Clinical Manifestations and Surgical Outcomes of Double Elevator Palsy

Hyun Ju Park; Jong Bok Lee; Soolienah Rhiu

doi:10.3341/jkos.2014.55.11.1674

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Park, Lee, and Rhiu: Clinical Manifestations and Surgical Outcomes of Double Elevator Palsy

Original Article

J Korean Ophthalmol Soc 2014;55(11):1674-1680.

Published online: 2 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.11.1674

Clinical Manifestations and Surgical Outcomes of Double Elevator Palsy

Hyun Ju Park, MD¹, Jong Bok Lee, MD¹, Soolienah Rhiu, MD²

¹Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea

²Department of Ophthalmology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea

Address reprint requests to Soolienah Rhiu, MD, Department of Ophthalmology, Hallym University Dongtan Sacred Heart Hospital, #7 Keunjaebong-gil, Hwaseong 445-907, Korea, Tel: 82-31-8086-2861, Fax: 82-31-8086-2029, E-mail: soolienah99@naver.com

Received 1 May 2014 Revised 8 June 2014 Accepted 3 October 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the clinical manifestations of double elevator palsy and describe the surgery outcomes in patients.

Methods

We performed a retrospective chart review of all patients who were treated surgically for double elevator palsy between 1999 and 2012 at Yonsei University, Severance Hospital in Seoul, Korea.

Results

Overall, 15 subjects (7 males and 8 females) with a mean age of 14.6 years (range, 3-40 years) underwent their first surgery during the study period. All patients received inferior rectus recession as a primary procedure. Nine patients (60.0%) underwent a secondary procedure which included 4 cases of horizontal muscle transposition, 2 cases of correction of exotropia, and 3 cases of correction of hypotropia and exotropia simultaneously. The mean preoperative hypotropia was decreased from 29.9 ± 8.4 prism diopter (PD) to 4.7 ± 5.3 PD postoperatively. Mean follow-up period was 40.9 ± 48.2 months. Seven patients (46.7%) underwent eyelid surgery for true ptosis. At last follow-up, a majority of patients showed mild or no amblyopia.

Conclusions

Primary inferior rectus recession and additive secondary horizontal muscle transposition surgery was effective in treatment of double elevator palsy. The clinical manifestations and surgical outcomes of monocular elevation deficiency in the present study can help in the treatment of Korean patients.

Keywords: Double elevator palsy, Hypotropia, Inferior rectus recession, Muscle transposition

References

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Figure 1.

Preoperative and postoperative visual acuity. Mild amblyopia better than 6/12, moderate 6/12–6/30, and severe amblyopia worse than 6/30–3/60 (derived from Pediatric Eye Disease Investigator Group definitions). (A) Total (B) patients who underwent their strabismus surgery under the age of 6 (C) patients who underwent their strabismus surgery over the age of 6.

Table 1.

Background and demographic data of patients with double elevator palsy

Demographics	Values
Neonatal abnormalities (%)	0 (0)
Family history (%)	1/13 (7.7)
Abnormal neurological imaging (%)	2/6 (33.3)
Age at onset (years) (range)	5.4 ± 10.7 (0-34.5)
Age at first surgery (years) (range)	14.6 ± 12.4 (3-40)
Ptosis (%)	9/15 (60.0)
Eyelid surgery (%)	7/15 (46.7)
Follow up (months) (range)	40.9 ± 48.2 (12-183)

Values are presented as mean ± SD unless otherwise indicated.

Table 2.

Strabismus and ptosis procedures performed in group 1 (negative traction test) and group 2 (positive traction test)

Patient//sex/age	Pre-op deviation (PD)	Forced duction test	Initial surgery (mm)	Second pre-op deviation (PD)	Second surgery (mm)	Final deviation (PD)	Length of follow-up (months)	Ptosis	Interval between strabismus op and ptosis op
Group 1
1/F/40	30 LHoT	Negative	IR recess 7.0	−	−	16 LHoT	32	−	−
2/M/18	30 RHoT	Negative	IR recess 5.0 SO tenotomy	−	−	10 XT	183	−	−
3/F/10	14 RHoT 14 XT	Negative	IR recess 6.0 LR recess 6.5	14 RHoT	Horizontal Hummelsheim op	3 RHoT	57	True ptosis	6 months after initial op
4/M/4	35 LHoT	Negative	IR recess 7.0	−	−	Ortho	12	True ptosis	10 months after initial op
5/F/29	40 LHoT	Negative	IR recess 6.0	40 XT	LR recess 10.0 MR resection 7.0	3 LHoT	18	True ptosis	1 year after initial op
6/F/1	30 RHoT	Negative	IR recess 6.0	14 RHoT 10 XT	MR half tendon up transposition LR recess 2.0	8 RHoT	21	Pseudoptosis	−
7/F/30	20 LHoT	Negative	IR recess 6.0	−	−	7 LHoT 7 XT	12	−	−
8/M/4	45 LHoT	Negative	IR recess 6.0	30 LHoT	Knapp op	Ortho	57	True ptosis	7 months after second op
9/F/5	35 RHoT	Negative	IR recess 6.0	16 RHoT 14 XT	LR half tendon up transposition MR resection 5.0	6 RHoT	12	True ptosis	10 months after second op
10/F/3	25 LHoT 20 XT	Negative	IR recess 5.0	12 LHoT 14 XT	SR resection 4.5 LR recess 5.5	6 LHoT 5 XT	21	−	−
Group 2
11/F/13	25 RHoT	Positive	IR recess 6.0	−	−	Ortho	30	−	−
12/M/33	40 RHoT 10 XT	Positive	IR recess 7.0	35 RHoT	Knapp op	Ortho	15	−	−
13/M/6	30 LHoT 8 ET	Positive	IR recess 6.0	−	−	15 LHoT 8 ET	12	True ptosis	2 years before initial op
14/M/14	30 LHoT	Positive	IR recess 6.0	16 LHoT	Horizontal Hummelsheim op	6 LHoT	116	Pseudoptosis	−
15/M/6	20º BHoT^∗	Positive	IR recess 6.0	25 XT	LR recess 6.0	Ortho	15	True ptosis	2 years before initial op

PD = prism diopter; LHoT = left eye hypotropia; IR = inferior rectus; RHoT = right eye hypotropia; XT = exotropia; SO = superior oblique; Op = operation; LR = latera rectus; MR = medial rectus; SR = superior rectus; ET = esotropia; BHoT = bilateral eye hypotropia.

^∗ Pre-op deviation measurement using Krimsky method was represented by degree.

Table 3.

Preoperative and final vertical deviation in group 1 (negative traction test) and group 2 (positive traction test)

Vertical deviation (PD)	Group 1 (n = 10)		Group 2 (n = 5)
Vertical deviation (PD)	Average	Range	Average	Range
XT
Preop	5.4 ± 12.7	0-25	9.8 ± 13.0	0-40
Final	−1.6 ± 3.6	−8∼0	2.2 ± 3.7	0-10
HoT
Preop	30.4 ± 9.2	14-45	29.0 ± 7.4	20-40
Initial postop	8.2 ± 6.9	0-16	11.2 ± 14.6	0-35
Final	4.9 ± 4.9	0-16	4.2 ± 6.6	0-15

Values are presented as mean ± SD.

PD = prism diopter; XT = exotropia; HoT = hypotropia.

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