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.].

Trochleaectomy: An Effective Treatment of Trochlear Pain in Monocular Patients.

BACKGROUND: Conventional treatment options for trochlear pain arising from trochleitis or primary trochlear headache include oral anti-inflammatory medications and/or local injection of corticosteroids and local anesthetic. Trochleaectomy is an additional option to consider for monocular patients with intractable trochlear pain. METHODS: We report 3 patients undergoing trochleaectomy for refractory trochlear pain syndromes. RESULTS: Trochleaectomy resulted in resolution of their periocular discomfort. CONCLUSIONS: Trochleaectomy is an effective procedure to treat trochlear pain syndrome in functionally monocular patients.

Unusual manifestation of heat stroke: Isolated trochlear nerve palsy.

Heat stroke is a life-threatening disease characterized by hyperthermia and neurological dysfunction. The central nervous system is highly sensitive to hyperthermia, which causes neurological complications due to the involvement of the cerebellum, basal ganglia, anterior horn cells, and peripheral nerves. Several studies reported about clinical symptoms and brain image findings of heat stroke. Isolated cranial nerve dysfunction caused by lacunar infarction is an extremely rare condition in patient with heat stroke. We experienced a rare case of trochlear nerve palsy due to midbrain infarction caused by heat stroke.

Surgical management of Helveston syndrome (triad of A- pattern exotropia, superior oblique overaction and dissociated vertical deviation) using 'Four Oblique' procedure.

Purpose: To report the surgical outcomes in six patients of Helveston syndrome using a "four oblique" procedure. The popular methods for surgical management include superior rectus recessions alone or combined with superior oblique tenectomy. However, large angle exotropia correction would entail a higher risk of anterior segment ischemia when the superior rectus needs to be operated along with the horizontal recti. Hence, we evaluated the long-term results of this uncommon procedure. Methods: This was a retrospective review of six patients diagnosed to have manifest dissociated vertical deviation (DVD) with A pattern exotropia with bilateral superior oblique over action. All patients underwent horizontal muscle recessions/resections for exotropia along with bilateral posterior tenectomy of the superior oblique with inferior oblique anterior transpositioning. Results: The median age was 10 years (Range 5-26 years). The mean postoperative follow-up was 26 ± 14.02 months (Range 12-48 months). The mean reduction in exotropia was from 36.5 ± 21.06 PD (Range 15-65 PD) to 6.1 ± 3.06 PD (Range 3-10 PD). The procedure corrected the A pattern from a mean 23 ± 7 PD (Range 15-35 PD) to 7.6 ± 3.2 PD (Range 3-10 PD). The average DVD in the right eye reduced from 14 ± 4.3 PD (Range 8-20 PD) to 5.3 ± 1.2 PD and in the left eye from 14.33 ± 3.6 PD (Range 10-18 PD) to 4.1 ± 1.1 PD. The DVD asymmetry reduced from 6.33 ± 3.4 PD to 1.5 ± 1.3 PD. Conclusion: "Four oblique" procedure with horizontal muscle surgery seems to be an effective method for significantly correcting the A pattern as well as reducing the DVD with good long-term outcome in our case series.

Isolated Bilateral Superior Rectii Paresis: A Rare Anomaly.

We present a case of bilateral isolated superior rectus paresis in a 13-year girl who presented with alternating exotropia and hypertropia. She demonstrated bilateral paresis of elevation in abduction with an overaction of both the contralateral yoke muscles, i.e. inferior obliques. Neuroimaging did not reveal a lesion along the pathway of the third nerve nor hypoplasia of the superior rectus muscle. We performed a bilateral lateral rectus recession on adjustable sutures with bilateral myectomy of the inferior obliques (weakening of contralateral yoke muscle). At 1 year, the patient is well aligned and happy. Isolated extraocular muscle pareses are rare events, which present occasionally to the strabismus surgeons and need to be looked out for if the patient's strabismus looks peculiar. We believe we are the first to report an isolated paresis of the superior rectus muscle in Pakistan.

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.

Superior oblique myokymia, a review.

PURPOSE OR REVIEW: Superior oblique myokymia is a rare, monocular condition that typically presents in healthy adults. In this article, we review the proposed pathophysiology, describe the typical clinical presentation, and discuss the recommended work up and various treatment options. RECENT FINDINGS: Treatment for this condition ranges from observation and reassurance to various topical and systemic medications. Both strabismus surgery and neurosurgery are reserved for patients who fail medical therapy or are intolerant to medication secondary to side effects. SUMMARY: Due to its episodic nature, SOM is often under-diagnosed. We highlight key features in a patient's clinical history and the examination findings that suggest and support the diagnosis, with review of available treatment options.

A case of bilateral fourth nerve palsy associated with pseudotumor cerebri syndrome / Caso de paralisia bilateral de quarto nervo associada com síndrome do pseudotumor cerebral

ABSTRACT Pseudotumor cerebri syndrome is puzzling because it results in elevated intracranial pressure with no identifiable underlying cause. Ocular motor nerve palsies, other than a unilateral or bilateral sixth cranial nerve palsy, are rarely seen in patients with this condition. We report here on a 25-year-old female patient with bilateral fourth cranial nerve palsy caused by pseudotumor cerebri syndrome, whose ocular and systemic signs and symptoms of nerve palsy were completely resolved after medical treatment. We infer that fourth nerve palsy could be associated with pseudotumor cerebri syndrome; therefore, clinicians should consider rare ocular motor nerve palsies, even bilaterally, in patients with pseudotumor cerebri syndrome.

RESUMO A sindrome do pseudotumor cerebral é uma síndrome enigmática caracterizada por aumento da pressão intracraniana sem causa definida. Na síndrome do pseudotumor cerebral, as paralisias de nervo oculomotor além da paralisia unilateral ou bilateral do sexto nervo craniano são raramente vistas. Nós reportamos o caso de uma paciente feminina de 25 anos com paralisia bilateral de quarto nervo craniano como resultado da síndrome do pseudotumor cerebral. Após tratamento médico para síndrome do pseudotumor cerebral, os sinais e sintomas oculares e sistêmicos da paralisia nervosa foram resolvidos. Em conclusão, a paralisia de quarto nervo craniano pode estar associada com síndrome de pseudotumor cerebral, portanto médicos devem considerar paralisias raras de nervo oculomotor, mesmo bilateralmente, em pacientes com síndrome do pseudotumor cerebral.

Comparison of ocular torsion between congenital and acquired unilateral superior oblique palsy.

BACKGROUND/OBJECTIVES: To compare ocular torsion between congenital and acquired unilateral superior oblique palsy (USOP). SUBJECTS/METHODS: Retrospective review was performed on medical records of 163 USOP patients. Qualitative fundus torsional states in both eyes were determined based on locations of optic disc and fovea. Disc-fovea angles (DFA) were collected in both eyes for quantitative analysis. DFAs and the proportions of qualitative fundus torsional states in paretic and non-paretic eyes were compared between USOP patients and normal controls, and between congenital and acquired USOP patients. RESULTS: This study included 90 patients with congenital USOP, 73 patients with acquired USOP, and 66 normal controls. Most control subjects showed no torsion in both eyes (93.9%), whereas 61.1% of congenital and 46.5% of acquired USOP patients showed extorsion in either eye. More patients with congenital USOP showed fundus extorsion in the non-paretic eye (24.4% versus 12.3%) or both eyes (20.0% versus 6.8%), compared with patients with acquired USOP (P = 0.007). DFAs of paretic and non-paretic eyes were larger in USOP patients than in normal controls (P < 0.001, for both congenital USOP versus control and acquired USOP versus control). DFAs of non-paretic eyes were larger in congenital USOP patients than in acquired USOP patients (10.3° versus 8.5°, P = 0.018). CONCLUSIONS: Congenital USOP showed greater fundus extorsion in the non-paretic eye, compared with acquired USOP. Fundus photographs of both eyes are necessary to understand the ocular torsion in USOP patients and the variations in fundus torsion with varying USOP aetiology.

A case of bilateral fourth nerve palsy associated with pseudotumor cerebri syndrome.

Pseudotumor cerebri syndrome is puzzling because it results in elevated intracranial pressure with no identifiable underlying cause. Ocular motor nerve palsies, other than a unilateral or bilateral sixth cranial nerve palsy, are rarely seen in patients with this condition. We report here on a 25-year-old female patient with bilateral fourth cranial nerve palsy caused by pseudotumor cerebri syndrome, whose ocular and systemic signs and symptoms of nerve palsy were completely resolved after medical treatment. We infer that fourth nerve palsy could be associated with pseudotumor cerebri syndrome; therefore, clinicians should consider rare ocular motor nerve palsies, even bilaterally, in patients with pseudotumor cerebri syndrome.

Acquired onset of third, fourth, and sixth cranial nerve palsies in children and adolescents.

PURPOSE: To describe the causes of third, fourth, and sixth cranial nerve palsies in children and adolescents. METHODS: In this retrospective case series, a total of 66 patients aged 0-19 years with third, fourth, and sixth cranial nerve palsies seen in strabismus and neuro-ophthalmic practice from 2010 to 2017 were included. Causes of palsies were determined based on clinical assessment, high-resolution magnetic resonance imaging (MRI), and laboratory work-up. RESULTS: Thirty-five patients had sixth cranial nerve palsy, 14 patients had third cranial nerve palsy (7 partial, 7 complete), 13 patients had fourth cranial nerve palsy, and 4 patients had combined cranial nerve palsies in this study. Neoplasia involving central nervous system was one of the most common causes of third, fourth, and sixth cranial nerve palsies both in children (age: 0-14 years) and adolescents (age: 15-19 years) (20% and 31%, respectively). Overall, neoplasia (23%) was the most common cause of acute third, fourth, and sixth cranial nerve palsies, followed by idiopathic cause (14%), inflammation (11%), and non-aneurysmal vascular contact (11%). Neoplasia was also the most common cause of sixth and third cranial nerve palsies (25% and 29%, respectively). The most common cause of fourth cranial nerve palsy was late decompensation in congenital fourth cranial nerve palsy (46%). CONCLUSIONS: A substantial proportion of pediatric and juvenile patients had serious pathologies for third, fourth, and sixth cranial nerve palsies. If nerve palsies are indicated, prompt diagnosis of etiologies using high-resolution MRI with contrast and laboratory work-up are important for this disease population.

Superior oblique tuck: evaluation of surgical outcomes.

PURPOSE: To report the surgical outcomes of the superior oblique tuck procedure in the management of superior oblique palsies performed at a single centre over a 25-year period. METHODS: A retrospective study of superior oblique tuck performed as a primary and secondary procedure by a single surgeon over a 25-year period between 1992 and 2016. We evaluated patient demographics, the angle of deviation pre- and post-surgery in prism dioptres (PD), amount of muscle tuck surgery performed (mm), complications (iatrogenic Brown's Syndrome) and improvement of diplopia post-operatively. RESULTS: 162 eyes from 162 patients were identified. Gender = 108 male patients (66.67%). Mean age at the time of surgery = 45.94 years; laterality = 85 left eyes (52.47%). 110 patients (67.90%) = congenital superior oblique palsy. Mean post-op follow-up time = 7.5 months. Mean pre-operative angle of deviation = 15.88 PD (range = 4-35 PD); mean post-operative angle of deviation = 5.09 PD (range = 0-20 PD; p < 0.0001). 157 patients (96.91%) displayed a reduction in angle of deviation post-operatively. Overall mean reduction in the angle of deviation = 10.79 PD (range = 0-34 PD). Mean amount of muscle tucking = 9.75 mm (range = 3-20 mm). 24 patients (14.82%) experienced post-operative iatrogenic Brown's syndrome but only two of these required further corrective surgery. 138 patients (85.19%) experienced improvement of diplopia post-operatively. Overall, 54 patients (33.33%) required additional extraocular muscle surgery to reduce diplopia further. CONCLUSIONS: This large series of superior oblique tuck procedures performed over a 25-year period, displays excellent surgical outcomes with regards to reduction of the angle of deviation, diplopia and limited complications.

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.

A standardized recession of the inferior oblique extraocular muscle - a safe and self-grading surgical procedure for trochlear nerve palsy: a 10-year material.

PURPOSE: To evaluate the results of surgical treatment in a large group of patients with trochlear nerve palsy, with emphasis on the self-grading effect of a standardized recession of the ipsilateral inferior oblique muscle. METHODS: All patients who underwent first-time surgery for trochlear nerve palsy in the period 2005-2014 in our department (n = 114) were retrospectively evaluated regarding pre- and postoperative data, surgical procedure, and the need for reoperations. Mean follow-up time was 8.5 ± 13.8 months. RESULTS: Among the 114 patients, 73 (64.0%) had a congenital palsy, 31 (27.2%) an acquired palsy, while in 10 cases (8.8%) the type of palsy was uncertain. A standardized recession of the ipsilateral inferior oblique muscle with reattachment at the lateral border of the inferior rectus muscle was carried out in 97.3% of the congenital palsies and in 80.5% of the acquired/uncertain group. In the total patient material, further surgery was needed in 15.8%. Among the patients who underwent a single standardized recession of the inferior oblique muscle, a significant correlation between preoperative vertical angle of deviation and the postoperative change in deviation was demonstrated (correlation coefficient -0.70, p < 0.001), confirming the self-grading nature of this procedure. Subjectively, 97.1% in the congenital and 91.4% in the acquired/uncertain group reported complete/near complete resolution or significant improvement of their symptoms at the final control examination. CONCLUSION: In the majority of patients with trochlear nerve palsy, a favourable outcome may be achieved after a single, standardized recession of the ipsilateral inferior oblique muscle.

The efficacy of superior rectus recession with simultaneous inferior oblique disinsertion on superior oblique palsy with superior rectus contracture.

PURPOSE: The information about superior rectus (SR) recession in cases with SR contracture coexisting with superior oblique palsy (SOP) is very limited in previous literature. The aim of this study is to evaluate the effect of SR recession, as a combined procedure with inferior oblique (IO) disinsertion, in long-standing SOP with secondary SR contracture. METHODS: The medical records of the 145 patients operated for SOP were retrospectively reviewed and 15 patients who underwent SR recession met the inclusion criteria. The mean follow-up was 50.4 months. RESULTS: The preoperative angle of deviation was within the range of 16-35 prism dioptres (PD) with a mean of 23.0 ± 5.03 PD. In all of the cases, SR recession was performed in combination with IO disinsertion. Adult patients (12) underwent adjustable SR recession. Postoperative overcorrection developed in 3 cases (20%), and in 12 patients, the postoperative vertical deviation was within the range of 0-5 PD with a mean of 1.41 ± 1.88 PD. The overcorrected three patients underwent botulinum toxin A (BTXA) injection into the ipsilateral inferior rectus muscle. The deviation is well controlled by BTXA injection in two patients, whereas the other one was considered as masked bilateral SOP and underwent IO disinsertion in the other eye. CONCLUSION: Our results suggested that SR recession in combination with IO disinsertion is an effective procedure to control large vertical deviations in SOP with SR contracture in the majority of cases. However, the risk of overcorrection should be considered despite adjustable SR weakening and BTXA injection seems efficient to rescue overcorrections in long term.