Superior rectus muscle recession for residual head tilt after inferior oblique muscle weakening in superior oblique palsy

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.

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.

Sternocleidomastoid muscle asymmetry in unilateral congenital superior oblique palsy

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

The efficacy of superior rectus recession with simultaneous inferior oblique disinsertion on superior oblique palsy with superior rectus contracture

PURPOSE

The information about superior rectus (SR) recession in cases with SR contracture coexisting with superior oblique palsy (SOP) is very limited in previous literature. The aim of this study is to evaluate the effect of SR recession, as a combined procedure with inferior oblique (IO) disinsertion, in long-standing SOP with secondary SR contracture.

METHODS

The medical records of the 145 patients operated for SOP were retrospectively reviewed and 15 patients who underwent SR recession met the inclusion criteria. The mean follow-up was 50.4 months.

RESULTS

The preoperative angle of deviation was within the range of 16-35 prism dioptres (PD) with a mean of 23.0 ± 5.03 PD. In all of the cases, SR recession was performed in combination with IO disinsertion. Adult patients (12) underwent adjustable SR recession. Postoperative overcorrection developed in 3 cases (20%), and in 12 patients, the postoperative vertical deviation was within the range of 0-5 PD with a mean of 1.41 ± 1.88 PD. The overcorrected three patients underwent botulinum toxin A (BTXA) injection into the ipsilateral inferior rectus muscle. The deviation is well controlled by BTXA injection in two patients, whereas the other one was considered as masked bilateral SOP and underwent IO disinsertion in the other eye.

CONCLUSION

Our results suggested that SR recession in combination with IO disinsertion is an effective procedure to control large vertical deviations in SOP with SR contracture in the majority of cases. However, the risk of overcorrection should be considered despite adjustable SR weakening and BTXA injection seems efficient to rescue overcorrections in long term.

Recurrent Superior Oblique Myokymia Treated by Distal Tendon Extirpation

BACKGROUND

We describe successful surgical treatment of superior oblique myokymia, which had recurred after superior oblique tenectomy.

METHODS

Single case report.

RESULTS

The distal stump of the superior oblique tendon was extirpated by stripping it from the globe. The ipsilateral superior rectus muscle also was recessed, to correct a hypertropia that had resulted from the original superior oblique tenectomy.

CONCLUSIONS

Complete removal of the distal superior oblique muscle tendon provided definitive relief of superior oblique myokymia. Superior rectus muscle recession, combined with previous inferior oblique myectomy, compensated effectively for loss of superior oblique function.

Surgical treatment of superior oblique palsy: Predictors of outcome

PURPOSE

The purpose of this study was to evaluate the incidence and outcome of surgically treated superior oblique palsy (SOP) and the factors involved in its resolution.

METHODS

We performed a retrospective study of 76 patients who underwent surgery for SOP. We recorded data from the physical examination and the number and type of procedures performed. Favorable outcome was defined as resolution of or improvement in torticollis (≤5°) and diplopia in primary position (PP) and downgaze or as vertical deviation (VD) <5 prism diopters (pd) in PP and 10 pd in the oblique diagnostic position.

RESULTS

Mean age was 33.12 years. Congenital SOP was the most frequent type (65.8%). Mean preoperative VD was 15.89 ± 9.94 pd, decreasing to 3.07 ± 4.36 pd after surgery. Associated horizontal deviation was recorded in 51.32% of cases. The mean number of procedures was 1.37 ± 0.62 (range 1-4), with 69.7% of patients requiring only one procedure. The mean number of muscles operated on was 1.96 ± 1.01 (inferior oblique being the most frequent). A greater reduction in VD after surgery was observed in patients with congenital SOP (P = 0.04). Although none of the factors evaluated influenced surgical outcome, amblyopic patients had a greater risk of reoperation (P = 0.04). A favorable outcome was achieved in 75% of cases. Mean follow-up was 37.08 months.

CONCLUSION

Congenital SOP was twice as frequent as acquired SOP and although surgery was successful in most cases, a greater reduction in VD was obtained in congenital cases. Amblyopia was identified as a risk factor for reoperation.

Surgical interventions for vertical strabismus in superior oblique palsy

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation.

DATA COLLECTION AND ANALYSIS

Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Impact of strabismus surgery on health-related quality of life in adults

PURPOSE OF REVIEW

Adult strabismus can cause many symptoms, which have generally been divided into functional complaints and social complaints. The validity of surgical correction has historically been based on the restoration of functional improvement. In the absence of this expectation, surgery was labeled cosmetic. Yet, many studies have revealed the immense impact of ocular misalignment on psychosocial variables. The purpose of this article is to review the potential functional and psychosocial benefits of strabismus surgery and to summarize the development and status of questionnaires to help quantify these benefits.

RECENT FINDINGS

Functional benefits of strabismus surgery have been recently summarized with a meta-analysis. Several questionnaires have been evaluated to assess the functional and psychosocial factors in adult strabismus. Two strabismus-specific questionnaires, the Amblyopia and Strabismus Questionnaire and the Adult Strabismus-20, reveal improvements in adults following surgery. The appropriate patient population, impact of comorbidities on the scores, and the timing of the administration of the questionnaire postoperatively still need to be determined.

SUMMARY

Future studies of the impact of strabismus surgery in adults will need to report not only objective motor results, but also the impact on health-related quality of life to encompass all the benefits of strabismus surgery.

One Year of Pediatric Ophthalmology and Strabismus Research in Review

PURPOSE

To highlight recent advances in amblyopia and strabismus.

DESIGN

Literature review.

METHODS

A literature search of articles published in the English language was performed in PubMed or MEDLINE between May 2012 and April 2013 using the terms amblyopia or strabismus. Articles deemed relevant were selected.

RESULTS

The review highlights articles that increase our understanding of strabismus and amblyopia as well as newer treatment strategies.

CONCLUSIONS

The review highlights some new information and possible future advances in amblyopia and strabismus.