EUGENE M. HELVESTON, M.D.

Emeritus Professor of Ophthalmology

Indiana University School of Medicine

Department of Ophthalmology

Section of Pediatric Ophthalmology and Strabismus

Indianapolis, Indiana

FIFTH EDITION

With 852 illustrations

With love and gratitude to my wife

Barbara

The 33 years since the publication of the Atlas of Strabismus Surgery has seen a steady growth in the number of ophthalmologists specializing in the diagnosis and treatment of strabismus. Membership in the American Association for Pediatric Ophthalmology and Strabismus has grown to more than 500 members and the International Strabismological Association boasts 300 members in 25 countries. Several journals deal exclusively or largely with the subject of strabismus and several high quality texts have been published dealing with strabismus diagnosis and management. Moreover, an explosion in the field of information technology has brought people together and facilitated the distribution of information in a way not dreamed of when the first edition of this book was written.

This fifth edition is renamed Surgical Management of Strabismus reflecting the fact that the major emphasis has shifted from a description of surgical procedures to a discussion of why and how these procedures are used to treat the patient with strabismus. There have been relatively few substantive changes in surgical technique. It is how these techniques are applied including the 'what' and 'when' which make up the bulk of this book.

A new concept that has influenced surgical management during the last decade is that of the pulleys associated with the horizontal rectus muscles. Study of these structures made possible in part by new imaging techniques, but more importantly by meticulous study of anatomic specimens, has helped make the management of 'A' and 'V' more logical and effective.

Included in this book are 135 strabismus cases managed by me either in the clinic or by means of consultation carried out by me and other mentors on patients sent by dozens of partners from countries around the world. These patients' consultations were made possible by ORBIS Telemedicine, Cyber-Sight that is supported by the server at Flight Safety in New York and provided through the generosity of Mr. Albert Ueltschi. By viewing these images and reading the discussion that accompanies each, it is my hope that the reader will by critical analysis along with comparison of the patients seen in his or her clinic hone skills for a more effective personal approach to the whole patient leading to better outcome.

This book represents the 'full circle' in that it is based on experience during a professional lifetime in the care of patients with strabismus. It is my hope that what I have learned and then shared here will be of use to those who follow.

As with any effort like this there are many deserving people to thank. First among these is Mrs. Lynda Smallwood who more than any person is responsible for this book being completed. She not only typed the manuscript, but also assembled and formatted the entire book making it ready for the printer by simply submitting it in electronic format ready for duplication. Truly a monumental task! Others who worked hard and effectively are Leslie Abrams, Michelle Harmon, Gwen Kopecky, Sharon Teal who so ably carried on the art work begun by Craig Gosling, and Ann Hammer who read the first three chapters. I am grateful to the many Cyber-Sight partners who submitted hundreds of cases, and to my fellow Cyber-Sight strabismus mentors, especially Dan Neely who faithfully and expertly responded when called on. I thank all of my teachers, especially Gunter von Noorden my mentor beginning in 1966 and my friend for life. Most of all, I thank my wife Barbara for her unselfish and unfailing support, and my two daughters both of whom had the good sense to marry outstanding strabismologists.

Eugene M. Helveston

From the

There have been several excellent texts on strabismus including strabismus surgery in the past few years, but developments have moved rapidly. Recent advances in technique have greatly expanded the options available to the strabismus surgeon. More accurate diagnostic tests leading to a better understanding of the pathophysiology of strabismus and amblyopia have convinced some surgeons of the need for surgery in infants as young as 5 months of age. Improved anesthesia and an increasing boldness on the part of the strabismus surgeon have led to outpatient extraocular muscle surgery in some instances without patch and without ointment or drops. The limbal and cul-de-sac (or fornix) extraocular muscle exposure techniques have largely superceded the transconjunctival incision in the interpalpebral space among younger surgeons. The retinal surgeon has opened new dimensions in the degree to which sub- Tenon’s space may be explored.

New sutures, adhesives, muscle sleeves, and implantation materials have proved useful innovations. Globe fixation sutures, conjunctival recession and relaxation procedures, forced duction and active forced generation tests, as well as topical anesthesia for extraocular muscle surgery, have greatly enlarged the vista of strabismus surgery.

For these reasons it seems appropriate at this time to compile an up-to-date atlas of strabismus surgery. This atlas employs schematic drawings designed to illustrate at each step only that anatomy significant to the step shown for easier orientation of the reader. Procedures that I have found useful have been given emphasis; those that are controversial or that I have not found to be particularly helpful have been omitted. Some "favorite technique" may be omitted simply because I prefer an alternative choice; those that I think should be avoided will be clearly labeled so.

No attempt will be made to give a set of surgical recipes that will result in a predetermined amount of straightening. Instead, general concepts leading to a philosophy for strabismus surgery will be presented. My intent is that this atlas will be of help to the practicing strabismus surgeon and the resident in ophthalmology by bringing together in one volume many techniques from a variety of sources for quick and easy reference.

Several people who assisted significantly in their own way to make this atlas possible deserve my sincere thanks. Dr. Gunter K. von Noorden, teacher, critic, and friend, introduced me to strabismus and to the pursuit of academic ophthalmology. Craig Gosling worked with industry and imagination on the illustrations, the heart of any atlas. My residents and many of my colleagues, in particular Drs. Marshall M. Parks and Phillip Knapp, provided both stimulus and direction.

Eugene M. Helveston