Unilateral Superior Oblique Palsy Research Articles

Surgical outcome of inferior oblique anteriorization in unilateral superior oblique palsy with large angle hypertropia

Purpose The aim of this study was to assess the effect of unilateral inferior oblique (IO) anteriorization as a single muscle surgery for treatment of unilateral superior oblique palsy (SOP) with large angle hypertropia. Patients and methods This is a retrospective study that included 28 patients, for whom IO anteriorization was performed for treatment of ipsilateral SOP with large angle hypertropia more than or equal to 20 prism diopters (PD). The patients were evaluated preoperatively and 3 months postoperatively for the vertical deviation (VD) in primary position and in adduction. Residual hypertropia less than or equal to 6 PD in primary position postoperatively was considered a successful outcome, together with improvement of the abnormal head tilt. Results The mean age of the patients was 30.75±17.05 years. The mean preoperative VD in the primary position was 25.29±4.50 PD. It significantly decreased postoperatively to 5.54±5.25 PD (P<0.001). The mean preoperative VD in adduction was 30.57±7.89 PD and decreased postoperatively to 8.50±5.27 PD (P<0.001). The preoperative IO overaction grade was 2.61±0.99 and decreased postoperatively to 0.39±0.50 (P<0.001). Successful outcome was reported in 75% of the cases and improvement of head tilt occurred in 78% of the patients. Conclusion IO anteriorization could be a simple one muscle surgery to correct large angle VD associated with unilateral SOP with a favorable outcome.

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.

Effect of inferior oblique myectomy on ocular torsion according to the absence of the trochlear nerve in unilateral congenital superior oblique palsy.

To evaluate the effect of inferior oblique (IO) myectomy on ocular torsion according to the absence of the trochlear nerve in unilateral congenital superior oblique palsy (UCSOP). We retrospectively reviewed the clinical data of patients who had been diagnosed with UCSOP and underwent ipsilateral IO myectomy (n = 43). Patients were classified into the present and absent groups according to the absence of the trochlear nerve and superior oblique hypoplasia on magnetic resonance imaging (MRI). For quantitative analysis of ocular torsion, disc-fovea angles (DFA) were collected in both eyes using fundus photographs taken within three months before surgery and one month after surgery. DFA of the paretic eye did not differ according to the absence of the trochlear nerve (9.4±5.6° in the present group vs. 11.0±5.4° in the absent group, p = 0.508). However, the present group had a larger DFA in the non-paretic eye than the absent group (14.1±6.7° in the present group vs. 8.0±5.0° in the absent group, p = 0.003). The change of ocular torsion after IO myectomy in the paretic eye was -5.3±3.7° in the present group and -4.8±3.5° in the absent group, respectively (p = 0.801). In the non-paretic eye, the change in DFA was -1.5±3.0° in the present group, which was larger than that in the absent group (0.7±2.6°, p = 0.047). In the multivariate analysis, the change in DFA was correlated with only the preoperative DFA (standardized β = -0.617, p<0.001 in the paretic eye, and standardized β = -0.517, p<0.001 in the non-paretic eye). In the paretic eye, there was no significant difference in the change of ocular torsion between both groups, whereas in the non-paretic eye, the present group had a larger change in DFA after IO myectomy than the absent group. However, in the multivariable analysis, the change in ocular torsion was significantly correlated with preoperative excyclotorsion but not with the presence of the trochlear nerve itself.

Can Binocular Alignment Distinguish Hypertropia in Sagging Eye Syndrome From Superior Oblique Palsy?

PurposeAlthough the three-step test (3ST) is typically used to diagnose superior oblique palsy (SOP), sagging eye syndrome (SES) has clinical similarities. We sought to determine if alignment measurements can distinguish unilateral SOP from hypertropia in SES.MethodsWe studied hypertropic subjects who underwent surface-coil magnetic resonance imaging (MRI) demonstrating either SO cross-section reduction indicative of congenital or acquired palsy (SOP group) or lateral rectus muscle sag (SES group). Alignment was measured by Hess screen and prism-cover testing. Multiple supervised machine learning methods were employed to evaluate diagnostic accuracy. Rectus pulley coordinates were determined in SES cases fulfilling the 3ST.ResultsTwenty-three subjects had unilateral SOP manifested by SO atrophy. Eighteen others had normal SO size but MRI findings of SES. Maximum cross-section of the palsied SO was much smaller than contralaterally and in SES (P < 2 × 10−5). Inferior oblique cross-sections were similar in SOP and SES. In both SOP and SES, hypertropia increased in contralateral and decreased in ipsilateral gaze and was greater in ipsilateral than contralateral head tilt. In SES, nine subjects (50%) fulfilled the 3ST and had greater infraplacement of the lateral than medial rectus pulleys in the hypotropic orbit. Supervised machine learning of alignment data distinguished the diagnoses with areas under the receiver operating curves up to 0.93, representing excellent yet imperfect differential diagnosis.ConclusionsBecause the 3ST is often positive in SES, clinical alignment patterns may confound SES with unilateral SOP, particularly acquired SOP. Machine learning substantially but imperfectly improves classification accuracy.

Temporal Slant Recession of the Inferior Rectus Muscle: A Simple Surgical Treatment for Diplopia Caused by Small Vertical Deviations.

To evaluate the therapeutic effect of temporal slant recession of the inferior rectus muscle (TSRIRM) for the treatment of small vertical deviations in patients with vertical diplopia, with consideration of the theoretical additive effects of this procedure on ocular torsion and horizontal incomitance. Retrospective review of 11 patients who were treated with TSRIRM. Eight patients with vertical diplopia and small hyperdeviations (up to 6 prism diopters (PDs)) were treated with isolated TSRIRMs. Three patients with vertical diplopia from unilateral superior oblique palsies with large hyperdeviations (>15 PDs) were treated with TSRIRMs in conjunction with contralateral inferior oblique recessions. Six of the 8 patients with small vertical deviations had successful vertical realignment with elimination of symptomatic diplopia after an isolated TSRIRM. Two of the eight patients had residual hypertropia with symptomatic diplopia. Three additional patients with unilateral superior oblique palsy had successful vertical realignment with elimination of symptomatic diplopia after ipsilateral inferior oblique recession and contralateral TSRIRM. In total, 9 of 11 patients had successful surgical results after TSRIRM. TSRIRM provides an effective and reliable treatment for small angle vertical strabismus. Its ease of surgical access renders it useful for implementation in an outpatient neuro-ophthalmology setting.

Masquerading Superior Oblique Palsy

We evaluated patients with hypertropia compatible with a diagnosis of superior oblique (SO) palsy to ascertain whether the 3-step test (3ST) can distinguish SO atrophy characteristic of trochlear nerve pathology from masquerading conditions. Prospective cross-sectional study. In an academic practice, we performed quasi-coronal plane, surface coil magnetic resonance imaging in 83 patients clinically diagnosed with SO palsy. We evaluated alignment, SO cross-sectional area, SO contractility, and rectus muscle pulley positions. A total of 57 patients with mean age 39 years (SD = 21 years) had unilateral SO palsy manifested by SO atrophy (22 congenital and 35 acquired). There was normal SO size in 26 patients with an average age of 39 years (SD =16 years) considered masquerades (8 congenital and 18 acquired). Maximum palsied SO cross-section averaged 9.5 ± 3.8 mm2, less than 18.4 ± 3.9 mm2 contralaterally (P < 10-24). In masquerades, maximum hypertropic SO cross-section was 20.7 ± 3.1 mm2, which was not different from the hypotropic SO or the contralesional muscle in SO palsy. Head tilt testing in masquerades was indistinguishable from SO palsy. In SO palsy, central hypertropia averaged 13.2 ± 9.4Δ, increasing to 21.1 ± 14.0Δ in ipsilateral tilt, and decreasing to 4.3 ± 5.3Δ in contralateral tilt. In masquerades, central hypertropia averaged 13.1 ± 8.7Δ, and was 17.7 ± 11.1Δ in ipsilateral and decreasing to 4.9 ± 5.1Δ in contralateral tilt. Upright hypertropia was larger at 17.7 ± 9.9Δ in congenital than 12.0 ± 8.4Δ in acquired SO palsy (P = 0025) but was indistinguishable from congenital masquerades. Contractile change in SO cross-section was bilaterally similar in masquerades. Relevant coordinates of rectus pulleys were similar bilaterally in masquerades. The 3ST pattern characteristic of unilateral SO palsy may be mimicked in all respects by masquerades.

Clinical features of excyclotorsion in the non-paretic eye of patients with congenital unilateral superior oblique palsy

BackgroundTo investigate preoperative clinical features and postoperative results according to the correspondence between excyclotorsion and the paretic eye in patients with congenital unilateral superior oblique palsy (USOP).MethodsA retrospective review of medical charts was performed. The patients were divided into the accordance (ocular excyclotorsion in the paretic eye) and disaccordance (ocular excyclotorsion in the non-paretic eye) groups. The degree of excyclotorsion (scale, 0–4) was measured. Age, sex, hypertropia at the primary position, fixation preference, inferior oblique overaction, and degree of excyclotorsion were measured.ResultsNinety-eight patients were included in this study. There were 70 (71.4%) and 28 patients (28.6%) in the accordance and disaccordance groups. Sixteen patients (22.9%) in the accordance group and 12 patients (42.9%) in the disaccordance group were aged under 2 years (p = 0.04). A fixation preference of the paretic eye was observed in 2 (2.9%) and 8 (28.6%) patients in the accordance and disaccordance groups (p < 0.01). The postoperative degree of excyclotorsion in the accordance group (0.14 ± 0.39) was lower than that in the disaccordance group (0.28 ± 0.71) (p = 0.01). The residual postoperative excyclotorsion (> 1) were observed in the disaccordance group (14 patients, 50%) and accordance group (16 patients, 22.9%) (p = 0.01).ConclusionPreoperative disaccordance between excyclotorsion and the paretic eye was observed in patients who were under 2 years of age and preferred fixation of the paretic eye. The postoperative degree of excyclotorsion was lower in the accordance group.

Spontaneous Recovery of Traumatic Unilateral Superior Oblique Palsy and Ocular Factors for Predicting Prognosis.

PurposeThis study evaluated the prognosis of patients with traumatic unilateral superior oblique palsy (SOP) and clinical factors associated with spontaneous resolution.MethodsMedical records of patients with traumatic unilateral SOP who visited two hospitals (Yeungnam University Hospital and Daegu Catholic University Medical Center) between January 2015 and June 2020 were reviewed retrospectively. When traumatic unilateral SOP did not recover within at least 1 year of follow-up, no spontaneous resolution was considered. Both traumatic and ocular factors were evaluated to evaluate their association with spontaneous recovery.ResultsFifty-nine patients (mean age, 52.6 years; 48 male patients) were enrolled in this study. The mean interval from trauma to initial presentation was 3.9 months. The mean vertical deviation at initial presentation was 6.34 ± 5.22 prism diopters (PD) (range, 0–25 PD). During the mean 24.1-month follow-up period, 28 patients (47.5%) achieved spontaneous resolution of SOP. Thirteen patients underwent surgical treatment for SOP. Vertical deviation <6 PD at the initial visit and low fundus torsion in the nonparetic eye and both eyes were significantly associated with spontaneous recovery (p < 0.05, logistic regression analysis). Traumatic factors, including the trauma type, presence of intracranial lesion, loss of consciousness, and Glasgow Coma Scale score, were not associated with spontaneous recovery.ConclusionsIn this multicenter study, spontaneously recovery was achieved in 47.5% patients with traumatic unilateral SOP. Even mild head trauma can lead to permanent SOP. Ocular factors, including the angle of deviation and fundus torsion, may better predict spontaneous resolution than traumatic factors in patients with traumatic unilateral SOP.

Effectiveness of Inferior Oblique Myectomy in Unilateral Superior Oblique Palsy Depending on Magnitude of Hyperdeviation

Purpose: To evaluate surgical outcome and effectiveness of inferior oblique (IO) myectomy on unilateral superior oblique palsy (SOP) as a primary treatment.Methods: This study is a retrospective review of the medical records of 99 patients who had undergone IO myectomy due to SOP as a first-line treatment. Sixty-five patients with hyperdeviation of 15 prism diopters (PD) or less were categorized into group 1, 22 patients with hyperdeviation between 16 PD to 20 PD into group 2, and 12 patients with hyperdeviation higher than 20 PD into group 3. Preoperative hyperdeviation, postoperative hyperdeviation, and improvement of head tilting were then compared between the 3 groups. Surgery was determined to be successful when the post-op residual hyperdeviation is less than 5 PD, or when the improvement of hyperdeviation and head tilting was noted, for the patients who had preoperative deviation less than 5 PD, and without hypercorrection.Results: All groups showed significant improvement of hyperdeviation, and the amount of correction was larger in group with larger preoperative hyperdeviation. 80.3%, 95.0%, and 90.9% of patients showed improvement of head tiling and success rate was 87.7%, 77.3%, and 50.0% in group 1, 2, and 3 respectively. Group 1 and 2, group 2 and 3 had no significant difference in success rate but only group 1 and 3 had significant difference.Conclusions: Considering success rate with improvement of head position, self-titrating and possibility of overcorrection, IO myectomy could be an effective option as a first-line surgical treatment for unilateral SOP with hyperdeviation of 20 PD or less. However, due to a 50% success rate in patients with hyperdeviation larger than 20 PD, a secondary operation must be considered following IO myectomy, or a two-muscle procedure must be considered as a primary treatment.

Special features of superior oblique hypofunction due to tendon abnormalities

ABSTRACT While most cases of superior oblique (SO) hypofunction represent contractile weakness due to denervation, sometimes the lesion is exclusively in the tendon. This study sought to distinguish the pattern of incomitant strabismus caused by deficiency of SO oculorotary force caused by tendon abnormalities versus that of neurogenic palsy. Clinical and magnetic resonance imaging (MRI) findings of 7 cases of unilateral SO tendon interruption or extirpation were compared with 11 cases of age matched unilateral SO palsy having intact tendons. We compared angles of misalignment with high-resolution MRI in central gaze and deorsumversion. Muscle bellies in neurogenic palsy were markedly atrophic with maximal cross sections averaging 6.5 ± 2.7 mm2, in contrast with 13.5 ± 3.0 mm2 contralesionally (P < .0001). In contrast, SO muscle bellies ipsilateral to tendon interruption had maximum cross sections averaging 15.1 ± 3.0 mm2 occurring more posterior than on the contralesional side whose maximum averaged 12.1 ± 2.4 mm2. While cross sections of SO bellies ipsilateral to tendon interruption exhibited normal contractile increase in infraduction (P < .0005), there was nevertheless strabismus with incomitance similar to that in SO atrophy. Binocular alignment was statistically similar (P > .5) in the two groups for all diagnostic positions, including head tilt, except in deorsumversion, where cases with SO tendon abnormalities averaged 20.5 ± 6.9Δ ipsilateral hypertropia, significantly more than 8.5 ± 6.6Δ in neurogenic SO atrophy (P = .001). The average difference in hypertropia Hypertropia averaged 9D greater in deorsumversion than central gaze in tendon abnormalities, but 4.1Δ less in SO atrophy (P< .019). In contralesional version, average overelevation in adduction was 1.7 (scale of 0–4) in tendon abnormalities, and 2.6 in SO atrophy (P = .23), while average underdepression in adduction was −2.3 in cases of tendon abnormalities and −1.6 in SO atrophy (P = .82). Repair of the SO tendon in three cases was effective, while alternative procedures were performed when repair was infeasible. While both denervation and tendon interruption impair SO oculorotary function, interruption causes greater hypertropia in infraversion. Surgical tightening of interrupted SO tendons may have particularly gratifying effects. Posterior SO thickening and large hypertropia in infraversion suggest SO tendon interruption that may guide a surgical strategy of tendon repair.

The Effects of Modified Graded Recession, Anteriorization and Myectomy of Inferior Oblique Muscles on Superior Oblique Muscle Palsy.

Background: The aim was to investigate the effect of inferior oblique (IO) operation (IO myectomy or graded recession and anteriorization) for unilateral and bilateral superior oblique muscle palsy (SOP); Methods: A total of 167 eyes undergoing IO surgery by a single surgeon between 2008 and 2015 were retrospectively reviewed. The method for treating symmetric bilateral SOP was bilateral IO myectomy (n = 102) and the method for treating unilateral SOP or non-symmetric bilateral SOP was IO-graded recession and anteriorization (n = 65). Associated clinical results and other factors were analyzed; Results: Head tilt, vertical deviation, IO overaction, SO underaction degree and ocular torsion angle were all clearly changed, but there was no statistically significance between these two procedures. Mean preoperative torsional angle was 15.3 ± 6.4 degree, which decreased to 5.3 ± 2.7 degree after surgery. Preoperative torsional angle, IOOA and SOUA degree were all significantly affected in postoperative torsional angle (p = 0.025, 0.003 and 0.038). Horizontal rectus muscle and IO muscle operation did not interfere with each other’s results (p = 0.98); Conclusions: Symmetric bilateral SOP could be treated with bilateral IO myectomy and IO-graded recession and anteriorization should be reserved for unilateral SOP or non-symmetric bilateral SOP.

Facial Asymmetry in Unilateral Congenital Superior Oblique Muscle Palsy.

This study was conducted to evaluate facial asymmetry in unilateral congenital superior oblique muscle palsy (SOP). The results showed that all facial asymmetry parameters had a higher frequency in SOP patients compared with orthotropic individuals. This study aimed to evaluate the characteristics of facial asymmetry in unilateral congenital SOP and compare with orthotropic individuals. This cross-sectional comparative case series was conducted in 58 patients with ocular torticollis caused by SOP (mean ± standard deviation age, 18 ± 12 years) and 58 orthotropic individuals (mean ± standard deviation age, 19 ± 13 years). The exact form of torticollis was determined by direct observation from yaw, roll, and pitch axes. Four photographs were taken from patients: (1) with torticollis to calculate the amount of head tilt; (2) with the head in the straight position to calculate the facial angle and relative facial size (RFS); and (3 and 4) with the head positioned downward (to compare the cheek size) and upward (to assess columella deviation and nostril asymmetry). Twenty-nine patients (50%) had a head tilt, 23 (39.66%) had combined head tilt and a face turn, and 6 (10.44%) had a pure face turn. The mean ± standard deviation of head tilt, facial angle, and RFS was 10.11 ± 6.31°, 1.11 ± 1.67°, and 1.003 ± 0.126 in SOP patients, respectively, and the mean RFS and facial angle were significantly higher in SOP patients compared with orthotropic individuals (both P < .001). Facial hemihypoplasia, unilateral cheek compression, nostril asymmetry, and columella deviation were observed in 43 (74.1%), 31 (53.4%), 39 (67.2%), and 38 patients (65.5%), respectively, which were all significantly more common compared orthotropic individuals (P < .001). Facial asymmetry was seen in 52 patients (91.2%) and 17 orthotropic subjects (29.3%), respectively (P < .001). All quantitative and qualitative facial asymmetry parameters had a higher frequency in SOP patients compared with orthotropic subjects.

Influence of eye dominance on objective and subjective excyclotorsion in unilateral superior oblique muscle palsy: objective cyclotorsion measured by fundus photography.

To study the effect of eye dominance on excyclotorsion in unilateral superior oblique palsy (USOP). Retrospective clinical study METHODS: Objective excyclotorsion was measured as the disc-to-fovea angle by fundus photography OU. Subjective excyclotorsion was determined with a major amblyoscope based on the difference in the earth vertical and subjective visual vertical. Eye dominance was determined by the hole-in-the-card method. A p-value ≤ 0.05 was considered statistically significant. Data of 24 USOP patients were retrospectively collected. The diagnosis was mainly made by the Parks 3-step method, history and the presence of characteristic excyclotorsion. When possible, orbital magnetic resonance imaging findings were obtained. The median angle of objective excyclotorsion in the paretic eyes was significantly larger than in the nonparetic eyes. Both median angles of objective/subjective excyclotorsion in the dominant eye were significantly smaller than those of the non-dominant eye. Patients were subdivided into two groups: group A, those whose paretic eye was the dominant eye (n = 13); group B, those whose paretic eye was the non-dominant eye (n = 11). The objective/subjective excyclotorsional angles of the paretic eye were significantly larger than of the non-paretic eye only in group B. In USOP the angle of excyclotorsion in the dominant eye is smaller than in the non-dominant eye. This may imply that the vertical sense of visual space is mainly adapted to the dominant eye, keeping the subjective vertical close to the earth vertical.

Inferior oblique recession associated to partial temporal inferior rectus recession in unilateral congenital superior oblique palsy.

To evaluate the effectiveness of inferior oblique recession with contralateral partial temporal inferior rectus recession in patients with decompensated congenital unilateral superior oblique palsy (SOP) in correcting moderate vertical deviations in primary position. The medical records of patients with SOP who underwent inferior oblique recession with contralateral partial temporal inferior rectus recession were reviewed retrospectively. Vertical deviation in primary position, subjective torsion, diplopia, residual deviation, and the deviation decrease were evaluated. Four patients (three males and one female, age range 29-56 years) with congenital unilateral SOP and mean vertical deviation of 21.0 ± 5.3PD (range 14-25D) in primary position were included. Mean correction of hypertropia in primary position with this technique was 15.5 ± 5.3PD (range 10-20PD). The mean hypertropia on gaze to the contralateral side changed from 30.0 ± 10.8D before surgery to 9.3 ± 7.9D after surgery. Torsion had a mean change of 4.8° of incyclodeviation. Preoperatively, all patients had head tilt and diplopia, which was resolved in all but one patient, who will need surgery. Patients were followed an average of 18 months. No adverse events were reported in any subjects. When performing recession of inferior oblique muscles in SOP associated to a full recession of the contralateral inferior rectus, there is a risk of overcorrection in those with moderate angles. Performing a partial recession in the contralateral inferior rectus eye corrected up to 20PD in primary position in our series, reducing this risk.

The Correlation between Hypertropia and Head Tilt in Congenital Unilateral Superior Oblique Muscle Palsy.

Purpose:To evaluate the correlation between the angle of deviation in different gazes and the amount of head tilt in patients with congenital unilateral superior oblique muscle palsy (SOP).Methods:This case series study was performed on 20 consecutive SOP patients with head tilt. Based on the Bielschowsky three-step test, the angle of deviation was measured in different gazes. Furthermore, the hypertropia difference between the two lateral gazes (gaze difference) and the two head tilt sides (bilateral head tilt difference) was calculated. For measuring head tilt, close-up pictures from 40 cm with a habitual abnormal head position were captured and analyzed by the Corel Draw X7 software.Results:The mean age of patients was 13 ± 9 years (range, 2.5–31 years). The mean angle of hypertropia in ipsilateral and contralateral head tilt was 24.5 Δ ± 7.1 Δ and 6.5 Δ ± 4.2 Δ, respectively (P < 0.001), and in ipsilateral and contralateral lateral gaze positions, it was 8.2 Δ ± 5.5 Δ and 22.5 Δ ± 6.1 Δ, respectively (P < 0.001). The mean of bilateral head tilt hypertropia difference was 18 Δ ± 5.3 Δ and gaze hypertropia difference was 14.3 Δ ± 6.16 Δ. There was a positive correlation between bilateral head tilt hypertropia difference and the amount of head tilt (R = 0.609, R2 = 0.371, P = 0.004, the amount of head tilt = 0.39 × [Bilateral head tilt hypertropia difference] +1.77). The amount of head tilt also had a positive correlation with the gaze hypertropia difference (R = 0.492, R2 = 0.242, P = 0.028, the amount of head tilt = 0.27 × [gaze hypertropia difference] +4.81).Conclusion:In SOP patients, the amount of head tilt had a positive correlation with bilateral head tilt hypertropia difference and also gaze hypertropia difference.

Measuring ocular torsion and its variations using different nonmydriatic fundus photographic methods.

PurposeTo compare the variations in ocular torsion measurements made using different fundus photographic methods.MethodsWe enrolled subjects with three conditions: (1) patients with intermittent exotropia (IXT) (n = 44), (2) patients with unilateral superior oblique palsy (SOP) (n = 10), and (3) normal subjects as controls (n = 85). Ocular torsion was measured by disc-center–fovea angle (DFA) using three different imaging modalities: (1) conventional fundus photography (CFP) with a 45° field of view (FV), (2) wide-field fundus photography (WFP) with a 200° FV, and (3) optical coherence tomography (OCT) with a 55° FV.ResultsIn the IXT group, the DFAs in the right and left eyes were 5.70±3.35° and 6.37±3.36°, respectively, for CFP, 8.39±5.24° and 8.61±3.67° for WFP, and 5.73±3.61° for 6.16±3.50° for OCT. In the SOP group, the DFAs in paretic and nonparetic eyes were 12.19±1.69° and 6.71±1.09°, respectively, for CFP, 14.29±2.36° and 8.23±3.31° for WFP, and 12.12±1.73° and 6.91±1.12° for OCT. In the control group, the DFAs in the right and left eyes were 5.39±2.65° and 5.71±3.16°, respectively, for CFP, 8.77±5.56° and 8.90±6.24° for WFP, and 5.27±2.67° and 5.72±3.20° for OCT. There was no difference between the results from CFP and OCT among the three groups. However, the torsional angle was larger when measured using WFP than the other two photographic methods (CFP and OCT) in all three groups (all p<0.05).ConclusionThe ocular torsion measurement varies with the fundus photographic method used to measure it. Clinicians should be careful to avoid overestimating ocular extorsion when it is evaluated using WFP.

Abnormal Head Posture in Unilateral Superior Oblique Palsy

ABSTRACT Purpose: To evaluate the manifestations and severity of abnormal head posture (AHP) in unilateral congenital and acquired superior oblique palsy (SOP) patients and to assess the effect of AHP on facial appearance. Patients and methods: This case series study was performed on 60 consecutive SOP patients, which consisted of 47 patients with congenital SOP and 13 patients with the acquired source. The exact type of AHP in congenital and acquired cases was determined based on direct observation. In addition, a close-up picture from 40 cm with habitual AHP was captured from all patients. For evaluation of the severity of AHP and measurement of head tilt, these pictures were analyzed by the Corel Draw X7 software (Corel Corp, Canada). Besides, qualitative and quantitative facial asymmetry parameters were evaluated by the assessment of pictures of patients, which were taken in different gazes. Results: Five different manifestations of AHP were observed to the contralateral side of the palsy; 1 – pure head tilt, 2 – simultaneous head tilt and turn, 3 – pure head turn, 4 – head tilt and chin down, and 5 – head tilt and turn with chin down. The frequency of these five manifestations of AHP in the congenital group were 23 (48.9%), 10 (21.3%), 4 (8.5%), 5 (10.6%), and 5 (10.6%) patients, respectively (P <.001) and in acquired patients, were 1 (7.7%), 8 (61.5%), 2 (15.4%), 2 (15.4%), and 0 (0%), respectively (P =.024). In all SOP patients, the most common manifestations of AHP were pure head tilt (40%), simultaneous head tilt and turn (30%), and head tilt with chin down (11.7%), respectively. The mean degrees of head tilt in congenital and acquired patients were 15.10° ± 9.34° and 9.61° ± 5.84°, respectively (P =.022). Conclusion: The most common type of AHP in congenital SOP patients was contralateral head tilt, but in acquired cases was simultaneous head tilt and turn. The mean amount of head tilt in the acquired group was significantly higher than congenital patients; in contrast, the frequency of facial asymmetry was higher in the congenital group compared with the acquired patients.

Characteristics of Facial Asymmetry in Congenital Superior Oblique Palsy according to Trochlear Nerve Absence.

Methods A total of 287 consecutive patients diagnosed with congenital SOP and 82 control subjects were included. Congenital SOP patients were grouped according to the presence (present group) or absence (absent group) of the trochlear nerve using thin-section high-resolution MRI of cranial nerves. We developed a computer-aided detection (CAD) system that could automatically analyze objective indices of facial asymmetry using frontal face photographs. Results Of the 287 patients with congenital SOP, 60% of patients had ipsilateral trochlear nerve absence and superior oblique muscle (SO) hypoplasia (absent group), while the remaining 40% had a normal SO and trochlear nerve (present group). All but one objective indices related to facial asymmetry were significantly different between congenital SOP patients and controls (all P < 0.05). Among these features, the angle of nose deviation was significantly larger in the absent group compared to the present group (P < 0.001). Conclusion Objective analysis of facial asymmetry using our novel CAD system was useful for identifying distinct features of congenital SOP. Deviation of the nose was more prominent in congenital SOP patients with trochlear nerve absence.

Effect of unilateral inferior oblique weakening on fundus torsion in bilateral eyes of children with congenital superior oblique palsy.

To study the change of torsion in both eyes after unilateral inferior oblique (IO) weakening on children with congenital superior oblique palsy (SOP). This retrospective study enrolled all patients diagnosed with unilateral congenital superior oblique palsy (UCSOP) accompanied by inferior oblique overaction (IOOA). A total of 120 eyes of 60 patients were divided into group 1 (more extorted paretic eye) and group 2 (more extorted nonparetic eye). The degree of fundus torsion was evaluated before and 1mo after the IO weakening procedure. The torsion of the fundus was recorded by measuring the disk-foveal angle (DFA) using fundus photography. Group 1 included 26 cases and group 2 included 34 cases, thus the rate of extorsion was insignificantly higher in the nonparetic eye (P=0.10). The preoperative DFA in the paretic and nonparetic eyes was 13.21±5.95, 7.97±4.25 in group 1, and 4.65±3.79, 13.16±5.35 in group 2 (both P<0.001). The postoperative DFA in the paretic and nonparetic eyes was 8.57±4.87, 7.32±4.27 in group 1 (P=0.24), and 3.85±6.00 and 9.94±5.45 in group 2 (P<0.001). The amount of postoperative reduction of the DFA in the paretic and nonparetic eyes was 4.64±3.90, 0.65±0.76 in group 1 (P=0.002), and 0.80±0.81, 3.21±5.50 in group 2 (P=0.01). The difference in the amount of reduction of DFA in the more extorted eye in group 1 (paretic eye) vs group 2 (nonparetic eye) was insignificant (P=0.30). Excyclotorsion in the nonparetic eye has a similar probability in the paretic eye in UCSOP children, and weakening of the ipsilateral IO has a more obvious effect on the decrement of extorsion in the more extorted eye regardless of which eye is paretic.

Sternocleidomastoid muscle asymmetry in unilateral congenital superior oblique palsy

To determine whether there is an asymmetry in bilateral sternocleidomastoid muscle (SCM) thickness in patients with unilateral congenital superior oblique palsy (SOP) and its association with surgical results. The medical records of 186 patients with head tilt secondary to unilateral SOP, who were evaluated for the status of the SCM with neck ultrasound or magnetic resonance imaging, were reviewed. The SCM asymmetry index was calculated as a bilateral difference in the maximal muscle thickness divided by each tilted-side SCM thickness. The presence of SCM asymmetry, defined as an index of >10%, and its relationship to residual torticollis ≥5° after SOP surgery were assessed. Of 186 patients with a median age of 1.2 years, SCM asymmetry was present in 102 (54.8%) patients (6.8 ± 1.9 mm for the SOP side vs. 6.6 ± 2.1 mm for the tilted side). The SCM asymmetry did not differ according to age, amount of head tilt or hypertropia. In the patients with SCM asymmetry, more patients (87.3%) underwent physiotherapy than those without asymmetry (61.9%) (P = 0.021). In 99 patients who underwent surgery for SOP, the resolution of torticollis was not significantly different between patients with and without SCM asymmetry (87.2% vs. 76.9%, P = 0.184). Nearly half of the patients with congenital SOP had SCM thickness asymmetry that was already determined at a young age. However, the surgical results did not differ significantly with respect to SCM asymmetry when physiotherapy was combined. Thus, SOP surgery can be considered despite preoperative SCM asymmetry.