Combined rectus muscle transposition with posterior fixation sutures for the treatment of double-elevator palsy

Purpose: To evaluate the surgical and functional results of full horizontal tendon rectus muscle transposition to the superior rectus (SR) insertion, augmented by posterior fixation sutures, in patients with double-elevator palsy (DEP). Design: Retrospective nonconcurrent interventional comparative case series. Participants: Fourteen consecutive patients with DEP. Intervention: Six patients treated for DEP by vertical transposition of the horizontal muscles to the SR insertion (Knapp procedure) were compared with 8 patients treated by the Knapp procedure combined with fixation of the transposed muscles to the sclera, adjacent to the SR, with nonabsorbable sutures. Main Outcome Measures: Postoperative ocular alignment, ductions, binocular functions, and rate of reoperation. Results: Ocular deviation: Mean distance and near deviations decreased by 84% and 83%, respectively (P = 0.012), in the augmented-surgery group versus 48% and 47%, respectively (P = 0.03), in the standard-surgery group. Duction: Mean elevation deficiency in abduction and adduction improved by 64% and 65%, respectively (P = 0.01), in the augmented surgery group versus 42% and 55% (P = 0.02) in the standard group. Binocular functions: 3 patients (37%), all in the study group, gained binocular function. Reoperation was required in 5 patients (83.3%) in the control group. The difference in postoperative improvement between the groups was statistically significant for all 4 parameters. No postoperative complications or duction anomalies were observed during the follow-up period of 15.4 months (standard deviation, 5.5). Conclusions: The augmented Knapp procedure with superior posterior fixation suture is the preferred surgical treatment for patients with DEP. Its use in this series avoided the need for multiple surgeries on other extraocular muscles.