Superior Oblique Tendon Research Articles

Surgical Management of Oculomotor Nerve Palsy

We treated seven patients with unilateral oculomotor nerve palsy by transposition of the insertion of the superior oblique tendon to a point anterior and medial to the insertion of the superior rectus muscle without trochleotomy (Scott procedure). Additionally, large recessions of the lateral rectus muscle of involved eyes and, occasionally, recess/resect procedures of horizontal recti muscles of non-involved eyes were performed. All patients were followed up between one and eight years. Orthophoria in the primary position was achieved and maintained with one operation in four patients. A fifth patient had only a small residual exotropia. In two patients who had aberrant regeneration of the oculomotor nerve, surgery on horizontal recti muscles of the noninvolved eye improved the eyelid position of the involved eye after three operations.

Brown's syndrome: an unusual ocular complication of rheumatoid arthritis.

A 55 year old man with rheumatoid vasculitis and an apparent left inferior oblique palsy is described. This unusual extraocular complication of rheumatoid arthritis probably resulted from a tenosynovitis of the superior oblique tendon sheath, and resolved with steroid treatment.

Orbital Myositis Involving the Oblique Muscles: An Echographic Study

Idiopathic orbital myositis is a common nonspecific orbital inflammatory syndrome that can involve one or more of the extraocular muscles. Oblique muscle involvement is infrequently reported, possibly because such involvement is difficult to identify clinically or by computed tomography (CT). The authors reviewed seven cases of orbital myositis involving the oblique muscles solely or in association with rectus muscle involvement. Standardized echography demonstrated homogeneous low-reflective enlargement, diagnostic of myositis, of the superior and inferior oblique muscles and tendons along their courses. The finding of massive inferior chemosis was associated with involvement of the inferior oblique muscle. Although the disease typically responds to therapy with systemic steroids, residual gaze restriction may occur. The oblique muscles may be frequently involved in idiopathic orbital myositis when evaluated by standardized orbital echography. In these cases, echography provides rapid, accurate, and reliable confirmation of the diagnosis of myositis, differentiates other orbital inflammatory diseases, and provides an objective measure of the therapeutic response.

Bilateral Superior Oblique Muscle Palsy Associated With Apert’s Syndrome

Eleven children had Apert's syndrome and bilateral superior oblique muscle palsy. Of seven patients who underwent surgical exploration of the superior oblique muscle area, five had no superior oblique tendon in either eye and two had only a small fibrous band as a remnant in each eye. All 11 patients had a significant horizontal deviation in primary gaze and downgaze, in addition to a vertical imbalance. The findings led to the conclusion that all patients with craniofacial anomalies, especially those with Apert's syndrome, should be examined for the presence of vertical muscle palsies and particularly bilateral superior oblique muscle palsy.

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.

Superior oblique myectomy and trochlectomy in recurrent superior oblique myokymia

In patients operated on for superior oblique myokymia with superior oblique tenotomy or tenectomy, symptoms of oscillopsia recur in approximately one-half. Failure of treatment may be caused by incomplete transection of the tendon or by residual attachments and postoperative adhesions between the proximal segment of superior oblique tendon and the globe which allow superior oblique muscle contractions to be partially transmitted to the globe. We report a patient with recurrent symptoms of superior oblique myokymia following superior oblique tenectomy who was successfully managed with superior oblique myectomy and trochlectomy via an anterior orbital approach.

Strengthening the Weak Superior Oblique Muscle

Tucking of the superior oblique tendon is an effective strengthening procedure, but it invariably results in at least transient postoperative Brown's syndrome. This complication may be avoided by using a modification of the Harada-Ito procedure, in which the entire superior oblique tendon is advanced anterolaterally without disinsertion or resection. The operation is easy to perform and may be used with adjustable sutures if desired.

Long-Term Strabismus Complications Following Retinal Detachment Surgery

Thirty-three consecutive patients with persistent strabismus following retinal detachment surgery were studied retrospectively. A large number of vertical and torsional problems were seen. Various restrictive abnormalities were identified during strabismus surgery. These included superior oblique tendon displacement anteriorly, leash and reverse leash types of restrictions, myoscleral adhesions posterior to the exoplants, and stretching of the muscles induced by large underlying exoplants. The results following strabismus surgery were analyzed. Eighty percent of the patients were able to achieve single binocular vision in the primary field of gaze, with a low incidence of complications. The adjustable suture procedure was thought to be helpful.

Treatment of Superior Oblique Palsy with Superior Oblique Tendon Tuck and Inferior Oblique Muscle Myectomy

Twelve patients underwent quantitated superior oblique tendon tuck and ipsilateral inferior oblique muscle myectomy in the primary treatment of unilateral superior oblique muscle palsy. Preoperatively, each patient exhibited a vertical deviation of 30–55 prism diopters in at least one position of gaze. Following a single operation, satisfactory ocular alignment was obtained in all but one case, with fusion demonstrable in clinically significant gaze positions. Eight of 12 patients had no measurable vertical deviation in primary position, and two others had residual hyperphorias of only two prism diopters. No tucks were removed for postoperative Brown's syndrome. Superior oblique tendon tuck combined with ipsilateral inferior oblique muscle myectomy appears to be a safe and effective treatment for large angle superior oblique muscle palsy.

Repairing the Superior Oblique Tendon-Reply

In Reply. —Dr Kopf's question highlights some difficulties involved in managing superior oblique paresis combined with restriction of upgaze in adduction. In managing both our cases, we did not wish to exacerbate the patients' poor elevation in adduction and, therefore, we did not weaken the ipsilateral inferior oblique muscle. In the first case, weakening of the ipsilateral superior rectus muscle at the initial procedure successfully diminished the vertical deviation and left the contralateral inferior rectus muscle available for a subsequent procedure. We learned from the first case that the initial procedure to free the restriction of the damaged superior oblique tendon is followed by months of gradual reduction of the restriction (aided by a functioning inferior oblique muscle) and gradual progression of the superior oblique paresis. Because of this, when faced with the second case, we did not attempt to address the vertical deviation at all during the initial procedure

Congenital Absence of the Superior Oblique Tendon in Craniofacial Dysostosis

Absence of each of the extraocular muscles as a rare cause of strabismus has been reported. Helveston suggests that a significant horizontal deviation with suppression and/or amblyopia in a patient with the preoperative diagnosis of congenital superior oblique palsy should alert one to a possible absence of the superior oblique tendon. We present and discuss two patients with craniofacial dysostosis in whom extensive surgical exploration showed an absence of the superior oblique tendon.

Computed tomography in the evaluation of Brown syndrome of the superior oblique tendon sheath.

Computed tomographic (CT) findings in 4 patients with superior oblique tendon sheath syndrome (congenital or acquired Brown syndrome) are described. When the inferior oblique muscle moves the eye upward, the superior oblique muscle normally relaxes, while its tendon lengthens and slides freely through the trochlea. In Brown syndrome this process is somehow restricted, which is most apparent during attempts at elevation when the eye is adducted, resulting in an apparent inferior oblique "palsy" (pseudopalsy). Brown syndrome is the most common cause of an apparent isolated limitation of the inferior oblique muscle. CT is a valuable tool in understanding the pathophysiology and management of acquired Brown syndrome, showing thickening and inflammatory changes of the reflected portion of the superior oblique tendon.

Ocular rotation as a tool for superior oblique tendon exposure.

In several clinical studies involving superior oblique surgery it was noticed that the posterior insertion of the superior oblique tendon can be moved outside from the undersurface of the superior rectus muscle. This was achieved by rotating the eye in a maximum nasal and downwards direction while avoiding intorsion or retraction of the globe. Traction was applied on the superior temporal quadrant of the globe.

Quantitated Superior Oblique Tendon Tuck in the Treatment of Superior Oblique Muscle Palsy

Quantitated Superior Oblique Tendon Tuck in the Treatment of Superior Oblique Muscle Palsy

The shape of the trochlea.

Dissections and serial sections of human orbits showed the shape of the trochlea to be more complex than has been previously described. A grooved cartilaginous flange extends posterolaterally from the front of the trochlea, guiding the reflected portion of the superior oblique tendon.

Superior oblique muscle surgery.

The anatomy and actions of the superior oblique muscle are discussed as a basis for logical surgical procedures. Weakening procedures are indicated for overaction or for a short superior oblique tendon. Tenectomy is performed nasal to the superior rectus while selective tenotomies for bilateral overaction are performed temporal to the superior rectus. Recession of the whole tendon on an adjustable suture is preferred for unilateral superior oblique overaction. Tendon tucking for unilateral superior oblique palsy is performed temporal to the superior rectus and inevitably causes a degree of pseudo-Brown's syndrome. Tucks may be used bilaterally in bilateral cases. Alternatively, anterior tendon advancement corrects tensional symptoms. It may be graded from a maximum advancement to the upper border of the lateral rectus to suit the degree of tension. Adjustable sutures may be used. Superior oblique tendon transfer for long-standing third nerve palsies may produce paradoxical eye movements in the long-term due to scarring.

Acquired Brown's Syndrome in Children with Juvenile Rheumatoid Arthritis

Two children with systemic juvenile rheumatoid arthritis developed the features of Brown's syndrome coincident with an increase in disease activity. While acquired Brown's syndrome is known to occur in adults with both classical adult rheumatoid arthritis and persistent polyarticular juvenile rheumatoid arthritis, this is the first report of such an occurrence in childhood. The mechanism is likely to be an inflammatory mass which restricts the passage of the superior oblique tendon through the trochlea.

Surgery for Bilateral Superior Oblique Palsy

Following head trauma, because the patient has no overt vertical or horizontal tropia to account for the complaint of diplopia, the symptoms are dismissed, when in fact cyclodiplopia resulting from the excyclotropic feature of bilateral superior oblique palsy is the cause. A prospective study of nine patients with bilateral superior oblique muscle palsy caused by head trauma and managed by an identical surgical regimen are presented. All patients had symptomatic cyclodiplopia that increased in downgaze. Cover testing performed in various gaze positions and in left and right head tilt positions plus the double Maddox rod tests confirmed the diagnosis. The four expected findings are left hypertropia (LHT) in right gaze and right hypertropia (RHT) in left gaze, RHT on right head tilt and LHT in left tilt, V pattern, and excyclodeviation. All patients received symmetrical bilateral superior oblique tendon surgery, using a modified technique originally described by Harada and Ito, which consisted of advancing the anterior tendon half along the equator of the globe toward the superior border of the lateral rectus muscle. Elimination of the cyclodiplopia symptom was achieved in all cases by reducing the quantity of excyclotropia.

Superior Oblique Transposition for Third Nerve Palsy

Four eyes of three adult patients underwent anterior transposition and advancement of the superior oblique tendon without trochleotomy in the surgical management of oculomotor nerve palsy. In each of the cases, this procedure proved unsatisfactory, either because of inadequate horizontal alignment, postoperative hyperdeviations, or paradoxical ocular movements. Even in these difficult cases, “supermaximum” horizontal rectus muscle surgery appeared to result in satisfactory ocular alignment.

Superior Oblique Tenectomy in Brown's Syndrome

Since its description in 1950, numerous surgical techniques have been advocated to treat Brown's superior oblique tendon sheath syndrome. Of these, a tenectomy of the homolateral superior oblique has emerged as the most effective method. However, an iatrogenically produced superior oblique paralysis has been found to be a frequent complication of this procedure. Of 12 patients with Brown's syndrome treated with a superior oblique tenectomy, this problem was encountered in eight patients, and additional surgery became necessary in each instance. The clinical management of such patients presents special problems and their solution will be illustrated by two case reports.