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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 NAME OF THE CANDIDATE & DR. SHWETHA H.R. ADDRESS NO.749, 4 TH BLOCK, 8TH MAIN, (IN BLOCK LETTERS) 9TH CROSS, B.E.L. LAYOUT, VIDYARANYAPURA BANGALORE – 560097. 2 NAME OF THE INSTITUTION MINTO OPHTHALMIC HOSPITAL, BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE. 3 COURSE OF THE STUDY AND SUBJECT M.S. IN OPHTHALMOLOGY 4. DATE OF ADMISSION TO COURSE 15TH APRIL, 2009 5. TITLE OF THE TOPIC ‘RESULTS OF EXTRAOCULAR MUSCLE TRANSPOSITIONS IN VARIOUS TYPES OF STRABISMUS’ 6. BRIEF RESUME OF THE INTENDED WORK 6.1 NEED FOR STUDY Muscle Transpositions are done in cases in which function of the muscle cannot be improved by any strengthening procedure. The adjacent muscles can be transposed to aid the action of paralytic muscle 1. There is no universal consensus on the type of surgery to be done for a particular type of strabismus. Hence the study to understand the results of muscle transpositions. 6.2 REVIEW OF LITERATURE Muscle Transposition is a technique of reinsertion of adjacent muscles close to the paralysed muscle to strengthen its action. It is indicated in oculomotor nerve palsy, lateral rectus muscle palsy, monocular elevator deficiency, monocular depressor palsy, alphabet pattern strabismus, and rarely in duane retraction syndrome. Types : Peter’s procedure: Indicated for oculomotor nerve palsy. Here, superior oblique tendon is shortened and reattached to sclera near insertion of medial rectus muscle 2. Hummelshiem’s procedure: Indicated for Lateral rectus palsy or lost muscle. Here, lateral halves of superior and inferior recti are dissected upto 14mm from their insertion and re-inserted adjacent to lateral rectus muscle insertion 3 . Jensen’s procedure: Indicated for lateral rectus muscle palsy. Here, lateral halves of superior and inferior rectus muscle and upper and lower halves of lateral rectus muscle are dissected for about 14mm from their insertion and lateral half of superior rectus muscle and upper half of lateral rectus muscle tied with mersilene suture. This procedure has lesser chance of anterior segment ischemia 4. Callahan’s procedure: Indicated for elevator deficiency. Here upper half of medial and lateral rectus muscle are sutured with the two halves of superior rectus muscle. O’Connor’s procedure: Here, vertical recti are transposed to lateral recti. Knapp’s procedure: Indicated in double elevator or depressor palsy. Here, horizontal recti are transposed to superior rectus muscle. STUDIES : Paysee EA, Saunders RA, Coats DK did a study on surgical management of strabismus after rupture of the inferior rectus muscle and showed that the modified Jenson’s transposition of the horizontal rectus muscles appears to be highly effective in the treatment of hypertropia and infraduction deficit produced by rupture of inferior rectus muscle 5. Young TL, Conahan BM, Summers CG, Egbert JE. did a study on anterior transposition of superior oblique tendon in the treatment of oculomotor nerve palsy and its influence on post operative hypertropia 6 . Goldchmit M, Felberg S, Souza-Dias C did a study on unilateral anterior transposition of the inferior oblique muscle for correction of hypertropia in primary position and showed that it is an effective technique for correction of large hypertropia associated with marked unilateral inferior oblique overaction 7. Hong S, Chang YH, Lee JB did a study on the effect of full tendon transposition augmented with posterior intermuscular suture for paralytic strabismus and showed that it is an effective procedure that results in improved ocular alignment in patients with paralytic strabismus 8. Britt MT, Velez FG, Thacker N, Alcorn D, Foster RS, Rosenbaum AL did a study on surgical management of globe retraction and pseudoptosis in Duane retraction syndrome and showed that partial transposition of vertical rectus muscles may improve the angle of esotropia in primary position and abduction 9. 6.3 OBJECTIVES OF STUDY : To study the results of extraocular muscle transposition in various types of strabismus. 7. MATERIALS AND METHODS 7.1 SOURCE OF DATA Patients attending squint clinic and OPD at MINTO OPHTHALMIC HOSPITAL, BMCRI, Bangalore presenting with various types of strabismus. 7.2 METHOD OF COLLECTION OF DATA It is a hospital based prospective, Non-comparative; period of study, 1 year interventional study of 20 patients undergoing muscle transposition surgeries in different types of strabismus. A detailed ophthalmic and orthoptic eval uation includes visual acuity, Refraction testing, Fundus examination, Prism cover test to measure the angle of deviation, Clinical photography and wherever indicated, Forced duction test will be performed. Informed consent will be taken prior to the surgical procedure after complete description of the procedure and its purpose to the patients. The type of surgery for the individual cases will be based on what is recommended in literature for such cases or some modification based on our experience and discretion. Post operatively patients will be followed up for a period of 1-2 months with a detailed ophthalmic and orthoptic evaluation done during their each visit as in preoperative evaluation. The amount of deviation is documented with photographs. The result of surgery in terms of improving ocular alignment and motility will be analysed. INCLUSION CRITERIA : a) b) c) d) e) f) g) h) Oculomotor nerve palsy Superior oblique muscle palsy Lateral rectus muscle palsy Monocular double elevator deficiency Monocular depressor palsy Traumatic rupture or loss of rectus muscle Duane Retraction syndrome Any other type of strabismus which may be helped by muscle transposition. EXCLUSION CRITERIA : a) Cases in which surgery is contraindicated. b) Cases in which patients have no realistic expectations. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENT, HUMAN OR ANIMAL? Yes, in addition to visual acuity, Prism cover tests, surgical procedure and follow up are required. 7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3? Yes. 8 LIST OF REFERENCES : 1. Sharma P. “strabismus simplified”. 1st ed. Sahibabad: 1991. P 190 2. Roperhall M.J. “stallard’s eye surgery”. 7th ed. Bombay: 1989. P 168. 3. Krachmer J.H. “atlas of ophthalmic surgery techniques complication”. Vol I. New Delhi: 1990. P 4.24. 4. The Requisites. “pediatric ophthalmology and strabismus”. Mosby; 1999. P.165-7. 5. Paysse EA, Saunders RA, Coats DK. Surgical management of strabismus after rupture of the inferior rectus muscle. American association of Pediatric ophthalmology and strabismus 2000; 4(3): 164-7. 6. Young TL, Conahan BM, Summers CG, Egbert JE. Anterior transposition of superior oblique tendon in the treatment of oculomotor nerve palsy and its influence on post operative hypertropia. Journal of pediatric Ophthalmology and strabismus 2000; 37(3): 149-55. 7. Goldchmit M, Felberg S, Souza-Dias C. Unilateral anterior transposition of the inferior oblique muscle for correction of hypertropia in primary position. American association of pediatric ophthalmology 2005; 140(3): 477-83. 8. Hong S, Chang YH, Han SH, Lee JB. Effect of full tendon transposition augmented with posterior intermuscular suture for paralytic strabismus. American Journal of ophthalmology 2005; 140(3): 47783. 9. Britt MT, Velez FG, et al. Surgical management of severe cocontraction, globe retraction, and pseudo-ptosis in Duane syndrome. American association of pediatric ophthalmology and strabismus 2004; 8(4): 361-7. 9. SIGNATURE OF THE CANDIDATE : 10. REMARKS OF THE GUIDE : Muscle Transposition surgeries are reported for various types of strabismus. Though they are useful, further improvements are necessary to enhance the quality of results. A systematic study of these procedures will enhance our knowledge pool and help us in giving better results. 11. NAME AND DESIGNATION OF GUIDE : DR. T.K. RAMESH MBBS, MS(OPH), DNB, FRCS. PROFESSOR DEPARTMENT OF OPHTHALMOLOGY MINTO OPHTHALMIC HOSPITAL BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE – 560001. 11.1 SIGNATURE OF THE GUIDE : 11.2 CO-GUIDE (IF ANY) : NONE 11.3 SIGNATURE OF CO-GUIDE: 11.4 NAME AND DESIGNATION OF HOD : DR. K.S. SRIPRAKASH MBBS, M.S.(OPH) MEDICAL SUPERINTENDENT PROFESSOR AND HOD DEPARTMENT OF OPHTHALMOLOGY MINTO OPHTHALMIC HOSPITAL BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE – 560001. 11.5 SIGNATURE OF HOD: 12.1 REMARKS OF CHAIRMAN AND PRINCIPAL : 12.2 SIGNATURE OF PRINCIPAL :