Orbital trochleitis: Literature review.

Trochleitis is clinically and/or radiologically evidenced inflammation of the trochlea or orbital pulley. Clinically it is characterized by pain and hypersensitivity in the superomedial orbital angle, which is increased or triggered by direct palpation of the area and/or eye movements. During the REM (rapid eye movements) phase of sleep, patients with trochleitis suffer from nocturnal micro-awakenings that impede their rest, and pain is often associated with visual symptoms (diplopia or Brown's syndrome). The lack of common guidelines for diagnosis and treatment of this disease, its low prevalence and the lack of knowledge of the different entities associated with trochlear pain, leads to underdiagnosis or misdiagnosis. It is essential to know the characteristics of this pathology and to diagnose it correctly, differentiating it from other trochlear pain entities, in order to be able to carry out an adequate therapeutic and prognostic approach. The lack of consensus on the therapeutic protocol means that various treatments are used, in different order and often with a combination of several without a firm scientific basis. This comprehensive review of previous studies concludes that nonsteroidal anti-inflammatory drugs (NSAIDs) achieve an overall complete cure rate of 77%, although this rate decreases to 30% in case of motility restriction or diplopia. Intratrochlear corticosteroid injection achieves an overall complete cure rate of 86%, even in the worst prognosis trochleitis, being the only effective option in NSAID-refractory trochleitis and currently being questioned as the first treatment option.

Parálisis del músculo oblicuo superior atípica / Atypical paralysis of the superior oblique muscle

Las paresias y parálisis oculomotoras implican todos aquellos procesos susceptibles de producir un déficit parcial o total de los movimientos del globo ocular. La lesión puede estar en cualquier parte del sistema oculomotor que incluye la corteza cerebral, el tronco cerebral, nervios, placa neuromuscular y del propio músculo. Las paresias y/o parálisis del músculo oblicuo superior o IV par craneal constituye una de las más frecuentes en la práctica médica estrabológica, puede ser de etiología congénita o adquirida, se caracteriza por hipertropía que aumenta con la inclinación de la cabeza hacia el hombro del lado del ojo afectado signo de Bielschowsky, anisotropía en V, exciclotropía. Los pacientes con paresias y/o parálisis adquirida muestran diplopía vertical y torsional que aumenta con la mirada hacia abajo, tortícolis con inclinación de la cabeza hacia el lado opuesto del ojo afectado y descenso del mentón. El paciente acude a consulta por presentar diplopía vertical y torsional de 13 años de evolución. Al examen de la motilidad ocular había ortotropía en la Posición Primaria de la Mirada con hiperforia al cover test ojo izquierdo, 10 Dp base inferior por barra de prismas, exciclotropía 5*, tortícolis hacia la derecha y Bielschowsky positivo hacia el lado izquierdo. La impresión diagnóstica fue paresia adquirida del músculo OS izquierdo de etiología no precisada. El tratamiento realizado fue la retroinserción del recto superior del ojo izquierdo 4 mm más el desplazamiento temporal de un 1/4 de la inserción con el objetivo de eliminar la diplopía vertical y torsional y la posición anómala de la cabeza

The oculomotor paresis and paralysis involve all those processes capable of producing partial or total deficit of the ocular globe movements. The injure may be located in any part of the oculomotor system that includes the brain cortex, the brain trunk, nerves, neuromuscular plate and of the muscle. Paresis and/or paralysis of the superior oblique muscle or IV cranial nerve is very frequent in the medical practice for strabismus; it can be congenital or acquired, characterized by hypertropia that increases with the head moving toward the shoulder next to the affected eye sign of Bielschowsky, V-anisotropy and excyclotropia. The patients affected by acquired paresis and/or paralysis show vertical and torsional diplopia that increases when they look down, torticollis from inclining the head towards the opposed side of the affected eye, and lowering of the chin. A patient went to the doctor's because he presented with vertical and torsional diplopia of 13 years of progression. The ocular motility exam revealed orthotropia at primary position of look with hyperphoria at cover test in the left eye, 10 Dp inferior basis in bar prism test, excyclotropia 5, torticollis toward the right side and positive Bielschowsky index toward the left side. The diagnosis was acquired paresis of the left oblique superior muscle left of unspecified etiology. The treatment was over 4 mm retroinsertion of the superior rectum of the left eye plus one-fourth temporary displacement of the insertion, with the objective of eliminating the vertical and torsional diplopia and the anomalous position of the head