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

Do Wook Kim; Jinu Han; So Young Han; Sueng-Han Han; Jong Bok Lee

doi:10.3341/jkos.2016.57.5.823

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Kim, Han, Han, Han, and Lee: Surgical Management of Superior Oblique Muscle Palsy in Hypertropia 16 Prism Diopters or More

Original Article

J Korean Ophthalmol Soc 2015;57(5):823-828.

Published online: 7 September 2015

DOI: https://doi.org/10.3341/jkos.2016.57.5.823

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

Do Wook Kim, MD, Jinu Han, MD, So Young Han, MD, Sueng-Han Han, MD, Jong Bok Lee, MD

The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea

Address reprint requests to Jinu Han, MD Department of Ophthalmology, Severance Hospital, #50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: 82-2-2228-3570, Fax: 82-2-312-0541 E-mail: jinuhan@yuhs.ac

Received 21 September 201530 November 2015 Accepted 25 January 2016

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 perm its unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Hypertropia, Superior oblique palsy, Surgery

References

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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.

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.

Table 1.

Patient characteristics

Number of patients	61
Age at surgery (years)	21.3 ± 17.3 (range, 2.1-78.8)
Follow-up (months)	23.0 ± 24.0 (range, 6.0-88.0)
Laterality OD/OS (no. of patients)	36/25
Etiology (congenital/acquired)	53/8
Concurrent horizontal deviation (n, %)	36 (59.0%)
Amount of preop vertical deviation (PD)	25.5 ± 7.1 (range, 16.0-60.0)
Amount of preop horizontal deviation (PD)	12.7 ± 4.6 (range, 6.0-25.0)
Adjustable suture (n, %)	30 (49.2%)

Values are presented as mean ± SD unless otherwise indicated. preop = preoperation; PD = prism diopters.

Table 2.

Clinical characteristics and surgical outcomes according to the first procedure performed

	IO myectomy + contralateral IR recession (n = 43)	IO myectomy + SR recession (n = 10)	SR recession + contralateral IR recession (n = 8)	p-value
Age at surgery (years)	20.1 ± 16.9 (range, 2.1-78.8)	17.5 ± 14.2 (range, 3.7-47.6)	32.3 ± 20.5 (range, 8.5-72)	0.093^∗
Hypertropia at primary (PD)	26.3 ± 7.4 (range, 16.0-60.0)	23.6 ± 7.0 (range, 16.0-40.0)	23.6 ± 5.2 (range, 16.0-30.0)	0.424^†
Hypertropia at adduction (PD)	29.1 ± 7.9 (range, 20.0-55.0)	27.1 ± 8.5 (range, 16.0-40.0)	23.5 ± 4.7 (range, 18.0-30.0)	0.178^†
Hypertropia at abduction (PD)	16.6 ± 9.0 (range, 0.0-35.0)	14.5 ± 10.1 (range, 0.0-30.0)	18.6 ± 6.2 (range, 12.0-30.0)	0.649^†
Excyclotropia (°)	4.7 ± 4.0 (range, 0.0-20.0)	4.2 ± 4.9 (range, 0.0-10.0)	4.4 ± 3.2 (range, 0.0-10.0)	0.937^†
Diplopia (n)	6 (13.95%)	1 (10%)	2 (25%)	0.725^‡
Adjustable suture (n)	20 (46.5%)	5 (50%)	6 (75%)	0.411^‡
Combined LR recession (n)	8 (18.6%)	1 (10.0%)	3	-
Successful outcome (n)	37 (86.1%)	6 (60%)	6 (75%)	0.131^‡

Values are presented as mean ± SD unless otherwise indicated.

IO = inferior oblique; IR = inferior rectus; SR = superior rectus; LR = left rectus.

^∗ Analysis of variance (ANOVA);

^† Kruskal-Wallis test;

^‡ Chi-squared test.

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