Experts’ opinion – Case 3

In addition to answering the questions posed to our members, our Experts were also asked ‘How they would Explain the below mentioned Phenomenon : After Transposition of the Inferior Oblique Eye Muscle, an Improvement was observed in Left Eye Inferior Gaze, while bearing in mind the fact that the Inferior Oblique Eye Muscle is Relaxed in Infraversion’

Dr. Pradeep Sharma

Dr. Pradeep Sharma would normally do a prior FDT for the tightness of Left SR and recess that only if it was positive. Otherwise I would prefer to explore the Left IR and if it has moderate tone I would do a plication of the IR. If it totally lax or missing I would do an Inverse Knapp procedure to improve the infraduction. If the hypertropia is too much in upgaze I would use the Ant transposition of Inferior Oblique. I would touch the right side IR or Faden as the last resort to improve the infraduction. In response to ‘How he would Explain the below mentioned Phenomenon : After Transposition of the Inferior Oblique Eye Muscle, an Improvement was observed in Left Eye Inferior Gaze, while bearing in mind the fact that the Inferior Oblique Eye Muscle is Relaxed in Infraversion’ Dr. Sharma replied ‘The improvement in hypertropia in primary position by IOAT is because of it increasing the infraduction tone more so in upgaze as it is working like an IR but this is not in downgaze’. Imaging is desirable but may not be possible in all cases and I may manage on FDT, AFGT and clinical findings.

 

 Dr. Alcina Toscano

Dr. Alcina Toscano would use Inferior Transposition (Total / Half) of both left horizontal rectus muscles in order to compensate for the function deficit of a traumatically detached left inferior rectus muscle that cannot be found. Considering the left eye hypertropia and infra-abduction limitation – inferior rectus palsy – I would have done half inferior transposition of both left horizontal rectus muscles. As the inferior rectus muscle was not found during surgery I would keep my option of half transposition to avoid ischemia. Anteriorization of the inferior oblique muscle and downward transposition of the medial rectus muscle for lost inferior rectus muscle has also been described but I have no experience with that technique. I would do surgery even without good MRI information, making account of FDT and exploratory surgery In response to ‘How she would Explain the below mentioned Phenomenon : After Transposition of the Inferior Oblique Eye Muscle, an Improvement was observed in Left Eye Inferior Gaze, while bearing in mind the fact that the Inferior Oblique Eye Muscle is Relaxed in Infraversion’ Dr. Toscano replied ‘It is unlikely that the inferior oblique becomes a depressor. One explanation could be the placement of the suture more nasal to the inferior rectus muscle than expected – this will invert the inferior oblique muscle into an intorter and depressor’.

 

Dr. Simon Ko

Dr. Simon Ko would choose Inferior Transposition (Total / Half) of both left horizontal rectus muscles in order to improve the infraduction across the lower field and improve primary position alignment. The chance of anterior segment ischaemia in this young gentleman is relatively small. I would have carried out a surgery(s), despite not obtaining a good quality MRI, if I had no other alternative & would still go ahead. In response to ‘How he would Explain the below mentioned Phenomenon : After Transposition of the Inferior Oblique Eye Muscle, an Improvement was observed in Left Eye Inferior Gaze, while bearing in mind the fact that the Inferior Oblique Eye Muscle is Relaxed in Infraversion’ Dr. Ko replied ‘After Transposition of the Inferior Oblique Eye Muscle, an Improvement was observed in Left Eye Inferior Gaze, while bearing in mind the fact that the Inferior Oblique Eye Muscle is relaxed in Infraversion. After the IO transposition surgery, the SO is acting against a weakened IO in primary and adduction, the depressor effect of SO results in an improved infraduction and primary. In abduction, the improvement in depression is not seen. The antielevation effect of anterior transposition surgery has helped to keep the eye in a more aligned position in primary gaze and facilitate the depressor action of the SO’.

 

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