Reduction In Vertical Deviation Research Articles

Teprotumumab for Thyroid Eye Disease-related Strabismus.

To assess and quantify teprotumumab's effect on thyroid eye disease-related strabismus by change in measured horizontal and vertical deviations and change in extraocular motility. We reviewed a series of patients with thyroid eye disease-related strabismus treated with teprotumumab. Exclusion criteria included age under 18 years, strabismus of alternate etiology, or thyroid eye disease-related reconstructive surgery during the treatment course. Primary outcomes were absolute (prism diopters) and relative (%) differences in horizontal and vertical deviations in primary position at distance, as well as change in ductions of the more affected eye. Secondary outcomes included incidence and timing of strabismus surgery postteprotumumab. Thirty-one patients were included, with mean age 63 years and thyroid eye disease duration 10 months. After teprotumumab, there was 6 prism diopters (39%) mean reduction in vertical deviation ( p < 0.001), without significant change in mean horizontal deviation ( p = 0.75). Supraduction, abduction, adduction, and infraduction significantly improved in the more restricted eye ( p < 0.01, p < 0.01, p = 0.04, and p = 0.01, respectively). Thirty-five percent of patients underwent strabismus surgery posttreatment, at an average 10 months after last infusion. Teprotumumab produced a statistically significant reduction in vertical but not horizontal strabismus angles in primary position at distance. Extraocular motility in all 4 ductions also improved. A substantial minority of patients still required strabismus surgery following teprotumumab.

Effect of inferior oblique muscle belly transposition on versions and vertical alignment in primary position.

To evaluate the effect of inferior oblique muscle belly transposition (IOBT) on vertical deviation (VD) in primary position and inferior oblique overaction (IOOA). Twenty-eight patients who underwent unilateral IOBT for mild hypertropia (≤ 10△) due to unilateral IOOA were included. Surgical results regarding the correction of hypertropia, IOOA, and fovea disc angle (FDA) were analyzed and compared between groups A (VD ≤ 5△) and B (5△ < VD ≤ 10△). IOBT showed an overall reduction of 5.86△ (± 2.24△) of primary position VD, a mean correction of 1.00 (± 0.27) of IOOA, and an average change of 1.83° (± 3.02°) of FDA. The surgical success rate of IOBT for VD correction and IOOA elimination in all patients was 68% and 71%, respectively. The correction of VD was correlated with preoperative VD significantly (r = 0.86, p < 0.001). Consistently, IOBT demonstrated comparable efficacy in reduction of VD between group A and group B (p = 0.507). Furthermore, the two groups were comparable in the success rates for correcting VD and IOOA (both p > 0.05). None of the patients developed consecutive hypotropia, postoperative contralateral IOOA, or anti-elevation syndrome postoperatively. IOBT achieved satisfactory outcomes in patients with mild primary position VD (≤ 10△) that is associated with unilateral IOOA, without any risk of overcorrection of VD and contralateral IOOA for a follow-up period of up to 12months. This procedure is considered effective and safe alternative for weakening the IO in patients with appropriate surgical indications.

Results after graded recession of inferior oblique muscle in strabismus sursoadductorius

Introduction: Idiopathic strabismus sursoadductorius is characterized by an overaction of the inferior oblique (IO) muscle, with elevation of the eye in adduction. This can result in chronic headache, eye pain, diplopia and abnormal head posture. Aim: Presentation of clinical results after graded recession of inferior oblique overaction (IOOA) in strabismus sursoadductorius. Method: During a period of 6 years (2012-2017) we performed a dosed transposition of IO muscle in 53 patients in the Department of Ophthalmology of the Semmelweis University and analyzed the clinical results retrospectively. The mean age was 12.8, min-max: 2-51 years. The transposition of the muscle (8 mm, 10 mm or maximal) was performed because of IOOA and was planned depending on the vertical deviation (VD) in maximal adduction. In case of maximal transposition, the insertion of IO was placed under the lateral part of the lower rectus muscle. We evaluated the squint angle in five positions of gaze preoperatively and postoperative 1 week, 1 month and 3-6 months. We examined best corrected visual acuity, binocular vision and complications after surgery. Results: Postoperatively 25 patients had acceptable stereopsis (Titmus 5). Visual acuity remained stable after surgery in all cases. The VD measured in maximal adduction changed with a decrease of 7.5° when 8 mm transposition was performed, and changed with a decrease to 12°, when maximal recession was performed. The mean reduction of VD was 17.8 prism dioptres (PD) after 1 week (p<0.01), 20.5 PD after 1 month and remained stable during a follow-up of 3-6 months. Conclusion: Graded recession of inferior oblique muscle is a suitable proposed procedure in patients with marked strabismus sursoadductorius. The rates of functional under- or overcorrection or other complications are low. Orv Hetil. 2019; 160(27): 1064-1069.

Surgical interventions for vertical strabismus in superior oblique palsy.

Superior oblique palsy is a common cause of vertical strabismus in adults and children. Patients may be symptomatic from binocular vertical diplopia or compensatory head tilt required to maintain single vision. Most patients who are symptomatic elect to undergo strabismus surgery, but the optimal surgical treatment for vertical strabismus in people with superior oblique palsy is unknown. To assess the relative effects of surgical treatments compared with another surgical intervention, non-surgical intervention, or observation for vertical strabismus in people with superior oblique palsy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 13 December 2016), Embase Ovid (1947 to 13 December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 13 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 13 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 13 December 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 13 December 2016. We did not use any date or language restrictions in the electronic searches for trials. We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation. Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. We identified two randomized trials comparing four different surgical treatments for this condition, two methods in each trial. The studies included a total of 45 children and adults. The surgical treatments were all procedures to weaken the ipsilateral inferior oblique muscle. One study compared inferior oblique myectomy to recession of 10 mm; the other study compared inferior oblique disinsertion to anterior transposition (2 mm anterior to the temporal border of the inferior rectus insertion).We judged both studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Neither study reported data on the primary outcome of this review, which was the proportion of participants with postoperative surgical success, defined as hypertropia less than 3 prism diopters (PD) in primary gaze. However, both studies reported the average reduction in hypertropia in primary gaze. One study found that at 12 months' postoperatively the average decrease in hypertropia was higher in participants who underwent inferior oblique myectomy than in those who underwent recession, however data were not available for statistical comparison. The other trial found that after at least six months of follow-up, the mean decrease in primary position hypertropia was lower in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (mean difference (MD) -5.20 PD, 95% confidence interval (CI) -7.76 to -2.64; moderate-quality evidence).Both trials also reported the average postoperative reduction in vertical deviation in adduction. One study reported that the average reduction in hypertropia in adduction was greater in participants who underwent inferior oblique myectomy than in those who underwent recession, but data were not available for statistical comparison. The other study found a lower decrease in hypertropia in contralateral gaze in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (MD -7.10 PD, 95% CI -13.85 to -0.35; moderate-quality evidence).Secondary outcomes with sufficient data for analysis included proportion of participants with preoperative head tilt that resolved postoperatively and proportion of participants who underwent a second surgery. These outcomes were assessed in the trial comparing inferior oblique anterior transposition to disinsertion; both outcomes favored anterior transposition (risk ratio 7.00, 95% CI 0.40 to 121.39 for both outcomes; very low-quality evidence). None of the participants who underwent inferior oblique anterior transposition or disinsertion developed postoperative hypotropia or reversal of the vertical deviation. All participants who underwent inferior oblique anterior transposition developed elevation deficiency, which the authors deemed to be clinically insignificant in all cases, whereas no participants who underwent inferior oblique disinsertion experienced this complication. Additionally, the trial comparing inferior oblique myectomy to recession reported that no participant in either group required another strabismus surgery during the postoperative period. The two trials included in this review evaluated four inferior oblique weakening procedures for surgical treatment of superior oblique palsy. We found no trials comparing other types of surgical procedures for this disorder. Both studies had enrolled a small number of participants and provided low-quality evidence due to limitations in completeness and applicability. We therefore found no high-quality evidence to support recommendations for optimal surgical treatment of superior oblique palsy. Rigorously designed, conducted, and reported randomized trials are needed to identify the optimal surgical treatment for vertical strabismus in this disorder.

Surgical treatment of superior oblique palsy: Predictors of outcome.

Purpose:The purpose of this study was to evaluate the incidence and outcome of surgically treated superior oblique palsy (SOP) and the factors involved in its resolution.Methods:We performed a retrospective study of 76 patients who underwent surgery for SOP. We recorded data from the physical examination and the number and type of procedures performed. Favorable outcome was defined as resolution of or improvement in torticollis (≤5°) and diplopia in primary position (PP) and downgaze or as vertical deviation (VD) <5 prism diopters (pd) in PP and 10 pd in the oblique diagnostic position.Results:Mean age was 33.12 years. Congenital SOP was the most frequent type (65.8%). Mean preoperative VD was 15.89 ± 9.94 pd, decreasing to 3.07 ± 4.36 pd after surgery. Associated horizontal deviation was recorded in 51.32% of cases. The mean number of procedures was 1.37 ± 0.62 (range 1–4), with 69.7% of patients requiring only one procedure. The mean number of muscles operated on was 1.96 ± 1.01 (inferior oblique being the most frequent). A greater reduction in VD after surgery was observed in patients with congenital SOP (P = 0.04). Although none of the factors evaluated influenced surgical outcome, amblyopic patients had a greater risk of reoperation (P = 0.04). A favorable outcome was achieved in 75% of cases. Mean follow-up was 37.08 months.Conclusion:Congenital SOP was twice as frequent as acquired SOP and although surgery was successful in most cases, a greater reduction in VD was obtained in congenital cases. Amblyopia was identified as a risk factor for reoperation.

Operative Behandlung der erworbenen Trochlearisparese

Various surgical procedures are recommended as treatment for trochlear nerve palsy. Recession of the inferior oblique muscle (IOR), tucking or advancement of the superior oblique tendon, combination of both procedures (COP), and recession of the contralateral inferior rectus muscle are recommended. In this study, the effects of IOR and COP were compared. Patients with isolated acquired unilateral trochlear nerve palsy were examined at a distance of 2.5 m from the Harms tangent scale before and 3 months after surgery. The onset of the palsy was 1-35 years previously (median 2 years). Subjective squint angles without diagnostic occlusion were measured with a dark red glass in front of the nonparetic eye. The field of binocular fusion was determined with an additional light bar and Bagolini striated glasses for control. The head-tilt phenomenon was defined as the difference between the vertical deviations at 45 degrees of head tilt to the right and to the left. For statistics, squint angles of left-sided palsy were transformed corresponding to palsy on the right side. The vertical and cyclodeviations were similar before IOR (n=13) and COP (n=21). The reduction of vertical deviation by IOR vs. COP was (median and range) 3 degrees (1; 9) vs. 6 degrees (0; 14) in primary position (PP), in side gaze 5 degrees (1; 11) vs. 9 degrees (3; 17), and in down gaze 3 degrees (-7; 11) vs. 8 degrees (2; 16). Excyclodeviation in down gaze was reduced by 4 degrees (-4; 11) vs. 7 degrees (0; 14), and the head-tilt phenomenon was improved by 1.5 degrees (-5; 7) vs. 6 degrees (-8; 14). Three months after surgery there was residual hyperdeviation of 1 degrees (0; 6) vs. 0 degrees (-7; 5) with excyclodeviation of 2 degrees (-2; 5) vs. 1 degrees (-2; 4) in PP, increasing to 2 degrees (-1; 8), ex 1 degrees (-1; 8) vs. 0 degrees (-8; 5), ex 1 degrees (-2; 5) in contralateral side gaze, and 6 degrees (-3; 13), ex 2 degrees (1; 9) vs. +1 degrees (-1; 8), ex 1 degrees (-4; 10) in down gaze. COP caused more or less significant Brown's syndrome. A second surgery was performed in one patient (4%) after COP. Augmenting surgery was done in four patients (22%) after OIR. Cyclovertical deviation and head-tilt phenomenon were significantly reduced when recession of the inferior oblique muscle was combined with tucking of the superior oblique tendon. To permanently minimize squint angles and abnormal head posture, initial postoperative incyclodeviation is necessary, which decreases during subsequent months due to both purely mechanical factors and modulation of cyclovertical innervation. Patient discomfort caused by this may be an argument to perform IOR as an initial procedure with fewer side effects but also fewer effects that may require further treatment.

Correction of Ptosis or Pseudoptosis in Congenital Double Elevator Palsy by Either Extraocular Muscle or Lid Surgery

Fifteen of 19 patients diagnosed with double elevator palsy (DEP) assocaited with ptosis or pseudoptosis underwent surgical intervention including muscle transposition operation, levator resection and/or frontal suspension surgery. Surgical intervention for DEP not only achieved significant reduction in vertical deviation but also accomplished correction of pseudoptosis. In subjects with true ptosis specific ptosis surgery is essential after strabismus surgery.

Traitement chirurgical de la parésie du grand oblique

Reduction of vertical deviation and ocular torsion are the goals of any surgical treatment of superior oblique palsy. Our study (n = 70) compares different surgical approaches: Resection (Tuck) of the superior oblique, recession of the inferior oblique, combined operation on both obliques of the involved side, posterior fixation of the inferior rectus on the fellow eye, with or without simultaneous tuck of the paretic superior oblique, Harada-Ito procedure. Reduction of the vertical deviation in different directions of gaze and reduction of cyclotropia in primary position have been compared for each type of operation.

Intraoperative Suspension-Recession Technique for Treatment of Vertical Strabismus in Thyroid Myopathy

Ten patients underwent extraocular muscle surgery with an intraoperative suspension-recession technique for diplopia induced by vertical strabismus in thyroid myopathy. The average ratio of the reduction of vertical deviation to the amount of surgery was 1.8 degrees/mm (range, 1.0 degrees/mm-2.8 degrees/mm). Eight (80%) patients had single binocular vision restored in the primary position without prism or compensatory torticollis after surgery. One patient who showed evidence of abnormal thyroid function at surgery developed an overcorrection postoperatively.