Poster 40

by in  Poster Session 1

Enlargement of the Superior Rectus and Superior Oblique Muscles Causes Intorsion in Graves’ Eye Disease

Yan Wei1, MD, PhD; Monte A. Del Monte2, MD
1 Shanghai Jiao Tong University School of Medicine
Shanghai, People’s Republic of China
2 W. K. Kellogg Eye Center, University of Michigan,
Ann Arbor, Michigan, USA


Introduction: To review the prevalence of preoperative and postoperative intorsion in patients with strabismus and Graves’ eye disease (GED), and to correlate the intorsion with coexisting superior rectus (SR) and superior oblique|(SO) muscle enlargement as a possible mechanism causing intorsion in these patients.

Methods: Charts of consecutive patients with GED who underwent strabismus surgery between 1 January 2010 and 1 April 2013 were retrospectively reviewed. Of these, patients with orbital CT or MRI scan were identified for further analysis. Clinical characteristics documented included age, gender, horizontal and vertical deviation, subjective torsional deviation, specific extraocular muscles (EOMs) operated upon, EOM enlargement on CT/MRI scans and width and thickness of SO, SR group and inferior rectus (IR).

Results: Charts of 45 patients (14 males and 31 females) were reviewed. Mean age was 56.8
±12.5 years. Of these, seven (15.6%) patients demonstrated intorsion, and 38 (84.4%) patients demonstrated extorsion preoperatively. But after strabismus surgery, 15 (39.5%) of the 38 patients with preoperative extorsion demonstrated postoperative intorsion and 23 (60.5%) patients continued to show postoperative extorsion. On analysis of CT/MRI scans in these patients, only an increase in the thickness of SR group and the thickness/width of SO muscle were significantly associated with preoperative and postoperative intorsion; while age, gender, preoperative horizontal or vertical deviation and IR recession were unrelated to preoperative or postoperative intorsion. Postoperative intorsion was also associated with smaller degrees of preoperative extorsion (<3.5°).

Discussion: Our study suggests that SR and SO enlargement may be a primary factor causing intorsion both preoperatively and postoperatively in patients with strabismus and GED. In patients with GED, IR is the most frequently enlarged EOM, whereas SR and SO muscles are much less often involved and when present, enlargement is usually masked by the coexisting ipsilateral IR involvement. Sometimes, it is difficult to observe SR and/or SO tightness by preoperative clinical examination. We suggest orbital imaging before surgery may be useful in earlier identification of enlargement of the SR group/SO muscles and global intorsion requiring alteration of surgical planning to prevent postoperative intorsion.

Conclusion: Preoperative SR and/or SO muscle enlargement appear to be a primary contributing factor relating to preoperative and postoperative intorsion in patients with GED-associated strabismus. Patients with only small amounts of preoperative extorsion (<3.5°) in the presence of tight IRs should be carefully evaluated for possible SR and/or SO involvement by CT or MRI scan to predict those at risk for and plan for prevention/treatment of postoperative

References: 1. Chatzistefanou K, Kushner BJ, Moschos MN. An unusually large incyclotropia associated with dysthyroid ophthalmopathy. Br J Ophthalmol 2008;92:291–2.
2. Thacker NM, Velez FG, Demer JL, et al. Superior oblique muscle involvement in thyroid ophthalmopathy. J AAPOS 2005;9:174–8.
3.Holmes JM, Hatt SR, Bradley EA. Identifying masked superior oblique involvement in thyroid eye disease to avoid postoperative A-pattern exotropia and intorsion. J AAPOS 2012;16:280–5.

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