Vertical Deviation In Adduction 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.

Isolated Unilateral Strabismus Sursoadductorius (Congenital Trochlear Palsy) with and without Hypotrophia of the Superior Oblique Muscle-Orthoptic Differences in Adulthood

The clinical feature of unilateral decompensating strabismus sursoadductorius (dSSA; often called congenital superior oblique palsy, CSOP) is not an etiologically uniform entity. Hypotrophy of the superior oblique muscle (HMOS) is a frequent and immediate cause of dSSA/CSOP. In this study, clinical characteristics of dSSA/CSOP with and without HMOS are compared. Twenty-five consecutive patients (age 14 - 69 years; median 43 years) were included in this study, 14 with 3T MRI-proven HMOS (group 1) and 11 without HMOS (group 2). HMOS was defined as a reduction of the medio-lateral (ML) as well as based on ML and cranio-caudal (CC) diameter calculated area = (ML · CC/4) · π of the affected superior oblique muscle (SOM) < 80% in comparison to the contralateral SOM (measured on the single coronal image on which the muscle has its greatest extent). The two groups were compared in terms of head tilt, cyclo- and vertical deviation and the Bielschowsky head tilt test. Patients were classified according the Knapp's classification. Both the incidence of head tilt with 14/14 vs. 5/11 (χ2 = 0.003) and its degree: 11.1 ± 4.5° vs. 3.2 ± 4.1° (p < 0.001) was higher in group 1 than in group 2, as well as the Bielschowsky head tilt test: 9.3 ± 4.3° vs. 3.8 ± 4.9° (p = 0.008). The average amount of hypertropia was larger in group 1 than in group 2 during adduction: 16.7 ± 5.3° vs. 9.3 ± 3.4° (p < 0.001) as well as during adduction and downgaze of the affected eye: 14.6 ± 7.1 vs. 7.2 ± 3.7° (p = 0.03). In the sagittal plane, the increase of vertical deviation was larger in group 1 than in group 2: 2.8 ± 7.8 vs. - 2.4 ± 4.2 (p = 0.04); the excyclodeviation was larger in group 1 in all three planes (sagittal plane, adduction and abduction) in comparison to group 2: 1.3 ± 4.1 vs. - 2.9 ± 2.8 (p = 0.006), 2.4 ± 5.2 vs. - 2.2 ± 2.9 (p = 0.01), 0.5 ± 3.8 vs. - 2.7 ± 3.9 (p = 0.05). Knapp's class II was found in 6 of 15 patients in group 1 and only in this patient group (χ2 = 0.03). In both groups, the vertical deviation showed a great dispersion. In patients without HMOS (group 2), vertical deviation in adduction did not exceed 15°. Patients with HMOS (group 1) do not show the typical features of a later acquired trochlear palsy due to an early developed compensating innervation. A vertical deviation in adduction of more than 15°, increasing excyclodeviation towards downgaze in all three planes (sagittal plane, adduction and abduction) and Knapp's class II are relatively reliable predictors of a hypoplasia of the SOM. An internationally uniform term for this group of patients, such as superior oblique weakness or superior oblique hypotrophy, would be desirable.

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.

Inferior oblique muscle recession with and without superior oblique tendon tuck for treatment of unilateral congenital superior oblique palsy

To compare the surgical results in patients with congenital superior oblique palsy treated with inferior oblique recession (IOR) versus those treated additionally with superior oblique tendon tuck (IOR+SOT). A consecutive, nonrandomized series of patients with congenital superior oblique palsy with vertical deviations in adduction between 10° and 20° were retrospectively reviewed. In the first series, patients were treated with IOR; in the second series, patients were treated with IOR+SOT. We examined the effects of surgery on binocular alignment and on the field of binocular single vision. Each group consisted of 20 patients. Preoperative ocular deviations were similar in both groups. Postoperative residual vertical deviations were not different in the primary position or in downgaze; however, significantly better alignment was achieved in the IOR+SOT group in adduction and downgaze in adduction. Consecutive Brown pattern occurred in 18 of 20 patients who underwent IOR+SOT versus 5 of 20 who underwent IOR. Residual torsion was not statistically different. The field of binocular single vision improved to 92%(range, 28%-100%) after IOR and to 96% (range, 64%-100%) after IOR+SOT (P= 0.20). IOR alone is a suitable procedure for most congenital superior oblique palsies with a moderate-to-large vertical deviation in adduction, resulting in a lower incidence of consecutive Brown pattern than with IOR+SOT.

Dose–response relationship in inferior oblique muscle recession

Recession of the inferior oblique muscle is a widely applied operation in the treatment of strabismus sursoadductorius. In this retrospective study, the dose-response relationship of this procedure was determined in order to improve surgical outcomes. In particular, the effect of an additional anteroposition of the operated muscle was analysed, as well as differences between short and long term results. This retrospective study included 37 patients. Inclusion criteria were unilateral strabismus sursoadductorius and normal retinal correspondence. Exclusion criteria comprised previous ocular muscle surgery and any ocular or orbital disease. Nineteen patients had received an additional anteroposition of the muscle. Patients were examined at a tangent screen pre-operatively and 1 day post-operatively (short-term effect). Sixteen patients underwent an additional examination 3 months post-operatively (long-term effect). Changes of vertical, torsional and horizontal deviations, measured in different positions of gaze, were related to the surgical dose in order to calculate the dose-response relationship by linear regression analysis. Surgery always reduced preoperative deviations. The short-term vertical dose-response without/with anteroposition was 0.6 degrees /0.5 degrees per mm in primary gaze and 1.2 degrees /1.1 degrees per mm in adduction. The short-term torsional dose-response without/with anteroposition was 0.8 degrees /0.5 degrees per mm in primary gaze. Three months later, the vertical effect had remained constant, whereas the torsional effect had decreased to 0.6 degrees /0.1 degrees per mm. Variance was high, e.g. the standard deviation of the short-term effect for the vertical deviation in adduction was 2.5 degrees . Despite the large variation of effects, a dose-response relationship could be established, facilitating surgical planning. Large vertical deviations with small excyclodeviation are an indication for additional anteropositioning. The torsional effect of inferior oblique muscle recessions can diminish over time.

Anterior and nasal transposition of the inferior oblique muscles in patients with missing superior oblique tendons

Patients with missing superior oblique (SO) tendons present with overelevation/underdepression in adduction. Unilateral cases often exhibit abnormal head postures, whereas in bilateral cases, there may be a marked V-pattern with upgaze exotropia. These patients may have craniosynostosis. Nine children with unilateral (n = 2) or bilateral (n = 7) absent SO tendons underwent anterior and nasal transposition of the inferior oblique (IO) muscles, some in combination with horizontal rectus recession for horizontal strabismus. They were evaluated 6 to 46 months postoperatively for alignment and oculomotor examination. Cyclodeviations were not evaluated in most children. Postoperatively, all patients improved. Both unilateral cases were orthotropic with no abnormal head posture. In the bilateral cases, vertical deviation in adduction and exotropia in upgaze had largely cleared, although some symptoms remained, most notably vertical deviation in side gaze (3 patients) and V-pattern esotropia in downgaze (2 patients). A patient missing both SO tendons as well as the left superior rectus muscle, who had the anterior and nasal transposition on the right side only, remained with 25(Delta) left hypotropia. Anterior and nasal transposition of the IO muscle reduces overelevation in adduction and helps eliminate or reduce divergence of the eyes in upgaze, but esodeviation may persist in downgaze. This procedure was most effective in unilateral absence of the SO tendon. It is likely to benefit patients with severe congenital fourth nerve palsy in which standard IO muscle weakening procedures have been ineffective.

Anterior and Nasal Transposition of the Inferior Oblique in Patients with Isolated Superior Oblique Tendon Absence

Introduction: Patients with missing superior oblique (SO) tendons present with overelevation/underdepression in adduction and excycloduction. In bilateral cases there may be a marked V- or Y-pattern, while unilateral cases often exhibit abnormal head postures. These patients may have craniofacial dysostosis (Apert or Crouzon syndrome). We previously described anterior and nasal transposition (ANT) of the inferior oblique (IO) muscles as a powerful IO weakening procedure that alleviates the cycloduction (J AAPOS 2003;7:167-73). Here we report findings with ANT in patients with missing SO tendons. Methods: Seven children with unilateral (N= 2) or bilateral (N= 5) absent SO tendons underwent ANT of the IO muscles in the affected eyes and were seen 1 to 147 weeks postoperatively. Results: Postoperatively, all patients were much improved. Both unilateral cases appeared orthophoric in primary position with no abnormal head posture. In the bilateral cases, vertical deviation in adduction and exodeviation in upgaze had largely cleared, although some vertical deviation in sidegaze (two patients) and 10 PD intermittent exotropia in primary position (one patient) remained. Most notably, one patient showed 30 PD constant esotropia in downgaze. Although it was not feasible to assess cyclodeviation using the double Maddox rod in these children, significant improvements in fundus ex-torsion were seen. Conclusions: The ANT procedure corrects, at least partially, the vertical deviation in adduction, exodeviation in upgaze, and ex-torsion, but esodeviation may persist in downgaze. This procedure could also be beneficial in cases of severe SO palsy when more conventional surgery fails.

Ist der einseitige Strabismus sursoadductorius eine paretische Störung? - Kernspintomographische Untersuchungen

Recent reports postulate that the concomitant vertical deviation found in congenital superior oblique palsy is due to mechanical abnormalities rather than a congenitally paretic muscle, and is overcome in most patients by fusion. On the basis of the clinical characteristics alone a primary paresis is indeed unlikely. Although intraoperatively a different elasticity of the superior oblique tendon exists in congenital versus acquired cases of superior oblique palsy, preoperatively performed MR imaging shows that the clinical findings in congenital superior oblique muscle malfunction could nevertheless be of paretic origin. Seventeen consecutive patients (males: n = 13; females: n = 4) were examined. The vertical deviation in adduction was concomitant in vertical versions, the excyclotropia was small and concomitant in all directions of gaze and was less than 10 degrees even after diagnostic occlusion. All patients showed a positive Bielschowsky head tilt phenomenon and large fusional ability. We performed preoperative MR imaging of both orbits in high resolution 3 mm sections in coronal and axial orientations with and without contrast enhancement. In sixteen patients we found a significant reduction in muscle volume or even total aplasia of the superior oblique muscle of the affected side in comparison to the sound muscle on the other side. In contrast, two patients had a full blown clinical picture of a congenital superior oblique palsy but showed symmetrical muscle volumes on both sides in all coronal sections. Hypoplasia or aplasia of the superior oblique muscle on magnetic resonance imaging provides evidence for a primary paretic cause for the vertical squint found with congenital superior oblique dysfunction. It is not clear, however, whether this is caused by a primary hypoplasia or is of neurogenic origin. Our data together with the consistent difference in tendon morphology of the congenital and acquired forms of superior oblique palsy seem to exclude a purely neurogenic cause for the affection.

Decompensated strabismus surso-adductorius

Strabismus surso-adductorius is a frequent unilateral or bilateral eye movement disorder. Its clinical features include eye elevation with concomitant vertical deviation in adduction, an abnormal head posture from which the patient is unaware (head turned and tilted towards the healthy side), a moderate subjective excyclotorsion, and a positive Bielschowsky head tilt test. Despite its anglo-saxon denomination as "congenital fourth nerve palsy", it is not a paretic disorder. Strabismus surso-adductorius differs from fourth nerve palsy both by etiology and by symptoms. A proper diagnosis is important as neuroradiological examination is mandatory in cases of acquired non-traumatic fourth nerve palsy, whereas decompensated strabismus surso-adductorius can be operated on without any further investigations. Early on, the oculomotor disorder is often well compensated and it does manifest at the adult age. Asthenopia and intermittent vertical diplopia appear as the fusional mechanisms fade out. The best surgical technique for strabismus surso-adductorius is an inferior oblique weakening procedure. In severe cases a combined shortening of the superior oblique tendon may be necessary.

Diagnostic occlusion test in cases of unilateral strabismus sursoadductorius

PURPOSE To investigate the diagnostic occlusion test (OT) according to Marlow in strabismus sursoadductorius (StS; also known as ‘unilateral superior oblique palsy’) and its implications for surgical treatment. METHODS In 67 cases of StS, angles of strabismus were measured before and after patching the affected eye for three days. Horizontal, vertical and torsional deviations were measured in front of the tangent screen of Harms in nine directions of gaze. RESULTS After OT, most cases of StS showed the following distribution of vertical deviation (VD) on horizontal versions: setting the VD in 30° adduction to 100%, VD in primary position (PP) was 50%, VD in abduction 14%, excyclotropia in PP about 40% of the amount of VD. Those StS-cases showing the same distribution of VD on horizontal versions before and after OT were called ‘typical’ ones (27% of the patients). However, 73% of the patients showed a different distribution before OT: 68% VD in PP, 36% VD in abduction, excyclotropia of 20% in PP. After OT these cases converted to the normal pattern described above: VD in PP was 53% and VD in 30° abduction was 19%, excyclotropia in PP was 36%. CONCLUSION In ‘typical’ StS-cases, OT is not necessary. ‘Atypical’ cases, however, can be converted into ‘typical’ ones: they get more incomitant VD on horizontal versions and greater excyclotropia in PP. As VD in adduction remains almost the same in both groups after OT, surgery can be based on the angle in adduction. In individual ‘atypical’ patients the amount of oblique muscle surgery has to be modified after OT.

Operative procedures in cases of disinserted or missing superior oblique muscles

If the surgeon cannot find the tendon of the superior oblique muscle in the right place, he has to change his operative plans intraoperatively. Different procedures are recommended: reinsertion of the superior oblique in the right place, recession of the inferior oblique muscle, and operations on the vertical muscles of the same or the yoke eye. No quantitative recommendations on the surgical amount are mentioned in the literature. Ten patients with different forms of aberrant tendons are presented, four patients with bilateral inferior oblique overaction and superior oblique underaction, and six patients with unilateral strabismus sursoadductorius. The pre-, intra- and postoperative findings are demonstrated. In cases of mild disinsertions (Helveston classes 1 and 2) the superior oblique tendon was shortened using the normal amount in one or two muscle procedures. If the superior tendon did not reach the sclera (Helveston classes 3 and 4), an operation on the superior oblique alone had not sufficiently corrected the long-term deviations. In cases where both oblique muscles are being operated on, the immediate postoperative effect was slight overcorrection, but the long-lasting effect was good. In only one case did the inferior oblique have to be reinserted in its original place because of long-lasting overcorrection of cyclotropia after the two-muscle procedure. An "absent" superior oblique tendon can often be found in the superior nasal part of the orbit near the superior rectus muscle. Reinsertion of the tendon in its physiological place (crossing over the superior rectus muscle) will correct smaller amounts of vertical deviation in adduction only. If the vertical deviation exceeds 12 degrees in adduction, the operation on both oblique muscles can always ameliorate the ocular motility. Only in rare cases can a second operation become necessary.

Evaluation of Superior Oblique Weakening Procedures

To evaluate two superior oblique weakening procedures, silicon expander (SE), and translational recession (TR), and their effects on correction of "A" pattern, vertical deviation in adduction and dorsoadduction, superior oblique overaction, and torsion. In a prospective, institution-based study, 32 eyes of 16 patients having bilateral superior oblique overaction with significant "A" pattern (>10 prism diopters [delta]) were evaluated. The parameters studied were: change in "A" pattern; effect on vertical deviation in adduction and dorsoadduction; superior oblique overaction; and torsion. 95% reduction in "A" pattern with SE and 92% reduction with TR, indicating equal effect in collapse of "A" phenomenon (p=0.78). The extorsion produced by TR was more than that produced by SE (p=0.001). Both the SE and TR procedures offered controlled weakening of the superior oblique and caused a 95% and 92% reduction in the "A" pattern. The latter procedure caused a marked extorsional change, three times that which resulted from SE. Both the procedures leave residual superior oblique overaction.