Dissociated Vertical Deviation Research Articles

Diagnosis dan Tata Laksana Dissociated Vertical Deviation

Dissociated vertical deviation (DVD) is characterized by an upward deviation of one eye in the absence of any compensatory movement in the other eye. This condition is often seen in strabismus and can cause visual disturbances such as double vision and amblyopia. Its underlying causes are believed to be related to abnormalities of the visual pathways to control eye movements. Treatment options include observation, conservative management, and surgical intervention, depending on the severity and underlying cause.

The Frequency and Manifestations of Ocular Causes of Abnormal Head Posture

ABSTRACT Purpose To determine the frequency and manifestations of different ocular causes of abnormal head posture (AHP). Method This prospective, consecutive case series study was performed on 149 patients with ocular AHP at Farabi hospital, Iran, from February 2020 to June 2021. All patients underwent routine ophthalmic examinations. The manifestation of AHP was determined by direct observation from three viewing angles, while the patient read the smallest line on the vision chart that they could see. In front, above, and lateral gazes, observations were performed to find head tilt, head turn, and chin abnormal position, respectively. A picture with habitual AHP was taken from all patients. The amount of head tilt was measured by calculating the angle between the line that connects the lips center to the center of the eyebrows and the vertical line using the Corel Draw X7 computer software. Results The mean age of 149 patients with ocular AHP [101 (67.8%) males and 48 (32.2%) females] was 16.2 ± 12.2 (range, 2–57) years. The most common ocular sources of AHP were found to be superior oblique palsy (SOP) in 66 (44.3%) patients, 54 (36.2%) cases with Duane’s retraction syndrome (DRS), and 12 (8.1%) patients with nystagmus. Other frequent causes of ocular AHP were dissociated vertical deviation (DVD) in 5 (3.4%), A and V pattern strabismus in 3 (2.0%), and 2 cases (1.3%) in each of Brown syndrome, inferior rectus (IR) palsy, and congenital fibrosis of the extraocular muscles (CFEOM). The most common manifestations of AHP in all cases were “pure head turn” (48.3%), followed by “pure head tilt” (24.8%), “simultaneous head tilt and head turn” (20.8%), and “chin up” (6.0%). The mean head tilt among all patients with head tilt was 10.4° ± 8.9° (range, 5.0°−31.7°). Conclusion The most frequent ocular sources of AHP were SOP, DRS, and nystagmus, followed by DVD, A and V pattern strabismus, IR palsy, CFEOM, and Brown syndrome. In addition, pure head turn and pure head tilt were the most common manifestations of ocular AHP but were not always seen in the same direction or combination as previously reported with these etiologies.

Evaluation of graded recession of inferior oblique muscle for correction of different grades of V-pattern strabismus

BackgroundV pattern identification is essential for proper strabismus management. Graded recession is a tailored approach to treat inferior oblique overaction (IOOA). The aim is to evaluate the efficacy of graded recession of inferior oblique muscle for correction of different grades of V pattern.MethodsForty patients from 3 to 18 years old with V pattern strabismus and primary IOOA were evaluated by prism cover test to assess the grade of IOOA and amplitude of V-pattern. Graded recession of IO muscle depends on the amplitude of the V-pattern and degree of IOOA. Eight mm recession for amplitude 15 PD to 20 PD and mild IOOA (10 PD-15 PD or + 1) ,10 mm recession for amplitude 20–30 PD and moderate IOOA (15–25 PD or + 2) and maximum recession for amplitude more than 30 PD and marked IOOA (≥ 25 PD or + 3). Simultaneous correction of the horizontal deviation was performed. Follow up after I week,1 month ,3 month and 6-month. Trial Registration Number (TRN) (NCT05786053) on 23/3/2023.ResultsThe mean age of the study patients was 9 ± 4.261. Twenty patients (50%) had V-pattern esotropia, 12 (30%) exotropia, 4 (10%) orthotropic and four (10%) had Dissociated vertical deviation (DVD). Four cases 10% were of grade 1, 20 cases (50%) grade 2 and 16 cases (40%) were of grade 3. Of eighty eyes, 66 eyes (82.5%) were fully corrected with no residual IOOA, and 14 eyes (17.5%) were under corrected. V-pattern was corrected in 28 cases 70% and only 12cases (30%) had residual V-pattern grade 1.ConclusionsGraded recession is an effective procedure for correction of V pattern strabismus with various grades of primary inferior oblique overaction. It can be tailored according to the the degree of IO overaction which is significantly related to the grade of V pattern. The 8 mm recession for IO was significantly related to recurrence or inadequate break of the V pattern in our studied cases. The grade of IOOA correlates with the amplitude of V-pattern. The amount of recession was planned according to preoperative IOOA and grade of V-pattern with frequent undercorrections obtained by the standard 8 mm recession. A + 2 overaction merits a 10-mm recession of the inferior oblique. A + 3 or + 4 overaction merits a 14-mm maximal recession.

Characteristics of childhood intermittent exotropia with and without DVD

ABSTRACT Purpose: Although dissociated vertical deviation (DVD) is reported to occur rarely in children with intermittent exotropia (IXT), little is known regarding the clinical features of these children. The purpose of this study was to compare the demographic and clinical characteristics of children with intermittent exotropia and DVD to those without DVD. Methods: The medical records of all children diagnosed with intermittent exotropia at our institution from 1 January 2002, through 31 December 2018, who had 2 or more exams with 3 or more assessments of control, were retrospectively reviewed. Exotropic children with DVD were compared to those without DVD. Results: During the 17-year study period, 115 children met the inclusion criteria, of which 25 (21.7%) had DVD. Compared to the 90 exotropic children without DVD, children with IXT and DVD were more likely to have a motility disorder (p = .021), a worse mean distance control score (2.8 vs 2.4; p = .09), a larger mean angle of deviation (27.8 prism diopters [PD] vs 25.1 PD; p = .04), and a lower median stereopsis (200 secs vs 100 secs; p = .08). The children with DVD were more likely to have undergone surgery (p = .17) although there was no difference in the mean age at initial surgery between the two groups. Conclusions: The presence of dissociated vertical deviation in children with intermittent exotropia is associated with more motility disorders and worse binocular function compared to those without DVD. These children will likely require closer observation and earlier intervention.

Occurrence and subsequent development of vertical deviations in patients treated surgically for infantile esotropia.

The purpose of this study was to evaluate the onset of dissociated vertical deviation (DVD) and inferior oblique overaction (IOOA), their subsequent development, and their correlation with pre and postoperative parameters. Medical records of patients with infantile esotropia who underwent surgery between 2005 and 2017 were retrospectively reviewed. DVD and IOOA were measured before and after surgery. Patients were divided into two groups based on horizontal and vertical deviation at the time of presentation: those with infantile esotropia only (group A) and patients with infantile esotropia who developed vertical deviation (group B). Out of a total of 102 patients, DVD occurrence was seen in 53 patients (51.9%) and IOOA was seen in 50 patients (48.04%). DVD was seen in 22 patients at the time of initial examination and in 31 patients postoperatively. IOOA at presentation was seen in 45 patients (44.1%) and 5 patients (8.8%) postoperatively. No statistical difference was found in the age of surgery, angle of deviation, mean follow-up, and mean refractive error within both groups. The postoperative motor outcome was statistically comparable between the two groups (P = 0.29). Sensory outcomes of fusion (P = 0.048) and stereopsis (P-value = 0.00063) were better in group A. No correlation was found between the age of occurrence and development of vertical deviation with refractive error, angle of deviation, age, or type of surgery. We found that motor outcomes are not affected but sensory outcomes are affected in patients with vertical deviations. This indicates that DVD and IOOA are developed due to inherent disruption of fusion and stereopsis.

Clinical features of Helveston syndrome and discussion of individualized surgical design.

Reasonable personalized surgical design can achieve good treatment results for Helveston syndrome in one surgery, reducing the psychological and economic burden on patients. This article aims to explore the clinical characteristics of Helveston syndrome and the clinical effectiveness and feasibility of individualized surgical design. In this retrospective case series study, 28 patients who underwent strabismus correction for Helveston syndrome at the Affiliated Hospital of Yunnan University from June 2018 to December 2020 with complete follow-up data were enrolled. Preoperatively, all patients received standard assessment of vision, intraocular pressure, slit lamp, fundus and refractive status, excluding other eye diseases, as well as detailed special examination of strabismus. These patients were divided into two groups according to the surgical modality: the horizontal muscle surgery alone group and the horizontal muscle surgery combined with superior oblique muscle surgery (combined surgery) group. We used SPSS software for data analysis and compared the postoperative eye position, eye movement, success rate, and reoperation rate between these two groups. Clinical measurement data were compared and analyzed with Fisher's exact test for count data, the t-test for normally distributed measurement data, and the Mann-Whitney U test for non-normally distributed measurement data. P<0.05 was considered statistically significant. This study included a total of 28 patients with Helveston syndrome, including 20 males and 8 females. The average age at the time of surgery is 12.04 ± 8.67 years (range, 4-43 years). The postoperative A-pattern degree was significantly greater in the group undergoing horizontal muscle surgery alone [6.23±1.31 prism diopters (PD); range, 0-10 PD] than in the group undergoing combined surgery (0.53±0.32 PD; range, 0-4 PD; P=0.002). Superior oblique muscle overactivity was significantly reduced in the combined surgery group (0.20±0.11+; range, 0-1+) compared to the horizontal muscle surgery alone group (1.31±0.26+; range, 0-2+; P=0.002). However, there was no significant difference in success rate or reoperation rate between the two groups. Additionally, after combining the recession of the superior rectus muscle with the horizontal muscle, the number of A-pattern degrees was greatly reduced. Helveston syndrome can be improved using a personalized surgical design according to the degree of external strabismus A-pattern, superior oblique muscle overaction, and dissociated vertical deviation (DVD) degree, which improves the success rate of single surgery.

Horizontal recti-down displacement for unilateral dissociated vertical deviations – A case series

This is a case series of 3 patients of comitant horizontal deviations with unilateral dissociated vertical deviations (DVD) who underwent half tendon down displacement of horizontal recti during recession resection surgery. Out of these 3 patients, 2 had exotropia and 1 had esotropia. The mean horizontal deviation preoperatively was 31.6 ± 7.6 prism diopters (PD) and post-operatively was 3.0 ± 2.6 PD. Mean preoperative DVD was 11.3 ± 1.1 PD which had a near-complete resolution in all patients. No increase in DVD of the other eye was noticed in any of the patients. None of the patients required second surgery for correction of horizontal deviation or DVD. The DVD was corrected in all patients with no complications. Half tendon down displacement with recession and resection surgery of horizontal recti is effective in the correction of unilateral DVD in selected patients.

Alterations in Cortical Thickness in Children with Congenital Strabismus and Dissociated Vertical Deviation

Introduction: Little is known about the morphometric changes that occur in the cerebral cortex of children with congenital strabismus and Dissociated Vertical Deviation (DVD). Mathematical morphology provides the opportunity to discover alterations in cortical thickness. Objective: Identify and measure differences in cortical thickness in children with congenital strabismus and DVD. Materials and Methods: Twenty-two MRI brain studies were conducted, each comprising 120 sagittal slices of 1 mm. A cohort of 11 healthy children formed the control group, and a cohort of 11 children with congenital strabismus and Dissociated Vertical Deviation, both in Dissociated Esotropia and Dissociated Exotropia formed the case group. Differences in cortical thickness between both groups were compared and identified using the FreeSurfer suite. Subsequently, areas of interest were analyzed using the ImageJ program to determine density, area, size, and pixel quantity in these regions. Study results are presented through tables and figures. Results: Twelve inflated brain projections were obtained from 2640 MRI images. Thickness differences between both groups exhibited three areas with significant morphometric changes: the Left Angular Gyrus, Left Supramarginal Gyrus, and Right Pars Opercularis. Discussion: Children with congenital strabismus and DVD showed changes in cortical thickness that could be identified and measured through Voxel-Based Morphometry (VBM). It is plausible to consider that these changes are related to suppression, aiming to avoid diplopia.

Muscle fenestration in vertical rectus muscle surgeries.

To evaluate the outcome of fenestration of the vertical rectus muscles in correcting vertical deviations. A retrospective chart review was conducted on patients who underwent fenestration surgery on the superior rectus (SR) or inferior rectus (IR) muscles. Ductions, versions, angle of deviations before and after surgery, and surgical details were analyzed. Success was defined as vertical alignment within 4 PD of orthophoria. Nineteen patients were identified. The mean age of the patients was 19.3 ± 13.1 (range; 4 to 48) years. The mean follow-up was 6.5 ± 2.7 (range, 3 to 12) months. Eleven patients presented with dissociated vertical deviation (DVD), 2 patients with sensory hypertropia, and 6 patients with sensory hypotropia. Fourteen patients had concomitant horizontal muscle surgery. The mean change of the angle of deviation was 13 ± 3 (range, 8 to 20) PD after SR fenestration. and 12 ± 2 (range; 10 to 15) PD after IR fenestration. There was a significant improvement in the post operative angle of deviation in both groups (P value <0.001). Success was achieved in 10 (77%) of patients who underwent SR fenestration and in all patients underwent ir fenestration. Only one patient in the IR group developed a 1-mm lower lid retraction. Fenestration of the vertical rectus muscles is an effective and safe method for correcting vertical deviations. We recommend increasing the amount of fenstration in DVD to further improve the outcome.

Treatment of Dissociated Vertical Deviation by Combined Recession–Resection of the Superior Rectus Muscle versus Recession with Posterior Fixation Suture

Background: Management of dissociated vertical deviation (DVD) is still a matter of controversy in strabismus practice. Different surgical techniques are available, ranging from the weakening of the superior rectus or inferior oblique muscles to strengthening of the inferior rectus muscle, with variable success rates. Objective: To report the outcomes of correcting DVD by combined recession-resection of the superior rectus muscle and to compare the results with those of superior rectus muscle (SR) recession with posterior fixation sutures. Methods: The medical records of patients who had a surgical correction for DVD were retrospectively reviewed. Two groups of patients were identified; Group I (29 patients) was treated with the combined recession –resection of the SR and group II (37 patients) was treated by SR recession with posterior fixation sutures (Faden). Collected preoperative data included age, best-corrected visual acuity, presence of amblyopia, history of previous surgeries and angle of DVD. Operative data such as amount of SR recession and operative time were also extracted. The outcome measures taken at the final postoperative follow up visit included the surgical success rate which is identified as the percentage of patients with absent manifest DVD and the amount of residual latent deviation measured by prism cover test. Results: The mean follow-up period for all patients was 22.6 ±4.6 months. In the last follow-up visit, the surgical success rate was 76% in the combined recession-resection group and 73% in the faden group with no significant difference between both groups (p=0.8). No significant difference was found in the residual latent deviation in both groups as well. The recorded surgical time was significantly shorter in the combined recession- resection group (p&lt;0.001). The reported complications included mild, temporary limitation of elevation without hypotropia in 5 patients (2 in group I (7%) and 3 patients in group II (8%)) with no significant difference between both groups (p=0.8). Conclusion: Combined recession-resection of SR is as effective as SR recession with posterior fixation suture in the management of DVD with the advantages of easier technique and less surgical time.

Different Surgical Approaches for treatment of isolated dissociated vertical deviation without inferior oblique overaction.

To report the surgical results on superior rectus recession (SRR) and inferior oblique anterior transposition (IOAT) for cases with isolated bilateral dissociated vertical deviation（DVD）without inferior oblique overaction (IOOA). A retrospective review was conducted for cases with isolated bilateral DVD without IOOA who were surgically treated using either bilateral SRR (SRR group) or IOAT (IOAT group). Pre- and post-operative ocular motility, ocular alignment, amount of DVD and complications were compared between the two groups. Records from 37 cases were reviewed. Preoperative levels of DVD (M ± SD) in the SRR group (N = 18) of 19.88 ± 6.72 prism diopter (PD) in the right eye and 19.54 ± 5.64 PD in the left eye, were reduced to 4.94 ± 7.26 PD and 4.11 ± 3.91 PD respectively after surgery (P＜0.0001 for both). Preoperative levels of DVD (M ± SD) in IOAT group (N = 19) of 15.89 ± 6.35 PD in the right eye and 18.58 ± 9.27 PD in the left eye, were reduced to 3.42 ± 4.49 PD and 3.42 ± 4.88 PD respectively after surgery (P＜0.0001 for both). Inferior oblique (IO) muscle function remained normal after surgery. Overall, outcomes within the SRR group revealed that 10 patients showed a complete resolution of their condition, 6 effective responses and 2 failures. In the IOAT group, 13 patients showed a complete resolution of their condition, 5 effective responses and 1 failure. There were no statistically significant differences between the two groups (Z = 0.48). SRR and IOAT were both effective in treating isolated DVD without IOOA with similar satisfactory results obtained for both procedures.

Early and late effects of botulinum toxin in infantile esotropia

AbstractPurposeTo observe the short‐ and long‐term effects of botulinum toxin in infantile esotropia.MethodsBetween February 26th of 2013 and January 27th of 2015, botulinum toxin was injected transconjunctival to bimedial rectus of 5 patients. Following, one patient was checked regularly until their 8th year, one 9th month, one 7th month, one 3rd month, one 1st month. During their regular follow‐up parents were instructed to patch the dominant eye either in consecutive exotropia or esotropia phases. And also, they were assisted on glass prescription. Further, patients were seen again between their 78th and 96th months to find out their current visual acuity and to observe if they had any late term accompanying squints.ResultsBased on our observation derived from the follow‐ups: After the 3rd month on the horizontal plan, orthophoria on 2 patients, monocular esotropia on 2 patients and orthophoria with dissociated horizontal deviation (DHD) developed on 1 patient. On exotropia stage, for 3 hours a day patching was applied on the dominant eye. Inferior oblique muscle hyperfuction (IOHF) developed on all the patients at the earliest 2nd month and at the latest 7.5th year. Dissociated vertical deviation (DVD) and latentnystagmus did not develop on any patient, DHD developed on 1 patient. On the last examination, patients’ visual acuities were determined. On the orthophoric ones who had IOHF development: on his 7.5th year had 1.0/1.0 visual acuity, on her 9th month had 0.4/0.6 visual acuity, and on her 2nd month had 0.2/0.2 visual acuity. In this state, there seems to be an inverse proportion between visual acuity and IOHF development. Monocular esotropia ones: on the strabismic eye 0.1, on the dominant eye full vision was described. These patients were not compliant on their follow‐ups so when IOHF development happened was not determined.ConclusionIt seems botulinum toxin injection gives a chance for restoration of visual immaturity, and by this way infantile esotropia can be made to behave almost similarly to acquired esotropia.

Surgical management of Helveston syndrome (Triad exotropia)

PurposeTo evaluate and compare different surgical approaches for the treatment of Helveston syndrome and provide further information for preoperative planning.MethodsFrom February 2008 to December 2018, data of 52 patients with Helveston syndrome were retrospectively reviewed. Different surgical approaches were selected based on the extent of A-pattern exotropia, dissociated vertical deviation (DVD), and both superior oblique muscle overaction (SOOA) with fundus photograph intorsion. Eye position, A-pattern, DVD, superior oblique muscle function, and binocular vision function were evaluated pre- and postoperatively. The average follow-up duration was 20.5 months.ResultsNine cases underwent simultaneous horizontal deviation correction with bilateral superior rectus recession, 24 underwent simultaneous horizontal deviation correction with bilateral superior oblique muscle lengthening, and 19 underwent two stages of horizontal deviation correction with superior oblique muscle lengthening, and later bilateral superior rectus recession. A-pattern, DVD, SOOA, and fundus intorsion were all collapsed in all patients postoperatively. Forty-five patients had an orthophoric eye position with considerably aligned ocular movements postoperatively. The total success rate was 86.5%. Postoperatively, eight of the 10 patients with diplopia experienced a recovery of binocular single vision and three had a recovery of rudimentary stereopsis (Titmus 3000–400 s of arc). The compensatory head posture of patients improved significantly postoperatively.ConclusionsThe surgical planning of Helveston syndrome should be designed based on the degree of the A-pattern, SOOA, DVD, and the intorsion in fundus photographs, and the appropriate approach should be selected to improve patient satisfaction.

Stereopsis in children with intermittent exotropia and dissociated vertical deviation

Dissociated vertical deviation (DVD) is generally associated with early-onset esotropic strabismus and poor stereopsis. It is infrequently observed among patients with intermittent exotropia. In this cohort of 242 consecutive children with intermittent exotropia examined over a 17-year period, 25 (10.3%) were found to have DVD, 13 (52%) of whom had normal stereopsis. In the children with both intermittent exotropia and DVD, disease severity appears to depend more on the quality of stereopsis than on the presence of DVD.

Congenital ocular counter-roll: a review of cases treated exclusively by ophthalmologists.

To review the demographics, clinical manifestations, and surgical experiences of patients with congenital ocular counter-roll, whose treatments were performed exclusively by ophthalmologists. A retrospective review was conducted consisting of patients who received strabismus surgery between 2017 to 2019. Patients with obvious ocular counter-roll were included. A total of 7008 patients who received strabismus surgery, 28 (12 males, 16 females) were diagnosed as congenital ocular counter-roll, accounting for 0.40%. All patients were initially misdiagnosed: 21 patients were misdiagnosed as superior oblique palsy (SOP), 3 as inferior oblique overaction, 2 as dissociated vertical deviation (DVD), 1 as superior oblique overaction with A-pattern exotropia, and 1 as medial rectus palsy. The mean±SD age was 12.4±9.4y (range 2.5-36y). The most common clinical findings included ocular counter-roll, vertical deviation or vertical deviation combined with outward deviation and head tilt. At follow-up, an excellent surgical result was achieved in 20 patients. Preoperative horizontal deviation of 26±24 prism diopter (PD) and vertical deviation of 18±12 PD were reduced to 0±12 PD (P=0.0001) and 3±4 PD (P=0.001), respectively. Congenital ocular counter-roll is a rare supranuclear vertical strabismus caused by congenital abnormalities involving vestibule-ocular reflex pathways. In addition to ocular counter-roll, the most salient clinical features included, but are not limited to, hyperdeviation, outward deviation, overelevation in adduction and head tilt.

Anterior and nasal transposition of inferior oblique muscle

We report the case of a 20-year-old woman who presented with residual esotropia, dissociated vertical deviation (DVD), and inferior oblique over-action (IOOA) who underwent horizontal rectus muscle surgery and anterior and nasal transposition of the inferior oblique muscle. Postoperatively, she was orthotropic and showed resolution of DVD and IOOA providing an excellent motor outcome.

Surgical outcomes and occurrence of associated vertical strabismus during a 10-year follow-up in patients with infantile esotropia.

Purpose:Authors analyzed long-term surgical outcomes of infantile esotropia and the occurrence of associated strabismus, inferior oblique overaction (IOOA), and dissociated vertical deviation (DVD). Clinical factors related to the occurrence of IOOA and DVD in patients with infantile esotropia were also evaluated.Methods:Medical records of patients with infantile esotropia, who underwent surgery between 1995 and 2008, were reviewed retrospectively. Included patients were followed for at least 10 years. The incidence and age at development of IOOA and DVD were analyzed. To evaluate predisposing factors for developing IOOA or DVD, patients were divided into two groups: those with infantile esotropia only (group A) and those who developed IOOA or DVD (group B).Results:A total of 122 patients were enrolled and mean follow-up period was 16.0 years (range: 10–32 years). The mean number of surgeries was 1.7 (range: 1–5), and 64 (52.5%) patients achieved optimal horizontal alignment (esotropia <10 prism diopters [PD] and orthotropia). Fifty (41.0%) patients developed IOOA at a median age of 3 years (range: 1–21 years); 54 (44.3%) developed DVD at a median age of 5 years (range: 1–25 years). Patients in group B underwent more horizontal surgeries than those in group A (P = 0.028), and favorable surgical outcomes between the two groups were not different at final visit. There were no other significant differences in clinical factors between the two groups.Conclusion:Approximately, 52.5% of patients achieved favorable surgical outcomes through 1.7 surgeries during the 10-year follow-up period. DVD tended to develop at a later age than IOOA, and in some cases, up to 20 years after diagnosis of infantile esotropia. To achieve favorable horizontal alignment at final visit, patients with associated vertical strabismus underwent more horizontal muscle surgeries than patients with infantile esotropia only. The presence of IOOA/DVD may affect horizontal alignment outcomes.

Bilateral hypotropic dissociated vertical deviation: a case report\xa0

BackgroundHypotropic dissociated vertical deviation (DVD) is a special form of strabismus characterized by a slow drift of the non-fixating eye when the other eye is fixating on a target. In contrast to hypertropic DVD, which is common, hypotropic DVD is exceedingly rare and seldom reported in previous literature. In this case, we report the clinical features of a rare case of a Syrian child with bilateral hypotropic DVD accompanied by manifest latent nystagmus and intermittent exotropia.Case presentationA 4-year-old Syrian Arab girl presented with intermittent exotropia of both eyes since the age of 7 months, without any prior treatment. The fixation was alternating. She had manifest latent nystagmus in both eyes and anomalous head posture. She had bilateral hypotropic DVD in both eyes which only appeared when covering each eye. The patient underwent bilateral lateral rectus recession with posterior fixation and bilateral inferior oblique recession. Three months after surgery, she was orthophoric in the primary gaze position with a normal head posture. No alteration of the appearance of the hypotropic DVD was observed after the surgery.ConclusionThis is a rare case of hypotropic DVD showing bilateral hypotropic DVD with different characteristics from those previously reported cases (bilateral hypotropic DVD with intermittent exotropia, dissociated horizontal deviation, manifest latent nystagmus, and bilateral inferior oblique overaction). The hypotropic DVD only appeared when covering each eye, and thus there was no need for surgery. Moreover, the inferior oblique recession did not seem to negatively affect the appearance of the eyes.

Heimann-Bielschowsky phenomenon and hypotropic DVD in case of monocular vision loss: a case report

BackgroundThe Heimann-Bielschowsky phenomenon (HBP) is an underrecognized condition characterized by slow, pendular, vertical oscillations of the eye accompanying monocular vision loss. Hypotropic dissociated vertical deviation (DVD) is another rare condition induced by asymmetric visual input. This report documents a rare case of HBP with hypotropic DVD.Case presentationThis report describes a case of a 58-year-old woman with HBP and hypotropic DVD, having suffered monocular vision loss in the left eye due to blunt trauma at the age of 10. Preoperatively, she was orthophoric at near fixation and demonstrated an intermittent, slow hypotropia of the left eye upon distance fixation that never rose above the midline. She underwent a 7 mm recession of the inferior rectus muscle in the left eye. After surgery, intermittent, downward drifts became constant vertical oscillations at both distance and near fixation.ConclusionsThis case describes the clinical manifestation of an eye movement disorder related to prolonged monocular vision loss.

The effects of simultaneous operation on dissociated vertical deviation with horizontal and torsional strabismus.

To investigate the therapeutic effects of simultaneous horizontal and vertical operations on dissociated vertical deviation (DVD) associated with other deviations. Forty-five cases of DVD with horizontal and torsional strabismus underwent combined operation were collected retrospectively. All clinical records were analyzed. All patients were followed up for 6 to 24mo. Wilcoxon signed-ranks test was performed to evaluate the changes of vertical and horizontal deviation. χ 2 test was used to evaluate the changes of binocular visual function. Forty-five cases included 36 patients with intermittent exotropia and binocular inferior oblique overaction (IOOA), 5 patients with concomitant esotropia and binocular IOOA, 4 patients with intermittent exotropia and monocular superior oblique palsy. The superior rectus recession (SRR) combined with horizontal rectus recession and the myectomy of inferior oblique or anterior transposition were operated simultaneously to correct all types of strabismus. There were 43 cases who achieved normal eye position in vertical direction, while 2 cases were with undercorrection of 5Δ to 6Δ. In patients with horizontal strabismus, 2 cases of exotropia were with overcorrection of 6Δ to 8Δ, 1 case of esotropia was with undercorrection of 6Δ, and 1 case of monocular superior oblique palsy with compensatory head posture was not significantly improved. The binocular visual function of most patients recovered after operation. The difference of the binocular visual function and eye position were significant compared with that before operation (P<0.05). The simultaneous operation on DVD with horizontal and torsional strabismus is successful.