 Good morning everyone. Welcome to our subspecialty rounds. I feel like I sounded like a game show host almost That's the proverbial it's time to start tab So completely unrelated to Grand Rounds, but I hope you're all following this there. There is a new Jeopardy champion That is approaching our own Utah's Ken Jennings. So Ken Jennings made like 2.5 million or something on Jeopardy And this he's a his profession is a professional sports gambler, but he also knows a lot of trivia And he's got this really interesting approach to Jeopardy where he goes really big on these daily doubles So Ken Jennings average daily intake from Jeopardy was around 36,000 dollars and this guy his average is up around 70 And he's made certain certain when he's had wins over a hundred thousand dollars a couple of times So has nothing to do with our next speaker, but I wanted to really draw in your attention for dr. Dave David Dries It's always meaningful for me to introduce a former mentor someone who taught me in training and today is our pediatric subspecialty rounds and We are honored to have you and David and learn more about surgical approach to superior oblique causing If that is indeed what you're speaking on Thank you, Jeff. Well, if if you ask me questions at the end of this, I will not answer in the form of a question And in addition, I would appreciate 70 thousand dollars today at the end of the talk if anyone So yep, I'm David Dries and one of the pediatric ophthalmologists adults for vismasurgeons today I Do want to acknowledge a few individuals Griffin Georgine helped me with some great photos The entire staff in the pediatric ophthalmology clinic Extraordinary extraordinary technicians. We have a fantastic orthoptist Julie There are a few outside docs who've helped me with this talk as well and then also for Sophia fang our first pediatric ophthalmology fellow this lecture is for you actually because this is a Framework an intellectual construct to begin to think about how to operate on these patients with superior oblique paris is so these patients end up with Diplopia in three dimensions and Their deviation changes in different gaze positions So they might have vertical to pull up your primary gaze that worsens and down gaze So they're pretty tricky and we have to figure out how to help them One of my patients photoshopped this for me He had Diplopia torsional and vertical and down gaze had a lot of trouble going down the stairs so they really need help and if This entity presents as a congenital entity Torticulus results a compensatory head posture to get the eye straight and This ultimately results in facially symmetry neck aches headaches even arthritis into adulthood So what are our goals? well, we're trying to alleviate or maybe even eliminate Diplopia in an area centered in primary gaze and in down gaze to help with driving and reading gaze and This of course helps the compensatory head posture as well and With congenital superior oblique paris is our idiopathic Here's a key point if you operate for the vertical deviation if they have extortion and a v-pattern any horizontal misalignment the extortion horizontal misalignment tends to follow The muscle that you operate on for the vertical deviation, so that's kind of nice however on the other hand Patients with a neurologic or traumatic causes superior oblique paris is they often need their vertical deviation of course addressed but also Directly addressing surgery with additional muscles their extortion and their horizontal misalignment So Diplopia in three dimensions. This is an easy lots of questions How many muscles do you need to operate on one two or even three muscles and which muscles and why choose those muscles and What does a surgeon do with a lack superior oblique tendon or other congenital anomalies of the tendon like an absent tendon? or diaphanous tendon with an ectopic insertion and What if other muscles have been contracted look if you live with an eye up the inferior oblique the antagonist to the superior oblique will shorten and become contracted and The superior rectus can become short and contracted over time So those two muscles can undergo contraction and can need to be addressed surgically So it's fairly complex. So where do we start? Well, a good start is where the patient has hypertropia and where their hypertropia is the worst What we call a pattern of incomitance for those not familiar with that word. I'll be using it a lot Incomitance means a deviation of the eyes Changes in different gaze positions Look at this patient left hypertropion primary gaze and when she looks to the right you really see the left hypertropia And this is a typical finding in patients with superior oblique preces with contracture of the inferior oblique and Overaction of it. And if you thought well, I need to weaken that muscle. You've already cracked the code to much of this lecture You choose the muscles that match the pattern of vertical and competence is the first step in deciding what to do Let's look at these diagrams of the superior oblique and the superior rectus in the right eye We all know the superior bleak is a depressor It's an AB doctor and in torture in primary gaze What happens with the superior bleak when the eyes in adduction? Well, it's vertical action is much greater You can see that in this diagram in an ABduction. It's a much better in torture And its vertical action is reduced so with the superior bleak there's no question that You're going to Think about operating on the oblique muscles when you see more vertical deviation in the adduction Please look at the vertical rectus of the right eye The vertical rectus is mainly an elevator It also has other actions But let's concentrate in the vertical action when the eyes in adduction It's still mainly a vertically acting muscle when the eyes in ABduction. It's mainly a vertically acting muscle So what sort of pattern of vertical and competence would you think would match that muscle? Probably a vertical deviation. That's the same across the board in horizontal gaze deviations In the 20th century Napa Moore published the paradigm to begin to classify patients based on their presentation So these are the presentations that patients come in And what you're seeing with these grids is the strabismus exam that we all know from our charting And this is shown as a right superior oblique peresis So patients with a right hypertrophy and primary gaze that worsens across the board and opposite gaze and worse up and opposite Generally, they respond well to inferior oblique weakening surgery. That's class one Nat class two is patients who have a hypertrophy and primary gaze that worsens opposite gaze and worsens opposite and down gaze They respond well to superior oblique strengthening surgery the third class our Worse across the board opposite gaze up and down and as you'd expect oblique surgery is the way to go and Two more classes. I'll talk about our class four and class five And what makes these unique is a vertical deviation worse across the board in down gaze That's probably the most boring slide the lecture And also I I want to say this this is a long lecture with a lot of material So if you need a second cup of coffee go get it Let me talk about the action of the superior oblique to help you understand extortion and esotropia in down gaze That happens with these patients This is a little tricky these Diagrams I want to make it clear Here's the left eye in primary gaze and you're looking straight down the top of the eye And you can see that it's the superior bleak set a presser And here's the this dot represents the vertical axis of horizontal rotation The fibers of the superior bleak when they pull a force vector goes in this direction behind that axis and ab ducts the eye in addition The superior bleak in torts imagine a satchel axis right down the middle of the pupil down to the fovea When this tendon contracts, there's a force factor That causes the eye to in tort But what happens in down gaze Well, what happens in down gaze is that the muscle becomes stronger. It's pulling harder And so it's a better in torter and better ab duct or in down gaze But there's more going on than pulling harder in addition to that The position of the superior bleak tendon changes relative to the axes of rotation of the eye So here's the eye in down gaze, but we're really not looking down the top of the eye like where with this view So bear with me here This view is the eye in down gaze, but you are looking over the top of that eye Just like this diagram And look what happens to this axis of horizontal rotation The tendon shifts posterior to it making Contraction of the muscle at a force factor in this direction ab duct the eye better in down gaze compared to primary gaze And the same is true of torsion Look at the angle of the superior bleak tendon and the muscle An acute angle here in a more right angle here So it's a better in torter and down gaze with respect to the axis of torsional rotation So What happens in down gaze When the superior bleak is weak It doesn't in tort well. It doesn't ab duct well And so extortion worsens in down gaze here fundus photographs of patients with extortion This is in primary gaze. There's mild extortion here The phobia should be no lower than a horizontal midline at the inferior border of the nerve So it's a little bit of extortion here, but with the patient in down gaze you can see there's much worse extortion Because the superior bleak has a greater in torting the action in down gaze when it's weak extortion and here Look an esotropia. So these eyes are not ab ducting as well Make sense Well, let's go back to our starting point the nap classification in vertical deviations and in cometon's patterns So i'm going to go through a series of case presentations to illustrate How to choose which muscles This is a 30 year old professional violinist who plays the violin right-handed and tilts her head to the left And unfortunately she was in a car accident and she has duplopia when she plays her violin Here she has a hypertropium primary gaze. That's worse In opposite gaze and worse and opposite in up gaze Measuring 14 prison diapters with near fixation 18 with distance. You can see the measurements are worse Opposite gaze and opposite up She has mild extortion of about 78 degrees in primary gaze and in down gaze and some inferior bleak overaction So Inferior bleak weakening matches this pattern of vertical and cometons Because these patients as i mentioned have overaction and contracture of the inferior bleak Here is a diagram of the normal position of the inferior bleak muscle on a right eye And here's the left eye showing the recession of an inferior bleak And this is what the recession of the inferior bleak looks like with a surgical photo This is the Left eye here is a green hook on the inferior rectus And here is the disinserted tendon Of the inferior bleak that's recessed from this position To here with the anterior pole of the so-called park's point. It's a roughly 10 millimeter recession So how the patient do the compensatory had position improved Her hypertrophy improved and she it was intermittent. She could control it Her torsion was less the torsion followed along when we operated on the oblique and she's playing the violin better Doesn't tilt her head quite as far as she used to but now she can play more easily So inferior bleak weakening. This is a surgical tool in your toolbox. It's effect matches nap class 1 incompetence Well, it corrects up to 15 prism doctors, but not more in primary gaze and about 5 to 10 degrees of extortion This patient was a little bit under corrected and so you might want to ask the question Should we've done a second muscle? When do you do two muscles? Let me talk about a larger deviation in a 55 year old commercial truck driver with diplopia making driving difficult Look at his photo He has a left hypertrophy worsens In opposite gaze and especially opposite up. He measures 25 prism doctors in primary gaze would near and with distance fixation Larger than the violinist again worse opposite gaze worsen up inferior bleak overaction mild torsion compensatory head tilt And two muscles were chosen because as I said the inferior bleak gets you about 15 prism doctors in primary gaze But you got to get more and for him going to the opposite eye and doing an inferior rectus recession Helped him. He's driving again compensatory head position is improved He's fusing in primary gaze and in opposite gaze and look at the what we call the collapse of the incommittance pattern with him So the inferior bleak muscle has greater action over here inside gaze And so we're assessing it gave us an action in primary gaze and inside gaze And the inferior rectus gave us those extra prism diopters beyond 15 So the inferior bleak is you know inferior bleak weakening is probably the most common muscle that we do for superior bleak paresis and all Strobism as a very familiar and comfortable with it because we do it in children for inferior bleak overaction And so it's tempting to go to that muscle as your fall black plan But there is a situation where it's not the best choice and that's a patient who has hypertrophy And exit torsion in down gaze it does not correct hypertrophy and torsion down gaze well So, uh, it should I think Probably should be avoided for those patients Here's an example of exactly that situation of patient referred from an outside physician This patient had a left superior bleak paresis Uh, a left inferior oblique was done and probably a superior bleak talk would have been a better choice as we shall see In the next case presentation But in any case he presented to me with a small hypertrophy in primary gaze A bit worse in opposite gaze and much worse in down gaze across the board and you can see he really has Uh deficit of depression Across the board here in the left eye and those torsion was gone He probably had extortion prior to the inferior bleak surgery His torsion was pretty much gone and that's that's a nice thing because it made the choice of surgery fairly simple for him What muscle would you do for a deviation that's the same across the board and side gazes? A vertical rectus, so he had the contralateral inferior rectus recessed And indeed had a procedure called a combined recession resection To get even more effect in down gaze don't have time to go into that But if you want to learn about it come ask me later And with this procedure he did really nicely look at these pre-op photos look he has this depression deficit Pre-operatively but post-operatively It's much better and his hypertrophy is actually measuring a little bit bigger, but he controls it And I think that's because I missed that he had large vertical fusional amplitudes at his pre-operative exam But in any case his diplopia is much better But if the inferior bleak is not the down gaze muscle, which one is? Well, I like superior bleak talk for these nap class 2 patients Again, these are uh patients hypertrophy in primary gaze worse In opposite gaze worse and down with diplopia These are patients that do not recover superior bleak function. Well, they tend to indeed have torsional diplopia And uh and it worsens in down gaze. They tend to be from traumatic or neurologic causes So let me talk about an engineer 55 year old male His diplopia began intermittently in down gaze and slowly over time The gaze position of his diplopia crept all the way up to the horizontal midline and that's when he came in Turned out he had a pre-pontine sister and fourth cranial nurse swanoma Thank you, neurophthalmology And here's an MRI showing atrophy of the belly of the superior bleak on the left compared to the right So the superior bleak talk, what is it? Well, we make an incision and isolate the tendon of the superior bleak and lift it up And put suture across the anterior and posterior sides of the tendon Shortening it putting a tuck in it Here it is with the suture here and here and here's the tuck laying on the side of the eye Here's the engineer's exam hypertropian primary gaze worse across the board worse in down gaze A bit uh not a huge amount of torsion three degrees in primary worse in down gaze with a compensatory head posture Here's his pre-op exam as his depression deficit here here And at deviation, it's worse in side gaze. Here's a surgical photo of a tuck You're looking at the right eye This is the superior oblique tendon insertion and that goes up over the hook and back down under the superior rectus And you can see two merciless sutures creating the tuck in that tendon 48 hours later. He's got a little bit of brown syndrome. He's a little over corrected. That's exactly where we want him to be just a little over corrected early And uh look at his incompetence pattern the worst hypertropian down gaze. That's collapsed So it's great news that muscle works for worse Hypertropian down gaze here is seven months post-op fusing in pretty much all gaze positions and he's working again So the superior oblique tuck another tool in your surgery surgical toolbox Uh, it's for class two patients who have a deviation greater in down gaze It cracks up to 15 prison interpreters in primary gaze of hypertropia more in down gaze And corrects 10 uh five to 10 of extortion in primary gaze and more in down gaze Now the superior oblique Talk is a little bit scary for some surgeons and I I understand that it's not a forgiving muscle You can't go back and re-operate on the superior oblique muscle in general very well and the outcomes aren't as good So there's a little bit of fear in addition inducing brown syndrome Who wants to induce brown syndrome in their patient if they have to plug in up gaze? Of course, you wouldn't want to so there's worry about that as well so um And then there are also patients who you cannot do a tuck. They've already had a tuck Uh or for other reasons you can't do a tuck and and so there is another alternative to the tuck that you can uh go to another tool in the surgical toolbox and that's um A contralateral inferior rectus recession Now if you do that alone, you'll get the hypertropian primary gaze and in down gaze But this doesn't correct extortion well So what could correct extortion? Well, there's another procedure to correct extortion on the same eye as the priestess A nasal transposition of the inferior rectus can help So here's the right eye and if you move the inferior rectus nasally it in towards the eye correcting extortion So doing those two muscles together Can be uh effective and here's an example a 56 year old woman had bilateral hemorrhagic thalamic stroke And diplopia with perinald syndrome and a left superior bleak paresis She has her hypertropian primary gaze at worsens an opposite gaze and worse opposite and down gaze She had a large degree of extortion. So this did definitely need to be addressed surgically And uh, you know, uh a tentative plan of a talk would have been nice, but in the operating room as it turned out The inferior rectus was restricted and had to be recessed And so that procedure had to be done. I knew it had to be done I knew it would correct the hypertropian primary gaze and the hypertropial worse and down gaze. But what about the torsion? Well, she had a nasal transposition of the inferior rectus Which Intorted the left eye and corrected extortion And here she is immediately postoperatively 48 hours later a little bit over corrected in primary gaze a collapse of the incommotence pattern no torsion Looking good there and then much later. She's fusing She's fusing in all gaze positions except down gaze for television when she's laying in bed But the nine months later, uh, that was even better as well. So here, uh, so fee in particular is your go-to plan If you can't do a superior bleak talk for these patients Let's stick with the nap classification. Let's talk about three kind of a straightforward one Again hypertropian primary gaze worse and opposite gaze and worse up and down opposite gaze This patient 12 prism doctors and primary gaze worsens to 20 18 up 18 down Mile degrees of x-cycle torsion What surgery would be best for that increased deviation in opposite gaze the oblique muscles? And he had an inferior oblique recession and ended up in ortho in these gaze positions with a nice result Now is anyone tired of the nap classification? I know I am let's let's let's get away from that for a little bit Let's just talk about something more interesting to me anyway Maybe to you too and that's superior bleak tendon laxity. So these are in uh patients who present As toddlers or infants with a head tilt They have a very long they have a question that yeah That are these generally pretty stable long term? I mean once you get them corrected with these do they generally hold it at a pretty stable level or or do you Often see that they then start regressing back because of the muscle They tend to stay stable unless there's a neurologic, uh issue that's progressive Like a fourth nerve schwannoma Or if they're surgical issues like a slowly slipping muscle, that's had a recession And then there are others where I can't explain their recurrence In the long term but in the short term Not getting their full db corrected. They did but they tend to be stable long. Yeah, they tend to They tend to so back to the infants Here's the main point with these lax tendons talk the tendon and infants and you get the best outcome The best outcome being resolution of the torticolas. That's the main point And uh facially symmetry results in the long term if it goes uncorrected Here's a case. This is a two-year-old. I don't have clinical photos, but her mom very kindly supplied me with a few So here they are backpacking. I know this is hard to see But with the left head tilt, there's a left hypertrophy in that baby Which was somewhat measurable. This is a guesstimate A bit worse and opposite gaze worse with tilt. I thought a superiorly presis given this Right head tilt the compensatory right head tilt and this is what the tendon looked like in the operating room Again, this is the insertion of the superior bleak tendon goes way up high. This is probably 14 maybe 10 to 15 millimeters from here to here. That's a very lax tendon and uh So you you might ask the question. How do we know it's lax for sure? You know, do we have to explore it to find out and the answer is no David Geiden developed what's called exaggerated for induction testing to try to determine if there's a lax superior bleak tendon And let me show you what that looks like You grasp the eye the limbis place the eye and adduction and elevation Which puts the superior bleak tendon on stretch? And then rock the eye back and forth and as you rock the eye back and forth you can feel the tendon Go over the top of the curve of the globe kind of life on knife edge click click click And if that isn't present that's a lax tendon and Let me show you I want to show you a video here No, I tested this last night and I tested it this morning. So it doesn't work You know how it is with video so here's Exaggerated for suction in a normal eye and I don't know if you can tell but it actually gives a little and goes back and forth One other thing I like to do is check torsion that's extortion of the eye taking it into an extorted position And I want to show that again Here's the exaggerated for stuctions rock back and forward Ding ding ding is the tendon goes over the top of the eye and then you can check torsion Grab the eye at three nine o'clock Extort the eye and the excursion here is about a clock hour a clock hour and a half So that's a normal eye Well, what does it look like when the tendons last? This is exaggerated for stuctions way up. See how the eye is going way too far Two plus ten and like really can't feel much of that tendon going back and forth across the eye Watch the torsion. There's about a two to three millimeter clock hour excursion of the eye So even before we make an incision and explore that tendon six o'clock we have a really important clue that it's nice So here's what the tuck on that patient look like you've seen this from previous slide Suture creates the tuck. Here's what it looks like laying down on the eye And let me show you the end point of the tuck. Remember I said the tuck produces brown syndrome But we want brown syndrome. We want Just the right amount Which is our joke and strabismus surgery. How much did you do doctor? Just the right amount? and uh So just the right amount is you be you take the eye into adduction and then elevate it in adduction And when you feel resistance as the inferior limbis crosses A line between the medial lateral canthus you just feel it then you know, okay, you got the right tuck And this is what it looks like and also this video shows some extortion You'll see the extortion is less than one clock hour. It's like dunk dunk with the extortion but first the First the this is after it. There's the eye. Here's the brown syndrome The horizontal just showing that horizontal line between the canthus So placing the eye in adduction is right here when this crosses the right amount horizontal midline And here's the torsion and then exaggerated forced action. Watch you only goes about a clock. Oh, sorry Here's exaggerated for instructions. Remember And now it's tight. Here's the torsion. Don't don't put a clock on a really tight stop there So that's the end point And so how this patient do here's the pre-op head position Here's the post-op head position with no deviation in primary gaze So this works really nicely for infants with a lax tendon So the superior oblique tuck. What are the indications for the superior oblique tuck number number one Almost all infants with certainly with a lax tendon deserve a talk. They do better It's it's known. It's in the literature inferior oblique recession is not the first choice for these Patients and then adults with hypertrophy are greater in down gaze than nap class two Especially when they have extortion that's worse in down gaze as well All right Now it's time for the second cup of coffee I've got to bolster my energy a little myself Because there's a lot more coming and I got to get through this um How many muscles one muscle two muscles three muscles are there patients who even need three And the answer is yes, there are and let's talk about them And I'm going to give a cautionary note about the superior oblique tuck Illustrated by the next case and the cautionary note is Don't do a tuck if there's already been an inferior oblique recession If you do that combined procedure at the same time or do it sequentially You'll probably end up with brown syndrome and that's what the first case demonstrates So let's talk about that now So this is a child with a lax tendon Look at the size of this deviation 30 prison diopters in primary gaze worsens Large amount of incompetence 45 prison doctors 50 up and across 40 fight down Large amount of inferior oblique overaction large amount of underaction of the superior oblique big compensatory head tilt and You know, it's really tempting when you see this incompetence pattern to say wow Maybe I should operate on both obliques on the eye with the priestess to talk on the superior oblique and an inferior oblique recession Really tempting, you know, it's going to help and indeed that's what I did in this patient and They hear here surgical photos at the inferior oblique recession and the talk And it really is oh, thank you I'll kind of be better than $70,000 right there um So, um, so this patient did have superior oblique tendon laxie and I did do a combined talk in an inferior oblique recession and It worked brilliantly initially With a great reduction of the hypertrophy and primary gaze Collapse of the incompetence pattern although it was still greater across here and look there's still this down gaze deviation So even those two muscles that very powerful combined talk Infra oblique recession Didn't get this deviation and there was still a head tilt And so I went ahead and did muscle number three a contralateral inferior erectus recession and good Position in primary gaze collapse of the incompetence pattern. I was very happy about that better in down gaze and again, unfortunately, I couldn't get this Measure because kids sometimes are kids my toys get boring But the real point and look at her here pretty good alignment in primary gaze and side gazes looking good down gaze looking good But looking up gaze This is pretty bad brown syndrome that eye doesn't go up in primary gaze It doesn't go up in abduction doesn't go up in adduction And there's a reversal in the hyper primary primary gaze and I think as a as a lifetime Of diplopia looking up. That's a pretty high cost to pay Uh to get this other effect from the combined oblique surgery Um, so that's a pretty challenging case big deviation three muscles. Can you get more complex? Well, I can Let's let's make it even more complex to talk about a grandma for uh, those who recall From the past when I presented I presented this before but this is a really nice example of very complex deviations of superior oblique precess Where we really need to break down the deviation into three components Well, let me tell her story and then we'll get to the exam and break it down into those three components So she's 44 year old lady in 1995. She was 44 And she had a large angle 35 prism top your hypertrophy worse opposite With inferior oblique overaction and that was the extent of the documentation I could find Her surgery was a very large superior oblique tuck Mark tendon laxity was noted in that satisfactory brown syndrome that I talked about Was noted in the surgical record Four months later back in 1995. She was under corrected, but she didn't want additional surgery And then way later in 2013 18 years later. She presented to me She'd been living with the plopia and ignoring one image for 18 years and living with the psychosocial impact of strabismus for a long time And she had a really fairly complex complex deviation. So what do you do with these? They're they're a little overwhelming But let's break it down into three components the first one you know Well, and that's the pattern of vertical and combatants So she had a left hypertrophy and primary gaze that's worse in opposite gaze worse up and down So the nap class three. So, you know, you're looking towards an oblique muscle probably an inferior oblique recession The uh Large extortion that she has 15 degrees at near and in down gaze that needs to be addressed directly with surgery because it's so large She had a v pattern esotropia 30 prism doctors of esotropia and primary gaze increased to 30 and down 18 and up gaze and so Break it down into those three components and The surgical choice becomes more clear an inferior oblique recession I broke my rule about combining the talk and inferior oblique recession with this patient Um Herata, ito procedure will correct extortion for those who don't know what's a herata ito. Let me explain that This is the right eye of a patient. Here's the superior oblique tendon And we want to create extra in torsion to correct the extortion in the patient So we split the tendon into two halves take the anterior half Disinsert it from the eye and then sew it in a position Where it's transposed anteriorly and temporally on the eye giving it a better mechanical advantage Uh for in torsion And then finally for her esotropia with the v pattern a bilateral medial rectus recession with one half tendon with Infor placement remember for the residents and so feel a little the acronym male medials to the apex laterals to the empty space So she had a v pattern the apex so the medials go down Now that'll correct her v pattern esotropia But transposing Recti causes torsion and you know that because I showed you how to correct extortion in a patient by a nasal transposition of the inferior rectus, right? Well, when you inferiorly transpose the medials you cause extortion And she had a lot in the first place and that's why she needed this herata ito. So she That that inferior transposition is going to create even more torsion That she had in the first place So her surgery was an inferior bleak recession the herata ito four millimeter Meteorectus recession with inferior tendon transposition here. She is postoperatively. She still has a hypertropia Uh, but her torsion is gone the esotropia is gone the v pattern is gone Incomotence is gone. So we're feeling pretty good and she confused with prism So I offered her one more surgery Which was an inferior rectus recession on the contralateral eye and after that surgery she was fusing And uh, you know a happy camper that heard the plopio was gone and she had normal appearance So with these large angle, uh, very complex deviations you have to break it down into those three components If you know the tools in your surgical toolbox, which you which you know What each muscle surgery does you can mat you can combine those different tools Once you break down complex deviations into different components And uh, I guess the other thing is don't don't give up on adults after 18 years. She fused so you know adults They they deserve an evaluation. Um, let me talk about okay. Let me, um Jump into what I call the curve balls of superior bleak precess and we're getting there now We're getting there Here's an anomalous tendon. This is a 39 year old female triathlete. Look at this So this is um, the left eye the surgical photo The superior rectus has been disinserted and it's fallen back underneath the conjugal. You can't see it These two four steps are on the insertion of the superior rectus This is the superior bleak tendon. Here's the anterior insertion of the superior bleak, which is in an ectopic position. It's about Two three millimeters posterior to the insertion of the superior rectus And then the posterior tendon was just diaphanous. There was no tendon there that you pull on it And it was just stretchy. It was there was no tendon tissue in there. And so Her her exam too is confusing keep in mind I didn't have the benefit of looking at that photo when I saw her in the clinic and her exam was a bit confusing She had a a deviation a hypertrophy that was worse in side gaze and worse with tilt But it was worse in up gaze and she had no torsion So she didn't really fit the three-step testing But I thought she probably had a superior bleak precess wasn't sure My tentative plan was to do a superior rectus recession Mainly because she had this across the board deviation again the vertical recti or for across the board and so she had that And did really nicely She's fusing in primary gaze down gaze and in up gaze and she actually had a large Compensatory head tilt that was much better after surgery and her diplopia was better as well Okay Two more cases to illustrate the nap class four and five. These are the patients with the deviation worse in down gaze Now these are these are very common. I've only seen about three in 22 years And you know when you look at these patterns you you what jumps out at you is oh do an inferior rectus recession on these patients That corrects the deviation in primary gaze and it helps so the deviation worse in down gaze But there's one little caveat Remember early in the lecture. I said the superior rectus can become contractured and shortened and restricted Well that rarely can cause a greater deviation in down gaze and To teach this let me talk about uh graves disease So we all are comfortable and know about graves disease And if you have unilateral inferior rectus restriction from grazed disease You have a hypotropic in primary gaze and it worsens in up gaze Right Well, this entity was superior rectus restriction is just upside down grazed disease Does that make sense? And so if there is contracture of the superior rectus then operating on the inferior rectus probably won't get the deviation in down gaze But let me let me talk about an example of a patient with a Knapp class 4 deviation. You know this man. He had a Left inferior rectus. I'm sorry left inferior bleak recession and referred in And he had this down gaze deficiency the same across the board And he did not have contracture of a superior rectus when it was checked in the operating room So he underwent an inferior rectus procedure And as you know, he had this nice outcome with his depression deficit improved This patient is an elderly patient. She had nap class 5. She's very interesting to me because this is a long-standing deviation I mean 40 years. I think she had this superior bleak paresis and She only meets two steps of the three-step parks fischelsky head tilt test where her Hypertropia is in primary gaze. It's a little better in opposite gaze. It's a little worse in ipsilateral gaze Uh, and it's worse with the tilt and she had extortion And uh, I wasn't sure she had a superior bleak paresis But I thought that's probably what was going on with superior rectus restriction And here's the clue in the exam the clue in the exam that there's superior rectus restriction Is that there's a hypertropia ipsilateral to the site of the paresis, which we usually don't see these patients In the operating room the superior rectus was restricted with forced suction testing And she underwent a small right superior bleak talk to help her with her down gaze Deviation and a superior rectus recession to help with the restriction and her deviation improved across the board Uh, in primary gaze and improved in down gaze across the board so That's the story with nap 4 and 5 in Infure rectus recession generally is a part of the surgery but sometimes they have contract for the superior rectus Okay, so let me sum up quickly The surgical options are an infure bleak recession Gets up to 15 prism doctors and small amounts of torsion matches in combatants. That's worse inside opposite Uh side gaze opposite the palsy the talk matches Class 2 well up to 15 prism doctors in primary gaze and more in down gaze Corrects torsion while in primary gaze and even more torsion at down gaze But there's a caution about a simultaneous superior bleak talk an inferior oblique recession Next surgical tool contralateral inferior rectus recession Gets a deviation across the board in primary gaze and more in down gaze, but it doesn't correct extortion well So what can we do a nasal transposition of the inferior rectus to correct extortion? Also, the herata edo helps correct extortion with transposition of the superior oblique tendon fibers Uh a superior rectus recession in our triathlete with the ectopic tendon worked well because the deviation was about the same Or maybe a little worse in up gaze and that needs to be done If there is superior rectus contracture in very long standing nap 4 and 5 patients V pattern pretty familiar to everyone media rectus recession with infratenant transposition And so in summary As you can tell these patients have you know pleomorphic presentations and you need to sort them out If there are complex deviations break it down into those three components And then look at your surgical toolbox and look what the tools do and match the tools to the presentation in front of you Uh more than one muscle for greater than 15 prison doctors, maybe three if over 30 Um inferior oblique recession is usually not the procedure for down gaze deviations An extortion more than 10 degrees generally needs to be addressed surgically especially in patients with traumatic or neurologic causes Tuck the infants in most cases don't give up on adults. They confuse Be ready for the curve balls with the surgical plan in case you need it That's different and be aware of the rare superior rectus restriction And i'm finally done after a very long talk. Thank you for uh listening through it This is my happy place playing hockey with my songs So i'll stop there and take any questions if you have