Myopexy of the vertical rectus muscles using expanded polytetrauoroethylene for management of a lost medial rectus muscle

Chong-Bin Tsai, MD, Po-Min Yang, MD, Chau-Yi Tan, MD, and Kuo-Pin Chang, MD

Strabismus due to a lost rectus muscle is uncommon. Surgical treatment of the condition by means of scleral augmented myopexy of the vertical rectus muscles can reduce the potential for anterior segment ischemia by leaving the vascular supply intact. We report a successful use of expanded polytetrauoroethylene in this procedure to correct long-term exotropia caused by a lost medial rectus muscle.

Case Report

70-year-old woman presented to the Chiayi Christian Hospital, Chiayi, Taiwan, with exodeviation of the right eye of more than 50 years duration. The right eye had been amblyopic since childhood. As an adolescent she had extraocular muscle surgery performed on this eye; an exodeviation developed gradually thereafter. On examination, best-corrected visual acuity was 20/400 in the right eye and 20/125 in the left. Grade 2 nuclear sclerosis was present in both eyes. With the left eye xating in primary position, the right eye had an exodeviation of 90D. The right eye maintained abduction in all gaze positions (Figure 1). Active force generation test of the right eye detected only minimal abducting movements. Passive force duction test under topical anesthesia could bring the right eye to the midline. After obtaining written informed consent regarding the off-label use of the product, we performed an expandedpolytetrauoroethylene (ePTFE) augmented muscle transposition on the patients right eye. To relieve the restriction, we rst detached the lateral rectus muscle, which showed brotic scarring at its insertion. An intraoperative passive forced duction test thereafter showed unrestricted adduction to cross the midline. The lateral rectus muscle was recessed 10 mm. No medial rectus muscle capsule could be found, conrming our diagnosis of lost rather than slipped medial rectus muscle. A 0.5 2 120 mm ePTFE band (France Chirurgie Instruments, Paris,

FIG 1. Preoperative photograph. A, Right exotropia in primary position; B, right gaze; C, left gaze.

Author afliations: Department of Ophthalmology, Chiayi Christian Hospital, Chiayi, Taiwan The authors have no conicts of interest to report. Submitted May 4, 2010. Revision accepted July 26, 2010. Reprint requests: Po-Min Yang, MD, Department of Ophthalmology, Chiayi Christian Hospital, 539 Jhongsiao Road, Chiayi, Taiwan (email: 00687@cych.org.tw). J AAPOS 2010;14:550-552. Copyright 2010 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2010.07.014

France) was interwoven with a 4-0 PDS-II suture (Ethicon Inc, NJ) for added strength (Figure 2). This band was anchored at its middle to the previous insertion site of the lost medial rectus muscle with 4-0 Surgilon (US Surgical, CT). The 2 ends of ePTFE bands were threaded through the middle of the superior and inferior rectus muscles, respectively, and trimmed to be just long enough to wrap the muscles and thus avoid the long-term erosion through conjunctiva associated with use of PDS-II suture alone. The sutures were tied together to enhance pulling strength for adduction of the globe (Figure 3). The temporal conjunctival wound was recessed to help prevent future restriction. Postoperatively, the patient had 15D of exotropia in primary gaze that was stable through her nal follow-up visit 7 months after surgery. The right eye was able to abduct 30 and to adduct 4 . Neither implant exposure nor any other complications were noted (Figure 4).

Discussion
A variety of transposition procedures, with and without augmentation sutures, are available to treat ocular

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FIG 2. A 0.5 mm 2 mm 120 mm ePTFE band was threaded with a 4-0 PDS-II Suture woven through at 4 mm intervals for added strength.

FIG 4. Photograph obtained 7 months postoperatively. A, 15D residual exotropia in primary position; B, the right eye could abduct 30 ; C, adduction of 4 . No conjunctival elevation was noted nasally.

FIG 3. Artists conception of the surgical procedure. The ePTFE band was sutured at the original medial rectus muscle insertion site. Both ends of the ePTFE band were passed through the 2 adjacent muscles, and extra length was trimmed. The PDS-II Sutures were tied together.

deviation created by a dysfunctional rectus muscle.1,2 In our case, the Jensen muscletendon transfer procedure was not an option due to the absence of a medial rectus muscle. A full or partial transposition of both vertical rectus muscles combined with a lateral rectus recession in the setting of an absent lateral rectus muscle was not feasible due to the high risk of anterior segment ischemia. Helveston and colleagues2 described scleral augmentation of a tendon transfer procedure to reduce this potential risk; however, scleral tissue is not always readily available. Moreover, synthetic materials are preferred due to concerns about potential infection through use of allograft tissue.3 Materials such as PTFE or Mersilene (Ethicon Inc) have good biocompatibility and can allow brovascular ingrowth and hence better tissue integration. Both materials have the disadvantages of possible complications of extrusion, infection, and granuloma formation. PTFE is also available as a thermomechanically expanded porous form called ePTFE. Aggarwal and colleagues4 rst described

a technique using PTFE as extraocular muscle implants for large-muscle recessions in a rabbit model; clinical ophthalmological uses of ePTFE have since been reported.5-8 Tsai and Tan9 reported a similar case of muscletendon transposition with an ePTFE band using Helvestons method, but in their case, band extrusion occurred 2 months postoperatively. Even though ePTFE is well tolerated under conjunctiva, it is not biodegradable. We modied Helvestons technique in our case to minimize contact of the ePTFE with conjunctiva. As a result, the ePTFE implant was well tolerated and band extrusion has not occurred after 7 months. In our case residual exotropia remains. With a less powerful transposition method (vis--vis full transposition), a a more powerful weakening of the antagonist might have given a better result. Velez and colleagues10 reported a technique to x rectus muscles on the orbital wall. The procedure provides profound weakening and is reversible; assistance of an orbit surgeon may be helpful.

References
1. Struck MC. Augmented vertical rectus transposition surgery with single posterior xation suture: Modication of Foster technique. J AAPOS 2009;13:343-9. 2. Helveston EM, Merriam W, Ellis FD. Extraocular muscle-tendon transfer with scleral augmentation. Am J Ophthalmol 1980;89: 819-23. 3. Mehta JS, Franks WA. The sclera, the prion, and the ophthalmologist. Br J Ophthalmol 2002;86:587-92. 4. Aggarwal RK, Willshaw HE, Townsend P. New materials for rectus muscle tendon extension in strabismus surgery. Eye 1993;7:40-42.

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implant for the treatment of refractory glaucoma. Korean J Ophthalmol 2003;17:106-13. 8. Huang WJ, Hu FR, Chang SW. Clinicopathologic study of Gore-Tex patch graft in corneoscleral surgery. Cornea 1994;13:82-6. 9. Tsai CB, Tan CY. Muscle-tendon transposition with expanded polytetrauoroethylene (e-PTFE) augmentation for strabismus due to lost rectus muscle: A case report. Taiwan J Ophthalmol 2007;46:468-74. 10. Velez FG, Thacker N, Britt MT, et al. Rectus muscle orbital wall xation: A reversible profound weakening procedure. J AAPOS 2004;8:473-80.

5. Harrer S, Stangler-Zuschrott E, Rossmann M, et al. Polytetrauoroethylene in the surgery of cases with severe limitation of abduction: Long-term results. Neuro-ophthalmology 1999;22:177-85. 6. Langmann A, Lindner S, Wackernagel W, et al. Polytetrauoroethylene (Goretex) for muscle elongation in the surgical treatment of strabismus with restricted motility. Acta Ophthalmol Scand 2006; 84:250-53. 7. Choi YJ, Kim CS, Ahn BH. A comparison of the clinical effect between ePTFE membrane-tube implant and Ahmed glaucoma valve

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