Effect of aging on human rectus extraocular muscle paths demonstrated by magnetic resonance imaging

Clark, Robert A.; Demer, Joseph L.

doi:10.1016/s0002-9394(02)01695-1

Cited by 112 publications

(95 citation statements)

References 9 publications

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“…8,22,23 The procedures reported have included suture anastomosis of the LR and superior rectus (SR) muscle margins approximately 10 mm posterior to their insertion, with superior transposition of the LR muscle insertion; 8 suture anastomosis of the margins of the LR and SR pulleys; 8 loop myopexy approximating the LR and SR muscles without splitting with MR recession or scleral fixation; 10,24 union of the LR and SR bellies after splitting these Adjustable LR resection has been reported effective in DPE, without causing consecutive exotropia at near. 5,11 Though not specifically reported for DPE associated with connective tissue degeneration in elderly individuals, MR recession has been reported to be as effective as LR resection for correcting distance ET.…”

Section: Commentmentioning

confidence: 99%

“…8,22,23 The procedures reported have included suture anastomosis of the LR and superior rectus (SR) muscle margins approximately 10 mm posterior to their insertion, with superior transposition of the LR muscle insertion; 8 suture anastomosis of the margins of the LR and SR pulleys; 8 loop myopexy approximating the LR and SR muscles without splitting with MR recession or scleral fixation; 10,24 union of the LR and SR bellies after splitting these muscles longitudinally, combined with MR recession; 12 MR recession and LR resection in 1 eye; 25 and LR resections. 5,9,11 These complex procedures are not required to treat DPE.…”

Section: Commentmentioning

confidence: 99%

“…Analysis of extraocular muscles by high-resolution orbital magnetic resonance imaging in sagging eye syndrome and heavy eye syndrome has suggested that inferior LR pulley heterotopia is the cause of the inferior LR sag in DPE. 8,17,22,30 Sagging eye syndrome is probably the most common etiology of surgically correctable DPE. Serious neurologic causes of DPE are associated with other neurologic manifestations, including abducting saccade slowing, nystagmus, and associated cranial neuropathies.…”

Section: Commentmentioning

confidence: 99%

“…19 The reason for the greater required MR recession for correction of DPE than other forms of ET is unknown at the present time but might be related to the sag of the MR pulley in older people who are susceptible to connective tissue degeneration. 22 However, this does not explain why DPE responds in a quantitatively typical fashion to doses of LR resection recommended for ET generally.This report presents stringent criteria for clinically defining DPE based on a 17-year retrospective study. It is proposed that the term DPE is a misnomer and is actually owing to degenerative inferior sag of the LR muscle that converts some of its abducting to infraducting force, perhaps in combination with LR elongation.…”

mentioning

confidence: 97%

“…Moreover, MR recession is reversible and convenient for intraoperative adjustment under topical anesthesia, and it is as effective as LR resection, both in this series and elsewhere. 5,11 In DPE, where degeneration of the suspensory ligaments of the LR pulley is the probable cause of LR sag, 8,20,[22][23][24] it is arguably preferable to avoid inducing further sag, and perhaps future recurrence of DPE, by operating on the affected LR muscle. …”

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confidence: 99%

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Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia

Zia¹,

Demer²

2012

Journal of American Association for Pediatric Ophthalmology and

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Objective-To propose medial rectus (MR) recession to be equally as effective as lateral rectus (LR) resection, which has heretofore been the preferred treatment for divergence paralysis esotropia (DPE).Methods-We examined a 17-year surgical experience comparing LR resection with MR recession in adults with DPE, defined as symptomatic distance esotropia (ET) at least double the asymptomatic ET of 10 or less prism diopters (Δ) at near.Results-Twenty-four patients with DPE underwent surgery. Six patients underwent bilateral LR resection and 2 underwent unilateral LR resection (group L), while 13 underwent bilateral MR recession and 3 underwent unilateral MR recession, with the target angle double the distance ET (group M). One of 8 patients in group L and 15 of 16 patients in group M underwent intraoperative adjustable surgery under topical anesthesia. Mean (SD) preoperative central gaze ET measured 15.0 (7.7) Δ at distance and 4.1 (3.4) Δ at near in group L, but 10.4 (6.8) Δ at distance and 0.6 (1.7) Δ at near in group M (P=.15; distance, 0.003, near). Postoperatively, no patient in either group had symptomatic diplopia or convergence insufficiency in follow-up from 8.5 to 40 months. Twice the usual surgical dose of MR recession per prism diopter was required to achieve correction of the distance deviation in DPE as compared with that recommended for ET generally and also for LR resection in the same condition.Conclusions-Recession of the MR provides binocular single vision in DPE without convergence insufficiency at near, and it is convenient for intraoperative adjustment under topical anesthesia.Divergence paralysis esotropia (DPE)-variably termed divergence insufficiency, divergence insufficiency esotropia, and divergence paresis esotropia-is characterized by comitant esotropia (ET) at distance fixation associated with symptomatic diplopia, fusion at near fixation, and normal saccadic velocities in adduction and abduction. As the name implies, early thinking about DPE was dominated by the presumed pathophysiological concept of a brain lesion involving a putative divergence center. 1,2 Indeed, isolated clinical reports have associated DPE with neurologic conditions such as brain tumors, multiple sclerosis, trauma, subdural hematoma, and tertiary syphilis. [2][3][4][5] Even postulated as a cause of DPE was increased medial rectus (MR) muscle tonicity as a compensatory mechanism for © 2012 American Medical Association Correspondence: Joseph L. Demer, MD, PhD, Jules Stein Eye Institute, University of California, Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095-7002 (jld@ucla.edu). Author Contributions: Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. 8 Therefore, it has most recently been proposed that DPE is more typically a mechanical rather than a neurogenic disorder. Although based on the modern proposal for etiology, the term DPE has become a misnomer; it is used here as a convenience for reference...

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Section: Commentmentioning

confidence: 99%

“…8,22,23 The procedures reported have included suture anastomosis of the LR and superior rectus (SR) muscle margins approximately 10 mm posterior to their insertion, with superior transposition of the LR muscle insertion; 8 suture anastomosis of the margins of the LR and SR pulleys; 8 loop myopexy approximating the LR and SR muscles without splitting with MR recession or scleral fixation; 10,24 union of the LR and SR bellies after splitting these muscles longitudinally, combined with MR recession; 12 MR recession and LR resection in 1 eye; 25 and LR resections. 5,9,11 These complex procedures are not required to treat DPE.…”

Section: Commentmentioning

confidence: 99%

Section: Commentmentioning

confidence: 99%

mentioning

confidence: 97%

mentioning

confidence: 99%

See 3 more Smart Citations

Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia

Zia¹,

Demer²

2012

Journal of American Association for Pediatric Ophthalmology and

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Medial Rectus Recession Is as Effective as Lateral Rectus Resection in Divergence Paralysis Esotropia

Zia¹,

Demer²

2012

Arch Ophthalmol

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Objective To propose medial rectus (MR) recession to be equally as effective as lateral rectus (LR) resection, which has heretofore been the preferred treatment for divergence paralysis esotropia (DPE). Methods We examined a 17-year surgical experience comparing LR resection with MR recession in adults with DPE, defined as symptomatic distance esotropia (ET) at least double the asymptomatic ET of 10 or less prism diopters (Δ) at near. Results Twenty-four patients with DPE underwent surgery. Six patients underwent bilateral LR resection and 2 underwent unilateral LR resection (group L), while 13 underwent bilateral MR recession and 3 underwent unilateral MR recession, with the target angle double the distance ET (group M). One of 8 patients in group L and 15 of 16 patients in group M underwent intraoperative adjustable surgery under topical anesthesia. Mean (SD) preoperative central gaze ET measured 15.0 (7.7) Δ at distance and 4.1 (3.4) Δ at near in group L, but 10.4 (6.8) Δ at distance and 0.6 (1.7) Δ at near in group M (P=.15; distance, 0.003, near). Postoperatively, no patient in either group had symptomatic diplopia or convergence insufficiency in follow-up from 8.5 to 40 months. Twice the usual surgical dose of MR recession per prism diopter was required to achieve correction of the distance deviation in DPE as compared with that recommended for ET generally and also for LR resection in the same condition. Conclusions Recession of the MR provides binocular single vision in DPE without convergence insufficiency at near, and it is convenient for intraoperative adjustment under topical anesthesia.

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Sagging Eye Syndrome

Zia¹,

Demer²

2013

JAMA Ophthalmol

145

109

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Importance: Recognition of sagging eye syndrome (SES) as the cause of chronic or acute acquired diplopia may avert neurologic evaluation and imaging in most cases.Objectives: To determine whether SES results from inferior shift of lateral rectus (LR) extraocular muscle (EOM) pulleys and to investigate anatomic correlates of strabismus in SES. Design and Setting:We used magnetic resonance imaging to evaluate rectus EOMs, pulleys, and the LRsuperior rectus (SR) band ligament at an eye institute.Participants: Patients with acquired diplopia suspected of having SES. We studied 56 orbits of 11 men and 17 women (mean [SD] age of 69.4 [11.9] years) clinically diagnosed with SES. Data were obtained from 25 orbits of 14 control participants age-matched to SES and from 52 orbits of 28 younger controls (23 [4.6] years).Main Outcome Measures: Rectus pulley locations compared with age-matched norms and lengths of the LR-SR band ligament and rectus EOMs. Data were correlated with facial features, binocular alignment, and fundus torsion.Results: Patients with SES commonly exhibited blepharoptosis and superior sulcus defect. Significant inferolateral LR pulley displacement was confirmed in SES, but the spectrum of abnormalities was extended to peripheral displacement of all other rectus pulleys and lateral displacement of the inferior rectus pulley, with elongation of rectus EOMs (PϽ .001). Symmetrical LR sag was associated with divergence paralysis esotropia and asymmetrical LR sag greater than 1 mm with cyclovertical strabismus. The LR-SR band was ruptured in 91% of patients with SES.Conclusions and Relevance: Widespread rectus pulley displacement and EOM elongation, associated with LR-SR band rupture, causes acquired vertical and horizontal strabismus. Small-angle esotropia or hypertropia may result from common involutional changes in EOMs and orbital connective tissues that may be suspected from features evident on external examination.

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Effect of aging on human rectus extraocular muscle paths demonstrated by magnetic resonance imaging

Cited by 112 publications

References 9 publications

Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia

Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia

Medial Rectus Recession Is as Effective as Lateral Rectus Resection in Divergence Paralysis Esotropia

Sagging Eye Syndrome

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