Turkiye Klinikleri Journal of Ophthalmology

.: REVIEW
Monoküler Elevasyon Defisiti (Çift Elevatör Felci): Geleneksel Derleme
Monocular Elevation Deficiency (Double Elevator Palsy): Traditional Review
Serpil AKARa
aBaşkent Üniversitesi Tıp Fakültesi, Göz Hastalıkları ABD, İstanbul, Türkiye
Turkiye Klinikleri J Ophthalmol. 2022;31(3):178-86
doi: 10.5336/ophthal.2022-89399
Article Language: TR
Full Text
ÖZET
 Monoküler elevasyon defisiti (MED); paretik, restriktif ya da kombine etiyolojinin neden olduğu tek taraflı elevasyon defekti ile karakterizedir. MED, konjenital ya da akkiz başlangıçlı olabilir. MED'in konjenital vakaları sporadik olarak gelişir, fakat ikizlerde oluşan vakalar da bildirilmiştir. Akkiz MED, genellikle hipertansiyon, tromboembolizm, arterit gibi serebrovasküler hastalıklardan kaynaklanır. MED, hipotropyanın sebeplerinden biridir ve pitoz/psödoptoz ile ilişkili olabilir. Normal göz ile fiksasyon yapıldığında etkilenmiş gözde hipotropya ve etkilenmiş göz ile fiksasyon yapıldığında normal gözde hipertropya mevcuttur. MED vakalarına aynı zamanda horizontal kaymalar da eşlik edebilir. Üç horizontal pozisyonun hepsinde, yani abdüksiyon, primer pozisyon ve addüksiyonda, monoküler, orta hattın üzerine çıkmayan yukarı bakış kısıtlılığı mevcuttur. Bu, çok faktörlü bozukluğun tedavisi çeşitlidir. Hipotropyanın düzeltilmesi için bile çeşitli nedensel mekanizmalara yönelik farklı cerrahi teknikler vardır. Cerrahinin amacı, primer pozisyonda etkilenmiş olan gözün kaymasını düzeltmek ve binoküler görme alanını artırmaktır. Cerrahi olarak düzeltilmede ilk adım, MED'in restriktif veya paralitik tiplerini ayırt etmektir. Bu ayrım, inferior rektus (IR) için zorlu düksiyon testi yapılarak belirlenir. MED'de vertikal kaymayı düzeltmek için kullanılan cerrahi türleri; Knapp (standart/artırılmış/modifiye), IR geriletmesi, vertikal kas geriletme-rezeksiyon, modifiye Nishida ve tek kas transpozisyon cerrahileridir. Şaşılık cerrahisi sonrası hâlâ pitoz mevcutsa frontal askılama veya levator rezeksiyonu cerrahileri uygulanabilir. Mevcut literatür ışığında; MED etiyolojisi, klinik bulguları, ayırıcı tanısı ve uygun tedaviler açısından değerlendirildi.

Anahtar Kelimeler: Elevasyon defisiti; hipotropya; inferior rektus geriletmesi; Knapp cerrahisi
ABSTRACT
 Monocular elevation deficiency (MED) is characterized by a unilateral elevation defect caused by a paretic, restrictive, or combined etiology. MED can be congenital or acquired in onset. Congenital cases of MED occur sporadically but cases occurring in twins have been reported. Acquired MED is usually caused by cerebrovascular diseases like hypertension, thromboembolism, arteritis. MED is one of the causes of hypotropia and may be associated with ptosis/pseudoptosis. There is hypotropia of the affected eye when the normal eye is fixing and hypertropia of the normal eye when the affected eye is fixing. Cases of MED may also have co-existent horizontal deviations. Monocular limitation of up gaze above midline (horizontal plane) is present in all the 3 horizontal positions, i.e., abduction, primary position and adduction. Treatment of this multifactorial disorder is varied. Even for the correction of hypotropia, different surgical techniques exist for different causal mechanisms. The goal of surgery is to improve the deviation of the affected eye in primary gaze and to increase binocular field of vision. The first step in surgical correction of MED is to distinguish the type of MED- restrictive or paralytic. It is done by doing FDT (forced duction test) for inferior rectus. The types of surgeries used to correct the vertical deviation in MED are Knapp's (standard/augmented/modified), IR recession, vertical muscle recession-resection, modified Nishida's and single horizontal muscle transposition surgeries. If ptosis is still present after strabismus surgery, frontal suspension or levator resection surgeries can be applied. In the light of the available literature, MED has been evaluated in terms of its etiology, clinical findings, differential diagnosis, and appropriate treatment.

Keywords: Elevation deficit; hypotropia; inferior rectus recession; Knapp's surgery
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