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Abstract
Purpose
To investigate the clinical features associated with hypertropia and report the surgical outcomes of hypertropia coexisting with exotropia.
Methods
We reviewed the medical records of 148 patients with intermittent exotropia coexisting with hypertropia over 4 PD who received exotropia surgery. The cases accompanied by apparent paralytic strabismus such as superior oblique palsy were excluded. Patients were divided into group I (clinically diagnosed hypertropia) and group II (non-specific hypertropia) and the clinical features of coexisting hypertropia and surgical outcomes were analyzed.
Results
Among the 148 patients, group I consisted of 38 patients (26%) and group II of 110 patients (74%). The average amount of preoperative hypertropia angle in primary gaze was 9.58 ± 3.89 PD and 6.62 ± 2.69 PD in group I and II, respectively. Group I included 12 patients with dissociated vertical deviation (DVD), 10 patients with unilateral inferior oblique overaction, 13 patients with asymmetric bilateral inferior oblique overaction and 3 patients with superior oblique overaction. Group II included 19 patients with comitant hypertropia (17%), head tilt positive pattern (simulated superior oblique palsy) was found in 84 patients (76.3%) and variable incomitance was observed. In group I, 29 patients received simultaneous horizontal muscle with hypertropia surgery. Postoperative hypertropia angle in group I was 1.41 ± 2.93 PD and 4 cases were considered surgical failure. In group II, hypertropia was resolved with horizontal muscle surgery only and the amount of postoperative hypertropia was 0.45 ± 1.60 PD.
Conclusions
In this study, vertical deviations in intermittent exotropia with concomitant hypertropia related to obvious oblique muscle dysfunction or DVD were corrected effectively by oblique or vertical rectus muscle surgery. Nonspecific hypertropia can be resolved after horizontal muscle surgery alone, however, for precise differential diagnosis, careful examination for variable clinical features is necessary before determining surgery.
References
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Figure 1.
Flow diagram summarizing the stepwise categorization of the patients with hypertropia coexisting with intermittent exotropia. PD = prism diopter; HT = hypertropia; IXT = intermittent exotropia; SO = superior oblique; MED = monocular elevation deficiency; DVD = dissociated vertical deviation; IOOA = inferior oblique overaction; SOOA = superior oblique overaction.
Table 1.
Clinical characteristics of patients
| Demographics | Results |
|---|---|
| N | 148 |
| Sex (M:F) | 70:78 |
| Mean age at surgery (years) | 12.47 ± 9.98 |
| Mean amount of preoperative exodeviation (PD) | 30.15 ± 1.76 |
| Mean amount of postoperative exodeviation (PD) | 7.17 ± 8.14 |
| Mean amount of preoperative hypertropia (PD) | 12.47 ± 9.89 |
| Laterality of the coexisting hypertropia (n) | |
| RHT | 78 |
| LHT | 58 |
| DVD (both) | 12 |
| Same as exotropic eye* | 49 |
| Opposite to exotropic eye* | 38 |
Table 2.
Distribution of surgery in clinically diagnosed hypertropia
Table 3.
Distribution of hypertropia coexisting with intermittent exotropia
Table 4.
Surgical failure of hypertropia in clinically diagnosed hypertropia
Table 5.
Classification of incomitance patterns in non-specific hypertropia
Values are presented as mean ± SD; Pattern 1: increment of HT angle on contralateral gaze, contralateral side gaze PD-ipsilateral side PD >4 PD; Pattern 2: increment of HT angle on ipsilateral gaze, ipsilateral side gaze PD-contralateral side PD >4 PD; Pattern 3: Bielschowsky HTT positive (increment of HT angle on ipsilateral HTT), ipsilateral HTT PD contralateral HTT PD>8 PD; Pattern 4: reversed Bielschowsky HTT positive (increment of HT angle on contralateral HTT), contralateral HTT PD-ipsilateral HTT PD >8 PD. HT = hypertropia; PD = prism diopter; HTT = head tilt test.
Table 6.
Distribution of incomitance pattern in non-specific hypertropia
Pattern 1: increment of hypertropia (HT) angle on contralateral gaze, contralateral side gaze prism diopter (PD)-ipsilateral side PD >4 PD; Pattern 2: increment of HT angle on ipsilateral gaze, ipsilateral side gaze PD-contralateral side PD >4 PD; Pattern 3: Bielschowsky head tilt test (HTT) positive (increment of HT angle on ipsilateral HTT), ipsilateral HTT PD-contralateral HTT PD >8 PD; Pattern 4: reversed Bielschowsky HTT positive (increment of HT angle on contralateral HTT), contralateral HTT PD-ipsilateral HTT PD >8 PD.
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