Intraoperative Traction Testing to Detect

Incomplete Inferior Oblique

Myotomy/Myectomy
David K. Coats, M D , a n d E v e l y n A. Paysse, M D

Purpose: Incomplete transection of the inferior oblique muscle during myotomy or myectomy is an important
preventable cause of ineffective inferior oblique weakening surgery. Intraoperative traction testing has been
suggested as a means of detecting an incomplete inferior oblique transection. The usefulness of intraoperative
traction testing to detect incomplete myotomy was evaluated. Methods:The subjective "tightness" of the inferior
oblique muscle was evaluated after partial and complete myotomy to determine how partial myotomy affected
inferior oblique traction testing and to determine whether intraoperative traction testing is an effective means of
ensuring that a complete myotomy has been achieved. Serial traction testing was performed on 10 inferior oblique
muscles atthe time of myotomy and scored, 0+ to 4+ tightness. Testing was performed before myotomy and after
50%, 90%, and total myotomy. Results: In 8 of 10 eyes traction testing remained strongly positive until the inferior
oblique muscle had been completely transected. The average inferior oblique muscle tightness of these eight
muscles was +1.69 before myotomy and after 50% and 90% myotomy. The tightness decreased to 0 after 100%
myotomy. In two cases no inferior oblique muscle could be detected after 50% and 90% myotomy, respectively.
These two muscles had preoperative traction testing of +0.5 and +1.00, respectively. Conclusions: Intraoperative
traction testing is a practical and effective method of detecting incomplete inferior oblique myotomy/myectomy, but
the test should be interpreted with caution in patients with loose premyotomy muscles. (J AAPOS 1997;1:197-200)

irtually all surgical procedures designed to weaken been isolated. Direct inspection, however, is sometimes

v the inferior oblique muscle depend on completely

transecting or disinserting the inferior oblique
muscle. Success depends on not only choosing the correct
procedure but performing the procedure correctly. Incom-
plete transection of the inferior oblique muscle is a well-
recognized problem leading to undercorrection after
inferior oblique muscle weakening surgery?
Failure to completely transect the inferior oblique
muscle at myotomy/myectomyresults in a residual band of
muscle connecting the origin and insertion (Figure 1).
Isotonic contraction of the inferior oblique muscle will
continue to have almost the same effect as before surgery)
This complication can be avoided by carefully inspecting
the posterior border of the inferior oblique muscle after it
has been hooked to ensure that all fibers of the muscle have
From the Cullen Eye Institute, Baylor College of Medicine, Texas Children's Hospital,
Houston, Texas.
Supported by an unrestricted grant from Research to Prevent Blindness, Inc., New York.
Presented in part at the Twenty-ninth Panhellenic Ophthalmological Congress, May 30-
J~me 2, 1996, and at Associationfor Research in Vision and Ophthalmology, May 199Z
Reprint requests: David K. Coats, MD, Baylor College of Medicine, Texas Children's
Hospital, 1102 Bates, #300, Houston, T X 77030.
Copyright © 1997 by the Amer~an Associationfor Pediatric Ophthalmology and Strabismus.
1091-8531/9755.00 + 0 75/1/85179
hindered by a poor surgical view. Traction testing has been
described as a final confirmatory test after surgery to
document that the muscle has been completely transected
or disinserted. 2 Although this test is often used to confirm
that a complete myotomy has been performed, no study has
been published to document its effectiveness in cases of
incomplete transection. We undertook this study to
determine the usefulness ofintraoperative traction testing
to detect an incomplete transection of the inferior oblique
muscle.
METHODS
We performed serial intraoperative inferior oblique
muscle traction testing on 10 muscles of nine patients
undergoing inferior oblique muscle myectomy. The mean
patient age was 31 years (range 2 to 78 years) and the male-
to-female ratio was 5:4. Four muscles were operated on for
primary inferior oblique muscle overaction and six muscles
were operated on to treat ipsilateral superior oblique
muscle paresis.
Traction testing was performed in a manner previously
reported2 but in serial fashion. Briefly, exaggerated traction
testing of the inferior oblique muscle was accomplished as
follows: (1) the conjunctiva was grasped at the 3 and 9 o'clock
positions just posterior to the limbus, (2) the globe was then

Journal of AAPOS December 1997 1 9 7


198 Coatsand Paysse
Fill 1. Residual band of intact inferior oblique muscle, left eye, after
incomplete myectomy (surgeon's view).
retroplaced, (3) incyclotorsion with inferonasal rotation was
was then done, and (4) while retroplacementand incyclotorsion
was maintained, temporal traction/rotation was used to
rotate the globe over the taut inferior oblique muscle. During
this movement the globe was felt to roll (or jump) over the
taut inferior oblique muscle as the muscle slipped nasally.
The above maneuver was performed before myotomy and
after 50%, 90%, and 100% myotomy. The serial traction
testing was rendered safe and reproducible in the following
manner. Two 4.0 silk ties were placed securely around the
inferior oblique muscle, each tie separated by
7 mm, after careful inspection to ensure that the entire extent
of the muscle had been isolated (Figure 2). These sutures
were used to retrieve the inferior oblique muscle between
tests and to control bleeding, thus allowing a reproducible
and safe means of retrieving the entire inferior oblique
muscle to extend the myotomy for serial testing (Figure 2).
After serial traction testing, the inferior oblique muscle
segment that was between the sutures was excised and the
sutures removed, thus completing the planned myectomy.
The tests were graded on a subjective scale, as previously
described, from 0 to 4+, with 0 indicating no muscle detected
and 4+ denoting a very tight muscle?
RESULTS
The results of serial traction testing are recorded in Table
1. The mean inferior oblique muscle tightness was +1.50
before myotomy, +1.45 after 50% myotomy, and +1.35
after 90% myotomy. The tightness decreased to 0 after
100% myotomy for all muscles. For eight muscles in which
traction testing did not change until complete myotomy
had been performed, the mean tightness was +1.69.
Seven patients had preoperative tightness greater than
or equal to +1.5 (mean +1.78). In all seven of these muscles
no change could be detected in the inferior oblique muscle
Journal ofAAPOS
Volume I Number 4 December 1997
tighmess after 50% and 90% myotomy, and the muscle
could be easily detected with traction testing until a
complete myotomy had been performed.
Three muscles had preoperative tightness of less than or
equal to +1.0. In one of these muscles the tightness
remained the same until a complete myotomy had been
performed. In two muscles the tightness decreased to 0
after a 50% and 90% myotomy, respectively. These two
muscles had a premyotomy tightness of +0.5 and +1.0,
respectively. They were therefore difficult to detect
preoperatively and undetectable after partial myotomy.
DISCUSSION
Incomplete transection of the inferior oblique muscle is an
important preventable cause of ineffective inferior oblique
muscle weakening surgery. 1 Careful inspection of the
posterior aspect of the inferior oblique muscle after
hooking the muscle and before transection is a helpful
means of minimizing this complication. In this manner the
surgeon can identify a residual muscle band and take
appropriate corrective action. The surgeon should see only
white tenon's capsule posterior to the hooked inferior
oblique muscle. A residual muscle band can be easily
recognized by its dark or pink color and may be present as
a small or broad band posterior to the hooked portion of
the muscle. Factors that can contribute to incomplete
myotomy/myectomyinclude inexperience of the surgeon,
bleeding, poor surgical exposure, abnormal anatomy, and
patient discomfort when the procedure is performed under
local anesthesia. Traction testing is often performed
postoperatively as a final confirmatory test to ensure that
the procedure has been performed correctly and to detect
a residual inferior oblique band. This test is particularly
useful when the surgical view is poor.
Exaggerated oblique muscle traction testing has been
determined to be useful in several clinical situations.
Plager3described the use of traction testing in patients with
superior oblique muscle palsy to distinguish congenital
from acquired superior oblique muscle palsy. Gnyton2
reported that the single most valuable application of
exaggerated traction testing was to confirm that the
intended surgical result had been achieved following
oblique muscle surgery. The test may also be a useful
technique to help detect incomplete myectomy/myotomy
associated with multiple inferior oblique muscle insertions
(heads), although usefulness of the technique in this setting
has not yet been confirmed.
Although inferior oblique traction testing is used
clinically and considered useful by many surgeons, no
previous study has been undertaken to evaluate whether
the test really performs as expected. In other words, will
intraoperative inferior oblique muscle traction testing
detect a small residual muscle band? In seven cases with
easily detected premyotomy inferior oblique muscles,
small residual bands were easily detected. In fact, no
difference in muscle tightness could be detected until these
Journal of AAPOS
Volume I Number 4 December 1997 Coats and Paysse 199

Y
J

FIG. 2. Preparation of inferior oblique muscle, left eye, for serial traction testing (surgeon's view).
A, Placement of 4.0 silk "retrieval" sutures. B, After 50% myotomy. C, After 90% myotomy. D, After
complete (100%) myotomy. E, After completion of myectomy.

TABLE 1. Serial traction testing results

Case No.
1 2 3 4 5 6 7 8 9 10
0% Myotomy +0.5 +1.5 +1 +1.5 +1 +2 +2 +2 +1.5 +2
50% Myotomy 0 +1.5 +1 +1.5 +1 +2 +2 +2 +1.5 +2
90% Myotomy 0 +1.5 0 +1.5 +1 +2 +2 +2 +1.5 +2
100% Myotomy 0 0 0 0 0 0 0 0 0 0
Diagnosis SOP 100A SOP SOP SOP 100A 100A 100A SOP SOP
Age (yr) 46 2 34 36 70 7 * 2 78 8
Sex M M M M F F * M F F
SOP,Superiorobliquemusclepalsy;IOOA, primaryinferiorobliquemuscleoveraction.
*Cases6 and 7 representtwo eyesof samepatient.

muscles had been completely transected. However, in two
of three cases with loose premyotomy inferior oblique
muscles, residual bands could not be detected. One such
band comprised 50% of the inferior oblique muscle width,
whereas the other comprised a 10% residual band. These
residual bands theoretically could render the procedure
ineffective.
The reason(s) these residual bands were not detected
with traction testing is unclear. Perhaps the loose residual
inferior oblique band slips forward on the globe as the
globe is retroplaced for traction testing. If this were to
occur and the band were to slip anterior to the axis of
rotation of the globe during traction testing, the band
could become difficult or impossible to detect. Alterna-
tively, the explanation may simply be that the residual
bands in these two cases were so loose that even with
exaggerated traction testing they were never stretched taut
enough to be detected as the globe was rotated during

200 Coatsand Paysse
traction testing. If this were the case, it would suggest that
the anterior fibers in loose inferior oblique muscles are
what presurgical traction testing is detecting. Could the
residual bands in these two cases have been missed by
ineffective traction testing, or were the authors biased?
Testing was not done in a masked fashion and these are
certainly reasonable arguments. However, Guyton2 dem-
onstrated that the technique of exaggerated traction testing
is relatively easy to learn, and the authors had performed
exaggerated traction testing on several hundred eyes before
beginning the study. Additionally, traction testing was
repeated several times in an unsuccessful attempt to detect
the residual bands. We do not feel therefore that testing
error or bias played a role.
We believe that direct visual inspection of the posterior
aspect of the inferior oblique muscle prior to myotomy/
myectomyisthe best means for ensuring that the entire width
of the inferior oblique muscle has been hooked, thus ensuring
a complete transection. Traction testing, however, remains a
Journal ofAAPOS
Volume 1 Number 4 December 1997
useful tool as a second adjunctive confirmatorytest, especially
in situations where the surgical view is suboptimal or the
surgical anatomy is abnormal. Inferior oblique traction
testing is a useful and effective means of detecting incomplete
inferior oblique transection in patients with normal to tight
premyotomy inferior oblique muscles but can be misleading
in patients with loose premyotomy muscles. Preoperative
traction testing should be performed, so that the results of
post-myectomy/myotomy traction testing can be properly
compared. This test should be interpreted with caution in
patients with loose preoperative inferior oblique muscle.
References
I. Helveston EM. Surgical management of strabismus. 4th ed. St.
Louis: Mosby-Year Book; 1993.
2. Guyton DL. Exaggerated traction test for the oblique muscles.
Ophthalmology 1981;88:1035-40.
3. Plager DA. Tendon laxity in superior oblique palsy. Ophthalmology
1992;99:1032-8.