Superior Oblique Muscle Tendon Research Articles

Clinical effect of superior oblique re-tucking for recurrent or residual compensatory head position

Objective: To evaluate the effects of re-tucking the superior oblique muscle on recurrent or residual compensatory head position. Methods: A retrospective case series study was conducted. 12 recurrent or residual compensatory head position patients (12 eyes) with congenital superior oblique palsy who underwent superior oblique re-tucking in Tianjin Eye Hospital from March 2015 to February 2021 were included. All patients had a history of superior oblique tucking procedure and showed signs of superior oblique muscle palsy without inferior oblique muscle overaction. During surgery, the Guyton forced duction test is used to evaluate the relaxation of the superior oblique muscle tendon, which affects the re-tucking length of the muscle.Their head position, vertical deviation, eye movement, fovea-disa angle, and Bielschowsky head tilt test were assessed pre-and post-surgery. Statistical analysis was performed using ttest and paired samples Wilcoxon signed rank test. Results: Out of the 12 patients, 8 were male and 4 were female, aged between 2 and 9 years. The initial surgery was done at age 6, with a superior oblique recession length of (7.17±1.03) mm. Recurrent head tilt occurred in 11 patients after (3.82±0.98) months postoperatively, and 1 patient had residual head tilt, with a followup period of six months or more. Ocular motility examination revealed underaction of the superior oblique muscle, positive Bielschowsky's head tilt test, and Guyton forced duction tese indicating relaxation of the paralyzed superior oblique muscle tendon. Scar adhesion was observed at the stop of the superior oblique muscle, as well as the previous sutures. The scar and the sutures around the stop of the superior oblique muscle were released, the mean re-tucking amount was(7.83±1.59)mm. Follow-up at 12 to 18 months postoperatively showed disappearance of compensatory head position, significant improvement in superior oblique muscle lag, normal ocular motility, and no occurrence of Brown syndrome. The results of Bielschowsky head tilt were negative in 9 cases and still positive in 3 cases after superior oblique re-tucking. The primary vertical deviation was 2.5 (2.0, 5.3) prism diopter pre-operatively and 1 (0, 1) prism diopter post-operatively, respectively. The difference was statistically significant (U=6.00, P<0.001). The total amount of FDA in both eyes was (-22.04±5.47)° and (-15.27±6.08)° pre-and post-operatively, respectively. The difference was statistically significant (t=2.87, P=0.009). All 12 patients have normal eye movement after superior oblique re-tucking procedure. All patients had no compensatory head position at last follow-up. Conclusions: Superior oblique re-tucking is suitable for patients with relaxation of the superior oblique muscle tendon and extrocular rotation as the main sign. It can effectively and safely correct the recurrent or residual compensatory head position after re-tucking the superior oblique muscle.

Brown syndrome: a literature review.

The current data on various aspects of Brown syndrome are limited and sporadic. This review provides a coherent and comprehensive review of basic features, etiology, classification, differential diagnosis, and different management strategies of patients with Brown syndrome. In this topical review, PubMed, Scopus, and Google Scholar search engines were searched for papers, published between 1950 and January 2023 based on the keywords of this article. The related articles were collected, summarized, categorized, assessed, concluded, and presented. Brown syndrome is identified by restricted passive and active elevation of the eye in adduction. The condition is divided into congenital and acquired causes. The clinical features result from a restricted motion of the superior oblique tendon sheath through the trochlea while trying to look up in adduction. The newest explanation of the underlying pathophysiology has been explained as the presence of a fibrotic strand in the superior oblique muscle tendon with variable insertion sites which creates various elevation deficits seen in Brown syndrome. The most common clinical features include the presence of an abnormal head posture, V-pattern strabismus, and hypotropia in the primary position. Management of Brown syndrome includes watchful observation, surgical, and non-surgical procedures. Some cases might resolve spontaneously without any intervention; however, some acquired cases might require systemic and/or intra-trochlear steroid administration to treat the underlying causes. Surgical procedures such as superior oblique tenectomy and using a silicon tendon expander are indicated in the presence of hypotropia and significant abnormal head posture in the primary position.

Postoperative outcomes for unilateral congenital trochlear nerve palsy: A retrospective cohort study

Congenital trochlear nerve palsy is the most common cause of vertical strabismus. The goal of this study was to investigate surgical outcomes after superior oblique tendon plication with or without inferior oblique recession in children and adults with unilateral congenital trochlear nerve palsy. Data and outcomes were collected in patients with a diagnosis of unilateral congenital superior oblique palsy during a retrospective single-center study conducted at the University Hospital of Tours. A reproducible, standard ophthalmological and oculomotor examination was performed pre- and postoperatively at 1 year, including presence or absence of diplopia, vertical and horizontal deviations, and compensatory head posture. Surgical success, defined as an endpoint including absence of diplopia in primary position, absence of head tilt, and vertical deviation at distance fixation<5 prism diopters (PD), was analyzed. A total of fifty-seven patients (median [IQR] age of 11 years [5-42]) were analyzed. Patients experienced a significant reduction in vertical distance and near deviations (p<0.001), compensatory head tilt (p<0.001), and diplopia after surgery (p<0.001). Surgical success was higher in adults (17/24, 70.8%) than in children (15/33, 45.5%), although this did not reach statistical significance (p=0.0657). This study suggests that plication of the superior oblique muscle tendon, with or without recession of the inferior oblique muscle, can be effective in treating unilateral congenital trochlear nerve palsy. Further studies are necessary to compare surgical procedures and investigate their efficacy in adults compared to children in the short and long term.

Characteristics of Guyton's exaggerated forced duction test (FDT) and torsional FDT in congenital superior oblique palsy

Objective: To investigate the characteristics of Guyton's exaggerated forced duction test (FDT) and torsional FDT in patients with congenital superior oblique palsy (CSOP) and their correlation with clinical features. Methods: This cross-sectional study included single-eye CSOP patients and intermittent exotropia (IXT) patients scheduled for strabismus correction surgery at Tianjin Eye Hospital from September 2021 to March 2022. Prior to surgery, measurements of fovea-disc angle (FDA) and maximum cross-sectional area of the superior oblique muscle (max-CSA) were obtained in both eyes of the patients. The Guyton's exaggerated FDT and torsional FDT were performed intraoperatively to assess the degree of superior oblique muscle relaxation. The characteristics of the two FDT tests and their correlation with vertical strabismus angle, FDA, and max-CSA were analyzed. Statistical analyses were conducted using t-test, ANOVA, Tukey's test, Mann-Whitney U test, and chi-square test. Results: A total of 42 patients (84 eyes) were included in the study, including 19 IXT patients (38 eyes) and 23 CSOP patients (46 eyes, 23 eyes with palsy and 23 eyes without palsy). There were no statistically significant differences in gender composition or age between the IXT and CSOP patients (all P>0.05). The degrees of superior oblique muscle relaxation measured by the Guyton's exaggerated FDT were (-2.52±1.20), (-0.35±0.71), and (-0.03±0.16) for the palsy eye, non-palsy eye, and IXT eyes, respectively, showing significant differences (F=88.10, P<0.001). The torsional FDT measurements yielded external rotation angles of 48.70°±9.67°, 37.39°±5.40°, and 38.95°±2.88° for the palsy eye, non-palsy eye, and IXT eyes, respectively, showing significant differences (F=16.67, P<0.001). There was no statistically significant difference in internal rotation angles (F=2.36, P=0.100). The FDA values were-12.11°±7.42° for IXT patients and-19.02°±4.95° for CSOP patients, while the max-CSA values for the palsy eye and non-palsy eye of CSOP patients were (7.59±4.69) mm² and (11.63±3.64) mm², respectively, all showing significant differences (all P<0.001). The degree of superior oblique muscle tendon relaxation assessed by the Guyton's exaggerated FDT was negatively correlated with the external rotation angle measured by the torsional FDT (r=-0.64, P=0.001). They were positively correlated with max-CSA (r=0.45, P=0.030) and negatively correlated with max-CSA (r=-0.52, P=0.011). However, there was no correlation with vertical and rotational strabismus angle (r=-0.12, P=0.579; r=0.33, P=0.126) and FDA (r=-0.02, P=0.921; r=-0.23, P=0.309). Conclusions: Guyton's exaggerated FDT and torsional FDT can both assess the degree of superior oblique muscle relaxation in patients with CSOP. Furthermore, these two tests are correlated with changes in superior oblique muscle morphology. However, FDT cannot reflect the degree of vertical and rotational strabismus in patients.

Results of anterior tucking of the superior oblique muscle tendon in bilateral fourth nerve palsy.

Bilateral fourth nerve palsy is characterised by excyclotorsion, which can be corrected by reinforcement of the anterior tendon fibres of the superior oblique muscle. A retrospective study of 40 consecutive patients with bilateral acquired fourth nerve palsy operated by a selective tuck of the anterior portion of the superior oblique tendon between 1994 and 2012 was undertaken. Horizontal, vertical and torsional deviations were measured in 9 diagnostic positions of gaze and the field of binocular single vision was evaluated with the Harms tangent screen. Postoperative follow-ups took place at 1 week, 6 months, and ≥3 years. Preoperative mean excyclotorsion was 9° in the primary position and 15° in downgaze. These values decreased to 2° and 5° 6 months after surgery, and 2.5° and 6° at ≥3 years. Immediate post-operative incyclotorsion in upgaze (28 patients) and Brown syndrome (15 patients) regressed spontaneously. The median score of field of binocular single vision improved from 4% preoperatively to 76% postoperatively. The selective tuck of the anterior tendon fibers of the superior oblique tendon enables an efficient and long-lasting correction of the ocular torsion induced by bilateral trochlear palsy.

Traumatic Rupture of the Superior Oblique Muscle Tendon Resulting in Acquired Brown’s Syndrome

Traumatic Rupture of the Superior Oblique Muscle Tendon Resulting in Acquired Brown’s Syndrome

Traumatic Rupture of the Superior Oblique Muscle Tendon Resulting in Acquired Brown's Syndrome

Traumatic rupture of the superior oblique tendon is a rare cause of acquired Brown's syndrome. This report describes a case of traumatic rupture of the superior oblique tendon, distal to the trochlea, after injury with a plant hook. The ruptured tendon was reapproximated. Postoperatively, asymptomatic Brown's syndrome developed, although residual function of the superior oblique muscle was retained. Full-thickness upper eyelid lacerations, especially those caused by a hook, must be explored carefully to exclude superior oblique tendon rupture. Careful reapproximation of the tendon can result in residual muscle function.

Long-Term Outcome of a Silicone Expander for Brown's Syndrome

Assessment of the long-term outcome of a silicone tendon expander for Brown's syndrome. Records of 22 eyes of 16 patients with the diagnosis of Brown's syndrome were reviewed. Patients who had previous superior oblique (SO) muscle surgery or previous or concurrent surgery on another muscle were not included. The average follow-up period was 58.4 months. The SO tendon was cut approximately 5 mm away from the nasal border of the superior rectus muscle. The expander, which varied from 5 to 7 mm in length, was placed in the tenotomized SO muscle tendon. Elevation in adduction was obtained in all patients who underwent surgery. One eye had undercorrection, one eye had limitation in downgaze, and three eyes had overcorrection postoperatively. Six eyes had a severe postoperative inflammatory reaction that was successfully treated with topical corticosteroids and oral nonsteroidal anti-inflammatory drugs. Six eyes had foreign body sensation that resolved in time. In two eyes, consecutive SO palsy developed. One eye was reoperated for extrusion and the silicone bands were removed from two eyes; these eyes improved in 2 to 4 months. Silicone expander surgery is a challenging procedure used to treat Brown's syndrome. No cyclotorsion occurred after this surgery. This procedure is reversible and repeatable. A learning period is required to obtain the skill needed to avoid entering the sub-Tenon space.

Assoziation von Kongenitaler kontraktureller Arachnodaktylie (Beals-Hecht-Syndrom) und Brown-Syndrom

We report what is probably the first report of an association between congenital contractural arachnodactyly (CCA) and Brown's syndrome. A 7 (1/2)-year-old boy exhibited characteristic signs of CCA: multiple flexion contractures, marfanoid habitus and "crumpled" ears. In addition, the boy had Brown's syndrome. He had an up-gaze deficit and a slight down-shoot of the left eye in adduction. He held his head tilted to the left shoulder. As the cause, computed tomography revealed a thickening of the superior oblique muscle tendon near the trochlea. A molecular genetic examination revealed a mutation of Fibrillin-2 (FBN2 - 5 q 23 - q 31). The association of the CCA and Brown's syndrome seems to be very rare. A specific link between the two mesenchymal disorders was not found. Probably the combination was coincidental.

Acquired brown syndrome secondary to superior oblique muscle cysticercosis

Background Acquired Brown syndrome is known to occur after trauma, iatrogenic events, cysts of superior oblique muscle tendon, and inflammation. The purpose of this study is to report a large series of patients with acquired Brown syndrome secondary to superior oblique muscle cysticercosis and to discuss its management. Methods Retrospective analysis was performed of clinical and imaging features, management, and outcome in seven patients with cysticercosis of the superior oblique muscle presenting clinically as Brown syndrome. Results Seven patients were identified (five male and two female) ranging in age from 6 to 45 years. All patients had the ocular motility limitation, ie, limitation of elevation in adduction., characteristic of Brown syndrome. This was associated with pain and swelling in the superior nasal orbit. Diagnosis was established by observing the cysticercus cyst with scolex on imaging (ultrasound B scan, magnetic resonance imaging, and/or computed tomography). Oral albendazole (15mg/kg) and oral prednisolone (1mg/kg) were given for 4 weeks, and the patients were followed up for 1 year. Clinical recovery with improvement of ocular motility and regression of imaging features was noted in all patients. Conclusions Acquired Brown syndrome secondary to superior oblique muscle cysticercosis is a rare entity. Awareness of this condition, which leads to early diagnosis and institution of prompt medical treatment, results in a successful clinical outcome.

Acquired brown syndrome secondary to superior oblique muscle cysticercosis.

Acquired Brown syndrome is known to occur after trauma, iatrogenic events, cysts of superior oblique muscle tendon, and inflammation. The purpose of this study is to report a large series of patients with acquired Brown syndrome secondary to superior oblique muscle cysticercosis and to discuss its management. Retrospective analysis was performed of clinical and imaging features, management, and outcome in seven patients with cysticercosis of the superior oblique muscle presenting clinically as Brown syndrome. Seven patients were identified (five male and two female) ranging in age from 6 to 45 years. All patients had the ocular motility limitation, ie, limitation of elevation in adduction., characteristic of Brown syndrome. This was associated with pain and swelling in the superior nasal orbit. Diagnosis was established by observing the cysticercus cyst with scolex on imaging (ultrasound B scan, magnetic resonance imaging, and/or computed tomography). Oral albendazole (15 mg/kg) and oral prednisolone (1mg/kg) were given for 4 weeks, and the patients were followed up for 1 year. Clinical recovery with improvement of ocular motility and regression of imaging features was noted in all patients. Acquired Brown syndrome secondary to superior oblique muscle cysticercosis is a rare entity. Awareness of this condition, which leads to early diagnosis and institution of prompt medical treatment, results in a successful clinical outcome.

Upper Blepharoplasty with Bony Anatomical Landmarks to Avoid Injury to Trochlea and Superior Oblique Muscle Tendon with Fat Resection

The trochlea and superior oblique muscle tendon separate the medial and central fat compartments in the upper lid. The purpose of this study was to determine anatomical landmarks to predict the location of and avoid injuring the trochlea and superior oblique muscle tendon with orbital fat resection during upper blepharoplasty. The trochlea and superior oblique muscle tendon were identified in 14 cadaver heads. Bony anatomical landmarks were identified to predict the oblique vector along which the trochlea and superior oblique tendon lie. The trochlea was measured in millimeters from the palpable superior orbital foramen. The oblique course of the superior oblique muscle tendon was measured from its medial location in the lateral direction in millimeters from the frontozygomatic suture. These measurements were obtained with 4.0-power loupe magnification. The trochlea was identified 10.0 ± 0.9 mm inferior to the palpable superior orbital foramen. The superior oblique muscle tendon coursed laterally along an oblique vector to within 1 mm of the frontozygomatic suture for all 14 dissections. The vertical vector of the superior orbital foramen was measured 15.9 ± 1.1 mm lateral to the medial canthus. The width of the bony orbit measured 42.2 ± 1.6 mm. In two dissections, the superior orbital foramen could not be palpated, and the latter measurements were used to predict the superior orbital foramen. This anatomical study showed that when performing orbital fat resection with upper blepharoplasty, the trochlea and superior oblique muscle tendon can be identified and avoided with the above-described bony landmarks. (Plast. Reconstr. Surg. 108: 2137, 2001.)

Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection.

The trochlea and superior oblique muscle tendon separate the medial and central fat compartments in the upper lid. The purpose of this study was to determine anatomical landmarks to predict the location of and avoid injuring the trochlea and superior oblique muscle tendon with orbital fat resection during upper blepharoplasty. The trochlea and superior oblique muscle tendon were identified in 14 cadaver heads. Bony anatomical landmarks were identified to predict the oblique vector along which the trochlea and superior oblique tendon lie. The trochlea was measured in millimeters from the palpable superior orbital foramen. The oblique course of the superior oblique muscle tendon was measured from its medial location in the lateral direction in millimeters from the frontozygomatic suture. These measurements were obtained with 4.0-power loupe magnification. The trochlea was identified 10.0 +/- 0.9 mm inferior to the palpable superior orbital foramen. The superior oblique muscle tendon coursed laterally along an oblique vector to within 1 mm of the frontozygomatic suture for all 14 dissections. The vertical vector of the superior orbital foramen was measured 15.9 +/- 1.1 mm lateral to the medial canthus. The width of the bony orbit measured 42.2 +/- 1.6 mm. In two dissections, the superior orbital foramen could not be palpated, and the latter measurements were used to predict the superior orbital foramen. This anatomical study showed that when performing orbital fat resection with upper blepharoplasty, the trochlea and superior oblique muscle tendon can be identified and avoided with the above-described bony landmarks.

National plastic surgery survey: brow lifting techniques and complications.

The purpose of this survey was to assess trends in brow lifting philosophy, techniques, and complications. This is the second of a three-part survey; the first part reported on complications with face lift techniques, and the final report will address practice management issues, including facility and ancillary procedures. Surveys were sent to 3800 members of the American Society of Plastic Surgeons; the response rate was 15 percent. This survey represents data on 6951 brow lifts, of which approximately 50 percent were performed endoscopically and 50 percent with a coronal incision. Several conclusions about the practice of the respondents were reached: (1) Both brow lift techniques were considered to be effective. (2) Surgeons considered coronal brow lifting to be more effective for the three basic goals of brow lifting: brow elevation, reduction of transverse lines, and reduction of glabellar lines. (3) Reported complication rates for both techniques were low, and the most frequent complication was alopecia (varying from 2.9 percent to 4 percent). (4) Patient satisfaction varied from 98.2 percent to 99.2 percent. (5) Major complications were rarely reported.

Correction of cyclovertical strabismus induced by limited macular translocation in a case of age-related macular degeneration

PURPOSE: To report a case of strabismus surgery performed to treat cyclovertical strabismus induced by limited macular translocation. METHODS: Case report. RESULTS: A 62-year-old man suffering with age-related macular degeneration and subfoveal choroidal neovascularization, RE, underwent limited macular translocation surgery. The fovea was rotated downward, and his visual acuity improved from 20/100 to 20/25 postoperatively. Cyclovertical diplopia persisted for 6 months after the operation. A Hess screen test revealed a pattern that simulated an underaction of the superior oblique muscle and inferior rectus muscle with an overaction of the ipsilateral inferior oblique muscle. To treat the diplopia, advancement of the superior oblique muscle tendon and resection of the ipsilateral inferior rectus muscle were performed. Binocular single vision with 140 seconds of arc for stereopsis was obtained. CONCLUSION: Cyclovertical strabismus after limited macular translocation is corrective with conventional surgery on the treated eye.

Long-term results of silicone expander for moderate and severe Brown syndrome (Brown syndrome “plus”)

Background: The treatment of Brown syndrome has been undergoing an evolution toward more effective procedures with fewer operative interventions. Dr Kenneth Wright has introduced a procedure of superior oblique muscle tenotomy with a silicone expander to reduce the incidence of overcorrection. Methods: There was a retrospective study of 20 eyes of 19 consecutive patients with moderate or severe Brown syndrome (Brown syndrome “plus”). Follow-up ranged from 12 to 72 months. The expander, which varies 6 to 10 mm in length, was placed in all patients in the tenotomized superior oblique muscle tendon 5 mm nasal to the nasal border of the superior rectus muscle using 7-0 or 8-0 Prolene suture without violating the inner layer of the intermuscular septum. The intermuscular septum was closed over the silicone expander. Results: One hundred percent of patients had resolution of the down shoot in adduction and some or full ability to elevate the eye in adduction. Twenty percent of patients required reoperation (12.5% using 5-8 mm expanders) for overcorrection. Restriction of downgaze was not seen postoperatively. Patients often show an undercorrection 1 to 6 months postoperatively and improve or occasionally overcorrect at 1 to 2 years postoperatively. One patient with a 10-mm expander extruded the implant. Discussion: Placement of a 5- to 8-mm silicone expander in the tenotomized superior oblique muscle tendon is an effective means of correcting Brown syndrome with a low rate of reoperation. Initial undercorrection should not discourage the surgeon because improvement may continue for up to 3 years. The goal of treatment should be to convert a moderate or severe Brown syndrome (Brown syndrome plus) to a mild Brown syndrome (“true” Brown syndrome). Conclusion: This technique reduces the need for either simultaneous or subsequent inferior oblique muscle weakening and represents an advance in the treatment of Brown syndrome. (J AAPOS 1999;3:328-32)

Orbital injury complicated by entrapment of the superior oblique tendon: A case report

Fractures of the orbital roof are rare. Entrapment of the extraocular muscles in such fractures has not, to our knowledge, been reported previously. A case of acquired Brown's syndrome due to entrapment of the superior oblique muscle tendon in an orbital roof fracture is reported.