A 80-year-old female presented with bilateral decreased vision for 2 years and an outward deviation of the right eye since childhood. Examination found right exotropia greater than 50 degrees. She underwent a true muscle transplantation procedure of the right eye which involved resection of the medial rectus muscle and suturing the stump to the lateral rectus muscle after its disinsertion and recession. This technique allows correction of large-angle strabismus in one eye and results in normal eye movements postoperatively, compared to supramaximal recessions which can limit eye movements. True muscle transplantation is a simple, safe, and effective procedure for large-angle strabismus correction.

1. True muscle transplantation for large angle
squint management
Case presentation
Dr . Amr Mohamed
MBBS, CABoph, JBO, FICO
Pediatric ophthalmologist
German Eye Center – Al Mukalla
Acknowledge Dr.Vidhya C , Sankara Eye Hospital -Bangalore

2. Case report
• 80 year old , female , not known to have any chronic illnesses.
• Presented to the clinic with complaints of bilateral decreased
vision since 2 years and outward deviation of the right eye since
childhood.
• Decreased vision is progressive painless , no history of eye
trauma.
• Outward deviation is the same according to the patient , no
history of diplopia.
• No history of using glasses , patching , surgical interventions or
using eye drops.
• No family history of squint.

3. Case report
On Examination :
• VA = CF @ 3 meters OU.
• BCVA= 6/60 OD , 6/36 OS.
• Anterior segment = Bilateral NS+3 / CC.
• IOP = 14 mm.Hg OU.
• Posterior segment = within normal limits .

4. Case report
• Motility examination :
• Fixation : CSM OD , CSUM OS.
• right exotropia > 50 degrees on Hirschberg test .
• right exotropia = 115 PD on krimsky test .
• Full EOM in OU apart from limitation of adduction in right (-1 to -2).

5. Pre-op photo

6. Intraoperatively
FDT done = Tight LR .
Operation done :
OD
MR resection 7mm +LR Recession 9 mm +true muscle
transplantion +SICS

7. Operation steps
1.Isolating medial rectus muscle

8. Operation steps
2. securing the insertion using 6-0 vicryl

9. Operation steps
3.putting another vicryl 6-0 suture at the resection as
normal resection

10. Operation steps
4.resecting the muscle stump

11. Operation steps
4.resecting muscle stump and keeping it in BSS
solution

12. Operation steps
5.completing MR resection by suturing resected muscle
to the insertion

13. Operation steps
6.isolating lateral rectus muscle

14. Operation steps
7.using 2 sutures ( single armed prolene 6-0 ) securing
the insertion

15. Operation steps
7.using 2 sutures ( single armed prolene 6-0 )
securing the insertion

16. Operation steps
8.disinserting lateral rectus muscle
9.suturing medial rectus muscle stump to lateral rectus
muscle

17. Operation steps
9.suturing medial rectus muscle stump to lateral
rectus muscle

18. Operation steps
10. completing lateral rectus muscle recession
as usual.

19. Operation steps
10. completing lateral rectus muscle recession
as usual.

20. Operation steps
10. completing lateral rectus muscle recession
as usual.

21. Pre-op and post-op photos

22. Conclusions
• True muscle transplantation is simple, safe and effective way in managing
large angle squint by operating one eye ( simultaneous squint and cataract ,
sensory squint , patient wants operation on one eye , etc..).
• Long-term results of the procedure ( up to 2 years) is documented in articles .
• Further studies and case series needed to assess the stability and titrate the
dosage/ length of stump required for correcting different squint angles.
• True muscle transplantation giving much better results in terms of normal
ductions after operation compared to supramaximal / maximal recession-
resection that usually leads to limitation of ductions .