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.

A Post-Surgical Stereovision Surprise in an Adult With an Exotropia Since Infancy Previously Managed, at Two Years With Surgery.

AIM: To describe an unexpected sensory outcome in an adult male who is seeking ocular re-alignment for a psychosocially symptomatic large non-specific exotropia with suppression. The primary diagnosis was infant onset exodeviation of unclear diagnosis, was managed with bilateral strabismus surgery at two years of age, little memory of follow-up. RESULT: Measurable binocular single vision (BSV) was demonstrable following surgery at 17 years of age, albeit slowly between two weeks and six months postoperatively and subsequently enhanced. His newly acquired sub-optimal BSV led to symptomatic occupation-associated asthenopia. Following two subsequent operations over a 15-year period, he has stable, symptom-free ocular realignment within three prism diopters of orthophoria and performing tasks that require extended periods of near-vision activity. CONCLUSION: Delayed high levels of stereovision were unexpectedly achieved in an adult with infant onset exotropia with pre-operative sensory suppression that was surgically aligned to near orthophoria. The re-establishment of BSV in such a clinical scenario has to attain a level that is robust enough to meet an individual's social and occupational needs.

The Utility of Fundus Fluorescein Angiography in Neuro-Ophthalmology.

While its use is still widespread within the medical retina field, fundus fluorescein angiography (FFA) is increasingly falling out of favour in the investigation of neuro-ophthalmological disease, with the introduction of new technologies, particularly optical coherence tomography. FFA does, however, provide useful diagnostic and prognostic information in many neuro-ophthalmological diseases including papilloedema, pseudo-papilloedema, optic neuropathies and central retinal artery occlusion to name a few. We aim to summarise the main FFA findings in each of these conditions and highlight where FFA is of most use in providing complementary information to other modes of investigation.

Do Optic Canal Dimensions Measured on CT Influence the Degree of Papilloedema and Visual Dysfunction in Idiopathic Intracranial Hypertension?

A recent study found that increased optic canal area on magnetic resonance imaging was associated with worse papilloedema in idiopathic intracranial hypertension (IIH). We repeated this study using more accurate computerized tomography derived measurements. Optic canal dimensions were measured from 42 IIH patients and 24 controls.  These were compared with papilloedema grade.  There was no correlation between any of the optic canal measurements and papilloedema grade and no significant difference in optic canal measurements between patients and controls. Our results cast doubt on the existing literature regarding the association between optic canal size and the degree of papilloedema in IIH. CT delineates bony anatomy more accurately than MRI and our CT-derived optic canal measurements cast doubt on the existing literature regarding the association between optic canal size and the degree of Papilloedema in IIH.

A Stereotyped Syndrome with Retro-Ocular Pain, Photophobia, and Visual Disturbance Masquerading as Optic Neuritis: Case Series.

We describe here a case series of six patients referred to the Neuro-ophthalmology service in Sheffield, UK with possible acute unilateral optic neuritis. Each patient had a triad of unilateral photophobia, ipsilateral retro-ocular pain, and ipsilateral loss of vision. All patients had normal ocular examinations and investigation findings with no objective structural or functional abnormalities identified. Patients were treated by weaning-off regular analgesia and, where appropriate, commencing migraine prophylaxis. In the three patients with complete recovery of pain, there was also complete recovery of vision. We propose that this is a migraine syndrome and that the decreased visual acuity is a functional consequence of the pain and photophobia.