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Anterior segment ischemia following augmented 2-muscle transposition surgery

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Case 1

A 60-year-old woman had diplopia 2 months following clipping of a bleeding aneurysm in the cerebellar circulation. Visual acuity measured 20/30 OD and 20/20 OS. Examination showed a total right VI nerve palsy with abduction limited to 20° nasal to the midline. Examination of the pupils, anterior segments, and fundi was unremarkable. Intraocular pressures measured 14 mm Hg in each eye.

The patient underwent a transposition of the right superior and inferior recti to the lateral rectus insertion

Case 2

A 61-year-old woman developed an extreme right esotropia over a 12-year period in association with a cordoma involving the right hemisphere. She had undergone surgical resection and radiation therapy 3 years before. Visual acuity measured 20/125 in the right eye and 20/20 in the left eye. The right eye could be voluntarily moved only about 10 degrees from its position of extreme adduction. Vertical rotations appeared intact. Examination of the pupils, anterior segments, and fundi, though

Discussion

The Foster augmentation procedure has enhanced the effect of transposing the vertical recti so that surgery on the medial rectus is rarely needed.2 Although anterior segment ischemia would be unexpected, it has been reported by Murdock and Kushner.3 Our two patients developed clear evidence of ASI following Foster transpositions. Both resolved without serious sequella.

Neither of our patients presented with a known risk factor for this complication. Case 1 subsequently required treatment for

References (5)

  • T.D. France et al.

    Anterior segment ischemia syndrome following eye muscle surgerythe AAPO and S experience

    J Pediatr Ophthalmol Strabismus

    (1986)
  • R.S. Foster

    Vertical muscle transposition augmented with lateral fixation

    J AAPOS

    (1997)
There are more references available in the full text version of this article.

Cited by (27)

  • Outcomes After Superior Rectus Transposition and Medial Rectus Recession Versus Vertical Recti Transposition for Sixth Nerve Palsy

    2017, American Journal of Ophthalmology
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    A variety of vertical rectus muscle transposition procedures have been reported to improve alignment in patients with sixth nerve palsy.2,3,12–15 Potential complications of these procedures include new vertical deviations, induced torsion, and anterior segment ischemia.5,16,17 Many patients with residual esotropia following vertical rectus muscle transposition later undergo ipsilateral medial rectus recession.

  • Outcomes of three different vertical rectus muscle transposition procedures for complete abducens nerve palsy

    2015, Journal of AAPOS
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    By not touching the medial rectus, the risk of anterior segment ischemia is reduced. It is important to remember that a significant percentage of the patients affected by complete abducens palsy are older patients, with some comorbidities that already put them at a higher risk of anterior segment ischemia.17 Weakening of the unoperated medial rectus remains as an option to treat an undercorrection.

  • Adjustable suture technique for enhanced transposition surgery for extraocular muscles

    2010, Journal of AAPOS
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    To avoid the need for concurrent or subsequent medial rectus muscle recession, in an attempt to reduce the risk of anterior segment ischemia, botulinum toxin injection to the medial rectus muscle and lateral fixation sutures for the transposed muscles have each been advocated. Nevertheless, anterior segment ischemia has still occurred with these techniques.21-25 The fact that no other cases of anterior segment ischemia were seen in either of our 2 groups may be the result of the vessel-sparing technique that we use but may also simply reflect the rare nature of this complication.25-28

  • Augmented vertical rectus transposition surgery with single posterior fixation suture: Modification of Foster technique

    2009, Journal of AAPOS
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    However, all of these patients who underwent more than 2-rectus muscle surgery had a cul-de-sac surgical approach with sparing of the limbal conjunctival vessels, and no patient had simultaneous medial rectus muscle surgery. Some surgeons believe that sparing of the limbal conjunctival vessels is helpful in limiting anterior segment ischemia.20 Also, because any surgery on the ipsilateral medial rectus muscle was separated by more than a year, there was the opportunity for reestablished collateral circulation.

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