Vertical Deviation In Primary Position Research Articles

Teprotumumab for Thyroid Eye Disease-related Strabismus.

To assess and quantify teprotumumab's effect on thyroid eye disease-related strabismus by change in measured horizontal and vertical deviations and change in extraocular motility. We reviewed a series of patients with thyroid eye disease-related strabismus treated with teprotumumab. Exclusion criteria included age under 18 years, strabismus of alternate etiology, or thyroid eye disease-related reconstructive surgery during the treatment course. Primary outcomes were absolute (prism diopters) and relative (%) differences in horizontal and vertical deviations in primary position at distance, as well as change in ductions of the more affected eye. Secondary outcomes included incidence and timing of strabismus surgery postteprotumumab. Thirty-one patients were included, with mean age 63 years and thyroid eye disease duration 10 months. After teprotumumab, there was 6 prism diopters (39%) mean reduction in vertical deviation (p < 0.001), without significant change in mean horizontal deviation (p = 0.75). Supraduction, abduction, adduction, and infraduction significantly improved in the more restricted eye (p < 0.01, p < 0.01, p = 0.04, and p = 0.01, respectively). Thirty-five percent of patients underwent strabismus surgery posttreatment, at an average 10 months after last infusion. Teprotumumab produced a statistically significant reduction in vertical but not horizontal strabismus angles in primary position at distance. Extraocular motility in all 4 ductions also improved. A substantial minority of patients still required strabismus surgery following teprotumumab.

Successful outcome of Knapp’s procedure with Foster augmentation suture in a case of monocular elevation deficiency with large primary position vertical deviation

Abstract A 26-year-old female patient presented to us with diminution of vision, downward deviation with restriction of extraocular movements of the left eye (LE) with drooping of ipsilateral upper lid since childhood. On examination, the best corrected visual acuity in LE was 6/12 and 6/6 in the right eye (RE), restriction of adduction and elevation (−4) on duction, and limitation on dextro-elevation and levo-elevation (−4) on version with moderate ptosis was present. On Hirschberg’s test, hypotropia of 30° was seen in LE with poor Bell’s phenomenon. Prism bar reflex test showed hypotropia of 65 prism diopters (PD). She was diagnosed with LE monocular elevation deficiency (MED) with mild LE amblyopia. Forced duction testing was strongly positive for LE Inferior Rectus muscle, therefore LE IR recession 6.5 mm with conjunctival recession was done as the first procedure. There was a residual hypotropia of 50 PD after 4 months of follow-up for which LE Knapp procedure with foster augmentation suture was performed. Post-operatively, the patient was orthophoric in the primary position with significant improvement LE upgaze limitation. Through this case report, we aim to conclude that a two-step surgical approach including inferior rectus recession followed by Knapp’s procedure with foster augmentation suture is an effective procedure in a case of MED with a large primary position vertical deviation.

Outcomes of inferior oblique myectomy versus recession combined with lateral rectus recession in V-pattern exotropias

PurposeTo compare outcomes of bilateral lateral rectus recession (BLRc) paired with either bilateral inferior oblique myectomy (BIOm) or bilateral inferior oblique recession (BIOc) to correct V-pattern exotropia. MethodsThe medical records of children (≤18 years) who underwent BLRc with BIOm or BIOc (10 mm) for V-pattern intermittent exotropia between December 2020 and May 2022 and who had at least 6 months’ postoperative follow-up were reviewed. Outcomes included horizontal alignment, bilateral inferior oblique action, stereopsis, postoperative exotropia control score, and additional strabismus surgeries. Analysis was stratified by preoperative V pattern into subgroups of 10Δ-14Δ and ≥15Δ. ResultsFifty patients underwent BLRc with BIOm (n = 26) or BIOc (n = 24), with no difference in age, sex, or follow-up length. Preoperatively, there were no differences in stereopsis, horizontal or vertical deviations in primary position, strabismus control, or inferior oblique overaction (IOOA). The BIOc group had greater preoperative V pattern than the BIOm group (18.1 ± 6.8 D vs 14.3 ± 7.0 D, resp. [P = 0.03]). There was no difference in BLRc surgical dose. At final follow-up (mean, 448 ± 189 days), both groups showed a postoperative decrease in horizontal deviation, amount of V pattern, and IOOA. For patients with ≥15Δ V pattern, BIOm decreased V pattern amount at distance (P = 0.02) and IOOA (P = 0.0035) more than BIOc, and BIOm patients had better control of residual strabismus at distance (P = 0.03) compared with the BIOc group overall, as well as for both V pattern subgroups. Two patients with BIOm and one with BIOc underwent additional strabismus surgery. ConclusionsBIOm or BIOc in combination with BLRc decreased the angle of exotropia and improved control. However, BIOm, especially with large V patterns, had a greater effect on decreasing the V pattern and IOOA and showed better control of residual strabismus.

The Role of Hypertropia in the Surgical Management of Bilateral Inferior Oblique Muscle Overaction

ABSTRACT Purpose Inferior oblique muscle overaction (IOOA) is an ocular motility anomaly consisting of overelevation in adduction, often associated with ipsilateral hypertropia. The weakening procedure of IO muscle is the most widely used procedure in IOOA. Usually, surgical planning is based on the degree of overaction of the IO muscle. Materials and Methods We have retrospectively analyzed patients with bilateral IOOA with and without hypertropia in primary position, who underwent a bilateral IO weakening procedure. Both the amount of IOOA and the presence of a hypertropia in primary position were taken into consideration for the surgical plan. Results Nineteen patients met the entry criteria for this study. In 12 patients, a hypertropia in primary position was present at baseline, and it was significantly lower after the asymmetrical IO weakening: 11 had an asymmetric IOOA at baseline, and one had symmetric IOOA. None of the remaining seven patients had a vertical deviation in primary position before surgery, despite having asymmetric IOOA. None of them developed a hypertropia in primary position after symmetric IO weakening. Conclusions Our findings outline the utility of considering both the presence of a vertical deviation in primary position and the magnitude of IOOA in this set of patients. Asymmetric inferior oblique weakening procedure is effective in treating a hypertropia in the primary position and bilateral IOOA.

Combined Rectus Muscle Transposition With Posterior Fixation Sutures (Augmented Knapp Procedure) for the Surgical Treatment of Double Elevator Palsy.

To evaluate the surgical results of full horizontal tendon rectus muscle transposition to the superior rectus muscle insertion, augmented by posterior fixation sutures, in patients with double elevator palsy. In this retrospective comparative study, 17 patients treated by the augmented Knapp procedure (study group) were compared with 28 patients treated by the standard Knapp procedure (control group). Pre-operative and postoperative vertical deviation in primary position, ocular motility, binocular function, and rate of reoperation were evaluated. The mean preoperative near and distance deviations (hypotropia) decreased by 93% and 97% in the study group and 68% and 69% in the control group, respectively. The improvement in near and distance deviation was statistically more significant in the study group than the control group (P = .001 for each parameter). The mean preoperative elevation deficiency in abduction and adduction improved by 64% and 66% in the study group and 37% and 39% in the control group, respectively. The improvement in elevation deficiency in abduction and adduction was statistically significantly greater in the study group than the control group (P = .001 and .04, respectively). Reoperation was required in 15 patients (54%) in the control group and 2 (12%) in the study group during the follow-up period of 26 ± 4 months. The postoperative improvement in near and distance deviation and elevation deficiency in abduction and adduction was significantly better in the augmented Knapp procedure than the standard Knapp procedure. This procedure demonstrated a stronger effect in the treatment of double elevator palsy. [J Pediatr Ophthalmol Strabismus. 2022;59(1):17-23.].

Inferior Oblique Recession with 5 mm Loop to Correct Vertical Deviation and Inferior Oblique Overaction Secondary to Superior Oblique Palsy

ABSTRACT Purpose: To evaluate the effect of augmented inferior oblique recession (recession +5 mm loop) on the vertical deviation in primary position (PP) and the inferior oblique overaction (IOOA) in patients with unilateral congenital or acquired superior oblique palsy. Patients and methods: The medical records of patients who underwent unilateral inferior oblique recession with 5 mm loop during 2012 and 2019 were retrospectively reviewed. All patients had small to moderate manifest or intermittent hypertropia in PP and overaction of the inferior oblique muscle of +2 or +3 in lateral gaze. Patients who had combined inferior rectus surgery of the contralateral eye or who had previous vertical muscle surgery were excluded. Results: A total of 26 patients were included. Of these, three patients had combined horizontal muscle surgery. In 22 patients, the superior oblique palsy was congenital or longstanding, in 4 it was acquired and stable for more than 9 months. The mean preoperative vertical deviation in PP at distance and near was 14.7Δ and 11.2Δ, respectively. The mean postoperative vertical deviation was 5.7Δ and 4.1Δ after a mean follow-up of 19 months. The IOOA improved in all patients, 16 patients had an improvement of +2 and 10 patients had an improvement of +1. Conclusion: Inferior oblique recession with a 5 mm loop is a simple and quick technique to correct small to moderate hypertropia in primary position and inferior oblique overaction in contralateral gaze in patients with congenital, longstanding or acquired superior oblique palsy without risk of overcorrection.

Superior Rectus Transposition and Medial Rectus Recession for Treatment of Duane Retraction Syndrome and Sixth Nerve Palsy

ABSTRACT Purpose: To evaluate the outcome of augmented superior rectus transposition (SRT) with medial rectus (MR) recession in patients with Duane Retraction Syndrome (DRS) and sixth nerve palsy. Methods: Twenty four patients (16 DRS and 8 sixth nerve palsy) that underwent the procedure were included. The superior rectus muscle was secured, detached, and re-attached to the sclera along the spiral of Tilaux, adjacent to lateral rectus insertion. A non-absorbable augmentation suture was passed through the sclera, 8 mm posterior to the insertion of the lateral rectus. Results: At the last follow-up, the effect of surgery in decreasing esotropia in both groups was significant (P = .001 for DRS group, P = .002 for sixth nerve palsy). In both groups, abduction deficit improved significantly (P < .001 for DRS and P = .008 for sixth nerve palsy). After the surgery, small, asymptomatic vertical deviation in primary position was induced in five patients (20.8%). Post-operatively, none of the patients complained of torsional diplopia. In the 6-month follow-up, compared with the first postoperative visit, an eso-drift at distance or near developed in 11 patients (45.8%). Of the 11 patients with eso-drift, overcorrection (exotropia of 3–14 PD) was present at the first post-operative visit in 5 cases. Four cases showed an exo-drift (2–5 PD) at distance or near over time. Conclusion: SRT with medial rectus recession improves esotropia and abduction limitation without inducing significant vertical deviations and torsional diplopia. Some of the cases that underwent SRT with MR recession may show an eso-drift. The eso-drift can correct initial exotropia in some cases.

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.

How Successful is Combined Superior and Inferior Oblique Muscle Surgery in Young Children with Superior Oblique Underaction Presenting in Infancy with a Severe Head Tilt?

Background/Objective:To evaluate the success of combining ipsilateral inferior and superior oblique muscle surgery in young children with congenital unilateral superior oblique under action who present in infancy with a large socially noticeable head-tilt.Methods:A consecutive retrospective case series of young children was analysed. The success of surgery in eliminating the head-tilt was evaluated by pre- and post-operative ocular motility assessment focusing on the vertical misalignment in primary position and downgaze, the magnitude of the head-tilt in degrees and the status of the superior oblique tendon.Results:Five children had a mean age at first surgery of 41 (range 25–63) months, a mean primary position vertical deviation of 26 (25–30) prism dioptres, a head-tilt of 30 (20–35) degrees and a mean post-operative follow up of 24 (8–43) months. While there was a uniform surgical plan, nonetheless each operation required individualisation based on a spectrum of per-operative superior oblique tendon findings. The head tilt was eliminated in 40% and reduced in the remainder, to a mean of 7 (0–18) degrees and with a mean post-operative primary position vertical misalignment of 3 (range 0–10) and of 10 (range 0–40) prism dioptres in downgaze.Conclusion:Combined, ipsilateral oblique muscle surgery reduced the severe head tilt and primary position alignment to a psychosocially and functionally acceptable level. For the majority, the outcome was stable or associated with further decremental improvement. A persistent downgaze vertical tropia occurred in children with macroscopically abnormal superior oblique tendons but these cases were not identifiable clinically pre-operatively.

Single-stage superior oblique tendon recession with suture adjustment under topical anesthesia and sedation for A-pattern strabismus with superior oblique overaction

To assess the surgical effect of single-stage superior oblique recession with intraoperative suture adjustment under topical anesthesia and sedation in terms of A-pattern correction, vertical alignment, and superior oblique overaction. The medical records of patients who underwent superior oblique weakening (recession with adjustable suture) for superior oblique overaction from 2015 to 2018 were reviewed retrospectively. Preoperative, pre- and postadjustment, and 6-week follow-up data were assessed and compared for A pattern, primary position hypertropia, superior oblique overaction scale and objective fundus torsion. A total of 29 patients (17-42years of age) were included. Of 51 operated eyes, 37 underwent intraoperative adjustment (further recession of 1-4mm) after superior oblique recession of 8mm. Mean decrease in primary position hyperdeviation after adjustment was 3.6Δ ± 2.7Δ (range, 0Δ-8Δ); in A-pattern deviation, 5.5Δ±4.8Δ (range, 0Δ-16Δ). At 6weeks' follow-up, A pattern had either resolved completely or became clinically insignificant (<10Δ) in 23 of 29 patients (79%); 24 (83%) patients had hyperdeviation in primary position of ≤5Δ. Of the 5 patients with preoperative primary position hyperdeviation of 15Δ-30Δ, 2 had residual primary position hyperdeviation of >10Δ. In our study cohort, single-stage, unilateral superior oblique tendon recession with adjustable suture under topical anesthesia and sedation was well tolerated and resulted in good postoperative outcomes at 6weeks' follow-up, effectively correcting primary position vertical deviation of <15Δ.

Diagnosis and surgical management of isolated inferior oblique palsy.

To describe the etiology, clinical characteristics, surgical options and surgical outcomes of isolated inferior oblique palsy (IOP). A retrospective review was performed on patients with isolated IOP who were seen between January 2010 and June 2017. The following clinical data were obtained from the patients' charts: visual acuity, ocular alignment, ocular motility, cyclotorsion, stereoacuity, Parks three-step test, surgical methods, surgical outcomes and complications. Surgical success was defined as horizontal deviation ≤10 prism diopters (PD) and a vertical deviation ≤5 PD in primary gaze at both near and distant vision as assessed at last follow-up. The records from a total of 18 patients (8 males and 10 females) with an average age of 27.56y were included in this study. The right eye was affected in 11 patients, the left in 6 patients and both eyes in 1 patient. Twelve cases (66.7%) were congenital and 6 (33.3%) were acquired IOP. The 6 acquired cases involved 2 resulting from orbital trauma/surgery, 2 from midbrain microvascular ischemia, 1 from myasthenia gravis and 1 of unknown etiology. Strabismus surgery was performed in 13 cases. Surgical techniques included weakening of superior oblique and vertical rectus recession and resection. After a mean follow-up of 15.11mo, the corrected vertical deviation in primary position was 19.92±8.52 PD (P=0.000) and the corrected horizontal deviation was 14.31±12.68 PD (P=0.002). The surgical success rate was 61.5% and no surgical complications were present. Isolated IOP represents a rare condition, with most cases (66.7%) involving a congenital basis. The acquired cases included vascular, orbital trauma/surgery and myasthenia gravis. Weakening of the ipsilateral superior oblique muscle and/or contralateral superior rectus recession often resulted in favorable surgical outcomes with a surgical success rate of 61.5%.

The efficacy of superior oblique posterior tenectomy in the treatment of A-pattern exotropia without ocular intorsion: A retrospective study

BackgroundSuperior oblique weakening is a common method to treat A-pattern strabismus. This study aims to evaluate the surgical results of the bilateral superior oblique posterior tenectomy procedure to treat A-pattern strabismus patients who had bilateral superior oblique overaction without objective ocular intorsion.MethodsThe records of 18 consecutive patients who underwent surgery of superior oblique posterior tenectomy close to its insertion with superior oblique overaction (SOOA)-associated A-pattern strabismus between September 1, 2015 and August 31, 2018 were retrospectively reviewed. Ocular alignment, objective torsion, A-pattern and ocular motility were assessed. Ocular alignment was measured in the primary position, 25° upgaze, and 25° downgaze using the prism bar cover test, and torsion was measured using fundus photographs.ResultsA total of 18 patients (mean age: 15 years; 6 female, 12 male) underwent bilateral superior oblique posterior tenectomy and simultaneous horizontal rectus muscle surgery were included. The mean preoperative A-pattern deviation was 15 PD and the mean postoperative A-pattern deviation was 2.25 PD with a mean reduction of 12.75 PD. The mean preoperative superior oblique overaction was 2.28 and the mean postoperative superior oblique overaction was 0.43 with a mean reduction of 1.85. There was no significant correlation between the ocular torsional, vertical alignment change and the superior oblique posterior tenectomy procedure.ConclusionsSuperior oblique posterior tenectomy surgery selectively improved the A-pattern and superior oblique overaction but not affect the primary position vertical deviation, as well as the ocular torsion. It is an effective procedure to treat the mild to moderate superior oblique overaction associated A pattern strabismus without ocular intorsion.

Inferior Oblique Overaction: The Results of Myectomy in Cases with a Primary Position Vertical Deviation Less and More Than 20 Prism Diopters.

PURPOSE:The purpose of this study is to evaluate the results of myectomy in inferior oblique overaction cases with a vertical deviation angle of <20 and ≥20 prism diopters (PD) in the primary position.METHODS:The medical records of cases with inferior oblique overaction that underwent inferior oblique myectomy for ≥6 PD hypertropia in the primary position and >+1 inferior oblique overaction were reviewed. Preoperative and postoperative examination findings and success rates were compared of cases with a deviation angle <20 PD (Group 1) and ≥20 PD (Group 2).RESULTS:The mean age of 35 (58%) female and 25 (42%) men cases of Group 1 (n = 60) were 12.8 ± 9.4 years; the mean age of 25 (58%) female and 18 (42%) male cases of Group 2 (n = 43) were 14.8 years (P = 0.340). The near hypertropia was decreased from 11 to 0.5 PD in Group 1, from 22.1 to 5.1 PD in Group 2 cases (P < 0.001). The distance hypertropia was decreased from 11.3 to 0.5 PD in Group 1 and from 23.3 to 6.1 PD in Group 2 cases (P < 0.001). The mean degree of hypertropia at near and distance was statistically significantly higher both pre- and post-operatively in Group 2 than in Group 1 (P < 0.001), and improved statistically significantly with the initial surgery in both groups (P < 0.001). The rate of the presence of stereopsis of ≥3000 s/arc and fusion, the main criteria of binocular vision (BOV), was not statistically significantly different between the Groups before (P = 0.577) and after the surgery (P = 0.678), but the presence of BOV significantly increased both in Group 1 (P < 0.001) and Group 2 (P = 0.004) postoperatively. The number of cases with surgical success was 57 (95%) and 25 (58%), respectively, in Groups 1 and 2 (P < 0.001).CONCLUSIONS:Myectomy is an effective surgical procedure that can be easily and quickly performed in inferior oblique overaction cases and has high success rates in cases with a small-to-moderate angle of deviation.

Lateral rectus belly transposition without tenotomy for acquired inferior rectus weakness: a Case series

We present a new procedure for treating inferior rectus weakness by means of lateral rectus belly transposition, without tenotomy or muscle splitting of the transposed muscle. In this technique, the lower margin of the lateral rectus belly is tied 8mm posterior to the insertion then transposed to the sclera 2mm temporal to and 8mm posterior to the temporal pole of the inferior rectus muscle. We report 3 cases of inferior rectus underaction treated using this procedure. Postoperatively all 3 patients showed complete correction of vertical deviation in primary position and experienced greatly improved depression capacity, without newly induced horizontal or torsional deviation.

Prioritising downgaze alignment in the management of vertical strabismus for thyroid eye disease: principles and outcomes.

To evaluate outcomes of surgery for vertical strabismus in thyroid eye disease (TED) employing a set of surgical principles aimed at avoiding reversal of downgaze deviation while restoring binocular single vision (BSV). A retrospective review of consecutive patients undergoing vertical strabismus surgery for TED using a set of surgical principles between 2008 and 2017. Principle outcome measure was the presence of BSV in primary position and downgaze 3 months postoperatively and at latest follow-up. Thirty five patients (29% male) with a mean age of 58 years (range 31-83 years) were included. Median follow-up was 16 months. At presentation, 17 (49%) used monocular occlusion to avoid diplopia; the remainder used a prism and/or abnormal head posture. In 12 (34%), combined horizontal and vertical muscle surgery was required. Median (inter-quartile range) preoperative vertical deviations in primary position and downgaze respectively were 20 prism dioptres (Δ) (15, 30) and 18Δ (8, 22), which improved to 1Δ (0, 3) and 1Δ (0, 3) after the first operation. BSV in primary position and downgaze, without prism, after a single surgery was achieved in 29 (83%). Second surgery was required in 5 (14%) and one patient who had reactivation of her TED required a third surgery. At final follow-up (median 16 months), 32 (91%) were diplopia free without prisms; 3 (9%) used a small prism correction (range 2-12Δ); no patients were left with intractable diplopia. Our management principles are characterised by prioritising downgaze alignment to avoid downgaze diplopia reversal, whilst limiting adjustable sutures and employing standard surgical dosing. They give favourable outcomes in TED associated vertical strabismus.

Aspects cliniques sensoriels et moteurs des syndromes de rétractions congénitaux : syndrome de Stilling-Duane et syndrome de Brown

Congenital Brown syndrome and Stilling-Duane syndrome, two rare causes of strabismus are caused by fibrosis of one or more extraocular muscles. This series aims to report the clinical sensory and motor features of patients with Brown or Stilling-Duane syndrome. Seventeen patients' records were retrospectively assessed for: the ocular deviation in primary position and in the 9positions of gaze, head tilt, visual acuity and binocular vision. Eleven patients with Stilling-Duane syndrome had a mean age of 12years, and monocular involvement, most frequently of typeI. The ocular deviation was variable; 16patients had an abnormal head position, while 50% presented with amblyopia, and only 37% achieved fusion in the compensatory head posture. Six patients presented with congenital Brown syndrome at mean age of 6years. Three had a moderate form, 3had a severe form with vertical deviation in primary position, compensatory head position, amblyopia and binocular vision impairment. The motility impairments depend highly on the identified syndrome, its classification and its severity. Therefore, these two retraction syndromes present some common features. Strabismus in primary position may lead to amblyopia and binocular vision impairment. Clinical motility and sensory assessment is essential, though difficult, to establish the diagnosis and the management of patients with retraction syndromes.

Comparison of augmented and nonaugmented modified Knapp procedure for the treatment of nonrestrictive double elevator palsies

To compare surgical results of augmented and nonaugmented modified Knapp procedure, for the treatment of nonrestrictive double elevator palsies (DEP). The medical records of patients with congenital DEP were reviewed retrospectively. Patients were divided into three treatment groups: standard transposition (group A), Foster transposition (group B), and resection transposition (group C). Pre- and postoperative vertical deviation in primary position, ocular motility, and binocular vision were compared. Thirty patients were enrolled. The pre- and postoperative deviations in group A were 34.7Δ ± 8.6Δ and 6.5Δ ± 6.5Δ; in group B, 38.6Δ ± 14.6Δ and 5.7Δ ± 9.3Δ; and in group C, 43.1Δ ± 10.3Δ and 8.5Δ ± 6.1Δ. The corrected vertical deviation of group B (32.9Δ±5.7Δ) and group C (34.6Δ±5.0Δ) were greater than that of group A (28.1Δ±3.6Δ; P=0.03, 0.002). The pre- and postoperative measures of upgaze in group A were -3.7 and -1.8; in group B, -4.0 and -1.3; and in group C, -3.6 and -2.0. The average improved upgaze in group B (2.6±0.5) was statistically significantly better than that in group A (1.9±0.6) and group C (1.5±0.5; P=0.03, 0.002). There was no significant difference in the surgical effect on downgaze in three groups (P>0.05). The surgical outcome was satisfactory in 19 (63.3%) patients with preoperative vertical devation of ≤40Δ. All transpositions are reasonably effective in treating vertical deviations of <35Δ without obviously limiting downgaze in DEP. Augmented procedures could correct greater vertical deviation of 30Δ-40Δ. The Foster transposition demonstrates the strongest effect in improving upgaze.

Isolated inferior oblique myectomy for vertical deviations of at least 20 prism diopters in the primary position

To investigate the efficacy of inferior oblique (IO) myectomy in patients with primary position hyperdeviations ≥20(Δ), with unilateral IO overaction and clinically normal or minimally underacting superior oblique ductions, where excyclotorsion was not a barrier to fusion in primary position. The medical records of patients who underwent IO myectomy from 1999 to 2014 were retrospectively reviewed to identify those with primary position hyperdeviations of ≥20(Δ). Postoperative changes in vertical deviations in primary position and horizontal and vertical planes were analyzed. A total of 17 patients were included. Mean follow-up was 17.3months. At last follow-up, the mean hyperdeviation decreased in all five documented positions of gaze by 84% of the initial value, with mean reduction in the primary position vertical deviation from 26.5(Δ) to 4.1(Δ). There was rapid early reduction of deviation in all gaze positions (mean, 53%) at 2-4weeks' follow-up, with a corresponding mean reduction of vertical deviation to 11.4(Δ). There were no overcorrections, but 5 patients (29%) had a postoperative primary position hyperdeviation of >5(Δ). Two patients (12%) required further vertical rectus surgery. In our patient cohort, isolated IO myectomy did not result in symptomatic overcorrections and had a reoperation rate that compares favorably to the traditional primary simultaneous two-muscle approach.

Surgical management of superior oblique paresis using inferior oblique anterior transposition.

Inferior oblique anterior transposition (IOAT) is an effective surgical procedure for weakening the inferior oblique muscle. The purpose of this study was to assess the effectiveness and complications of IOAT for superior oblique paresis at a single center over a period of 11 years. The medical records of consecutive patients treated for congenital and acquired fourth nerve paresis with IOAT procedures at Addenbrookes Hospital, Cambridge, from 2001 to 2012 were retrospectively reviewed. All patients were examined before and after surgery: the vertical deviation in primary position and on contralateral gaze was measured, as were versions. The data collected included patient sex and age, presenting complaint, follow-up period, abnormal head position before and after surgery, postoperative complications, and further operative procedures. A total of 98 IOAT procedures were reviewed, with a mean follow-up of 5.8 months. The technique produced a mean correction of 9.5(Δ) in primary position and 17(Δ) in contralateral gaze. Inferior oblique overaction was reduced in all cases, with 20% having a residual overaction and 47% having an underaction. No patients had symptomatic antielevation syndrome. In this patient cohort, IOAT effectively managed appropriately selected patients with superior oblique paresis, improving the vertical deviation in primary position and contralateral gaze. The procedure induced limitation of elevation in some patients. No patient experienced major postoperative symptoms.

Outcome of Inferior and Superior Rectus Recession in Graves’ Orbitopathy Patients

Purpose: To evaluate the surgical effect of unilateral inferior rectus recession (IR-group) with or without a recession of contralateral superior rectus (IR-SR-group) on squint angle and motility restrictions in Graves’ Orbitopathy (GO) patients.Design: Retrospective case series.Materials and Methods: Primary outcome parameters were the changes of squint angle 3 months and 6–12 months postoperatively. As in a previous study, success was defined as a postoperative vertical squint angle of ≤3° in primary position and on downgaze. Secondary outcome parameters were the influence of surgery on duction range and influence of muscle size on dose-effect response.Results: Fifty-six patients were included in the study; 31 patients in the IR-group and 25 patients in the IR-SR-group. The amount of (fixed suture) recession ranged from 2 mm to 7 mm. Vertical deviations in primary position changed from 8.0° [95% CI 6.6–9.7°] to 1.0° [95% CI −0.4–6.5°] in the IR-group and from 17.0° [95% CI 15.7–20.0°] to 1.5° [95% CI 0.8–2.9°] in the IR-SR-group. The success rate was 74% in the IR-group and 64% in the IR-SR-group. Elevation significantly improved in both groups (IR-group p = 0.007; IR-SR- group p = 0.000). The volume of vertical rectus muscles as assessed on CT-scans did not influence the dose-effect response.Conclusions: The highest success rate and highest reduction of depression was found in the IR-group. The total duction range remained stable after strabismus surgery (IR-group) or improved (IR-SR-group). Both squint angle and cyclodeviation remained stable during long time follow-up (6–12 months after surgery).