Acquired bilateral superior oblique palsy

Acquired bilateral superior oblique palsy following severe head injury is characterized by a disabling torsional diplopia, with a right hypertropia present in gaze down left, and a left hypertropia present in gaze down right. It is caused by a hemorrhage in the roof of the midbrain at the caudal end of the quadrigeminal plate. This is the area of the decussation of the fourth cranial nerve.The condition may go unrecognized by the clinician if the palsy is equal in the two eyes in which case there may be little or no deviation present on cover test in the primary position. Testing of the cardinal fields and diplopia field testing reveals the underaction of each superior oblique, and the resultant hypertropia with extorsion.Spontaneous improvement of superior oblique function of each eye often occurs in these cases. Occasionally only one superior oblique recovers completely and the resolution of the condition is a residual unilateral palsy.     

Classification and treatment of bilateral superior oblique palsy

Twenty-one patients with bilateral superior oblique palsy were studied in order to classify them into five major categories. By classifying the presentations, an orderly approach to the diagnosis as well as the treatment of bilateral superior oblique palsy is made.     

外伤性双上斜肌麻痹的临床观察

目的 探讨外伤性双眼上斜肌麻痹（又名外旋转斜视）的典型临床特征及治疗方法。方法 先保守治疗半年,不能治愈者,后采用上斜肌矢状移位术治疗。结果 １６例中,保守治疗治愈２例,手术治愈１４例,追踪观察１年以上无复发。结论 上斜肌矢状移位术治疗效果满意。     

The diagnosis and treatment of bilateral masked superior oblique palsy

I reviewed retrospectively the records of 147 consecutive patients who had superior oblique palsy. Of the 147 patients, 28 had bilateral superior oblique palsies, and in nine of the 28 the involvement was so asymmetric that the palsy in the lesser affected eye was either completely masked or almost masked preoperatively. Relying on preoperative diagnostic criteria such as the presence of bilateral objective torsion, cover testing in the oblique fields of gaze, size of the subjective cyclotropia, amount of the "V" shift, and subjective symptoms, all nine patients underwent bilateral surgery at the time of their initial operation and obtained satisfactory results. No patient was later found to have bilateral masked superior oblique palsy after unilateral surgery.     

双上斜肌麻痹的临床特征与治疗

双眼上斜肌同时麻痹称为双上斜肌麻痹,近年来受到国内外眼科学者的重视。本文报告13例,均是我科近年来手术治疗并在术后观察3个月以上者。13例病人都无明显外伤史,发病在出生时及出生后早期,为先天性病变。手术次数1～2次。临床特征:不对称病变以单眼上斜视,代偿头位为主要表现,其中有一部分病人为潜在型双侧病变。对称型以两侧同向注视时的反向上斜视为主要表现,双侧Bielschowsky征为阳性。不少病人同时有V型斜视。需要手术治疗的病人一般应做双眼手术。可根据病情决定是同时做双侧手术,还是分次做,以及术式、术量。术后大部分病人能获得满意的头位及眼位。     

Temporary incyclotorsion following surgical correction of bilateral superior oblique palsy.

We report three patients with acquired bilateral superior oblique paresis who had bilateral modified Harada-Ito procedures, which resulted in significant incyclotorsion (ranging from 6 degrees to 19 degrees ) on the first day postoperatively. For Case 1 this was the only procedure, while Cases 2 and 3 also underwent simultaneous bilateral inferior oblique weakening. This overcorrection decreased spontaneously over the following 8 months to leave all patients asymptomatic. One patient returned 8 years following the initial surgery with symptoms of diplopia and recurrence of excyclotorsion.     

隐匿性双眼上斜肌麻痹性斜视的临床特征和手术治疗

目的探讨双侧隐匿性双眼上斜肌麻痹性斜视的临床特点和诊疗方法。方法对1999年1月至2003年12月住院行手术治疗的7例双侧隐匿性双眼上斜肌麻痹性斜视患者的临床资料进行回顾性分析,观察患者手术前、后的代偿头位、原在位垂直偏斜度数、上斜肌和下斜肌功能状况的变化情况。结果全部患者首次就诊时头均向健侧肩倾斜,均诊断为单侧上斜肌麻痹性斜视,原在位平均上斜视度数为19．7^△（6^△-30^△）,麻痹眼下斜肌功能亢进程度为＋2～＋4,上斜肌功能不足程度为-1或-2,对侧眼上、下斜肌功能未见明显异常。第1次手术2例患者选择单纯下斜肌减弱术,5例患者选择下斜肌前转位联合同侧上直肌后退术,术后原在位平均上斜视度数为12．0^△（0^△～20^△）。术后1周至4年内全部患者对侧眼均出现不同程度的上斜肌麻痹表现,下斜肌功能亢进程度为＋2或＋3,上斜肌功能不足程度为0或-1。全部患者均在第1次手术后4个月至4年内接受第2次手术,术后原在位平均上斜视度数为2．3^△（0^△-7^△）,眼位矫正效果较为满意。结论双侧隐匿性双眼上斜肌麻痹性斜视难以在第1次手术前确诊,对于单侧上斜肌麻痹性斜视患者术前应考虑到对侧眼存在上斜肌麻痹的可能。下斜肌减弱手术与垂直肌后退术宜分期进行。第1次手术后当对侧眼隐匿的麻痹症状明显表现时,应考虑行第2次矫正手术。     

Familial congenital superior oblique palsy

Four pedigrees, each with two or more cases of congenital superior oblique palsy among immediate family members, are presented. Except for a single case report in 1926, this disorder has not been known to occur in a hereditary manner. Theories of pathogenesis of congenital fourth cranial nerve palsy are discussed, with special reference to the hereditary occurrence of this disorder. Analogy is drawn between the familial forms of congenital superior oblique palsy and Duane's syndrome.     

Residual symptomatic superior oblique palsy

PURPOSE: To determine the outcome of patients treated for residual symptomatic hyperdeviations, in a tertiary referral centre, following a previous weakening procedure of the ipsilateral Inferior Oblique (IO) muscle in Superior Oblique (SO) palsy. METHODS: A retrospective review of 37 patients seen over 6 years at one institution who had remained symptomatic from a SO palsy despite having had an initial weakening procedure to their ipsilateral IO (myectomy or recession). Median age was 19 years (range 3 to 56 years). Information recorded included pre- and postoperative deviation and ocular motility findings, preoperative symptoms, findings at the time of surgery, and outcome. RESULTS: Nine patients underwent repeat weakening surgery (disinsertion) on the ipsilateral IO only. Thirteen patients underwent strengthening surgery on the ipsilateral SO only. Nine patients had surgery on both the ipsilateral IO and SO. Six patients had surgery on the ipsilateral IO with either horizontal or vertical rectus surgery. Nine (24%) patients remained symptomatic after their initial procedure and are regarded as initial failures. Four of these patients had masked bilateral IO weakness. Five patients required additional surgery. At final outcome, 84% were discharged with resolution of their symptoms. CONCLUSIONS: In the light of these findings we suggest an approach for the management of these patients. This should always include exploring a previously operated ipsilateral IO. Despite this, patients should be warned that they have a 1 in 4 chance of needing further surgery to achieve adequate ocular motility.     

Diagnosis of superior oblique palsy

Superior oblique muscle palsy is not only the most frequent cause of acquired vertical strabismus, anomalous head posturing and torsional diplopia, but also the most common isolated oculomotor paralysis seen in everyday ophthalmic practice. Adults typically present to the ophthalmologist with asthenopic symptoms of long duration, while children present with objective clinical signs. An understanding of the available subjective and objective examination techniques will enable the clinician to diagnose the presence of this cyclovertical muscle paralysis. There are clues from the examination that suggest a superior oblique palsy of long duration, which may save the patient a needless neurological workup and a 6-month wait before surgical options can be considered. There are also clues from the examination that suggest the presence of a "masked" bilateral superior oblique palsy. Most cases of previously diagnosed skew deviation, if examined closely, will actually turn out to be mild trochlear nerve pareses.     

Vertical saccades in superior oblique palsy

Vertical saccadic velocities in 10 patients who had unilateral superior oblique muscle palsy and 14 normal subjects were measured with the magnetic scleral search coil. The authors sought to determine whether downward saccades in patients who had superior oblique palsy are slow. Peak velocities of 10 degrees and 20 degrees saccades performed in the superior and inferior fields of the orbit, and 10 degrees, 20 degrees, and 30 degrees saccades performed across the center of the orbit were recorded with the eye in center gaze, 30 degrees of adduction, and 30 degrees of abduction. Paired t-tests did not show statistically significant differences between upward and downward saccades in patients with superior oblique palsy; no effects of orbital field or position of horizontal gaze were found (P greater than 0.01). Comparison of similar saccades between normal subjects and patients with superior oblique palsy by two-sample t-tests did not show significant differences between the two groups (P greater than 0.01).     

先天性上斜肌麻痹的手术方式选择

目的观察不同手术方式对先天性上斜肌麻痹的治疗效果。方法对我院收治的52例(59眼)先天性上斜肌麻痹的手术方式和疗效作回顾性分析。结果52例(59眼)中11例(13眼)施行了下斜肌断腱术,23例(26眼)施行了下斜肌后徙术,18例(20眼)施行了下斜肌后徙前转位术。18例(20眼)治愈,23例(28眼)好转,总有效率78.85%(41例)。下斜肌断腱术有效率81.82%,下斜肌后徙术有效率78.26%,下斜肌后徙前转位术有效率77.78%。结论上斜≤15Δ可采用下斜肌断腱术或下斜肌后徙术,下斜肌断腱术与下斜肌后徙术具有同样的矫正效果。上斜16Δ~25Δ可采用下斜肌后徙并前转位术,上斜≥25Δ可采用下斜肌后徙并前转位联合配偶肌(对侧眼下直肌)后徙术。     

反向偏斜与上斜肌麻痹

反向偏斜（dkew deviation）为一种后天获得性的共同性垂直斜视,临床表现为头部倾斜、眼球旋转及主观视觉的垂直方向倾斜,该类患者大脑感知的主观视觉世界在垂直方向是倾斜的,因而眼睛和头部向偏斜的视觉方向旋转,以恢复垂直方向的定位。反向偏斜的病因为内耳椭圆囊至眼运动神经核的前庭-眼反射通路受损。通过文献回顾,简要概述反向偏斜的病因、临床表现、临床分型,并与常见的上斜肌麻痹相鉴别,借以提高眼科临床医师对反向偏斜的重视,避免将其误诊为单纯的上斜肌麻痹,而忽略对椭圆囊耳石器或中枢神经病灶的诊断。     

Treatment of superior oblique palsy with superior oblique tendon tuck and inferior oblique muscle myectomy

Twelve patients underwent quantitated superior oblique tendon tuck and ipsilateral inferior oblique muscle myectomy in the primary treatment of unilateral superior oblique muscle palsy. Preoperatively, each patient exhibited a vertical deviation of 30-55 prism diopters in at least one position of gaze. Following a single operation, satisfactory ocular alignment was obtained in all but one case, with fusion demonstrable in clinically significant gaze positions. Eight of 12 patients had no measurable vertical deviation in primary position, and two others had residual hyperphorias of only two prism diopters. No tucks were removed for postoperative Brown's syndrome. Superior oblique tendon tuck combined with ipsilateral inferior oblique muscle myectomy appears to be a safe and effective treatment for large angle superior oblique muscle palsy.     

Inferior oblique myositis presenting as superior oblique muscle palsy

A 14-year-old girl presented with progressive vertical strabismus simulating superior oblique muscle palsy. However, because of the presence of limitation of infraduction, computed tomography was done; it showed a large mass in the region of the right inferior oblique muscle. A biopsy specimen of the enlarged muscle showed mainly degenerative and some regenerative changes. The diagnosis was orbital myositis, which should be considered in the differential diagnosis of strabismus, especially if the clinical findings are atypical of strabismus.     

Isolated superior oblique tucking: an effective procedure for superior oblique palsy with profound superior oblique underaction.

PURPOSE: To compare efficacy and complications of isolated unilateral superior oblique tucking in patients with unilateral superior oblique palsy (SOP). METHOD: A retrospective analysis of 24 cases of unilateral SOP, 13 Acquired (group 1), and 11 Congenital (group 2), who underwent isolated unilateral superior oblique tuck over a 13-year period was performed. RESULTS: The mean preoperative vertical deviation in primary gaze was 10 +/- 3 PD for group 1 and 12 +/- 5 PD for group 2 and mean vertical deviation in lateral gaze of affected superior oblique was 19 +/- 5 PD for group 1 and 21 +/- 9 PD for group 2. The mean postoperative vertical deviation in primary gaze for group 1 after a mean follow-up period of 15 +/- 21 months was 1 +/- 3 PD; for group 2 after a mean follow-up period of 17 +/- 13 months was 2 +/- 3 PD, and in lateral gaze of affected superior oblique was 3 +/- 5 PD for group 1 and 5 +/- 6 PD for group 2. The mean correction of vertical deviation in primary gaze at last follow-up was 8 +/- 2 PD for group 1 and 9 +/- 5PD for group 2 ( P > 0.05) and in the lateral gaze field of affected superior oblique muscle was 16 +/- 4 PD for group 1 and 15 +/- 5 PD for group 2 ( P > 0.05). The mean preoperative torsion was 9 +/- 4 degrees for group 1 and 9 +/- 2 degrees for group 2; mean postoperative torsion was 1.2 +/- 2.2 degrees for group 1 and 1 +/- 1 degrees for group 2. The mean torsion corrected for group 1 was 8 +/- 3 degrees and for group 2 was 8 +/- 2 degrees ( P > 0.05). Only one patient in group 1 and three patients in group 2 required reoperation to correct residual deviation. A mild postoperative limitation to elevation in adduction was seen in all cases but was asymptomatic and lessened over time. CONCLUSION: Isolated unilateral superior oblique tucking corrected a large amount of the vertical deviation and torsion with minimal complications in selective patients of both congenital and acquired superior oblique palsy. Superior oblique tucking is a safe and effective procedure and can be considered in patients with SOP meeting selective criteria.     

Tendon laxity in superior oblique palsy.

BACKGROUND: Some congenital superior oblique palsies are known to be due to anomalous or lax superior oblique tendons. This prospective study of 24 patients with a diagnosis of superior oblique palsy was performed to determine the prevalence and significance of anatomic tendon anomaly or laxity as diagnosed by traction testing of the superior oblique tendon. METHODS: Traction testing was performed on 24 consecutive superior oblique palsy patients to determine the relative laxity of the tendons. RESULTS: All 14 patients who were believed to have congenital palsy by history and clinical examination were found to have lax tendons. No patient with acquired unilateral palsy showed similar tendon laxity. CONCLUSION: These findings have significant implications regarding the diagnosis and possible cause of congenital superior oblique palsy as well as implications for surgical management.