 Can everyone hear me okay? Okay? Good morning. Thank you to Jeff Petty for organizing this and devoting a whole Grand Rounds to Pete. It's wonderful. Also, thank you of course to Bob and Randy for making it all possible. Hopefully, I'll be able to figure out how to get my presentation going here. Yeah, any residents or fellows feel free to help the man the man. A partner, Rama Supermanian is the name of the last presenter and I suspect you're going to be hearing that name a lot more in the coming decades. I think she'll be compared to Carol Shields one day. Unfortunately, she's leaving us for love because her husband is taking her with him wherever they end up and I wish her the best along. So we're going to switch gears a bit. To Strabismus and the patient I'm going to talk about I'm presenting for many reasons, many teaching points, teaching points for medical students, residents, fellows, teaching points for faculty and teaching points for general ophthalmologists. The patient was initially seen by Bob Hoffman many years ago. This patient has a lifelong condition that started during childhood and the first thing I'd like to touch on is just diagnosis. I don't have all photos in all gaze positions, but a few and you'll see here the measurements that were done on this adult back in 1995. Because I saw the patient up at the Layton Satellite Clinic and not here I don't have Strabismus photos of this particular patient and so these measurements are larger than what you see in the patient, but the photos do demonstrate some of the findings well enough that I included them. So any of the residents or fellows want to take a stab at a diagnosis based on the Strabismus exam? Anyone? Anyone? So Brian Stagg is not here and I would pick on him because he's on peeds. So this patient is a 35 prism doctor, left hypertropion primary gaze, quite large. It increases in right gaze and it increases with left tilt. And if you look at the photo here, there's a finding that is helpful to make the diagnosis. Sure, go ahead, way in the back. Yeah, that's that's what the patient has. So this patient had Strabismus since childhood and went unoperated during childhood and only during adulthood did the patient seek out care. So this exam is consistent with the unilateral superior bleak parisus and notice that the deviation is larger in right gaze, larger right and down and quite large in down gaze. So with a 44-year-old adult who's had lifelong Strabismus for the residents, are there any concerns about a neuroephthalmic problem? Do you have any concerns about additional testing or is the history sufficient to say that there's no underlying neurologic cause of the fourth nerve? Parisus. Yeah. Yeah, absolutely. And also looking for neuroephthalmic signs on the exams such as nystagmus, optic atrophy, taking a decent review of systems, looking for neurologic symptoms. Well, that's reassuring enough that I definitely do not evaluate these patients further. So moving on up higher up in the educational hierarchy for the pediatric ophthalmologist, any faculty, this is, this photo is not the patient. So he's fusing with a head tilt and he's a surgical candidate, but our patient actually has constant tuplopia and has had constant tuplopia for many, many years and any ideas on treatment here? Would prism work? Eye muscle surgery? No. I hear no. Prism will not be helpful for that sort of deviation and prism also in large torsional deviations is not helpful. Prism can't help torsion. So this is a surgical candidate. So any ideas for surgery? What surgeries would be considered? Any testing intraoperatively that might be helpful? Especially in a patient with a congenital fourth cranial nerve, briscus? Anyone want to comment? And these, this isn't the patient unfortunately, but I'll tell you these versions are the patient. So it looks similar to him. Right. Absolutely. Anyone else want to comment? Okay. So Dr. Bob took the patient in the operating room and did four-stuction testing of the superior oblique. Now the superior oblique can be quite lax physically, especially with congenital superior oblique peresis. And these children tend to have very large head tilts and they tend to be a bit troublesome in treatment simply because they often need multiple surgeries in the end. But you don't know up front if they're going to need multiple surgeries, multiple muscles. When you find a very lax superior oblique tendon, it can even be absent where there's no superior oblique. So with the finding of laxity, you have to explore the tendon. And when Bob did that, he found a tendon, but it was very, very thin, very lax and did a huge tuck. 20 millimeters is a very large tuck for the superior oblique. And that was the right thing to do. What we shoot for is shortening the superior oblique tendon with a tuck, such that with four-stuction testing, the eye starts to have resistance to elevation and adduction as the inferior limbis crosses the horizontal midline between the canthi. And the patient did well, had a nice response to surgery. 20 prismed after left hypertropia in primary gaze, 25 here. And in parentheses is the number of prismed diopters of correction that this huge tuck achieved. So again, you can't predict how much of the ocular deviation you'll get from a tuck. And so additional surgery was offered to the patient. And at that point she declined additional surgery and did not come back for follow-up. And then this, again, look, this is 1995. So she lived about 19 years. And then I saw her up at the Layton Clinic. And this is the exam at that point. She's lived with Diplopia, ignored one image and had an abnormal appearance and has put up with that. But she's interested in improvement. So now what to do? So now you can see she still has a hypertropia, but because she hasn't been fusing, fusing she started to develop an esotropia. And there is still incommittance to the hypertropia. And there's a v-pattern to the esotropia, a v-pattern to the horizontal deviation. And she has a large amount of x-cycle torsion. Now I'm pointing out all those findings to give you an idea of how challenging it is to do surgery for cyclovertical strabismus. So we have to think in three dimensions in different gaze positions, not just primary gaze. So it's pretty tricky to do, to plan. Here's a funnest photograph of x-cycle torsion in the left eye that was present. And you can measure that with double med-x rod testing, bagolini lenses, but frankly, you can just ask the patient, how much does your second image tilt? And you really get a sense of how much torsion they have. So at this point, she wants more help and she's a surgical patient. This is a challenge. She has ran and she's ignored her Diplopia and just kind of lived with it. She's a very shy lady, and she just decided not to pursue more. And since you asked that question, Randy, one of the teaching points is here is don't give up, don't give up on the adults with strabismus. Encourage them to seek out care because there's a happy ending at the end of this case. And so for the strabismus gurus, any thoughts on this complex case, what you would consider doing? Now for sure I'd go after that oblique because you've got a v-pattern and you've got a... Right. So just to share with you my surgical decision making for complex cyclovertical strabismus, the way I view it is I try to treat each of the three dimensions one step at a time with the hope that the treatment for the deviation in one dimension doesn't disturb it in another. Just to be clear, there's a vertical deviation and it's incommitant. Okay. So there's a vertical deviation in primary gaze that increases in right gaze and there's still overaction of the inferior oblique. So one principle of strabismus surgery is if you have vertical incommitance and overaction and underaction of the oblique muscles, the oblique muscles need to be addressed surgically in order to get that incommitance. So that's the first thing. And in this patient, I thought an inferior oblique recession would be the best way to go. Nicely, that has... that hits another one of my goals, torsion, that helps with excicletorsion. And you can expect to achieve anywhere from three to maybe eight degrees of excicletorsion with an inferior oblique recession. So we're making progress. You know, we're making progress there. So the next goal, the next dimension, if you will, is the horizontal deviation. And it also is incommitant because there's a v-pattern. So there's an esotropium primary gaze that increases in down gaze. And so, of course, we have to address the esotropium primary gaze. But if we don't do something for that v-pattern as well, there'll be diplopia in down gaze, even though you have treated the horizontal deviation in primary gaze. And the inferior oblique recession actually is a three-four, a three-four. It'll help you with a v-pattern too, but maybe not enough in this case. And so one of... for v-patterns, operating on oblique muscles can be helpful, but also transposing horizontal recti can be helpful. So I thought doing a recession of a meteor recti with an inferior transposition would help. And for the residents, remember the acronym male, medials to the apex, laterals to the empty space for patterns. One of the troubles though, and this is where it gets a little sticky, is that if you transpose recti, you can induce torsion. And indeed, if you inferiorly transpose the meteor recti, in this case, you'll likely worsen the x-cycletorgen. So to get the pattern, the v-pattern treated with the transposition, the x-cycletorgen can be worsened. And so I decided, because of that, as well as having 15 degrees of x-cycletorgen, that a procedure that specifically addresses torsion would be needed, the surgery called the Herata Edo on her opposite eye. So those are my thoughts. And in the operating room, she no longer had superior oblique tendon laxity. That was very well treated. She also had no restriction of her superior rectus or inferior rectus in the hypertropic eye for the superior rectus and the hypotropic eye for the inferior rectus. Over time, over decades, in fact, with a large vertical deviation, muscles shorten. And that may need to be addressed, but as it turned out, they weren't restricted in her. So that didn't need to be addressed. And finally, that's another little pearl about stirbismus surgery. Muscles can become restricted over time with constant deviations over decades. And if you don't address that, you won't get success. So that wasn't there. So I stuck with the original plan, 10 millimeter inferior oblique recession, a four millimeter meteor rectus recession, both sides with one half tendon with infraplacement. I did a right superior oblique Herata Edo, just to be specific with the Fells modification, because Herata Edo isn't exactly what I did. Fells modified this procedure, I don't know, 30 years ago, 25 years ago. But it amounts to taking one half to one quarter of the superior oblique tendon, and moving it from the back of the eye to the front of the eye, making it a better in-torter. And so she did pretty well with that. And don't let this messy slide confuse you. Let me just stick right to this number. So her hypertropia was about the same, but it was now comatent, the incompetence was treated. Her V pattern was gone and her horizontal deviation was gone, and her x-cycle adortion was down to four degrees. And she confused this with vertical prism. And at that point, I wanted to have a parade in fireworks because it's torsion, vitreous seeds of the enemy in retinoblastoma, torsion is the enemy in complex cycle of vertical strabismus. So if you can get torsion, then you're 90% of the way. So she couldn't fuse. She still had her hypertropia, but she could see big improvement. She started to get more excited, and she said, well, what's next step? And I offered her prism. And I said, but additional surgery is a possibility. And so I offered her that. Any thoughts on the next procedure for a comatent hypertropia in a patient who's had the previous surgeries? The previously recessed one on the right inferior. Well, that is what she had on an adjustable suture. And the first day after surgery, she was starting to fuse. She still had her hypertropia most of the time, but she was starting to fuse. And what was really nice is it was comatent across the board. Her horizontal was gone. And she could control the sex cycle torsion herself with fusion. So super happy. And then months later, she came back and she was fusing in all gaze positions. And then I did have a parade in fireworks. I was so happy. So I guess the teaching points are diagnosis for the resonance, no three-step testing, know how to diagnose a unilateral spirally peresis, know that if it's congenital, it's been present for a lifetime, and an otherwise completely healthy patient on whose review assistance is negative, that you don't have to scan them. You don't have to worry about neuroephthalmic problem. For the strabismus surgeons in the room, you have to think about all three dimensions, horizontal, vertical, torsional deviations, and thank goodness we don't have a fourth dimension. And I'll stop there. Any questions? Yeah, four-stuction testing in the operating room. And over the years, I've become way more picky about the technique for four-structions too. I didn't touch on that earlier, but I'll touch on it real quickly. So in order to make sure that you're doing proper four-structions for recti, both vertical and horizontal, you really need to grasp the globe in two places. For example, for the vertical recti, you need to elevate and depress the eye. But I like to put the four sets at three and nine o'clock and make sure the globe isn't depressed into the orbit. You can't push the globe in or you'll put slack on those muscles, right? And so I make sure the globe is elevated just slightly, and then I do my four-structions. And then for the obliques, the opposite is true. To put the obliques on taut stretch, you have to retro pulse the globe slightly, for example, for the superior bleak, and then x-cycle toward the eye. And that puts the tendon on stretch, and you can feel the restriction far better. So just a few tips for four-structions. Other questions?