Case of the week 44 (
March 2012
) Fat Adherence Syndrome
22 years old girl had been operated
3 times by
the same strabismologist throughout the last 5 years ,
as usual , no operative details could be obtained , all
what I could gather from the history that she was
initially exotropic and the previous 3 surgeries were
done to correct that XT .
Both she and her mother are totally unsatisfied with the
result of the surgeries , she
asks for another surgery .
During the last three months , she was examined by 5
surgeons who successively refer her one to another, no
one of them give
an operative decision ( I usually call this : The
Great Escape ).
I assume she was subjected to bilateral horizotal surgeries since the examination showed conjunctival scars in both eyes
along the paths of
the horizontal recti , there is also right inferior fornix scar and a
very
ugly scar right nasal . The patient is habitually fixing
with the right eye , the left eye is deeply amblyopic .
other data in my sheet about the fundus , refraction ,
...etc are irrelevant
See video of this patient
Fat Adherence syndrome
Fat adherence is one of the most
disastrous complications following vigorous
strabismus surgery .
Normally, Tenon’s capsule
acts as a barrier separating the globe from
the surrounding orbital fat. Fat adherence is caused
by violation of the posterior Tenon’s capsule,
allowing exposure of extraconal fat
, which allows adhesions of these
tissues to the sclera. In severe cases, like the
right eye of this girl , the eye is almost frozen ,
where restrictive ocular movements were observed
nearly in all gazes .In
such cases ,there is no one strategy , according to
the findings the plan is applied .
Rules to be followed in these cases :
1. Deal with these patients having multiple
unknown strabismus surgeries as they as now, in
many cases the initial pathology couldn't be
known .
2. Fat adherence is
very difficult - and sometimes impossible - to
be
surgically corrected, as recurrence of fat adherence
after removal of adhesions is very common. Once Tenon’s capsule is violated and scarred ,
it is almost impossible to reestablish the fascial barrier to prevent recurrence of scarring.
3. In patients have had multiple strabismus
surgeries , we have to think about the anterior
ciliary arteries , this may preclude a promising
successful work in a desired muscle .
4.Don't do a huge job in an eye with scarred
periorbita , the results of minimal surgery is
usually better than much manipulations which
occasionally lead to more restrictions .
5.Only correct what bothers the patient not what
bothers you .
From the foregoing
introduction , I found that :
1. The girl is
almost horizontally aligned in primary position
.
2. An ugly Rt nasal conj. preventing the outward
extrusion of the Rt eye .
3. Left XT which appears only in the Lt gazes (
Up-left , left and down-left ) , this is because
the imbalance between the normal out extrusion
of the left eye and the restrictive movements of
the Rt eye .
4. Hypertropia of the left eye giving an
appearance of false marked ptosis which
completely disappears on looking up.
My recommended
strategy is :
1. Conj. recession
of the Rt eye .
2. Retro-equatorial myopexy ( Faden ) of the
left LR , this will limit the outward extrusion
of the left eye ( since we can't regain normal
extrusion of the frozen Rt eye ).
3. Lt. SR recession.
الموقع المصري للحول
وامراض الجهاز الحركي للعين
The Egyptian Site of
Strabismus & Oculomotor Disorders
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