Clinical characteristics and surgical outcomes in patients with superior oblique muscle palsy: a retrospective study on 1057 patients

BACKGROUND

To evaluate the clinical findings of patients with SOP who underwent surgery.

METHODS

This historical cohort study was performed on 1057 SOP patients managed with surgery in Farabi Hospital, Iran, from 2011 to 2022.

RESULTS

There were 990 (93.7%) patients with unilateral SOP with the mean age of 21.8 ± 14.8 years. Of these, 715 patients (72.2%) were diagnosed with congenital SOP, and 275 patients (27.8%) had acquired SOP (P < 0.001). In contrast, 67 (6.3%) patients were diagnosed with bilateral SOP, with the mean age of 19.4 ± 15.6 years. Among these, 18 cases exhibited the masked type. The mean angle of vertical deviation in primary position at far in unilateral and bilateral cases was 15.6 ± 8.3 and 13.3 ± 9.1 △, respectively (P < 0.001). In unilateral cases, abnormal head posture (AHP) was detected in 847 (85.5%) patients and 12 (1.2%) had paradoxical AHP. Amblyopia was found in 89 (9.9%) unilateral and 7 (10.3%) bilateral cases. Solitary inferior oblique myectomy, was the most common surgery in both unilateral (n = 756, 77.1%) and bilateral (n = 35, 52.2%) patients. The second surgery was performed for 84 (8.6%) unilateral and 33 (49.3%) bilateral cases (P < 0.001). The prevalence of amblyopia and the mean angle of horizontal deviation were significantly higher in patients who needed more than one surgery (all P < 0.05).

CONCLUSION

Congenital SOP was more than twice as frequent as acquired SOP and about 90% of unilateral and 50% of bilateral cases were managed with one surgery. Amblyopia and significant horizontal deviation were the most important factors for reoperation.

TRIAL REGISTRATION

The Institutional Review Board approval was obtained from the Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1400.012) and this study adhered to the tenets of the Declaration of Helsinki and HIPAA.

Botulinum Toxin Injection for the Treatment of Third, Fourth, and Sixth Nerve Palsy: A Meta-Analysis

The efficacy of botulinum toxin injection for the treatment of third, fourth, and sixth nerve palsy was evaluated. PubMed, Scopus, EMBASE, Web of Science, and Google Scholar databases were searched. Data about the duration of palsy (acute vs chronic), cause of the palsy, type of toxin used, mean dose, and other background characteristics were collected. Outcome variables were success rate (defined by alleviation of diplopia or reduction in eye deviation) and standardized mean difference of prism diopter and abduction deficit before and after injection. The Joanna Briggs Institute checklist was implemented for the risk of bias assessment. The analysis included 38 articles, comprising 643 patients. The overall treatment success rate in acute and chronic nerve palsy was 79% and 33%, respectively. The success rate was not significantly different between different subgroups of age, type of botulinum toxin, pre-injection prism diopter, etiology of the palsy, duration of follow-up, and mean dose of botulinum toxin injection. However, in both acute and chronic palsy, diabetes etiology was accompanied by the highest success rate. Overall symptomatic response to botulinum injection was 84% (95% CI: 67% to 96%), whereas functional response was observed in 64% (95% CI: 47% to 79%) of the patients. The odds ratio for the success rate of treatment of palsies with botulinum toxin versus expectant management was 2.67 (95% CI: 1.12 to 6.36) for acute palsy and 0.87 (95% CI: 0.17 to 4.42) for chronic palsy. Botulinum toxin can be used for the treatment of acute third, fourth, and sixth nerve palsy, especially in patients with acute palsy and more severe tropia. [J Pediatr Ophthalmol Strabismus. 2024;61(3):160-171.].

Sudden-onset trochlear nerve palsy: clinical characteristics and treatment implications

PURPOSE

To identify clinical characteristics, etiologies, and treatment implications of sudden-onset, acquired cases of superior oblique palsy.

METHODS

The medical records of patients diagnosed with trochlear nerve palsy between January 2010 and January 2018 were reviewed retrospectively to identify cases of acquired trochlear nerve palsy with a specific date of onset of acute symptoms or specific causative incident. Patients with congenital palsies or an uncertain date of onset, history of other strabismus, concomitant oculomotor or abducens nerve palsies, or history of strabismus surgery were excluded.

RESULTS

Of 214 patients with superior oblique palsy, 23 had sudden-onset, acquired palsies. There were 14 cases of unilateral palsy and 9 cases of bilateral palsy. Patients with unilateral palsy presented with vertical diplopia, while those with bilateral palsy complained of either torsional (4/9 patients) or vertical (5/9 patients) diplopia. The most common etiologies were severe trauma associated with traumatic brain injury, followed by central nervous system neoplasm and stroke. Fifteen patients underwent surgical intervention, 3 of whom required more than one surgery.

CONCLUSIONS

Patients with acute superior oblique palsy invariably complain of vertical and/or torsional diplopia. Neuroimaging should be considered in cases of acquired superior oblique palsy without a known traumatic cause. Bilateral cases of acquired superior oblique palsy are more challenging to manage surgically because of symptomatic torsional diplopia.

Surgical Outcome of Single Inferior Oblique Myectomy in Small and Large Hypertropia of Unilateral Superior Oblique Palsy

PURPOSE

To determine the efficacy of isolated inferior oblique myectomy on hypertropia in primary position, side gazes, and tilts, and its effect on comitancy and abnormal head posture in unilateral superior oblique palsy.

METHODS

Thirty-nine patients with unilateral superior oblique palsy who had inferior oblique overaction underwent inferior oblique myectomy. The hypertropia was measured in primary position, side gazes, and tilts preoperatively and postoperatively. Abnormal head posture was also assessed. Success was defined as primary position hypertropia of 5 prism diopters (PD) or less.

RESULTS

The mean distance hypertropia was 15.7 ± 7.7 PD (range: 3 to 30 PD) preoperatively and 1.5 ± 3.3 PD (range: 0 to 16 PD) postoperatively (P < .001). The mean reduction of distance hypertropia postoperatively was 14.2 ± 7.8 PD (range: 3 to 30 PD). The contralateral gaze hypertropia decreased from 21.7 ± 9.0 PD (range: 5 to 45 PD) preoperatively to 3.6 ± 5.1 PD postoperatively (range: 0 to 20 PD) and ipsilateral head tilt hypertropia decreased from 21.9 ± 8.4 PD (range: 8 to 40 PD) preoperatively to 5.0 ± 5.9 PD (range: 0 to 24 PD) postoperatively (P < .000 for both). Incomitance (contralateralipsilateral gaze hypertropia) decreased from 15.0 ± 7.4 PD (range: 3 to 35 PD) preoperatively to 2.8 ± 4.1 PD (range: 0 to 16 PD) postoperatively (P < .001). The success rate between the two groups of patients who had hypertropia of 15 PD or less and greater than 15 PD in primary position was not statistically different (94.7% vs 85%). Two patients underwent a second operation for residual hypertropia. There was no overcorrection. Thirty-two patients had abnormal head posture, which resolved postoperatively in 29 cases.

CONCLUSIONS

Isolated inferior oblique myectomy is an effective procedure in resolving hypertropia up to 30 PD due to unilateral superior oblique palsy, with a minimal risk of overcorrection and low risk of undercorrection. It decreases incomitancy, is a self-titrating procedure, and resolves abnormal head posture efficiently. [J Pediatr Ophthalmol Strabismus. 2019;56(1):23-27.].

Superior Oblique Palsy: Efficacy of Isolated Inferior Oblique Recession in Cases with Ipsilateral Hypertropia in Abduction

PURPOSE

To evaluate the effects of isolated inferior oblique (IO) muscle recession in patients with superior oblique palsy (SOP) and persistent hypertropia in abduction.

METHODS

Retrospective review of patients with unilateral SOP who were treated with isolated IO recession by a single surgeon (MCB) between January 2008 and December 2017. We included patients with congenital and acquired fourth nerve palsies, with a hyperdeviation of less than 20 prism diopters in primary position and at least 4 prism diopters in abduction by prism and alternate cover test (PACT) during distance fixation. A minimum follow-up of 4-6 weeks was required. Age at surgery, etiology, presence of head tilt, motor alignment in primary and secondary gaze positions at distance and near using PACT, versions, ductions, and torsion were recorded from the patients' chart.

RESULTS

Seven patients with SOP were included in this study. Four (57.14%) males, with a mean age at presentation of 41.86 years (range: 6-66 years). Mean follow-up was 13.25 months (range: 1.3-52.2 months). A decrease in mean central gaze hypertropia from 11.4 to 1.71 PD was found. A mean contralateral gaze hypertropia that decreased from 22.28 to 5.71 PD and an ipsilateral gaze hypertropia that improved from 5.86 to 1.14 PD were also noted. Torsion had a mean change of 3.4° of incyclodeviation at the final examination.

CONCLUSIONS

This study confirms the efficacy of isolated maximal IO recession for the treatment of unilateral SOP that is accompanied by a modest hypertropia of the paretic eye in abduction.

Clinical Course and Prognostic Factors of Acquired Third, Fourth, and Sixth Cranial Nerve Palsy in Korean Patients

PURPOSE

This study aimed to evaluate the clinical course and prognostic factors of acquired third, fourth, and sixth cranial nerve (CN) palsy grouped according to etiology.

METHODS

This study involved a retrospective review of the medical records of 153 patients who were diagnosed with acquired paralytic strabismus from January 2004 to July 2015. Outcomes, recovery rates, and time to recovery were investigated according to the affected CN: CN3, CN4, and CN6 palsies. The patients were classified into four groups based on etiology: idiopathic, traumatic, neoplastic, and vascular.

RESULTS

The mean age of the patients was 59.8 ± 14.5 years and the mean follow-up period was 10.8 months. Out of the 153 patients, 63 (41.2%) had CN3 palsy, 35 (22.9%) had CN4 palsy, and 55 (35.9%) had CN6 palsy. The most common causes were vascular related (54.9%), followed by idiopathic (28.1%), trauma (8.5%), and neoplasm (5.88%). About 50% of the patients recovered within six months. Among the four etiologic groups, the idiopathic group showed the best prognosis because about 50% of the patients in this group recovered within three months. This was followed by the vascular, traumatic, and neoplastic groups. Cox proportional hazard analysis revealed a significant association between the baseline prism diopter and recovery rate.

CONCLUSIONS

The prognosis and natural history of paralytic strabismus vary depending on its cause. The vascular group had the best recovery rate and shortest recovery time, whereas the neoplastic group required the longest time to recover.

Adjustable Bilateral Superior Oblique Tendon Advancement for Bilateral Fourth Nerve Palsy

PURPOSE

Bilateral fourth nerve palsy may be symmetric or asymmetric with combined vertical and excylotropic deviations and so there may be an advantage to independent adjustment of vertical and torsional components. We report a surgical technique that allows such independent adjustment.

DESIGN

Retrospective interventional case series.

METHODS

Fifteen patients, aged 17-73 years, underwent adjustable bilateral superior oblique tendon advancements for bilateral fourth nerve palsy: 11 symmetric (≤2 prism diopters [pd] hyperdeviation in straight-ahead gaze) and 4 asymmetric. Motor alignment was assessed with double Maddox rods and prism and alternate cover tests preoperatively, pre- and postadjustment, and 6 weeks postoperatively.

RESULTS

Preoperative torsion ranged from 7 to 30 degrees excyclotropia (mean 17 ± 7 degrees) and hyperdeviation from 0 to 10 pd. Preadjustment torsion ranged from 5 degrees excyclotropia to 40 degrees incyclotropia, and hyperdeviation from 0 to 8 pd. Twelve of the 15 patients (80%) were adjusted to a target of 0 pd hyperphoria and 10 degrees incyclotropia (actual mean 9 degrees incyclotropia, range 2-13 degrees incyclotropia). At 6 weeks postoperatively there was expected excyclodrift (to mean 4 degrees excyclotropia, range 0 degrees incyclotropia to 15 degrees excyclotropia), but 13 (87%) had 5 degrees or less excyclotropia and 14 (93%) had 2 pd or less hyperdeviation. Mean torsional correction from preoperative to preadjustment was 31 ± 14 degrees (P < .0001), and from preoperative to 6 weeks was 13 ± 6 degrees (P < .0001).

CONCLUSIONS

Adjustable bilateral superior oblique tendon advancement allows independent control of torsional and vertical components of the deviation, and therefore may be useful in cases of bilateral superior oblique palsy.

Effect of modified graded recession and anteriorization on unilateral superior oblique palsy: a retrospective study

BACKGROUND

Several inferior oblique (IO) weakening methods exist for correction of superior oblique palsy (SOP). A previously reported method involved recession and anteriorization according to IO overaction (IOOA) grade, which might be subjective and cause upgaze limitation and opposite vertical strabismus. Therefore, this study attempted to examine the efficacy of modified graded recession and anteriorization of the IO muscle in correction of unilateral SOP without resulting in upgaze limitation or opposite vertical strabismus.

METHODS

A total of 26 patients (male, 16; female, 10; age: 3-40 years) with SOP and head tilt or diplopia underwent modified graded recession and anteriorization. Patients were grouped by the position at which the IO muscle was attached inferior/temporal to the lateral border of the inferior rectus (IR) as follows: (1) 7.0/2.0 mm (4 patients), (2) 6.0/2.0 mm (3 patients), (3) 5.0/2.0 mm (3 patients), (4) 4.0/2.0 mm (11 patients), (5) 3.0/0.0 mm (2 patients), and (6) 2.0/0.0 mm (3 patients). Recession and anteriorization were matched to vertical deviation in the primary position at far distance. Remaining diplopia, head tilt, vertical deviation (≤3 prism diopter (PD), excellent; 4-7 PD, good; and ≥ 8 PD, poor), upgaze limitation, and opposite vertical strabismus were evaluated.

RESULTS

The average pre and postoperative 1-year vertical deviation angles in the primary position at far distance were 15.0 ± 5.6 PD and 1.2 ± 2.0 PD, respectively. At 1 year post-surgery, the vertical deviation angles were reduced by 6.8-21.0 PD from those at baseline. Few patients exhibited remaining head tilt, diplopia, upgaze limitation, or opposite vertical strabismus. Correction of hypertropia was excellent in 22 and good in 4 patients.

CONCLUSIONS

Modified graded recession and anteriorization of the IO muscle is an effective surgical method for treating unilateral SOP. It exhibits good results and reduces the incidence of opposite vertical strabismus.

Inferior Oblique Botulinum Toxin Injection: A Postoperative Diplopia Test for Secondary Inferior Oblique Muscle Overaction

PURPOSE

To evaluate the utility of botulinum toxin injection into the inferior oblique muscle for secondary inferior oblique muscle overaction.

METHODS

A retrospective review of 18 patients and 23 injections performed over a 9-year period. Indications and deviations in primary position and contralateral gaze before and after injection were recorded. Functional outcomes and further management (conservative vs surgical) were observed.

RESULTS

In 14 patients, chemodenervation resulted in a temporary improvement in symptoms. Eleven of these patients went on to have inferior oblique myectomy with resolution of their diplopia. Two patients preferred to receive regular injections of botulinum toxin as a treatment.

CONCLUSIONS

Botulinum toxin chemodenervation of the inferior oblique muscle in cases of secondary inferior oblique muscle overaction is useful where one needs to establish a risk of overcorrection following planned inferior oblique muscle weakening. This is particularly true in cases where the primary position deviation may be small but symptoms of diplopia exist on contralateral side gaze, giving rise to a narrowed field of binocular single vision.

Superior oblique tucking for treatment of superior oblique palsy

PURPOSE

To investigate the efficacy and safety of isolated superior oblique tucking in the treatment of congenital superior oblique palsy.

METHODS

Twenty-one patients with unilateral congenital superior oblique palsy and lax superior oblique tendon underwent isolated superior oblique tucking and retrospective analysis of the amount of tucking procedure, preoperative and postoperative vertical deviation in the primary position and reading position, abnormal head posture, ocular motility, and corrected objective torsion. Patients were evaluated before and 6 to 12 months after surgery.

RESULTS

The average vertical deviation in the primary position was 10.9 ± 3.3 prism diopters (PD) before surgery and 1.5 ± 2.6 PD after surgery (n = 21, P < .05). The average vertical deviation in the reading position was 15.6 ± 3.6 PD before surgery and 2.6 ± 3.1 PD after surgery (P < .05). The average corrected vertical deviation was 9.9 ± 3.2 PD in the primary position and 13.0 ± 3.4 PD in the reading position (P < .05). The amount of tucking ranged from 5 to 12 mm (mean: 8.3 ± 2.3 mm), which was not related to the corrected vertical deviation in the primary and reading positions, the preoperative vertical deviation in the reading position, or the corrected objective torsion. After surgery, all patients had head posture that was normal or less than 5°. Unremarkable superior oblique underaction and negative head tilt test were found in all patients after surgery. All patients had mild Brown syndrome after surgery, but none were symptomatic.

CONCLUSIONS

Isolated superior oblique tucking is an efficient and safe procedure for treatment of superior oblique palsy with hyperdeviation less than 15 PD in the primary position and remarkable superior oblique underaction. The superior oblique forced duction test was the most important criterion for planning surgery.

Surgical results of patients with unilateral superior oblique palsy presenting with large hypertropias

PURPOSE

Surgical management of superior oblique palsy (SOP) is challenging because of combined vertical, horizontal, and torsional misalignment. The authors report the surgical results of patients with large primary position hypertropias (> 20 prism diopters [PD]) due to unilateral SOP.

METHODS

Criteria for success included correction of the anomalous head posture, primary position alignment between orthotropia and 6 PD of undercorrection, and no reoperation required for residual deviations in any direction of gaze.

RESULTS

Forty-five patients met inclusion criteria. Mean preoperative alignment in primary gaze was 26.5 ± 6.5 PD compared to 3.0 ± 4.4 PD postoperatively (P < .001). Twenty-three (51%) cases met the criteria for success with one operation. Of the patients who had single muscle surgery, 14% had a successful outcome, with a mean 67% (17.3 PD) reduction in hypertropia. Of patients who underwent simultaneous multiple muscle surgery, 58% met the criteria for a successful result, with a mean 92% (24.6 PD) reduction in primary gaze hypertropia. Success was the highest in patients who underwent ipsilateral inferior oblique combined with contralateral inferior rectus recessions with (60% success) or without (65% success) a Harada-Ito procedure.

CONCLUSION

Undercorrections are frequent following surgery for unilateral SOP with preoperative deviations greater than 20 PD in primary position, especially after single-muscle surgery. Simultaneous multiple muscle surgery rarely results in overcorrection and is recommended in patients with SOP and more than 20 PD of hypertropia in primary position.

Clinical course and characteristics of acute presentation of fourth nerve paresis

PURPOSE

Many cases of acute-onset cranial nerve paresis have benign etiologies such as microvascular occlusion. Most will resolve completely and neuroimaging is usually unnecessary. Few reports exist on acute fourth nerve paresis.

METHODS

A retrospective review was conducted of all patients presenting with diplopia to the emergency department for 1 year caused by isolated fourth cranial nerve paresis from any cause including trauma.

RESULTS

Thirty-two patients met the criteria, 26 (81%) males and 6 (19%) females, with an average age of 59.5 years (range: 14 to 80 years). Eighteen (56%) had a microvascular etiology with diabetes mellitus, hypertension, or both; 6 were already taking medication. Six (19%) had decompensating fourth nerve paresis (2 had hypertension and 1 had recent head trauma). Closed head trauma accounted for 2 patients, migraine and herpes zoster virus accounted for one each, and 4 remained unknown. Nineteen patients (59%) were prescribed prisms and 2 patients were given occlusion. Diplopia resolved without treatment in 23 patients (72%) within 2 weeks to 10 months, but 89% of patients with microvascular etiology resolved spontaneously. Three patients continued with prisms, one patient underwent surgery.

CONCLUSION

The prognosis for complete and spontaneous resolution of microvascular fourth nerve paresis was excellent, with 89% completely resolved within 10 months.

Isolated trochlear nerve palsy in Tolosa-Hunt syndrome

A 67-year-old Japanese woman without contributory medical history developed acute onset of left-sided trochlear nerve palsy (TNP) with persistent and severe periorbital pain. There were no other neurological abnormalities. Funduscopic findings were normal. Cranial and orbital magnetic resonance (MR) imaging, and cranial MR angiography demonstrated no abnormalities. By administration of prednisolone 40 mg/day from the day after onset, periorbital pain was resolved within 24 hours, and TNP within 5 days. Thereafter, prednisolone was gradually tapered off. She remained asymptomatic under no medication. In the English language literature, this is the first reported case of Tolosa-Hunt syndrome presenting with isolated TNP.

Recovery of ophthalmoplegia after endovascular treatment of intracranial aneurysms

BACKGROUND AND PURPOSE

Recovery of aneurysm induced CNP after endosaccular coiling has been reported in the literature. The aim of this study was to assess in detail the parameters that affect the outcome after endovascular treatment of ophthalmoplegic aneurysms due CNP.

MATERIALS AND METHODS

Between November 1999 and March 2008, 30 consecutive patients (8 men, 22 women; mean age, 54.9 years) presenting with CNP underwent endosaccular coiling with or without additional use of stents in the parent artery. Subarachnoid hemorrhage was present in 10 patients, whereas 20 patients had unruptured aneurysms. The mean size of the aneurysms was 10 mm. Initial CNP was complete in 11 patients and partial in 19. Mean follow-up after coiling was 19 months.

RESULTS

The mean interval between the onset of CNP and aneurysm embolization was 48 days. Fifteen patients (50%) had complete recovery of oculomotor function, 12 had incomplete recovery (40%), and 3 (10%) remained unchanged after treatment. In 4 aneurysms (13.3%), 1 additional embolization was performed, whereas in 4 other aneurysms, 2 additional embolization procedures were necessary. Procedure-related permanent morbidity occurred in 2 patients (6.6%).

CONCLUSIONS

Endosaccular coiling is an effective and safe method for the treatment of ophthalmoplegic aneurysms. Age, neck size, and time of treatment do not seem to constitute prognostic factors with respect to CNP recovery, though patients with small aneurysms, unruptured status, and/or location in the posterior circulation showed a tendency for better outcome. The degree of initial CNP was the only statistically significant prognostic factor concerning the final outcome, resulting in better recovery, in case of incomplete initial CNP.

Acute superior oblique palsy in the monkey: effects of viewing conditions on ocular alignment and modelling of the ocular motor plant

We investigated the immediate and long-term changes in static eye alignment with acute superior oblique palsy (SOP) in the monkey. When the paretic eye was patched immediately after the lesion for 6-9 days, vertical alignment slowly improved. When the patch was removed and binocular viewing was allowed, alignment slowly worsened. In contrast when a monkey was not patched immediately after the lesion vertical alignment did not improve. We also show that a model of the eye plant can reproduce the observed acute deficit induced by SOP, but only by abandoning Robinson's symmetric simplification of the reciprocal innervation relationship within pairs of agonist-antagonist muscles. The model also demonstrated that physiologic variability in orbital geometry can have a large impact on SOP deficits.