Treatment Of Superior Oblique Palsy Research Articles

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.

The effect of superior oblique tucking on the status of ocular torsion

To investigate the effect of superior oblique tucking on the status of ocular torsion. It was a retrospective case series study. We reviewed the records of 25 patients underwent superior oblique tucking for treatment of superior oblique palsy in Tianjin Eye Hospital from January 2012 to and August 2013, among them, there were 12 patients had undergone inferior oblique myectomy or inferior rectus recession before this operation. All clinical records, including eye movement, vertical deviation, abnormal head position, Bielschowsky test et al were analyzed. Objective cyclotorsion were examined pre-operation, as well as 1, 30 days post-operation with fundus photograph. The photographs were transferred to a computer and then the fovea-disa angle (FDA) was measured by a software for drawing pictures. The difference of the two eyes was compared by the paired t-test, and the difference of the two groups was compared by the one-way analysis of variance. All patients had no more than 12 PD vertical deviation and significant abnormal head position before the operations. After underwent superior oblique tucking from 6 mm to 10 mm, their vertical deviation were less than 3 PD, and symptom of unacceptable abnormal head position were ameliorated or disappeared. In 25 cases of the monocular eye involvement, FDA was -10.60° ± 4.93° in the affected eyes preoperatively, while it was -9.67° ± 5.47° in the fellow eyes. There was also no statistically significant difference between two eyes (t = 0.54, P = 0.59). The combined FDA in both eyes were -20.27° ± 6.00° and -10.53° ± 8.04°, -10.83° ± 7.38° preoperatively, 1, and 30 days after operation. The comparison of objective ocular cyclotorsion for both eyes showed significant difference pre- and post-operation (F = 14.81, P < 0.01). Superior oblique tucking can correct ocular excyclodeviation effectively, and simultaneously correct little vertical deviation. It's good to ameliorate abnormal head position.

Superior oblique tucking for treatment of superior oblique palsy.

To investigate the efficacy and safety of isolated superior oblique tucking in the treatment of congenital superior oblique palsy. Twenty-one patients with unilateral congenital superior oblique palsy and lax superior oblique tendon underwent isolated superior oblique tucking and retrospective analysis of the amount of tucking procedure, preoperative and postoperative vertical deviation in the primary position and reading position, abnormal head posture, ocular motility, and corrected objective torsion. Patients were evaluated before and 6 to 12 months after surgery. The average vertical deviation in the primary position was 10.9 ± 3.3 prism diopters (PD) before surgery and 1.5 ± 2.6 PD after surgery (n = 21, P < .05). The average vertical deviation in the reading position was 15.6 ± 3.6 PD before surgery and 2.6 ± 3.1 PD after surgery (P < .05). The average corrected vertical deviation was 9.9 ± 3.2 PD in the primary position and 13.0 ± 3.4 PD in the reading position (P < .05). The amount of tucking ranged from 5 to 12 mm (mean: 8.3 ± 2.3 mm), which was not related to the corrected vertical deviation in the primary and reading positions, the preoperative vertical deviation in the reading position, or the corrected objective torsion. After surgery, all patients had head posture that was normal or less than 5°. Unremarkable superior oblique underaction and negative head tilt test were found in all patients after surgery. All patients had mild Brown syndrome after surgery, but none were symptomatic. Isolated superior oblique tucking is an efficient and safe procedure for treatment of superior oblique palsy with hyperdeviation less than 15 PD in the primary position and remarkable superior oblique underaction. The superior oblique forced duction test was the most important criterion for planning surgery.

Comparison of inferior oblique myectomy to recession for the treatment of superior oblique palsy

PurposeTo compare inferior oblique (IO) myectomy with recession for the treatment of superior oblique (SO) palsy.MethodsA retrospective review of medical records identified all patients with SO palsy who underwent IO...

SUPERIOR OBLIQUE PALSY: A REVIEW OF 135 CASES

Purpose. Paresis of the superior oblique muscle is a common isolated palsy of an extraocular muscle. The aim of this study is to investigate clinical findings and surgical approaches to this ocular motility imbalance. Methods. We reviewed the records of 135 patients with superior oblique palsy who were examined in our Department of Ophthalmology over the period 2000- 2005 to evaluate the etiology, clinical patterns, surgical management and outcome. results. Congenital palsy were mostly unilateral (79%), traumatic palsy bilateral (70%). An excyclotropia of greater than 15 degrees was highly suggestive of bilaterality. Our patients reported diplopia more frequently in acquired (60%) than in con- genital (21%) superior oblique palsy. The surgical procedures were performed according to Knapp’s classification of superior oblique palsy. In 47 cases (35%) tucking of superior oblique alone corrected the full deviation. In 14 cases tucking of superior oblique was combined with weakening of inferior oblique when the deviation exceeded 30 prism dioptres. In 60 cases (45%; Knapp class 8th) tucking the superior oblique was performed concurrently with recession of superior rectus. Conclusion. In our experience surgical treatment of superior oblique palsy, according to Knapp’s classification, is not as difficult or unpredictable as that of horizontal strabismus; in fact if one uses a well thought out plan of diagnosis and treatment the results are most gratifying to the patient and to the surgeon

When is Isolated Inferior Oblique Muscle Surgery an Appropriate Treatment for Superior Oblique Palsy?

To evaluate the efficacy of isolated inferior oblique muscle weakening in the treatment of superior oblique palsy. Forty-seven patients with superior oblique palsy underwent either single-muscle surgery (anteriorization or recession of the inferior oblique muscle) or two-muscle surgery (anteriorization of the inferior oblique muscle combined with recession of the contralateral inferior rectus muscle according to the amount of vertical deviation). In a retrospective noncomparative study the objective surgical effect was calculated as the difference between the deviation at the day before surgery and the deviations 6 weeks and at least 1 year after surgery. Pre- and postoperative sensorimotor status and subjective outcome were evaluated. In patients who underwent isolated inferior oblique muscle surgery the mean preoperative vertical deviation decreased from 15+/-9 (distance)/16+/-10 (near) prism diopters (PD) (anteriorization) and 7+/-5 (distance)/9+/-8 (near) PD (recession) to 4+/-4 (distance)/4+/-6 (near) PD (anteriorization) and 2+/-2 (distance)/2+/-3 (near) PD (recession) at the 1-year follow-up. In patients who underwent two-muscle surgery the mean vertical deviation decreased from 20+/-11 (distance)/21+/-10 (near) PD preoperatively and 6+/-7 (distance)/6+/-6 (near) PD at 1-year follow-up. Subjective assessment showed excellent scores among the patients treated with single-muscle surgery and slightly lower but also favorable scores among the patients treated with combined techniques. A direct comparison of the different outcome scores was not possible because of the more difficult initial situation in patients who underwent combined surgery. Isolated inferior oblique muscle weakening is an effective treatment option for superior oblique palsy up to 15 PD of vertical deviation in primary position. Two-muscle surgery should be reserved for patients with larger vertical deviations.

Surgical treatment of superior oblique palsy

Reports of several large series of patients with superior oblique palsy (SOP) published in 1986 or before set forth important guidelines for both diagnosis and treatment of this condition. Newer information about the anatomy, physiology, and pathophysiology of the superior oblique has accrued over the past decade. This paper reviews our experience with diagnosis and treatment of SOP over the past 5 years in light of this new information. Charts of patients treated for SOP over 5 year (1990 to 1995) were reviewed for male or female sex, age, symptoms, refraction, vision, stereo acuity, head posture, facial asymmetry, intraoperative superior oblique traction test, diagnostic position prism and cover test, torsion, surgery performed, and results of treatment. The charts of 190 patients were reviewed. In 181, postoperative examinations were performed by us. The etiology of the SOP was congenital in 137 and acquired in 53. Twenty-nine acquired cases were due to trauma and 24 arose from other causes. Fifty-six patients had facial asymmetry, 51 of whom had congenital SOP. Ninety-five had a lax tendon, 83 (87%) of whom had congenital SOP. Sixty-six had a normal tendon, 29 (44%) of whom had acquired SOP. Seventy-seven percent of patients had Knapp class I, III, or IV palsy. An average of 1.26 surgeries was performed per patient. Inferior oblique weakening was performed in 177 (93%), while 68 vertical rectus recessions were done. Thirty-five patients had superior oblique tuck or resection, all on lax tendons, and 15 had Harada Ito procedures for torsion. Six patients had mild Brown syndrome postoperatively, none of which required a takedown. A cure, defined as relief of symptoms or elimination of strabismus and head tilt, was achieved in 166 of 181 (92%) of patients. Successful treatment of SOP can be accomplished in the majority of cases by selective surgery usually beginning with inferior oblique weakening plus additional vertical rectus and horizontal surgery as needed, with superior oblique strengthening used only for lax tendons or when torsion is the main problem.

Classification and Treatment of Superior Oblique Palsy

(1974). Classification and Treatment of Superior Oblique Palsy. American Orthoptic Journal: Vol. 24, No. 1, pp. 18-22.