s capsule is most likely to occur. Direct visualization of the posterior bor-

der of the inferior oblique muscle during its isolation can help to reduce the risk of penetrating Tenon’s capsule (>Fig. 25.2). Blind sweeps of the inferotemporal quadrant to isolate the inferior oblique muscle are discouraged. Overhead lighting directed into the operative space is helpful. Some surgeons find use of a headlamp helpful during surgery on the inferior oblique muscle. In addition, overly aggressive dissection posterior to the inferior oblique muscle should be avoided. If a defect in posterior Tenon’s capsule is noted during surgery, it should be treated. It may be possible to reposition small amounts of orbital fat that protrude through a rent in posterior Tenon’s capsule back into the extraconal space followed by closure of the rent. When this is not possible, as for example when a large amount of extraconal fat has entered the episcleral space, we recommend placing a hemostat across the fat at the opening of the defect and excising that portion of the fat that has pro-

Fig. 25.2. Identification of the posterior border of the inferior oblique muscle prior to isolation of the muscle on a hook may help to reduce the risk of violating posterior Tenon’s capsule

truded into the operative site. The defect in Tenon’s capsule can then be sutured closed using absorbable sutures. The use of antimetabolites is not warranted. Brooks and coworkers [7] investigated the prophylactic use of intraoperative mitomy- cin-C in a rabbit model of fat adherence syndrome to prevent the development of restrictive scar formation. They could find no significant difference between the treated and untreated groups. They also found that longer exposure to mitomycin-C resulted in an increase in the postoperative inflammatory response and was associated with an increase in restriction.

25.4 Treatment

Surgical treatment of a patient with significant fat adherence syndrome can be difficult. The goal of treatment is to align the eyes in the primary position and restore the ocular movements as much as possible. Most reports in the literature support the notion that a return of normal ocular rotations is not possible in most cases. Burton and coworkers [8] reported 14 cases of fat adherence syndrome that underwent attempted surgical treatment. Their results agreed with the generally held belief that surgery is difficult and that outcomes are often poor. They suggested that patients be given realistic expectations as to their final possible outcome. In most cases, treatment involves disruption of the adhesions to minimize restriction. Simultaneous surgery on the extraocular muscles is almost always also necessary. For example, if there is a hypotropia due to longstanding restrictive forces exist in the inferior orbit, surgery to release the adhesions will usually have a limited impact on ocular alignment. Instead, the inferior rectus muscle must usually be recessed to achieve significant improvement. The use of temporary postoperative traction sutures (Chap. 15) may be beneficial to reduce the risk of recurrent adhesions in these cases.

Other treatments have been reported with varying levels of success. Most reports involve isolated cases and interpretation of these results should bear this in mind. Ozkan and coworkers

[9] reported the use of botulinum toxin in the early postoperative period of a patient who developed fat adherence syndrome following inferior oblique surgery for the treatment of a superior oblique palsy. They suggested that injection before scar tissue could fully develop was a key element in the success they had in the management of their patient. Yamada and Shinoda [10] combined strabismus surgery and placement of an amniotic membrane to prevent re-formation of adhesions to successfully treat fat adherence syndrome in a patient who had previously undergone retina surgery.

25.5Miscellaneous Adhesion Syndromes Due to Strabismus Surgery

25.5.1Adhesion Syndrome Following Superior Oblique Tendon Expander Surgery

Wilson and co-workers [11] reported two patients who developed diplopia in the reading position following insertion of a silicone superior oblique tendon expander for the treatment of unilateral Brown syndrome. In both cases, forced duction testing to down gaze demonstrated restriction and surgical exploration revealed adhesions that prevented normal movement of the superior oblique tendon beneath the superior rectus muscle. Following removal of the silicone band, forced ductions became normal and down gaze was improved Restrictive strabismus may also occur if the sub-Tenon’s space is violated at the time of expander insertion [12].

25.5.2 Inferior Oblique Inclusion Syndrome

Price [13] described an L-deformity of the inferior oblique muscle which can occur following lateral rectus muscle surgery due to deep passage of a muscle hook in an attempt to hook the lateral rectus muscle with inadvertent, simultaneous hooking of the inferior oblique muscle or by failure to sever the fascial attachments between the inferior oblique muscle and the lateral rectus muscle. The condition is more likely to occur following lateral rectus resection than with lateral rectus muscle recessions [13, 14] (>Fig. 25.3). Postoperatively, patients may have a residual esotropia or exotropia and typically exhibit a hypotropia of the involved eye with limitation of elevation. The condition can sometimes mimic Brown syndrome.

Price [13] recommended several techniques to avoid inclusion of the inferior oblique muscle during lateral rectus muscle surgery, noting that the surgeon was less likely to inadvertently hook the inferior oblique muscle when the hook was passed from above. He noted that even this maneuver sometimes resulted in inadvertent hooking of the inferior oblique muscle, however. Helveston and coworkers [14] recommended that surgeons could avoid inadvertent inferior oblique inclusion by inspecting the global surface of the lateral rectus muscle and freeing any inferior oblique attachments prior to reattaching

Fig. 25.3. Inferior oblique adhesion syndrome. Note dense adhesions between the inferior border of the lateral rectus muscle and the inferior oblique muscle which has been displaced anteriorly

the lateral rectus muscle to the globe during surgery to recess or resect the lateral rectus muscle.

Price [13] noted that repair of strabismus caused by inferior oblique inclusion in the lateral rectus muscle insertion was difficult. He recommended releasing adhesions between the inferior oblique and lateral rectus muscles until forced duction testing was normal. He further recommended that prolapsed orbital fat and scarring around Tenon’s capsule is often present and should be excised. Helveston and coworkers [14] reported that most patients had a persistent vertical deviation even after adhesions between the lateral rectus and inferior oblique muscles were freed. A recession of the inferior rectus muscle was usually required to correct the hypotropia, because secondary contraction of the inferior rectus muscle during a long-stand- ing hypotropia will not be corrected by release of the adhesions alone.

in the development of restrictive strabismus. Treatment is often difficult and additional surgery can further compound the problem by inciting more fibrovascular scar formation. Excessive scarring of the conjunctiva may lead to a duction deficit. This may occur secondary to shortening of the conjunctiva or due to scarring between the conjunctiva and the extraocular muscle(s). Often the tightness of the conjunctiva can be visualized clinically when the patient attempts to move his or her eyes. It can also be demonstrated with forced duction testing before or during surgery, which will demonstrate restriction to passive movement of the eyes. Extensive scarring between Tenon’s fascia and the extraocular muscles can also be similarly demonstrated. Often both the conjunctiva and Tenon’s fascia are involved.

At the time of surgery, the restrictive forces should be eliminated or reduced whenever possible. Once forced duction testing indicates that this goal has been obtained, the next step involves reducing the chance of recurrent scarring, if possible. This can be accomplished by recessing the conjunctiva if it is contracted and is wholly or partly responsible for the restriction (Chap. 8). The use of medications to alter scar formation, such as mitomycin-C and 5-fluorouracil [15], and the application of Seprafilm®, a bioabsorbable membrane composed of sodium hyaluronate and carboxymethylcellulose, have been studied in animals [16], but have not been shown to be effective for routine use in human restrictive strabismus.

Adherence and adhesion syndromes can occur with any strabismus surgery, but are most likely to occur with surgery involving the inferior oblique muscles. Treatment can be difficult and the surgical outcome is often suboptimal. In theory, most cases of fat adherence syndrome should be avoidable through knowledge of the relevant surgical anatomy and attention to surgical technique. Adherence syndromes such as that which may occur following placement of a silicone expander in the superior oblique tendon and after inadvertent inclusion of the inferior oblique muscle in the lateral rectus muscle insertion likewise are probably avoidable in most, though not all, cases.

25.5.3 J-Deformity of a Rectus Muscle

Price [13] described J-deformity of a rectus muscle that he believed occurred because of failure to adequately dissect the surrounding Tenon’s capsule during rectus muscle surgery. He believed that contracture of Tenon’s capsule could advance the belly of the muscle anteriorly toward the limbus causing the recurrence of strabismus, limited ductions, and a characteristic J-deformity of the muscle. We have not treated a patient with this J-deformity of a rectus muscle.

25.5.4Scarring of Tenon’s Capsule and Conjunctiva

Scarring of the conjunctiva and Tenon’s capsule following strabismus surgery is inevitable, but generally mild. Occasionally scarring of these tissues will be extensive and can result

References

1.Parks MM (1972) The weakening surgical procedures for eliminating overaction of the inferior oblique muscle. Am J Ophthalmol 73:107–122

2.Brooks SE, Yu JC, Preston D, Johnson MH (1998) Restricted ocular motility after orbital trauma – studies with an animal model. J AAPOS 2:246–252

3.Kerr NC (2004) Fat adherence syndrome: an animal model. J AAPOS 8:349–356

4.Helveston EM, Haldi BA (1976) Surgical weakening of the inferior oblique. Int Ophthalmol Clin 16:113–126

5.Hwang JM, Wright KW (1994) Combined study on the causes of strabismus after the retinal surgery. Korean J Ophthalmol 8:83–91

6.Jameson NA, Good WV, Hoyt CS (1992) Fat adherence simulating inferior oblique palsy following blepharoplasty. Arch Ophthalmol 110:1369

7.Brooks SE, Ribeiro GB, Archer SM, Elner VM, Del Monte MA (1996) Fat adherence syndrome treated with intraoperative mi- tomycin-C: a rabbit model. J Pediatr Ophthalmol Strabismus 33:21–27

12.Pollard ZF, Greenberg MF (2000) Results and complications in 66 cases using a silicone tendon expander on overacting superior obliques with A-pattern anisotropias. Binocul Vis Strabismus Q 15:113–120

ing inferior oblique surgery: management and outcome of 14 cases. Strabismus 12:169–174

9.Ozkan SB, Kir E, Dayanir V, Dundar SO (2003) Botulinum toxin A in the treatment of adherence syndrome. Ophthalmic Surg Lasers Imaging 34:391–395

10.Yamada M, Shinoda K, Hatakeyama A, Nishina S, Mashima Y (2001) Fat adherence syndrome after retinal surgery treated with amniotic membrane transplantation. Am J Ophthalmol 132:280–282

11.Wilson ME, Sinatra RB, Saunders RA (1995) Downgaze restriction after placement of superior oblique tendon spacer for Brown syndrome. J Pediatr Ophthalmol Strabismus 32:29–34; discussion 35–36

tions. Int Ophthalmol Clin 16:197–207

14.Helveston EM, Alcorn DM, Ellis FD (1988) Inferior oblique inclusion after lateral rectus surgery. Graefes Arch Clin Exp Ophthalmol 226:102–105

15.Mora JS, Sprunger DT, Helveston EM, Evan AP (1997) Intraoperative sponge 5-fluorouracil to reduce postoperative scarring in strabismus surgery. J AAPOS 1:92–97

16.Özka S, Kır E, Culhac N, Dayanır V (2004) The effect of seprafilm on adhesions in strabismus surgery – an experimental study. J AAPOS 8:46–49

Serious complications involving the ocular adnexa are unusual following strabismus surgery. However, noticeable changes in the eyelids are a frequent source of concern for patients after strabismus surgery, though concern is usually greater in the immediate than in the later postoperative period. It is helpful to document obvious abnormalities and asymmetry of the eyelids prior to surgery. This documentation can be comforting to patients who first become aware of asymmetry or abnormalities in their own anatomy after surgery, a time when patients tend to look very critically at their eyes.

Unless the surgeon has pointed out preexisting abnormalities to the patient before surgery, the patient may feel that the surgeon and the surgery are responsible for the findings. This can be a source of significant concern for patients and for strabismus surgeons alike. For example, dehiscence of the levator muscle of the upper eyelid, especially when asymmetric, is not infrequently first noticed by patients following strabismus surgery. Though we are generally very careful to make note of preexisting eyelid problems, occasionally we have found ourselves in the position of trying to explain the presence of preexisting eyelid abnormalities that we did not note prior to surgery. Examination of the patient’s driver’s license photograph or other preoperative photographs may allow an easy means of demonstrating to the patient that the eyelid feature they find objectionable was actually present prior to surgery.

gery. Both eyelid retraction and advancement can occur. Eyelid advancement is usually better tolerated than eyelid retraction, unless the advancement is marked, and particularly if it involves the upper eyelid. Bothersome alteration of eyelid position is less likely to occur following recessions and resections of 5 mm or less. Patients who are at greatest risk of developing eyelid retraction are those undergoing very large recessions, especially if undergoing surgical repair of restrictive strabismus, such as thyroid-related ophthalmopathy.

Retraction of the lower eyelid following inferior rectus recession is not uncommon (>Fig. 26.1). Lower eyelid retraction may occur following recession of the inferior rectus muscle due to anatomic connections between the inferior rectus muscle and the capsulopalpebral fascia and the inferior tarsal muscle. Pacheco and coworkers [1] reported that 94% of patients who underwent an inferior rectus muscle recession developed lower eyelid retraction. They believed that approximately 0.5 mm of lower eyelid retraction would occur with each 3 mm of inferior rectus muscle recession. According to Meyer and coworkers [2], lower eyelid retraction can occasionally be associated with lagophthalmos and corneal exposure.

Several techniques to reduce or eliminate the occurrence of lower eyelid retraction following inferior rectus muscle recession have been proposed. Helveston [3] recommended generous dissection around the inferior rectus muscle in an attempt

26.1Eyelid Retraction and Advancement Following Vertical Rectus

Muscle Surgery

The orbital aspect of the sheath of the superior rectus muscles is adherent to the internal surface of the sheath of the levator palpebrae superioris muscle of the upper eyelid (Chap. 1). The close association of these two structures through their fascial sheaths accounts for the cooperative action seen during contraction of these two muscles, such as depression of the upper eyelid with down gaze. Likewise, similar connections exist between the inferior rectus muscle and the lower eyelid retractors. The surgeon must be aware of these connections because they can have important implications for the patient following surgery on the vertical rectus muscles. Postoperative alteration of the position of the upper and lower eyelids is the most common eyelid abnormality that occurs following strabismus sur-

Fig. 26.1. Marked lower eyelid retraction following a large recession of the inferior rectus muscle to treat hypotropia in a patient with thyroidrelated ophthalmopathy

to sever fascial connections between the inferior rectus muscle and the lower eyelid retractors. Care should be taken during posterior dissection of the attachments around the inferior rectus muscle not to disturb the vortex veins that are usually found adjacent to the medial and lateral borders of the inferior rectus muscle and to avoid intrusion into the surrounding extraconal fat.

Advancement of the capsulopalpebral head and securing it to the inferior rectus muscle with sutures has been advocated as a means to mitigate lower eyelid retraction [4, 5]. Pacheco and co-workers [1] recommended suspension of the capsulopalpe-

bral head from the inferior rectus muscle insertion utilizing a separate adjustable suture (>Fig. 26.2). Using this technique, the surgeon is able to separately adjust the position of the lower eyelid after ocular alignment has been adjusted. We have found this procedure useful in patients with thyroid-related ophthalmopathy when undergoing large inferior rectus muscle recessions. When using the technique reported by Pacheco and coworkers [1] we have found it important to postpone conversion of the inferior rectus muscle sutures to a permanent knot until after the eyelid position has been adjusted, because adjustment of the eyelid position can alter ocular alignment via remain-

ing attachments between the inferior rectus muscle and eyelid retractors. A compromise is sometimes necessary, preventing optimal adjustment of eyelid position.

The techniques outlined above typically result in improvement, but not normalization of the lower eyelid position. Additionally, they are less likely to be effective with larger inferior rectus muscle recessions, particularly if significant restriction is present. Meyer and coworkers [2] reported a technique to address lower eyelid retraction at the time of inferior rectus muscle recession. They referred to the technique as primary infratarsal lower eyelid retractor lysis. Unlike other procedures which are designed to counteract the posterior movement of the capsulopalpebral head caused by inferior rectus muscle recession, their procedure was designed to reduce or eliminate

traction on the capsulopalpebral head at the level of the tarsus and adjacent eyelid connective tissues, thus preventing lower eyelid retraction, rather than attempting to counteract it. They reported use of this technique during inferior rectus muscle recession to treat hypotropia due to thyroid-related ophthalmopathy, blow out fracture, and orbital fibrosis.

Following inferior rectus muscle recession, the eyelid is retracted anteriorly and superiorly using a 4–0 silk suture placed through the central portion of the eyelid margin (>Fig. 26.3). An infratarsal incision is made through the conjunctiva and through the lower eyelid retractors 3–4 mm below the inferior tarsal border. The infratarsal incision is extended medially and laterally after spreading in the plane between the lower eyelid retractors and orbital septum on one side and the orbicularis muscle on the other side. Maintaining traction on the eyelid margin and on the conjunctival/lower eyelid retractors, a cot- ton-tipped applicator is used to bluntly dissect inferiorly between the orbicularis muscle and the orbital septum, allowing the conjunctiva, lower eyelid retractors, and orbital septum to maximally recess. The incision is left to heal by primary intention. At the conclusion of the case, antibiotic ointment is placed in the eye and the lid suture is taped to the forehead under slight upward tension. The lid suture is removed 1–5 days later. Mild symblepharon formation was reported in several patients following the procedure, but was easily managed.

Significant upper and lower eyelid retraction and advancement can be corrected postoperatively if attempts to prevent it during strabismus surgery are not fully successful. This is most likely to be required following large resections and recessions, especially if restrictive strabismus is present. Upper and lower eyelid retraction can be managed using oculoplastic surgery techniques [6].

Occasionally, we have made use of the normal fascial attachments between the vertical rectus muscles and the eyelid retractors to create intentional alterations in the position of the eyelids. For example, if a patient undergoing a vertical rectus muscle resection has preexisting retraction of the ipsilateral eyelid, care will be taken to minimize dissection of the capsulopalpebral attachments between the upper eyelid and the superior rectus muscle. This will result in a larger degree of upper eyelid advancement with resulting improvement of the eyelid retraction. A patient with mild ptosis of the upper eyelid who is undergoing a superior rectus muscle recession can achieve improvement of their ptosis by minimizing dissection of the capsulopalpebral attachments during surgery.

Fig. 26.3. Primary infratarsal lower eyelid retractor lysis. Top: horizontal incision through conjunctiva and lower eyelid retractors. Mid­ dle: lysis of the conjunctiva and lower eyelid retractors medially and laterally. Bottom: blunt dissection using a cotton-tipped applicator to further recess the eyelid retractors. {Reprinted from Meyer DR, Simon JW, Kansora M (1996) Primary infratarsal lower eyelid retractor lysis to prevent eyelid retraction after inferior rectus muscle recession. Am J Ophthalmol 122:331–339, copyright 1996, with permission from Elsevier [2]}

26.2Aberrant Regeneration of the Third Cranial Nerve

Surgery to correct a vertical and/or horizontal strabismus in patients with aberrant regeneration following a third nerve palsy can produce some dramatic and unpredictable changes in eyelid position and function. Patients undergoing strabismus surgery in this setting should be advised of this potential complication and made aware of the fact that eyelid surgery may be required to address the problem postoperatively.

26.3Eyelid Changes Following Horizontal Rectus Muscle Surgery

Several unique surgical situations and complications have been shown to alter the width of the eyelid fissures following horizontal rectus muscle surgery. The lid fissures have been noted to widen in patients with a slipped horizontal rectus muscle [7, 8]. Recession of both horizontal rectus muscles in patients with Duane syndrome who have severe globe retraction in the primary position can significantly reduce globe retraction, resulting in widening of the palpebral fissures. Sprunger [9] reported a mean reduction in globe retraction of 3.0 mm (>Fig. 26.4).

Full tendon transposition of the superior rectus and inferior rectus muscles to the lateral rectus muscle insertion can be associated with globe retraction and lid fissure narrowing during adduction of the involved eye, due to restrictive forces in adduction that are created by the transposition procedure. In our experience, this is more likely to occur if the transposition procedure has been enhanced using the posterior fixation suture

Chapter 26

technique described by Foster [10] (>Fig. 26.5). The problem is usually mild and is rarely bothersome to patients. Resection of the lateral rectus muscle in patients with Duane syndrome may worsen the co-contraction and lid fissure narrowing on adduction. Lateral rectus resection is rarely indicated in Duane syndrome and should almost never be done, especially when significant co-contraction already exists.

Lagréze and coworkers [11] reported that eyelid fissure width changes occurred commonly following isolated horizontal rectus muscle surgery (>Fig. 26.6). The majority of the effect occurs due to changes in lower eyelid position, while upper eyelid position showed a variable response to horizontal rectus muscle surgery. A mean change in the width of the palpebral fissures of 1 mm was typical of a recession or resection procedure on a single horizontal rectus muscle of 7.7 mm. They believed that the change in eyelid fissure width was induced by changes in muscle tension that resulted in displacement of the eye in the anterior–posterior axis, with subsequent alteration of lid position. They suggested that surgical planning might be utilized to compensate for preexisting lid fissure differences.

Fig. 26.6. Lid fissure changes following standard horizontal rectus muscle surgery. {Reprinted from Lagréze WA, Gerling J, Staubach F (2005) Changes of the lid fissure after surgery on horizontal extraocu-

26.4 Ptosis and Pseudoptosis

Though mild ptosis may occur following resection or advancement of the superior rectus muscle, pronounced ptosis is uncommon. Injury to the levator aponeurosis can occur as a result of intraoperative eyelid retraction with an eyelid speculum. This complication is uncommon and is most likely to occur in elderly patients who presumably have tenuous connections between the levator aponeurosis and the tarsal plate. Marked postoperative edema or hemorrhage into the upper eyelid can also result in injury to the levator aponeurosis, producing ptosis.

Temporary ptosis is often seen in the immediate postoperative period (>Fig. 26.7). It can be the result of eyelid edema and can occur as a side-effect of local ocular corticosteroid administration. The cause of ptosis associated with topical corticosteroid administration is believed to be related to a myopathic effect of the agent on Mueller’s muscle [12] although others have suggested that it is caused by a myopathic effect of the vehicle rather then the corticosteroid itself [12].

Patients with severe restrictive strabismus due to congenital or acquired fibrosis and contracture of the inferior rectus muscle(s) often present with simultaneous hypotropia of the involved eye and apparent ptosis. Pseudoptosis may occur in this setting because of the natural tendency for the upper eyelid to move downward during infraduction, as the superior rectus muscle relaxes. It is not always possible for the surgeon to determine if true ptosis or pseudoptosis is present in this setting, especially when planning surgery on a young child. Correction of the strabismus alone by recession of the restricted inferior rectus muscle may result in complete restoration of the upper eyelid to its normal position, confirming a diagnosis of pseudoptosis. Thus, simultaneous surgery on the upper eyelid in this setting is contraindicated and can result in marked upper eyelid retraction. The child in Fig. 26.8 had bilateral congenital fibrosis of the inferior rectus muscles, an inability to elevate

lar muscles. Am J Ophthalmol 140:1145–1146, copyright 2005, with permission from Elsevier [11]}

the eyes to midline, marked ptosis, and a pronounced chin-up head posture. In this case, recession of the inferior rectus muscles resulted in moving the eyes to the primary position but the ptosis persisted and ptosis surgery was required. Pseudoptosis is also common in patients with monocular elevator deficiency (also known as double elevator palsy).

Fig. 26.7. Mild, temporary ptosis noted 1 week after strabismus surgery

26.5Lid Changes Associated with Inferior Oblique Muscle Anterior Transposition

Anterior transposition of the inferior oblique muscles is most commonly performed on both eyes, but occasionally is performed unilaterally. Regardless if performed on one or both eyes, alteration of the eyelids can occur and may be a source of concern for patients after surgery. During this procedure, the inferior oblique muscle is detached from the sclera and is reattached to the sclera near the temporal border of the inferior rectus muscle insertion. Because of attachments between the inferior oblique muscle and the lower eyelid retractors, the contour of the lower eyelid can be and often is altered following surgery. In a prospective study of patients undergoing inferior oblique anterior transposition, Kushsner [4] noted a number of changes that could occur in the contour of the lower eyelid following inferior oblique muscle anterior transposition surgery. He reported that the lower eyelid tends to become elevated in the primary position relative to the unoperated state (>Fig. 26.9). The lower eyelid also tends to rise or elevate with up gaze and a bulge may be noted in the lower eyelid in the area of the transposition (>Fig. 26.10). There is narrowing of the palpebral fissure, which may be particularly noticeable in patients with asymmetric or unilateral inferior oblique anterior transposition. He concluded that anterior transposition of the inferior oblique muscle commonly produced a noticeable effect on the size of the palpebral fissure and on the lower eyelid

Fig. 26.8. Child with congenital fibrosis of the inferior rectus muscles with ptosis of the upper eyelids that persisted after recession of restricted inferior rectus muscles, confirming a diagnosis of true not pseudoptosis

configuration in up gaze. In addition to narrowing of the palpebral fissure, Kushner [4] also reported marked upper eyelid retraction in three patients with a previous history of superior rectus muscle recession following anterior transposition of the inferior oblique muscles.

26.6 Eyelid Adhesions

Fascial attachments between the vertical rectus muscles and the eyelid retractors are generally severed in the normal course of surgery on the vertical rectus muscles. Excessive dissection of the fascial planes between the superior rectus muscle and the levator muscle can lead to the development of adhesions between the superior rectus muscle and the levator palpebrae superioris muscle. We cared for a patient with this complication following retina surgery who exhibited a hypertropia upon elevation of his eyelids due to adhesions between the superior rectus muscle and the levator muscle of the upper eyelid. Several attempts to surgically correct the problem failed.

Simpson and co-workers [13] reported a patient with thy- roid-related ophthalmopathy who underwent simultaneous recessions of the levator palpebrae superioris and lateral rectus muscles in both eyes. Postoperatively, the palpebral and bulbar conjunctiva of the right eye fused. This produced postoperative ptosis and restriction of ocular motility. Movement of the right globe produced abnormal lid movements and movement

Fig. 26.9. Elevation of the right lower eyelid and loss of the normal inferior curvature of the lid margin following unilateral inferior oblique anterior transposition

Fig. 26.10. A visible bulge noted in the lower eyelid with up gaze in a patient with a history of inferior oblique anterior transposition surgery in right eye