Biomedical subjects
Publications and source records attributed to M J Urist.
The Müller's muscle-conjunctival resection procedure is a relatively simple means of relieving ptosis in patients whose upper eyelids elevate to a normal level with phenylephrine instillation. The Müller's muscle-conjunctival resection procedure has advantages over the Fasanella operation because tarsus is preserved, and over the levator aponeurosis advancement and tuck operation because the results are more predictable.
We retrospectively studied 101 consecutive patients with Duane's retraction syndrome. Eighty-five percent were unilaterally affected and 15% were bilaterally affected. More patients had straight eyes in primary position than esotropia or exotropia. On lateral version reflex testing the amount of underaction of the lateral and medial rectus muscles could be determined, and could be used to predict whether the patients' eyes were esotropic, exotropic, or straight in primary position. Almost all the patients showed an esotropia when looking to one side and either an exotropia or no deviation to the other side. The degree of the exotropia and the esotropia on opposite sides determined whether a head turn would be present and in what direction. On adduction, the palpebral fissure in the affected eye narrowed in one half the patients because of motion of both upper and lower eyelids, and in 40% because of motion of only one eyelid. When the lower eyelid elevated, it usually assumed a straight horizontal contour with peaking of the punctum lacrimalis (appearing as a small pyramid). The statistical predominance of females and left eyes was more significant among patients whose eyes were straight in primary position. All patients tested demonstrated stereopsis. Most of the amblyopic patients had anisometropia.
Two patients developed upper eyelid retraction secondary to a blowout fracture of the orbital floor. Posttraumatic overaction of Muller muscle is a possible cause of the eyelid retraction.
For good cosmesis the upper eyelid creases and folds must be symmetric. The lid creases must be the same height above the upper lid margins. The skin below the crease must be smooth and firmly attached to the tarsus, or, in cases with a short tarsus, adherent to the short tarsus and levator muscle up to the crease. The skin above the crease must be loosely attached so that it forms symmetric folds over the crease. We have developed surgical procedures aimed at the following: (1) equalizing the upper lid creases and folds where they are asymmetric, (2) creating lid creases and folds where absent, as in Orientals, (3) removing excess unsightly skin folds, as in dermatochalasis, and (4) forming a lid fold by skin grafting where there is insufficient skin above the crease.
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A 69-year-old woman with chronic lymphocytic leukemia developed segmental iris atrophy and iridocyclitis after routine surgery for exotropia. Both the clinical picture and fluorescein angiogram indicated anterior segment ischemia. It is postulated that this was related to hyperviscosity of the blood caused by a high white blood cell count (114,000/cu mm). The possibility of anterior segment ischemia should be kept in mind when contemplating strabismus or retinal detachment surgery in the presence of hematologic disorders likely to increase blood viscosity. In these cases a minimal amount of surgery should be done with proper supportive therapy. Strabismus surgery should be done in stages allowing for hemodynamic compensation between procedures.
A new technique for resecting the Müller muscle and the conjunctiva for correction of blepharoptosis has been developed. The operation is performed on all patients in whom a 10% phenylephrine hydrochloride solution instilled in the conjunctival cul-de-sac will elevate the blepharoptotic eyelid to a cosmetically acceptable level. The results of the surgery have been satisfactory in 27 of 28 operated eyelids.
We examined 21 patients with closed-head trauma and resulting paralysis of the lateral rectus muscle. Clinical findings included laterally directed gaze palsy, some unconsciousness, and pseudo-duane's phenomenon suggesting a supranuclear lesion at the level of the upper pontine tegmentum, and pontine paramedial reticular formation. The surgical procedure of choice was a "midline operation," that is, the appropriate number of millimeters of recession and resection to achieve 0 to 5 degrees of exotropia in the primary position of gaze. Frequently, the medial rectus muscle must be recessed 10 nm or more and the lateral rectus muscle resected 10 nm or more to achieve this result. None of the 21 patients had diplopia after the midline procedure.
A retrospective study of 170 cases of horizontal rectus muscle surgery performed during the years 1969 and 1970 at the University of Illinois Eye and Ear Infirmary revealed a 6-5 per cent incidence of dellen with the limbal approach to the muscle and a 2-2 per cent of incidence of dellen with the nonlimbal or direct approach to the muscle. This was significant to the 5 per cent level of confidence by the chi2 test. We feel that this finding of an increased incidence of dellen with the limbal approach complements the current theory of desiccation as the cause of corneal dellen. We do not recommend abandonment of the limbal approach to rectus muscle surgery because of this finding, but suggest that surgeons scrutinize more carefully their postoperative patients for dellen. If dellen do not occur careful trimming of the conjunctiva to avoid bunching and thickening may perhaps eliminate them.
After glaucoma filtration surgery, 2 patients developed overaction of Müller's muscle with resultant upper eyelid retraction. We theorize that stimulation of Müller's muscle is caused by a sympathomimetic chemical in the aqueous that travels from the bleb, under the bulbar and palpebral conjunctiva, to Muüller's muscle. In one case excision of Muüller's muscle relieved the retraction. In the other case, preventing aqueous from reaching Müller's muscle reduced the retraction.
The characteristic clinical findings of pseudoparalysis of the medial rectus muscle include exotropia in primary position, widened medial fissure on the affected side, limitation of adduction on the affected side, an A-pattern exotropia, and a paradoxical forced-traction test. We have devised a surgical technique to restore good movement of the eye in adduction. The priniciple behind the technique is that all adhesions between Tenon's capsule covering the muscle and conjunctiva, and between muscle and sclera must be found and cut posterior to the fornix. This will allow the muscle to be brought forward easily so that it can be resected and advanced for restoration of function.
Surgery for a narrow palpebral fissure caused by enophthalmos after a blow-out orbital fracture was performed in three patients from seven months to three years after injury. The surgery was directed not to the cause of the enophthalmos, but to the narrowed palpebral fissure which was the noticeable cosmetic defect. The surgical procedure used to widen the palpebral fissure was the Müller's muscle-conjunctival resection blepharoptosis operation, and a phenylephrine test was used preoperatively to select candidates for this operation. After widening of the palpebral fissure, which created the illusion of exophthalmos, the cosmetic result was acceptable.
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Explore the source record for details and available documents.