Dr. Daniel Neely presents more real patient cases in Pediatric Ophthalmology / Strabismus that have been submitted on Cybersight Consult. The examination, diagnosis and treatment of each case are covered.
Lecturer: Dr. Daniel Neely, Indiana University
DR NEELY: Welcome to a continuation of our Orbis Cybersight clinical case series. I’m Dr. Daniel Neely. I am a pediatric ophthalmologist at the Indiana University School of Medicine in Indianapolis, USA. I’m also your chief Orbis Cybersight telemedicine consultant. And a longtime Orbis volunteer faculty member. Today what we’re going to do is continue discussing some complex strabismus cases. Now, next time I’m with you, We’ll move on to some non-strabismus cases. I think I would like to do some pediatric cataract, and possibly some glaucoma, plastics, ROP. Whatever we would like to do. So if you have any requests, go ahead and send those to us at [email protected]
And we’ll get representative cases on for you. Today I’ve chosen four cases. That’s not a lot of cases. But I’ve chosen these four specifically because I have surgical teaching videos to go with them. So half our time will be spent on looking at the case. And then a good portion of our time will be spent looking at the surgical technique video. They’re usually about 5-minute clips. And then we’ll talk about… I’ll take your questions relative to that case. So four cases. Case presentation. Surgical video. And then answering your questions, which you can submit during the presentation. Once we’re done with that case and questions relative to it, we’ll move on to the next one and we’ll cover all four cases. At the end of those four cases, if you have other questions not related to these specific questions, We’ll open it up I’ll talk about anything you want in the remaining time. The cases today are from the old Cybersight system, before the upgrades a few years ago. So the format might look a little different. These had to be migrated from the old system. The format might look different. There might be some data fields missing. But they’re great cases, and I’ve chosen these not just because of the videos, but because they’re from one of our absolutely outstanding Cybersight partners, Dr. Doquang Noc in Hanoi, Vietnam. Dr. Noc I think holds the record for number of case submissions especially in the early days, was a great user of Cybersight, and is now one of the most preeminent ophthalmologists in Vietnam. I think he’s done a wonderful job. And you’ll see he does a nice job of putting these cases together, with the photographs and the medical histories. So I thank him for allowing me to use these cases. And we’re not gonna focus so much on our discussion at the end, with the treatment plan, but mostly the technique based on that. So thank you, Dr. Noc. I’ll also show you how to search these cases. So these are going to have case numbers. But there are other ways you can search for cases in Cybersight. If you have a superior oblique palsy and you want to see other cases, you can find that. And I’ll show you how to do that. I’m gonna move on to our first case here. So I will go to screen share. You’ll see my screen now. And those are our questions for later. Let me open up Keynote. All right. So here we go. Our strabismus case series. Number two. We did four a couple months ago. And our first case… Is an interesting trauma case. So we’ll sign in here. All right, so this first case — this is from 2003. So this is an older case. But the first case here… Here’s the case number. And that’s always one way you can search these cases. But also up here is a search function. And as we get further into things, I’ll show you how that works. But you can basically enter that datafield, type in keywords, and find representative cases. So this is Dr. Noc’s case. This is from a long time ago. 8-year-old whose vision is 20/30 in both eyes — and this 8-year-old suffered trauma to the right eye two years ago. One year ago he’d had some surgery at another location. In Ho Chi Minh City. At that time, we don’t know what his initial findings were. But we know he was thought to have had a lateral rectus recession on the right eye, 6 millimeters, there, and he was thought to have had a superior rectus recession on the right eye of 5 millimeters. So whatever the underlying problem was, he had an XT and a right hyper. All right? But he still has a right hyper, and it’s about 25 prism diopters, and he still has some exotropia, and he has a chin-down head posture. And that’s going to be interesting. So scrolling down… Refractive error looks normal. So let’s get to his photographs here. Let’s just start off with his primary position. And here you can see it doesn’t look too bad. You can tell he’s got a right hyper, you can see how the sclera is showing a little bit here. But the most noticeable thing is that he’s got his chin dipped down. So he’s trying to drop that chin down. So let’s look at his… So chin down. So what does that usually mean? Well, let’s talk about that for a second. If you have a chin-down posture or any kind of restriction, people are typically putting the head where the eyes won’t go. So if you have a chin-down posture, it means there’s a good chance he can’t depress one of his eyes. Okay? It also could mean that he has nystagmus with a null point upgaze. Two diagnostic things you start to think of when you see the head in postures. So the head goes where the eyes won’t go. All right. So chin down. We’re concerned that maybe he can’t depress. So let’s look at his upgaze first. And as you can see with the migrated system, these photos are a little bit out of order. But we can see upgaze. Here’s his upgaze. And it looks like his right eye doesn’t go up very well. Let’s go gaze up and to the right. Also not quite going all the way up and to the right there, with the right eye. Let’s find up and to the left. Right here. Does a little better there. So that’s an interesting thing. Up and to the left he does okay. Up and to the right he does not. The elevators in right gaze are typically the right superior rectus. So it could be a paresis of that. Or it could be that it’s being restricted by its antagonist muscle, the right inferior rectus. So we’re kind of already narrowing it down to a couple of possibilities here of which muscles could be affected. Simply because he’s got incomitance between right and left gaze. An when we talk about surgery, we’re always talking about finding the area where the deviation is greatest, and those are the muscles you work on. All right, but we’re concerned about downgaze. So let’s look at that. Let’s go straight down. And I’m gonna go to large pictures now. Here’s straight down. Now you can definitely see that that right eye is not going down, and the left eye is going down normally. Let’s go down and left. Let me find that one. Looks like it’s probably right here. This is down and to his left. Again, not depressing very well at all. And then let’s go down and to the right. Last picture we’ll look at. Really can barely get past the horizontal meridian there. So he’s either not depressing… So he’s either got a problem of this inferior rectus or he could have a problem of the superior rectus. So one way to help sort that out… Of course, we didn’t know what kind of trauma he had. So did he have penetrating sharp trauma? Where maybe we’re worried about this inferior rectus being lacerated? Or does he have blunt trauma, where maybe the inferior floor is blown out, the inferior rectus is entrapped, our even a roof fracture with entrapment of the superior rectus. Less common, but those two things can definitely happen. That’s something we don’t know yet, but I think it comes up down here in some of the follow-up questions. We were talking about laceration there. And here we have the response from Dr. Noc. When we had some questions. Sustained a closed head trauma. Fell and was struck in the right forehead by the floor that he hit. So his right eye and forehead were swollen. No suturing was needed. So we’re talking about blunt trauma. So that raises the possibility of floor or roof fracture to be higher than the inferior rectus problem. So he had some surgery. We’ll talk a little bit about that. He had some imaging, some evidence of a floor injury. The traction test of the superior rectus was free, but his inferior rectus was tight. So the superior rectus was not trapped but the inferior rectus was. It was trapped, maybe had some adhesions. Did some exploration of the floor. And tried to free up the inferior rectus as much as possible. Some additional work was done. He had the superior rectus recessed and the lateral rectus recessed. He was pretty good in the primary position, but still having some diplopia on downgaze. And that’s what I want to talk about here. So he’s got diplopia on downgaze. Let’s just say he still looks like this. Even though you’ve gone in and you worked on the floor and freed everything up. He still can’t depress this. So once you’ve made sure that there are no inclusions or restrictions or entrapments, once you’ve done your surgery, if you still have this kind of picture, it’s really tough to fix this. So sometimes what we have to do is, once we try to fix the inferior rectus, well, we’re okay in the primary position, but when he looks down, he’s got diplopia. One way to address this is to move over to the normal eye. Okay? Seems like we’re unlikely to make the abnormal eye go down better. So what we do is we come over to the normal eye. You don’t want to change the primary position. Right? Because you don’t want to… He’s ortho in primary position. He’s just got this hyper in downgaze. So what we want to do is equalize downgaze only. To do that, you can do a Faden suture or posterior fixation suture on the normal eye. On the inferior rectus. And what that will do is it won’t change that primary position, but it will keep the left eye from not going down so far, so that you can increase their diplopia-free field in downgaze only. So posterior fixation suture or Faden suture. And that’s the video I want to show you today. It’s a nice technique to have in your armamentarium. People use it for this particular problem. It can be used for sidegaze incomitance, a 6th nerve palsy, I’ve seen people use it for Duane syndrome, although I don’t do that personally. Another big use for it is accomodative esotropia with high AC/A ratios. Do this on the medial rectus, and it decreases that high AC/A ratio, that overconvergence, if you do this on both medial rectus muscles. So these are people that either aren’t fixed by a bifocal or they’re not outgrowing the bifocal as teenagers, and you want to get them out of the bifocal. So we’ll talk about that some other time. But those are the general uses for it. So let’s go to the video that I have for this. That’s gonna be Faden. Let’s pull that up. All right, okay. So Faden… This is one of my partners. He’s using traction sutures, 4-0 silk, to expose that inferior rectus. I’ll just use a couple of locking Cassie forceps to pull the eye up. But either way is fine. We like to have good exposure on these. We’re usually doing limbal incisions on this, rather than a fornix incision, because we really want to dissect posteriorly to do this. We want to get back towards the equator at the globe and we want to put a couple sutures back there. So good exposure is important. The Faden suture or posterior fixation suture… You can combine it with a small recession of the muscle, or you can do it on a muscle that you don’t disinsert at all. What you usually don’t do is a large recession and combine it with the posterior fixation suture. It just doesn’t seem to add a whole lot to that. If you were gonna recess this muscle 6 millimeters, you’re probably not gonna get much benefit to adding a Faden. Plus if they are ortho in the primary position, you don’t want to recess this muscle. They can be combined, but in this particular case, the patient is ortho in the primary position. All we want to do is change downgaze. So we need to dissect that carefully. We need to clean this muscle off more than you normally would. You can see we’re trying to lyse all these attachments to the lower lid retractors. Especially if you’re doing a recession of this muscle, you don’t want to cause retraction of the lower eyelid. Particularly common when you do large recessions in young people. Where those attachments are very firm. This is how I like to do it here. A little incision being made right there. But I like to just open those scissors a little bit, and just kind of push. So you don’t even have to cut. That way if you’re just pushing with the scissors open a little bit, you won’t cut a vortex vein, you won’t cut the vessels on the surface. So this is a 5-0 Mersilene suture. The needle is kind of large. This is probably an S14. I don’t love this needle, but it’s hard to find 5-0 sutures on smaller needles. I don’t love this needle because it’s very thick and you have to be careful about not perforating the sclera. This suture is being placed at the equator. So it’s about 14 millimeters, hopefully, from the limbus. 13, 14 millimeters. And once you pass it to the side, to the sclera, we’re gonna go through about a third of the muscle width. So we’re elevating the muscle away from the sclera, little Stevens hook. You don’t want to engage the sclera under the muscle. And you’ve got to be careful to push all that stuff out of the way. So here we are. Gonna lift the muscle away from the sclera. And now we’re gonna pass the suture through the other third. So these are two single-armed 5-0 Mersilene sutures. Now, the key to this, once you’ve done your scleral pass, and then the muscle pass, the key is: You need to tie this suture really tight. If it’s loose, you’re not going to get the posterior fixation suture effect. So you need to have all the garbage out of the way. All that Tenon’s and muscle capsule out of the way. And this is another reason why we use a 5-0 suture, because we can really pull on it and get that knot tight. If you’re using a 6-0, a lot of times it’ll break when you’re horsing it around like that. So nice big, hefty suture. Again, this is Mersilene, but any kind of heavy-duty, braided, non-absorbable suture will work. So here you see… I’ll freeze this for a second. Let me just back up a touch. So we can see our final effect here. Maybe a touch more. Not quite that far. Okay. A little bit more. All right. There we go. That’s perfect. So here we can see what we’ve done. The limbus is up here, the limbus is offscreen, down at the bottom. Then we have our inferior rectus insertion right here, the muscle hook, and we have our inferior rectus, and here’s one 5-0 Mersilene. And here’s the other 5-0 Mersilene. They were passed through the sclera right here. Partial thickness scleral bite, very carefully, right next to the muscle, then we elevated the muscle, and we came up through it, and we tied it. And we did that twice. So what this does is… When the eye is straight ahead, the insertion right here is the effective insertion. So we’re not changing the position in the primary. The alignment in the primary position. This is still the insertion. However, when the eye tries to look down, this muscle is contracting. But because this suture is back here, now this is the effective insertion. So it’s just like in downgaze — it’s like you recess the muscle back here. So that’s why it only has action in downgaze. And so this is why you can be ortho in primary, and you can try and treat 15 or 20 prism diopters of hypertropia in downgaze. So that’s the Faden or posterior fixation suture. Really nice technique. Again, key element: Tie that knot really tight. So let me break out of that. Gonna check in on our questions now, before we move on to our next case. See if we have anything. The question is: Could be a reverse leash? Jampolsky, strongly suggesting restriction with or without associated weakness? Yes, of course you can have restriction. Which is why the very first thing you want to do on any of these cases… Any case that’s abnormal, but especially a case where you have incomitance, or you have a history of trauma, you just have to do a traction test. And you need to know what feels normal, and you need to know what’s not normal. So that you can rule out restriction. All right? This one did feel restricted. Work was done on the inferior rectus to free it up, and it wasn’t sufficient, and now we’ve moved on to that. So let’s boogie on to our next case. And I’ve got one more question. Let me pop back up. Will the Faden in this case take care of the chin depression? The Faden may take care of the chin depression. So it’s gonna diminish it. You may not eliminate it all the way. If he’s doing a head posture in the primary position, it may be because his range of diplopia-free vision is limited. In which case the Faden is probably gonna help the chin depression. But the other possibility is that you’ve got diplopia in the primary position. And if that’s it, you’re gonna need to recess that inferior rectus, as well as place a Faden. So that’s why you have to look at those both. And one more on the Faden technique. For the superior rectus Faden, what is the advice to avoid the oblique? And that’s important. Because with the… If you measure back… So we’re about… So the superior rectus is about 7, 7.5 millimeters back from the limbus. And then we’re talking about working back at the equator, which is 14. So you’re getting right in the area where the superior oblique is crossing underneath the superior rectus. And what I would do is… At least on the temporal border, it’s probably gonna be close to that. And so just take a Stevens hook, identify the anterior corner of the superior oblique, and just pull it back a little bit. If it’s too much in the way, you’ve just got to move in front of it. But do not get your Faden suture into the superior rectus fiber. Especially in the temporal corner. Either pull it back out of the way or go just in front of it. Because you’ll induce some torsional issues or even a vertical issue. Along the nasal border of the superior rectus, the superior oblique tendon is usually further back, and so it should be out of the way. Because of that kind of slanting course that it runs. If not, just, again, same thing. Pull it back out of the way, or put your suture just in front of it. We’re gonna move on to the next case, so we can cover some more cases. But if there are more questions, I’ll come back to those. Go back to our screen share. And let’s exit out of this one. All right. Second case. Moving on. There’s our video and our questions. All right. Second case… Here we have an 11-year-old. Vision 20/40, 20/25. Basically normal. 11-year-old girl. She’s had a history of some right head tilting and a right hyper — sorry, a small left hyper. The interesting thing about this case is that she’s got significant — she’s got some esotropia. Okay, let me just highlight… She’s got esotropia of 25 prism diopters, and really got some overaction of both inferior obliques. 3+ overaction. So we grade inferior oblique overaction +1, +2, +3, +4. So +3 is a pretty significant amount. And that’s what I want to concentrate on with her. Because she also has a little bit of DVD with this. It’s not a lot, but it’s a little bit. And I want to talk about inferior obliques and DVD surgery. Let’s look at her in the primary position. There’s that little bit of head posture she has, a little bit of a tilt. Let’s look at inferior oblique overaction. Let’s go to the large pictures for that. And here you can see… She’s not really quite up and left yet. But this left eye is starting to shoot up. She’s got a little bit of upshoot going on there. And let’s look at her up and to the left. Kind of the same deal going on there. So she’s really just in left gaze here. She’s not even up and left. And here we have right inferior oblique overaction. And then I want to show you a couple more photos, relative to her. Especially this right eye. So her right eye — when you put a translucent occluder in front of her — this is one way you can photograph or visualize a DVD. It’s hazy enough that the eye is dissociated. And you’ll get the upward drifting. And you can see that the sclera is visible underneath that eye right there. So she’s got a moderate DVD in this eye. Not so much on the left eye. At least, not that I can see real easy. There’s a little bit, kind of at the limbus there. Here she’s at the limbus, but because of her esotropia, she’s at the limbus, and the eye is in the middle. Out here, the eye is in, and the eyelid slants up, so the limbus and lid margin are still touching, but she’s actually got DVD here as well. It’s just not quite as apparent. So we’re talking about esotropia and inferior oblique overaction and DVD. So that’s a pretty common scenario, when you have congenital esotropia. And then they get inferior oblique overaction later. And they get DVDs. And so what I want to talk about is inferior oblique overaction. And treating that DVD in those cases. So inferior oblique anterior transposition. So let’s open that up. Before I start this, we’re just gonna pause it and talk for a second. Okay. So this person, as we’re talking about commonly, you see esotropia with V patterns and inferior oblique overaction and DVD. It’s pretty much a classic set of findings for patients with congenital esotropia. You can see DVD and inferior oblique overaction, of course, with exotropia, but this is the classic one that we probably see the most. She’s had a medial rectus recession through the fornix already. Now the inferior oblique is being addressed. So looking down here, this is the inferotemporal quadrant. So the inferior rectus is right here, of course. The inferior oblique is running across here and it’s inserting over here, underneath the lateral rectus. This is where your inferior oblique is. 8 millimeters back from the lateral rectus insertion is where your inferior oblique terminates. If you recess the inferior oblique, you’re simply moving it from here to back over here. So you’re sewing it right along its course. Along the inferior rectus. If you’re gonna do a myectomy, you disinsert it here, and then you make another cut across the inferior oblique here, and you remove this whole section of the inferior oblique. The third option is to disinsert the inferior oblique from here, put a suture in this end, bring it over here, but instead of putting it in a recessed position, we’re gonna pull it forward, up by the corner of the inferior rectus. So now that inferior oblique is gonna run across, underneath the inferior, to the inferior rectus, and then it’s gonna curve back up in kind of a J shape and be attached right here, so that’s an inferior oblique anterior transposition. What that’s doing… You moved the inferior oblique back. So it’s weakened it. So it’s like a recession. But you’ve pulled it forward. So now, because it’s forward, perhaps it has a little bit of a depressing effect. Rather than being elevated. Or perhaps it just acts as a passive tether, because it’s stretched and pulled forward a little bit. That it keeps the eye from not drifting up and giving you that DVD. Or it limits that DVD upward motion. Okay? So inferior oblique anterior transposition. Let’s let this video run now. Again, inferior oblique I think is easiest to approach through the fornix incision. Even if you don’t usually do fornix incisions for your other muscles. Going through Tenon’s now. And using the lateral rectus as a way to isolate the inferior oblique. So this is a 4-0 silk suture, being used for traction under the lateral rectus. Now the eye is going to be drawn into adduction and elevation. You can see that the cornea is above that suture. So that’s putting the inferior oblique where you can hook it. And let’s stop right there. Because that is just a key thing to see. Back up. Right here. And I’ll pause it as it gets there. Right there. Okay. So we’re using the 4-0 silk as a traction suture. We’ve got a hook elevating the inferior oblique away from the sclera. This is the triangle you want to see here. So here’s the inferior oblique. This hook, this Stevens hook, is just pulling the conjunctiva up out of the way. Lateral rectus is running here. But this right here — you want to see the posterior border of the inferior oblique as it runs up here to insert. So you’re gonna see a white triangle of posterior Tenon’s and orbital fat behind there. Get this out of the way. And you’re gonna put your Stevens hook right there past that border. And you’re gonna hook the inferior oblique out this way towards the orbital rim. Down here, you’re gonna see as the inferior oblique is draped up and over that hook, you’re gonna see another side of the inferior oblique. Make a little triangle. Right down here in this corner, you’re gonna see a vortex vein. And you want to see that vortex vein, because you don’t want to accidentally hook it with the Stevens hook. So let’s back up a touch. Let it run through this step again, which is so important. And watch that exposure. There is the triangle, hooking. And didn’t see the vortex vein there. But now we’re gonna buttonhole on the other side of that inferior oblique. Clean it off. So we’re right up against the muscle. We don’t want a bunch of Tenon’s and fat and muscle sheath. Well, we want muscle sheath, but we don’t want all the connective tissue going to it. So you’ve got to unload the orbital fat away from that inferior oblique. So you don’t create adhesions. There it’s being pulled away. And cleaning off the insertion. And now we’ve got a hemostat being put on. Now we’re gonna cut underneath the hemostat. So it’s right up against the inferior oblique insertion. So we’ve disinserted the muscle. Now at the distal end of the inferior oblique, we’re putting this… Just 6-0 vicryl. You don’t need anything more than that. It’s just one solid pass across it, and then a couple locking bites. There’s the first locking bite and the second one. This muscle is not under a lot of tension. So you don’t need it super secure. You just need to have some sutures in it. It’s not going anywhere. So now we have it untwisted. It’s ready to go. Now we’re going to hook the inferior rectus. Boom. Jameson hook under the inferior rectus. And so that’s the corner of the inferior rectus right there. Right where the muscle is sitting right now. So that is a zero anterior transposition. We’re gonna come forward a millimeter or two, in front of the corner of the inferior rectus, and we’re gonna put this suture right there. This one is 2 millimeters in front of the temporal corner of the inferior rectus. And these two sutures are gonna be close to each other. They’re only 2 millimeters apart. And the reason for that is, if you spread them out like we normally do with muscle recessions and resections, you can create a restriction, an antielevation syndrome. So here they’re being clustered right together, just 2 or 3 millimeters apart, and you get that little knot of inferior oblique, and it’s right in front of the corner of the inferior rectus. Just to its side. And there, there’s your anterior transposition. Reposition our conjunctiva. And then, like you can see, a lot of times no suture is needed. All right? So inferior oblique anterior transposition. Great procedure when you have dissociated vertical deviation in the presence of inferior oblique overaction. Now, if you don’t have inferior oblique overaction, you don’t want to do an anterior transposition. If you have a dissociated vertical deviation and no inferior oblique overaction, I recommend that you do a superior rectus recession. You can even do an inferior rectus resection if you need to. But usually an 8 millimeter recession of both superior rectus muscles or an asymmetric 5 and 8 is the way to go for me, when you have DVD and no inferior oblique overaction. So let’s find our questions here. Get my little captions out of the way. Open up our questions. And… Let’s see. Here’s one. It’s about reoperations. We’ll hold that until the end. Here’s one still about the Faden. Let’s cover that. And the question is: What about reversibility of the Faden, if required? To me, that’s one of the potential downsides. Because once that’s been in there any length of time, it’s gonna be scar tissue, and you’re gonna have atrophy of the tissue around the suture as well as some possible restrictions. So they can be kind of tough to reverse. It’s not something that you go into with the idea that you need to reverse it. Now, on stuff like this inferior rectus we were looking at, these trauma cases, you’re not gonna reverse it. You’re probably gonna be undercorrected anyway. So you’re just doing what you can. However, the one case where sometimes you might need to reverse it are those accommodative esotropes with high AC/A ratios where you’re doing it on both medial rectus muscles. And this is why you don’t do that procedure in a 6-year-old. Those kids, you put them in bifocals and maybe do medial rectus recessions. But I kind of only do the Faden procedure on teenagers with high AC/A ratios, once I see if it’s gonna extinguish itself. Because a lot of times as their hyperopia goes away and the accommodative excess starts to burn out, you don’t need bifocals and don’t need posterior fixation sutures. So the last thing you want to do is be aggressive, put one in, without seeing what the natural history is gonna be, and then get burned, and you’re trying to take it down and it’s all beat up. So they are reversible, but it’s not something you really want to take a chance on. Okay. So this question is about: Can dissociated vertical deviation come without esotropia? Definitely. You can see people who have what looks like congenital esotropia, they’ve got latent nystagmus, they’ve got inferior oblique overaction, they’ve got DVD, but they’ve got no esotropia. Or they’ve got very little. So they have congenital ET without the ET. You can also see it definitely with exotropia. So you can have V pattern exotropia with inferior oblique overaction and dissociated vertical deviation. So that’s another relatively common scenario when you can see DVD. Okay? All right. So… Caught up on our questions. Let’s roll on to our third case. Because it looks like we might not even get to all four, as it is. All right. Go back to our screen share. And… Dah-dah-dah… Okay, so our next case, superior oblique case. Superior oblique tenotomy case… That’s not what I want to do. Superior oblique is challenging for everybody. And superior oblique operating is also challenging for everybody. You just don’t do superior obliques that often. It doesn’t come up. So I wanted to put in a superior oblique case and a superior oblique tenotomy. Where is my pointer? Come on. In here somewhere. Out of the way. All right, got it now. For some reason, I can’t find my arrow in this one. But what we’ll do… It’s case 15193. Let’s just go that route. The struggle bus is here for sure. Let me open four. But we’ll go… We’ll find my case. So search… I want… So I’m going to 15193. But let me just show you something first. You want to look at superior oblique cases. Type in superior oblique. Oh, I see I got signed out. Sign back in. If I want to find superior oblique cases, superior oblique… And this will search all the closed cases that are public cases. So if someone’s made a case private, it won’t pop up. But if it’s a public case, and open access to all of us, then you can find it. So superior oblique. I’ve got 215 results. And you can look at these individually. Or you can filter these. So there are other ways to filter these. If you want to look at Orbis program cases, if you want to look by location, I want cases in South Africa, I want cases from Vietnam, you can look by location. Diagnosis, subspecialty, if you want to see user cases — so if you want cases just from Dr. Noc or just cases from me as a mentor, or dates — all that stuff can be thrown in there, and you can use all the filters to sort the stuff out. But if you just want to start looking at cases with superior oblique involved in them, you got it. Just do that. But let’s go to the case that I want. And I want 15193. All right. And here it is. Again, this is an old case. This is from 2003. It’s a while ago. Let’s see. Yep, okay. That’s her. Another trauma case. So another 11-year-old girl. Seems like they’ve all been in this range today. Trauma to the right eye 7 years ago. She fell, hit the ground, and her right eye and cheekbone were swollen. No sutures were needed. She’s got a face turn. Exotropia in the primary position. Go away! Exotropia in the primary position. 30 diopters larger in upgaze. And downgaze. So she maybe has kind of like an X pattern, perhaps, if it’s larger in upgaze than downgaze. Let’s look at her photographs. So a lot of times when we’re doing superior oblique weakening, we’re talking about A patterns. So she may not have a perfect A pattern, but she does have the superior oblique overaction. So let’s look at that. Let’s go primary position first, right? Always look at the primary position first. There she is. There’s a little bit of head posturing going on. Maybe she’s got her chin down a little bit, turned to the right. Let’s look at straight ahead. A little closer up, got her chin down. So chin down, again, pattern strabismus. Sometimes if they’re straighter in upgaze, they’ll drop their chin. So she could have exotropia with an A pattern. And she’s straighter in upgaze. Or she could have an esotropia with a V pattern. And be straighter in upgaze. We already know she’s got exotropia. So she’s probably got an A pattern exotropia, and that’s why she’s dropping her chin, because her exotropia is less in upgaze. All right? Where is the picture I want? Oh, there it is, right there in front of me. Upgaze. Got a little bit of exotropia. Definitely has some there. Let’s look at her downgaze and see what’s going on there. That could be it right there. Here we are. Downgaze. Wow, look at downgaze. Huge divergence in downgaze. So let’s call this an A pattern exotropia. Either an A or an X. But she’s got big A pattern in downgaze. A pattern exotropia, A patterns in general, a lot of times indicate superior oblique dysfunction. V patterns frequently indicate inferior oblique dysfunction. So she’s got really bad A pattern, superior oblique overaction. Head trauma, starting to think about… This one looks like it’s down and to the left. That’s probably down and to the right. Again, just confirming this A pattern. Let’s get her in straight side gaze. And that’ll a lot of times show us possibly more of the A pattern? I don’t see a really good side gaze illustration here. So A pattern exotropia, superior oblique overaction. What do you do for an A pattern exotropia with superior oblique overaction? Well, for that… Let’s go… I’m sorry. Come back. I want to go to my whiteboard. So let me break out of the share here. And let’s talk about A pattern exotropia. With our whiteboard. And let’s go full screen with that. So she’s got an A pattern exotropia. So let’s say her XT is… She’s got some. I’m just gonna say 10. And she’s got XT of 30 in primary. And then downgaze she’s got this huge XT. I’m gonna say 90 just for fun. All right. So A pattern exotropia. Her exotropia is less in upgaze, it’s more in downgaze. And her motility… Different grid systems here. Remember, we talked about this before. You can either do an H or you can do an asterisk. I’m gonna show you one of each. So this is right and this is left. And so we’re looking at motility. We know she’s got big-time superior oblique overaction.So down arrow indicates overaction of the superior oblique. And she’s a +3 and a +3. Amazing artwork, no extra charge. So there you see what that looks like, A pattern exotropia… So exotropia, A pattern, you could recess her laterals. If you’re gonna up or downshift them, that mnemonic, MALE, medials go to the apex, laterals go to the empty space, so this is the empty space, open end of the V. So you could do lateral rectus recession for 30. So that’s a BLR of 7. That would get you that. But then you would do a downshift for the A pattern. And so I might downshift laterals for A pattern. Usually it’s 1/2 to 2/3 of a tendon width. What that’s gonna do… Well, it’s not gonna touch this. That’s what it’s gonna do. You might be able to get 30 in primary and then maybe you can get 40 in downgaze by doing the shift. You’re not gonna come close to that. And the reason is because you’ve got this. When you have big time oblique dysfunction, you’ve got to operate on the oblique. You have no choice. So downshifting is not gonna work. What do we want? We want to do oblique surgery. So let’s go find some oblique surgery here. Back to my screenshare, let’s go to my desktop, screenshare, and let’s roll into oblique surgery. First we’re gonna run out of time, but we’ll just do general questions after this one. We won’t start a fourth case. So let’s look at traction testing. The traction test I’m gonna look at is a Brown syndrome. Because that’s another time you’re doing superior oblique tenotomies. But I’m gonna show you what superior oblique traction testing looks like. This is left eye being forced up and in with forceps. Watch that again. Come back. No, not this one. Post-op, pre-op, Brown syndrome. Oh, there it is. Come back! All right. We’re gonna restart it. Okay. Left eye being forced up and in, rotating back and forth. Look how tight that is. Just get past the sclera. It’s tight, tight, tight. All right. So then let’s look at what a tenotomy looks like, and then we’ll do the postop test. All right. So here we have a Brown syndrome traction test, and then it goes into the surgery. Tight, tight, tight. Other one’s being done on the other eye. And then we’re going to do a superior oblique tenotomy. And I’ll pause it so I can make a comment here. Approach — it’s a little bit edited. So it goes kind of fast. Approach to the superior oblique is the same whether you’re doing a tenotomy or a spacer or a transposition of the superior oblique for a 3rd nerve palsy. So all of these have the same general approach. I like to approach them from the temporal side. It’s going on to the other movie! All right. I’ll get this yet. I promise. So… All right. Restart playback. Try not to stop this time. Because it doesn’t like that. All right. Same thing. Traction test. So I do these from the temporal side. You can stay out of the… Make the incision on the temporal side, but then you’re locating the superior oblique on the nasal side, where it becomes condensed. All right, this has switched eyes, so we’re actually on the… This is the right eye right now. And this was going from the temporal. All we’ve done is hook the superior rectus. Now we’re reflecting the conjunctiva and Tenon’s back over to expose the superior rectus. Okay? We didn’t buttonhole here, nasally. We made our incision out here. We hooked the superior rectus. And then we simply stretched that incision up over and tucked it under the knot with a hook. Now we’ve put in a Desmarres retractor, and we’re looking at the filmy cover of the muscle capsule of the superior rectus. You like to not cause a lot of dissection up in here. Especially if you’re doing superior oblique spacers. Because if you’re doing a spacer, you don’t want adhesions or scar tissue. So we’ve made a temporal incision. But we’re gonna be looking for the superior oblique over here. And because that’s where the tendon condenses down and is discrete — if you’re looking for the temporal corner, it’s really posterior, and the insertion is all fanned out, and it’s kind of hard to find out there. Here it’s like a little rope and it’s easier to hook. So we’re gonna open up this muscle capsule, and then we’re going to identify the superior oblique along the nasal border of the superior rectus. And that’s gonna be about 8 millimeters back. This is gonna be about 8 millimeters behind the insertion. All right. So let’s start it up. And do that. And just replacing the hook. You want to be sure you don’t have that superior oblique tendon incorporated into the hook. What did they just do? They just measured back 8 millimeters to get a ballpark idea, right there. See, calipers are up there. Getting a ballpark idea of where is that tendon going to be. Good little pearl there. Now, picking up with two forceps, two Thorpe, picking up the cover of the superior rectus, and we’re dissecting down to the surface. Down to the surface. You don’t want to cut into the muscle. But we want to see the superior rectus border. And the surface. There’s the surface of the superior rectus muscle. And then we’re gonna stretch that hole open. Now the Desmarres retractor is gonna go into that hole and kind of hold it open. So now we’ve got some tissue out of the way. We should be able to find that discrete border of the superior oblique. Right where that cotton tip is. We’re gonna find it right there. And that’s that pearly strand right there. Once you see that pearly strand, then you’re gonna put a Stevens hook from the back side and hook forward. Now we’ve got it plus the tendon sheath, and you can stretch it out, and you can put a cotton tip on there and dry it, and you can see that pearly band right there. That’s our superior oblique tendon right there. And in front of it, we’re just gonna open this stuff up. So if you’re gonna put a spacer in, you put in some sutures after you open it up, then we’re gonna open it up, we want to see the tendon. We don’t just want to cut through all this stuff indiscriminately. All right. Getting close. Now there’s the tendon. Now we’re cutting through the tendon. And it’s gonna snap. Boom. There it goes. Cut the superior oblique tendon. And this tenotomy is right along the nasal border. That’s where you generally want to do it. If you get close to the trochlear, you can get overcorrections. You can get too much effect. So we’ve tucked it all back in place. Now we’re gonna repeat that traction test. Again, this is the right eye, so we’re gonna push it up this way. Look how almost you can bury the cornea. That’s what it looks like after our traction test. If it doesn’t look like that, you may not have done a complete tenotomy. That is a great little demonstration of a superior oblique tenotomy. We are down to just five minutes. So let’s break out of here and let’s do some questions. And cover all this. Close that. Stop my screen share, and here we are. Boom. Back. Gotcha. All right. Opening up questions. Okay. Is it common to develop superior oblique palsy with weakening surgery? Well, yeah, definitely. You can cause a superior oblique palsy when you weaken it. So you have to be careful. You don’t want to do it unless you need it. Because if you cause a superior oblique palsy, it’s hard to fix. So that’s where the decision to perform the surgery is more important almost than the technique, perhaps. But that’s why some people do spacers. Or chicken sutures. They control the lengthening of that superior oblique tenotomy. If you sew in a 240 retinal band and you’re gonna put in a 7-millimeter retinal band, the superior oblique can only go out that far. Or if you put in a chicken suture, 5-0 Mersilene, and you measure that those two ends of the tendon are only 5, 7 millimeters apart, yeah, you’ve controlled that. But if you really need to weaken a superior oblique tenotomy, then you do a tenotomy. Now, when you cut those ends, it doesn’t just go like this and go anywhere. There are so many attachments between that tendon and the periocular tissues. And the trochlea. The tendon doesn’t slide through the trochlea. It’s still in the trochlea. So you’re just getting some lengthening. But yeah, that’s why some people will try spacers first and then only do a tenotomy if the spacer doesn’t work. Another way to do this — you can do not a tenotomy, and just do a disinsertion. You can go out, isolate the tendon nasally or isolate it temporally, and once you hook that superior oblique insertion, you just cut it loose there. And that’s a mild way of weakening the superior oblique tendon, or you just do the posterior fibers, and leave the torsional fibers intact. So there are different ways to do it. I only do superior oblique tenotomies if I have 3+ superior oblique overaction. I think if it’s just 1+, I usually try to stay out of there and maybe just do upshifts, downshifts. And someone is asking an appropriate question about torsion. Will a complete tenotomy induce torsion? It can, yeah. So people who have fusion — you have to be careful about doing bilateral complete tenotomies. Because if they have normal stereopsis and normal fusion, and you do a tenotomy, then they’ll have some torsional diplopia. You just gave them a bilateral superior oblique palsy. In my experience, though, usually when you’re doing this, these people have great big strabismus angles, and no fusion. And so you can usually… They’re not bothered by the torsion. Okay? So be careful if you have a fusing patient with an A pattern. You may want to just play it safe and do upshifts of the rectus muscles. Or downshifts. Whatever you need. So torsional diplopia. Good question. And there was another question about torsion. But those are good questions. But again, patient selection. You don’t do it on people who are going to get that. Or who are at risk for it. All right. And this is a good one too. I hinted at this during the discussion. The question is: What to do if there’s a recurrent or residual Brown’s effect when you do SO, superior oblique, spacer for Brown syndrome. So this happens to me not too infrequently. I like the spacers, but I frequently find that the people are undercorrected. So maximum size for a spacer… Well, it can be whatever size you want. I suppose maybe in the ballpark of 10 millimeters is gonna be maximum. Because whatever distance you have between the nasal border of the superior rectus and the trochlea — that’s the maximum spacer length that you can do. Most typically, when I do a spacer, it’s 6 or 7 millimeters. 5 millimeters. So I think kind of 7 is more maximum, from a practical standpoint. If you do a spacer, and two months later, they still have a big restriction, big head posture, what I do is I go… Two months after any strabismus surgery, because there was a question about timing of repeat surgeries — two months after any strabismus surgery, if I don’t have the effect that I need, or if I have an effect that I didn’t want, then I go back and I do a second surgery. So that’s timing. Go back and I just do a tenotomy. I may take the spacer out or I may just cut it. And this is a good question. This will be our last question. And this is: Please explain the MALE, the MALE mnemonic. All right? So let me go back to my whiteboard for this. Because I think it’s easier to see it. And I’m gonna use a V pattern for this. Because usually we see V pattern strabismus and there’ll be, let’s just say, they’re 30 ET down there, this person is 20 ET there. So these are all ET. And maybe they’re pretty straight up here. Just 10. All right. And then the mnemonic is MALE. M… A… L… E. And it’s a simple way to remember which way to shift the muscles. So 20 ET, you’re operating on the medial rectus. Right? That’s a BMR. For 20. But I want to help compensate for the 30 in downgaze. So I want to shift the medials while I recess them, to help get this 30 down here. And so the first part of the mnemonic is MA. And that stands for medials. So your medial rectus. Shifted to the apex. All right. Shift. And then the A is apex. A-P-E-X. Apex is the point of a triangle. All right? So shift… And it doesn’t matter if you’re doing recessions or resections of the medials. If you are treating any pattern strabismus, and you’re working on the medials, wherever the point of the triangle in the pattern is, medial is to the apex. So if I was working on an A pattern esotropia, the medials would be upshifted. Medials to the apex. If I’m working on a V pattern esotropia, medials go down. So let’s clear that. Clear all. Okay. So MALE. The second part of MALE. M-A-L-E. Laterals to the empty space. What’s the empty space? If this is the apex of the pattern, the empty space is the area between the legs. So this is the empty space. So if I’m operating on the laterals for a V pattern, they get shifted up to the empty space. If we have an A pattern, that’s the apex, A, if I’m working on the laterals for an A pattern, they go to the empty space. So they get downshifted. So you don’t really have to understand the mechanics. You just have to understand the MALE. Medials to the apex, laterals to the empty space. Boom, you got it. Advanced placement is understanding the mechanics of that. Okay. We are over time limit. I know there are more questions, so I will answer these by text or email. And will include those with the case discussion here. So thank you for your time today. Keep in mind our next case series will move on to some non-strabismus. I’ll cover some pediatric cataracts and pediatric glaucoma. Maybe show you some vitrector technique for infant cataract surgery, maybe talk about goniotomy and trabeculotomy, some very practical discussion, I think. So thank you for your time today. This will be available with transcription on Cybersight, in the webinar library. Take a look at this, and all the other material that we have for you there. Please send us your consults. Free consults. Not today only. So send us your consults. We’ll get them to a subspecialist. We’ll get you an opinion on what you should do. And then you can do what you want to do, based on that advice. Thank you for your time today. Good day.