Idiopathic superior oblique palsies in children

Management of paretic vertical deviations

Paretic vertical deviations are characterized by complex patterns of incomitance that make them some of the most challenging strabismus problems to treat. Optimum results are obtained by performing surgery on those muscles, selected from among the eight cyclovertical muscles in the two eyes, that minimize the incomitance. In superior oblique paresis the additional factors of torticollis and torsion need to be addressed and aberrant regeneration can alter the surgical plan in third nerve paresis.

Bilateral fourth-nerve palsy occurring after shaking injury in infancy

The shaken baby syndrome is a serious form of child abuse that typically results in serious short- and long-term neurological sequelae. Isolated cranial nerve palsies have been reported after shaking injuries in infants. We report a child with bilateral fourth cranial nerve palsy that developed after a shaking injury.

Superior oblique palsy or paresis in pediatric patients

PURPOSE

To examine sensory and motor outcomes of superior oblique paresis (SOP) presenting in patients < 8 years old and to ascertain whether SOP was ever the presenting manifestation of intracranial pathology.

METHODS

Retrospective observational case series of SOP in children < 8 years old in an outpatient university center.

RESULTS

Ninety-two patients with SOP presented at a median age of 3.9 years. The etiologies were likely congenital (n = 56), craniofacial anomalies (n = 12), head trauma (n = 5), postresection of brain tumors (n = 3), orbital inflammation (n = 1), prenatal stroke (n = 1), and unknown (n = 14). Twenty-six were followed-up for a median of 2.1 years and did not have surgery; 46 were followed-up for a median of 3 years and did undergo surgery. No cases of new intracranial pathology occurred during follow-up. In 42 patients observed for at least 6 months without surgery, motor status was stable or improved (each in approximately one third of cases) or deteriorated (in one fourth of cases). Motor outcomes were better (P =.01) in patients undergoing surgery (87% aligned within 5 prism diopters) than in those not undergoing surgery despite worse presenting deviations. Sensory status did not show a similar improvement with surgery. Patients presenting before age 4 had worse sensory outcomes (P =.00001) than patients presenting later. At the last examination, 4 patients had vision < 20/40 from amblyopia.

CONCLUSIONS

SOP in children < 8 years old was not associated with the development of new intracranial pathology. Motor alignment and sensory function were often stable, although some patients improved, and others deteriorated. With surgery, satisfactory motor outcomes were usually achieved, but sensory status often was not improved. Sensory outcomes were generally worse in patients presenting at younger ages.

Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves

We collected data from a large series of patients with ocular palsies and compared them with data in previous series from the Mayo Clinic. The largest group of patients among 4,278 cases was that in which the cause was undetermined for a long period of follow-up. The abducens nerve was most commonly affected. The probability of establishing a diagnosis was higher in patients younger than 50 years and among those with associated neurologic findings or multiple ocular palsies. The prognosis for recovery was best in the vascular group but was better than 50% for all groups except those with tumors. Investigation may be tailored to each patient according to clinical findings and probabilities of finding a cause, and judicious clinical judgement should be exercised.