SURGERY OF THE

EXTRAOCULAR
MUSCLES
I Wayan Ardy Paribrajaka
 EVALUATION
• The history and a detailed evaluation of ocular motility, as part of a complete
ophthalmologic examination, provide the information necessary for the surgeon to plan
optimal strabismus surgery.

• Preoperative discussions should address the expectations of the patient and family, as
well as the risks and potential complications of strabismus surgery, especially if surgery
on the only eye with good vision is considered.
 INDICATIONS FOR SURGERY
• Surgery of the extraocular muscles (EOMs) is performed to improve visual function,
appearance, patient well-being, or any combination of these, relieve asthenopia, may
relieve the diplopia, establish or restore binocular fusion and stereopsis

• Correction of strabismus should be considered reconstructive rather than merely

cosmetic, as it has many functional and psychosocial benefits
 SYMMETRIC SURGERY
• The amount of surgery is based on the size of the preoperative deviation
• One commonly used surgical formula for medial rectus muscle recession
or lateral rectus muscle resection for esodeviations is given in table below.
• Infants with large-angle esotropia (>60 prism diopters [Δ]) include
combined recession-resection of 3 or 4 horizontal rectus muscles or
bilateral medial rectus muscle recessions of 7.0 mm
 PREPARATION

• Anesthesia
• This procedure may be performed under local (topical, peribulbar, or retrobulbar) or 
general anesthesia in an adult but should be performed under general anesthesia in a
child

• Equipment
• Equipment should include a basic muscle surgery set with a good selection of muscle
hooks, silk 5-0 stay suture, Vicryl 6-0 for muscle recession, and Vicryl 8-0 for
conjunctival incision closure.
 SURGICAL TECHNIQUES FOR THE
EXTRAOCULAR MUSCLES AND TENDONS

• Conjunctival incision
• Fornix incision
• The limbal incision gives the best exposure
for the rectus muscle and can be
conveniently combined with a conjunctival
recession if necessary.
RECTUS MUSCLE WEAKENING
PROCEDURES
RECTUS MUSCLE TIGHTENING PROCEDURES
RECTUS MUSCLE SURGERY FOR HYPOTROPIA
AND HYPERTROPIA
• Commitant vertical deviations  recession and resection of vertical rectus muscles are
appropriate.
• Recessions are generally preferred as a first procedure
• Approximately 3Δ of correction in primary position can be expected for every millimeter
of vertical rectus muscle recession
• For commitant vertical deviations less than 10Δ that accompany horizontal deviations,
displacement of the reinsertions of the horizontal rectus muscles in the same direction, by
approximately one-half the tendon width (up for hypotropia, down for hypertropia)
 ADJUSTABLE SUTURES
• Some surgeons use adjustable sutures to avoid an immediately
obvious poor result or to increase the likelihood of success with
1 operation, but this modification does not ensure long-term
satisfactory alignment.
 COMPLICATION OF STRABISMUS SURGERY

Diplopia
• Within a few months after the surgery can occur:
• Fusion of 2 Images
• New scotoma suppression can form, causing the formation of a new angle of alignment.
• Diplopia can settle
Further treatment is indicated for symptomatic diplopia patients who persist more than 4-6 weeks after surgery,
especially if it is heavier in the primary position

Unsatisfactory Alignment
• Overcorrect, under correct, or development of a new problem strabismus.
• Such as poor fusion, poor vision, and contracture of scar tissue.
• Re-operation is often required.
Iatrogenic Brown Syndrome
• can be produced from superior oblique muscle strengthening procedures. Take care to
avoid excessive tendon tightening when this procedure is performed to minimize the risk
of these complications.
Anti-Elevation Syndrome
• Anteriorization of inferior obliques may cause elevation restriction during eye adduksi
(antielevation syndrome).
• Re-attaching the lateral part of the anterior muscle to the spiral of Tillaux increases the risk
• ”Bouncing up" insertion at the lateral boundary of the inferior rectus muscle may lower the
risk
Lost and slipped Muscles
• Tucked muscles are the result
of poor sewing techniques. The
muscle will shrink to the
posterior in its capsule during
the postoperative period
• Transposition surgery is performed if the missing muscle is not
found, but ischemia in the anterior segment can be a risk.
• Surgery on the slipped muscle is immediately performed to save
the muscle before further reaction and contracture occurs.
Pulled-in-Two Syndrome
• Muscle dehiscence during surgery is called pull-in-two syndrome (PITS). Dehiscence
usually occurs at the intersection of tendon-muscles, and inferior rectus is the most
commonly exposed muscle.
• Old age, myopathy, previous surgery, trauma, or infiltrative disease can affect the
occurrence of PITS old because of the weakening of the structure of muscle integrities.
• Therapy: muscle re-anastomosis
Perforation of Sclera
• At the time of EOM re-installation, the needle can penetrate the sclera and enter the
suprachoroidal chamber or perforate the coroid and retina. Perforation can cause retinal
detachment or endophthalmitis.
Post Operative Infection
• Some patients experience mild conjunctivitis, which may be caused by allergies to sewing materials or
postoperative medicines, as well as by infectious agents.
• Patients are warned if there are signs and symptoms of orbital cellulitis and endophthalmitis to go to the
hospital immediately

Granulomas due to Foreign Bodies and Allergic Reactions

• Granulomas caused by foreign bodies appear after EOM surgery, usually at the site of muscle re-
installation. Granulomas are characterized by a localized, elevated, hyperemic, and somewhat soft mass
• Response to topical corticosteroids
• When settling - excision
• Adherence Syndrome
• Surgeries involving inferior
abdominal muscles are particularly
susceptible to these complications
due to the proximity of fat space to
the posterior limits of inferior
muscles.
Conjunctival Scarring
Satisfaction from improved alignment may occasionally be overshadowed by unsightly scarring of the
conjunctiva and the Tenon capsule, as a result of the following:
• Advancement of thickened Tenon capsule too close to the limbus & Advancement of the plica
semilunaris.
• Treatment : conjunctivoplasty with resection of scarred conjunctiva and transposition of adjacent
conjunctiva, resection of subconjunctival fibrous tissue, re­cession of scarred conjunctiva, and
amniotic membrane grafting.
Dellen
• A shallow area of corneal thinning near the limbus, occur when raised abnormal bulbar conjunctiva
prevents adequate lubrication of the cornea adjacent to the raised conjunctiva
Anterior Segment Ischemia
• Simultaneous surgery on 3 rectus muscles (as in the procedure of transposition
with simultaneous antagonistic recession) or even 2 rectus muscles in patients
with poor blood circulation can cause anterior segment ischemia (breast milk).
• The earliest signs of this complication are cells and flares in the chambers of
the foreight. More severe cases are characterized by edema of the corneal
epithelium, folds in the Descemet membrane, and ireguler pupils.
Eyelid Position Change
Changes in eyelid position are most likely to occur in surgery on vertical rectus muscles.
• Inferior rectus muscle fractures  lower eyelids pulled up
• Inferior rectus muscle recess -lower eyelids pulled down - scleral show
• Surgery on the superior rectus muscle is less likely to cause complications to the upper
eyelid
• Removal of the lower eyelid retractor or manipulation of capsulopalpebral can prevent
the retraction of the lower eyelid after an inferior rectus muscle recess
Refractive Changes
• Often performed when strabismus surgery is performed on 2 eye rectus muscles.
• Induced cylindrical usually heals within a few months
CHEMODENERVATION USING BOTULINUM TOXIN

• This agent paralyzes muscles by blocking the release of acetylcholine at

neuromuscular junction
• Within 24-48 hours of injection, botulinum toxin is bound and internalized
with local motor nerve terminals, where it remains active for many weeks
• Paralysis of the injected muscle begins within 2-4 days after injection and
last clinically for least 5-8 weeks, in the case of EOM
Indication, Techniques and Results
• Injection into EOMs are performed with the use of a portable electromyography
• Most effective in the following conditions :
• small to moderate angle esotropia and exotropia
• postoperative residual strabismus (2-8 weeks following surgery or later)
• acute paralytic strabismus (especially sixth nerve palsy), to elimination diplopia while the
palsy resolves
• cyclic esotropia
 • active TED or inflamed
• as a supplement to medial rectus recessions for large angle exotropia

• Multiple injection may be required

Complication
• Ptosis
• Incomplete eyelid closure
• Dry eye
• Induced vertical strabismus after horizontal muscle injection
THANK YOU