J Korean Ophthalmol Soc.  2016 May;57(5):823-828. 10.3341/jkos.2016.57.5.823.

Surgical Management of Superior Oblique Muscle Palsy in Hypertropia 16 Prism Diopters or More

• Kim DW
• Han J
• Han SY
• Han SH
• Lee JB

• KMID: 2212727
• DOI: http://doi.org/10.3341/jkos.2016.57.5.823

Abstract

PURPOSE
Isolated inferior oblique weakening procedure is an effective treatment for patients with superior oblique muscle palsy who had up to 15 prism diopters (PD) of vertical deviation in the primary position, but 2-muscle surgery is needed for patients with larger deviations. Herein, we report the surgical results of simultaneous 2-extraocular muscle surgery for large primary position hypertropia 16 PD or more caused by superior oblique palsy.
METHODS
This study was a retrospective review of the records of patients who presented with central gaze hypertropia 16 PD or more and underwent simultaneous 2-extraocular muscle surgery between January 2003 and June 2014 in Severance Hospital. The patients were divided into 3 groups: 43 patients who underwent inferior oblique (IO) myectomy and contralateral inferior rectus (IR) recession (Group 1), 10 patients who underwent IO myectomy and superior rectus (SR) recession (Group 2), and 8 patients who underwent SR recession and contralateral IR recession (Group 3). Criteria for success included correction of head posture and a primary position alignment within 5 PD of vertical deviation.
RESULTS
Mean preoperative alignment at primary gaze was 25.5 ± 7.1 PD (range, 16-60 PD) compared to the postoperative value of -1.3 ± 6.8 PD (range, -20~25 PD) (p < 0.001). Surgery was successful in 49 (80%) patients. Nine (15%) patients were overcorrected and the other 3 (5%) patients were undercorrected. Success rate was the highest in subjects who underwent IO myectomy and contralateral IR recession. Among the 24 patients who did not receive combined horizontal muscle surgery, horizontal deviations decreased from 10.4 ± 2.7 PD to 1.5 ± 5.5 PD (p < 0.001)
CONCLUSIONS
Two-muscle surgery can be effective in patients with large hypertropia 16 PD or more. Additionally, horizontal deviations are more likely to be resolved with vertical muscle surgery alone. However, IO myectomy combined with ipsilateral SR recession can cause overcorrection postoperatively, so surgical dose should be reduced when performing weakening procedure of two elevators in one eye.

Keyword

Hypertropia; Superior oblique palsy; Surgery

MeSH Terms

Elevators and Escalators
Head
Humans
Jupiter
Paralysis*
Posture
Retrospective Studies
Strabismus*

Figure

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  Figure 1. Preoperative Hess screening tests of patients. (A) Group 1. A 45-year-old male with 18 PD exotropia and 30 PD left hypertropia at primary position. Duction and version testing revealed left inferior oblique overaction 3 + and left superior oblique underaction 2-. Left inferior oblique (LIO) myectomy and right inferior rectus (RIR) recession 5.0 mm was performed. (B) Group 2. A 34-year-old female with 12 PD exotropia and 30 PD left hypertropia at primary position with left inferior oblique overaction 3 + and right superior oblique overaction 4+. LIO myectomy and left superior rectus (LSR) recession 7.5 mm was performed in this patient. (C) Group 3. A 38-year-old female with 10 PD exotropia and 30 PD right hypertropia at primary position showed spread of comitance with no definite inferior oblique overaction. Right superior rectus (RSR) recession 10.0 mm and left inferior rectus (LIR) recession 5.5 mm was performed. PD = prism diopters; Sup = superior; Rect = rectus; Inf = inferior; Obl = oblique; Temp = temporal; Lat = lateral; Med = medial.

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  Figure 2. The change of vertical deviations before and after simultaneous 2-muscle surgery in patients with large-angle (≥16 PD) superior oblique palsy. The graphs showed that overcorrection was observed in 9 patients (15%) after simultaneous 2-muscle surgery. Preop = preoperation; Postop = postoperation.

Reference

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