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Purpose: Literature regarding different superior oblique (SO) weakening procedures showed variable results. Here, we aim to evaluate the effect of a novel superior oblique tendon suture lengthening (SOSL) procedure on weakening of SO in patients with A-pattern exotropia associated with dissociated vertical deviation and SO overaction (triad exotropia). Methods: The medical records of triad exotropia patients who underwent SOSL or SO tenotomy were reviewed. Surgical results of SOSL procedure mainly regarding the correction of A pattern, SO overaction, and fundus intorsion were analyzed and compared with those of SO tenotomy procedure. Results: SOSL demonstrated comparable efficacy in correction of A pattern (20.2△ ± 10.7△ vs 29.2△ ± 16.1△, p = 0.172), normalization of SO overaction (1.9 ± 0.9 vs 2.4 ± 1.5, p = 0.349), and conversion of fundus intorsion (11.1° ± 7.0° vs 11.3° ± 4.4°, p = 0.691) as SO tenotomy. Moreover, the success rate of A pattern collapse was significantly higher in the SOSL group than in the SO tenotomy group (86% vs 40%, p = 0.028). None of the patients in the SOSL group, but two in the SO tenotomy group, presented SO palsy postoperatively. In the SOSL group, the corrected magnitude of SO overaction strongly correlated with the dosage of suture lengthening ( p < 0.001). Conclusion: SOSL procedure could effectively eliminate the clinical manifestations associated with SO overaction. The graded dosage of SOSL leads to more controllable and predictable results compared to SO tenotomy, which makes SOSL a good alternative choice for SO weakening.

Background Few studies have evaluated the surgical outcome of superior oblique weakening procedures in patients with superior oblique overaction associated with exotropia or esotropia. This study aimed to evaluate the outcome of superior oblique muscle weakening and the influencing factors in patients with superior oblique overaction. Methods The medical charts of 37 patients (55 eyes) with superior oblique overaction associated with esotropia or exotropia who were treated with a superior oblique weakening procedure at the Seoul National University Hospital from January 2010 to June 2017 were retrospectively reviewed. Superior oblique overaction was graded using, a 6-point scale ranging from + 0.5 to + 3, and pre- and postoperative grades were recorded for all patients. Results The mean age of the patients was 91.81 ± 59.37 months. Superior oblique muscle suture spacer and superior oblique posterior tenectomy were performed for 17 (23 eyes) and 20 (32 eyes) patients, respectively. Surgical success was achieved in 15 (65.2%) eyes in the suture spacer group and 23 (71.9%) eyes in the posterior tenectomy group. Surgical success was achieved for 69.1% (38/55 eyes) of patients. Dissociated vertical deviation exhibited a significant negative association with the surgical success rate (p Conclusions There was no significant difference in surgical success rate between the superior oblique posterior tenectomy and superior oblique suture spacer groups in superior oblique overaction associated with horizontal strabismus. Associated dissociated vertical deviation can affect the surgical success of the superior oblique weakening procedure.

Introduction: The aim was to evaluate the effectiveness of the procedure of the superior oblique split Z-tendon lengthening to collapse A pattern and treat face turn in a cohort of patients with both incomitant intermittent exotropia and a vertical deviation associated with a bilateral asymmetric superior oblique overaction. Methods: We retrospectively reviewed the clinical records of patients with facial turn associated with intermittent exotropia and bilateral asymmetric superior oblique overaction, who underwent superior oblique muscle split tendon lengthening and concurrent horizontal surgery between 2009 and 2017. Results: A total of eight patients met the inclusion criteria. The preoperative average face turn was 26.8° (range, 20°–5°), and it significantly improved to 5.4° (range, 2°–8°) ( p Conclusion: The superior oblique split Z-tendon lengthening was an effective procedure to collapse the A pattern and the treatment of the face turn in a cohort of patients with both incomitant intermittent exotropia and a vertical deviation associated with a bilateral asymmetric superior oblique muscle overaction with less complications, and less varying results.

Purpose To assess the surgical effect of single-stage superior oblique recession with intraoperative suture adjustment under topical anesthesia and sedation in terms of A-pattern correction, vertical alignment, and superior oblique overaction. Methods The medical records of patients who underwent superior oblique weakening (recession with adjustable suture) for superior oblique overaction from 2015 to 2018 were reviewed retrospectively. Preoperative, pre- and postadjustment, and 6-week follow-up data were assessed and compared for A pattern, primary position hypertropia, superior oblique overaction scale and objective fundus torsion. Results A total of 29 patients (17-42 years of age) were included. Of 51 operated eyes, 37 underwent intraoperative adjustment (further recession of 1–4 mm) after superior oblique recession of 8 mm. Mean decrease in primary position hyperdeviation after adjustment was 3.6Δ ± 2.7Δ (range, 0Δ-8Δ); in A-pattern deviation, 5.5Δ ± 4.8Δ (range, 0Δ-16Δ). At 6 weeks’ follow-up, A pattern had either resolved completely or became clinically insignificant ( 10Δ. Conclusions In our study cohort, single-stage, unilateral superior oblique tendon recession with adjustable suture under topical anesthesia and sedation was well tolerated and resulted in good postoperative outcomes at 6 weeks’ follow-up, effectively correcting primary position vertical deviation of

Purpose To assess the efficacy of superior oblique temporal tenectomy 6.0 mm from its insertion to treat A-pattern strabismus of all magnitudes. Methods The clinical records of patients with A-pattern eso- or exotropia associated with bilateral superior oblique overaction who underwent bilateral superior oblique 6.0 mm temporal tenectomy at a single institution over a 17-year period were reviewed retrospectively. Outcome measures were change in the A pattern and correlation with preoperative A pattern. Results A total of 102 patients were included. The mean preoperative A-pattern deviation was 21Δ ± 9Δ, with a postoperative pattern collapse of 18Δ ± 10Δ. Change in A pattern was significantly correlated with the preoperative A pattern (r = 0.70; P Conclusions In our study cohort, bilateral superior oblique temporal tenectomy was an effective and self-adjusting procedure for A-pattern strabismus associated with superior oblique overaction. Larger preoperative A patterns did not show a significant trend toward larger residual postoperative deviations compared with smaller preoperative patterns. A uniform dose of bilateral superior oblique temporal tenectomy collapses A patterns of all magnitudes.

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.

To investigate the efficacy and safety of bilateral hang-back recession of superior oblique (SO) muscles in the treatment of A-pattern strabismus with superior oblique overaction (SOOA).Thirty-one (31) patients (62 eyes) with A-pattern horizontal deviation and SOOA underwent hang-back recession of SO and retrospective analysis of the surgical amount of hang-back recession of SO, preoperative and postoperative A-pattern, ocular motility, and corrected objective torsion. Patients were evaluated before and 6 to 9 months after surgery.The average A-pattern horizontal deviation was 27.58 ± 11.47 prism diopters (PD) before surgery and 3.48 ± 3.70 PD after surgery (n=31, P0.05). The mean corrected A-pattern was horizontal deviation 24.10 ± 10.32 PD. The average scale of SOOA on a scale of +1 to +4 was +3.05 ± 0.80 before surgery and +0.42 ± 0.50 after surgery in 62 eyes (P0.05). The mean corrected objective torsion was 4.91° ± 4.53°. The surgical amount of SO hang-back recession ranged from 4 to 10 mm (mean: 7.62 ± 1.18 mm), which was related to the preoperative A-pattern and corrected A-pattern. There were no surgical complications.SO hang-back recession is a safe and efficient option for A-pattern caused by SOOA.

Anterior plagiocephaly is a craniofacial anomaly related to premature unilateral synostosis. We present three cases of anterior plagiocephaly with contralateral superior oblique dysfunction. A detailed ophthalmic examination, including orthoptic assessment for the extraocular muscle misalignment, with appropriate radio- imaging was done in all the three cases. All of them showed a right-sided plagiocephaly, with overaction of the left superior oblique muscle, alternating exotropia and a dissociated vertical deviation. Two underwent surgical correction of squint. Both were well aligned after squint surgery. Plagiocephaly has been reported to simulate superior oblique muscle paresis. We report a rare occurrence of contralateral superior oblique muscle overaction in three children with anterior plagiocephaly.

Purpose: To evaluate the subjective and objective cyclodeviational changes following different weakening procedures on superior and inferior oblique muscles Design: Comparative case series Materials and Methods: In a prospective institution based study, 16 cases of A pattern horizontal strabismus having superior oblique overaction were randomized to superior oblique weakening procedures: either silicon expander or translational-recession. Similarly, 20 cases of V pattern horizontal strabismus with inferior oblique overaction were randomized for inferior oblique weakening procedures: either 10 mm Fink′s recession or modified Elliot and Nankin′s anteropositioning. Cyclodeviation was assessed subjectively with the synoptophore and objectively using the fundus photograph before surgery and 3 months postoperatively. Change in cyclodeviation was measured by subjective and objective methods. The index of surgical effect (ISE) was defined as the net torsional change postoperatively. Results: The difference between the extorsional change induced by the two superior oblique procedures, silicone expander (-6°) and translational recession (-11.3°), was statistically significant (P=0.001). Translational recession caused more extorsional change (ISE=296%) than silicone expander surgery (ISE=107%). The two inferior oblique weakening procedures, Fink′s recession (+2.5°) and modified Elliot and Nankin′s anteropositioning (+4.7°) produced equitable amount of intorsional shift with no statistical difference (P=0.93). Objective measurements were significantly more than the subjective measurements. Conclusions: Different weakening procedures on oblique muscles produce different changes in cyclodeviation, which persists even up to 3 months. Subjective cyclodeviation is less than the objective measurements indicating partial compensation by sensorial adaptations.

Purpose To evaluate the efficacy of superior oblique muscle split Z-tendon lengthening in the treatment of superior oblique muscle overaction with respect to normalization of superior oblique ductions and versions, reduction of A -pattern strabismus and correction of vertical deviations. In addition, to determine the incidence of complications of the procedure including overcorrection and the effect of the procedure on horizontal deviation. Methods A retrospective review was performed of 19 patients who underwent superior oblique muscle split Z-tendon lengthening for A -pattern strabismus or significant vertical deviation associated with superior oblique overaction between June 1980 and September 1999. Ten males and 9 females were included, ranging in age from 2 to 45 years (mean: 9 years). Patients underwent either a unilateral or bilateral superior oblique tendon lengthening based on the patient’s clinical picture. Results Ten of 11 patients (91%) who underwent unilateral tendon lengthening and 10 of 16 eyes (63%) that underwent bilateral superior oblique tendon had complete normalization of superior oblique action. Seven of 10 patients (70%) who underwent unilateral or bilateral tendon lengthening for a clinically significant A -pattern had the A -pattern completely eliminated or brought to a clinically insignificant level. All 8 patients who underwent a unilateral tendon lengthening for a clinically significant vertical deviation had reduction of the vertical deviation. There was no statistically significant effect of either the unilateral or bilateral procedure on horizontal deviation. Conclusions The superior oblique muscle split Z-tendon lengthening procedure is highly effective for normalization of superior oblique muscle function and reduction of A -pattern strabismus and vertical deviations associated with superior oblique muscle overaction.

Introduction To evaluate the efficacy of superior oblique Z-tenotomy in the treatment of overdepression in adduction (superior oblique overaction) with respect to collapse of A-pattern strabismus and normalization of versions. Methods The medical records of patients who underwent bilateral superior oblique Z-tenotomy for mild to moderate overdepression in adduction and A-pattern strabismus between June 2004 and August 2010 were retrospectively reviewed. Surgical indications included mild to moderate overdepression in adduction (+2 to 3) and an A pattern of 10 Δ to 40 Δ between upgaze and downgaze. A monopolar electrode microdissection needle was used to make two tenotomies, 60% to 80% in width and 8 mm apart, perpendicular to the axes of the tendon in opposite directions. Surgical success included a postoperative A pattern of ≤10 Δ and overdepression in adduction of ≤1. Results A total of 20 patients (mean age, 9.8 years; age range, 3-34) underwent bilateral superior oblique Z-tenotomy during the study period: 2 patients (10%) with esotropia and 18 with exotropia (90%). Average decrease in pattern was 16 Δ (range, 0 Δ -32.5 Δ ). Success rate for pattern collapse was 78%, with resolution of overdepression in adduction of 90%. Conclusions Z-tenotomy of the superior oblique tendon collapsed A-pattern strabismus and normalized versions.

Purpose: Philip Knapp described a method, sometimes referred to as the "chicken suture,"of securing a loose nonabsorbable suture to the cut ends of the superior oblique tendon to facilitate future reversal. The purpose of this study is to describe a modification of Knapp's technique to achieve partial, reversible, and intraoperatively adjustable superior oblique weakening. Methods: The superior oblique tendon was exposed, 2 polyester nonabsorbable sutures were placed 4 mm apart, and the tendon was cut. With the use of a slip knot, the cut ends of the tendon were separated by 2 to 8 mm. Tendon separation was adjusted intraoperatively according to the exaggerated traction test and, in some cases, fundus torsion. Medical records of all patients who underwent surgery with this technique were reviewed and the outcomes tabulated. Results: Twelve patients (16 eyes) were treated for superior oblique overaction and 3 patients (3 eyes) for Brown syndrome. Follow-up was 2 to 46 months (mean, 17 months). Mean superior oblique overaction improved from +1.3 before surgery to +0.3 after surgery, mean A pattern improved from 20 PD to 2 PD, and fundus intorsion improved from +1.2 to +0.3. In Brown syndrome, the mean elevation in adduction improved from −3.8 to −1.0. One patient from each group developed an overcorrection. None of the patients developed recurrence. The patients with Brown syndrome continued to improve over a 1-year period. Conclusions: The superior oblique tendon suture spacer is effective, intraoperatively adjustable, and technically easier to perform than a silicone expander procedure. This technique should be considered as an alternative for patients requiring superior oblique weakening. (J AAPOS 2001;5:164-71)

Dissociated vertical deviation (DVD) is an enigmatic strabismus entity for which various theories of causation have been proposed. Commonly seen in association with infantile esotropia, it responds unpredictably to surgical intervention hence fuelling theories for a supranuclear center defect albeit at the midbrain level. Cases of DVD associated with A- pattern eso or exotropia and superior oblique overaction have been reported, although rarely. We report a case of bilateral congenital ptosis associated with this complex. Not reported earlier, we hope this case may help in better understanding of the obscure etiology of this symptom complex.

Purpose: The purpose of the study was to evaluate the results obtained by the superior oblique posterior tenotomy close to its insertion in patients with A-pattern strabismus and vertical strabismus who had bilateral or unilateral superior oblique overaction. Methods: We retrospectively analyzed the results of superior oblique posterior tenotomy close to its insertion performed bilaterally in 13 consecutive patients with A-pattern strabismus and unilaterally in 14 consecutive patients with hypotropia performed between March 1989 and October 1996. Results: The mean preoperative A-pattern deviation was 25.31 PD and the mean postoperative A-pattern deviation was 3.23 PD with a mean reduction of 22.08 PD. The mean follow-up for the above group was months (range 3 to 58 months). In the hypotropia group the mean preoperative vertical deviation was 11.07 PD and the mean postoperative vertical deviation was 4.28 PD with a mean reduction of 6.78 PD. The mean follow-up for this group was 16.21 months (range 3 to 72 months). Conclusions: Superior oblique posterior tenotomy selectively weakens its vertical action. Bilateral weakening showed marked and consistent improvement in A-pattern deviation and unilateral weakening showed definite but less consistent reduction in deviation in cases of hypotropia with superior oblique overaction.

Purpose: To report the results of treatment of a series of patients with superior oblique overaction using the superior oblique silicone tendon-expander technique. Methods: A chart review of 17 patients with superior oblique overaction who had a total of 26 silicone tendonexpander procedures was conducted. Results: Mean preoperative degree of superior oblique overaction was +2.7. 92% of eyes had mild (+1) or no residual overaction at last postoperative assessment (follow-up range: 6 to 59 months). Of 15 patients with preoperative ?-pattern of 10 prism diopter (A) or more, only two patients (1 3%) had ?-pattern of 1 0 ? or more at last assessment. Of 13 patients with preoperative hypotropia in primary position, five patients (38%) had no vertical deviation in primary position, and seven patients (54%) had persistent, but less vertical deviation in primary position at last assessment (mean reduced from 11Δ to 4Δ). No patient manifested superior oblique palsy at their last postoperative assessment. Conclusions: We believe that the superior oblique tendon-expander technique should be strongly considered for the treatment of superior oblique overaction associated with ?-pattern or hypotropia In primary position, because it has a high success rate and a low incidence of postoperative complications. Consecutive superior oblique underaction did not occur In this series.

During the past year, there have been interesting reports on the association of head tilt, facial asymmetry, and congenital superior oblique palsy. The etiology of sixth nerve palsy and its outcome in adults and children have been studied in two large series, and an orbital surgical approach has been reported to be valuable in cases of Brown's syndrome and superior oblique overaction.

Introduction and purpose Surgical treatment of vertical deviations secondary to other causes can be difficult and treatment approaches may vary. The purpose of this discussion is to present surgical treatment options for the management of vertical deviations secondary to other causes including dissociated vertical deviation, primary inferior oblique overaction, superior oblique overaction, and nonspecific eccentric gaze hypertropia with diplopia. Results Surgical treatment of vertical deviations secondary to other causes is beneficial to patients. Treatment approaches may vary depending upon patient circumstances and surgeon preference. Side effects and complications from surgery to manage these conditions can occur but are usually of minor significance and not vision threatening. Conclusions Treatment of vertical deviations secondary to other causes is effective and results usually satisfactory.

Background: Previous studies of patients with heterogeneous, often diffuse neurologic disorders concluded that the neurologic substrate for alternating skew on lateral gaze may be localized at the level of the brain stem tegmentum or the cervico-medullary junction, or both. The localized nature of brain tumors offers an opportunity to further investigate the anatomic localization for this as well as other conditions. Methods: To test the hypothesis that cervico-medullary and cerebellar lesions are responsible for alternating skew on lateral gaze, the authors investigated a series of 50 children with brain tumors, 39 of whom showed neuro-ophthalmologic abnormalities on clinical testing. Seven children had alternating skew on lateral gaze. Results: All seven children with alternating skew on lateral gaze showed neoplastic involvement at the level of the cervico-medullary junction and/or the cerebellum on critical analysis of neuro-imaging studies. Conclusion: The authors conclude that the neuroanatomic substrate for alternating skew on lateral gaze is localized at the level of the cervico-medullary junction and/or the cerebellum. Knowing that (1) alternating skew on lateral gaze closely mimics superior oblique overaction clinically, (2) superior oblique overaction is frequently found in patients with myelomeningocele, and (3) myelomeningocele is uniformly associated with ArnoldChiari type II which includes cerebellar and cervico-medullary region abnormalities, the authors propose that alternating skew on lateral gaze and superior oblique overaction associated with myelomeningocele have similar neuroanatomic pathways.

Mechanisms that underlie overdepression of the eye in adduction, the so-called superior oblique overaction, are multiple. The various pathophysiologic processes involved remain incompletely defined...

Purpose To evaluate and report the outcomes of a superior oblique tendon spacer procedure using nonabsorbable adjustable sutures in patients with inferior oblique (IO) paresis. Methods This interventional case series included 6 eyes of 6 patients with IO paresis. All met Bielschowsky/Parks Three-step Test criteria to identify an isolated IO paresis. In all patients, the superior oblique tendon was exposed; 2 nonabsorbable polyester sutures were placed 3 mm apart, and the tendon was cut. With the use of a slipknot, the cut ends of the tendon were separated 5 to 7 mm. Tendon separation was adjusted intraoperatively according to the fundus torsion and exaggerated traction test. Results The mean duration of follow-up was 8.1 months (range, 5-12 months). Four patients had congenital IO paresis and 2 had iatrogenic IO paresis following denervation/myectomy of IO. Mean primary position hypotropia improved from 15.2 prism diopters (PD) before surgery to 2.7 PD in congenital IO paresis and from 11.5 PD to 2.5 PD in iatrogenic IO paresis. In congenital IO paresis, mean preoperative superior oblique overaction and IO underaction was +2 and −2, which decreased to 0 and −1.25 respectively; fundus incyclotorsion resolved in all patients. Superior oblique overaction and IO underaction improved in iatrogenic IO paresis as well. In no patient did an overcorrection develop. Conclusions The adjustable superior oblique tendon suture spacer procedure is an effective and safe option for correcting IO paresis without developing iatrogenic superior oblique paresis.

Purpose To evaluate the effect of 10-mm tenectomy of the posterior fibers of the superior oblique (SO) tendon combined with dissection of the frenulum for correction of A-pattern deviation and vertical deviation with SO overaction. Design Retrospective, interventional case series. Methods Seventy-five patients with A-pattern strabismus associated with SO overaction who underwent surgery between March 1, 2004 and August 31, 2007. Retrospective analysis of A-pattern strabismus patients with SO overaction who underwent unilateral or bilateral 10-mm SO posterior tenectomy combined with frenulum dissection and who underwent at least 12 months of follow-up. Results The mean preoperative amount of A-pattern for all patients was 21.20 ± 7.25 prism diopters (PD), with a mean postoperative collapse of 17.63 ± 5.33 PD (range, 10 to 30 PD), which was statistically significant ( P = .001). After surgery, the mean A-pattern correction was 22.12 ± 6.30 PD in the group that underwent bilateral posterior tenectomy and 13.33 ± 5.20 PD in the group that underwent unilateral posterior tenectomy. The mean degree of preoperative vertical deviation in the group that underwent unilateral posterior tenectomy was 11.50 ± 3.96 PD, and the mean correction was 9.21 ± 4.22 PD ( P = .01). There were no surgical complications, except in 5 patients, who manifested mild inferior oblique overaction. Conclusions We believe that 10-mm SO posterior tenectomy combined with frenulum dissection effectively collapses A-pattern deviation of less than 25 PD with mild to moderate SO overaction and reduces associated vertical deviation of 10 PD.

When superior oblique overaction coexists with dissociated vertical deviation, it may produce a pattern of disparity in the amount of dissociated vertical deviation in different horizontal gaze fields, which the authors have termed incomitance. Seven patients with the constellation of esotropia, bilateral superior oblique overaction, "A"-pattern, and incomitant dissociated vertical deviation are presented. In each case, a distinctive incomitant pattern of dissociated vertical deviation was noted in which dissociated vertical deviation was least in adduction, moderate in primary position, and greatest in abduction. Four patients underwent asymmetric superior rectus recessions and partial tenotomy of the superior oblique tendons at their insertions as the initial treatment for their incomitant dissociated vertical deviation. Recognition of such a pattern of incomitant dissociated vertical deviation is important in choosing appropriate surgical management.

Purpose: To investigate the degree of reunion in rabbit eyes of the superior oblique tendon after several surgical weakening procedures. Methods: A total of 32 rabbits (64 eyes) were used in this study. The rabbits were randomly assigned to four groups, eight rabbits (16 eyes) in the tenotomy group, eight rabbits (16 eyes) in the tenectomy group, eight rabbits (16 eyes) in the disinsertion group and eight rabbits (16 eyes) in the recession group. The degree of reunion or reattachment of the superior oblique tendon on the globe were examined on four eyes in each group at postoperative weeks two, four, six and eight. Results: At eight weeks, the newly created insertion site remained at the same site in all eyes in the recession group, and the distal end of the superior oblique tendon was reattached at the medial border of the superior rectus muscle in all four eyes in the tenotomy and disinsertion groups, and in three of four eyes in the tenectomy group. Conclusions: From this experimental study, it was speculated that superior oblique recession is more effective than other superior oblique weakening procedures. This result could be helpful in the prediction of time of recurrence for superior oblique overaction after superior oblique weakening procedures. Korean J Ophthalmol 2009;23:198-203 ⓒ 2009 by the Korean Ophthalmological Society.

BACKGROUND AND OBJECTIVE To compare the effectiveness of augmented superior oblique Z-tenotomy (SOZT) with fixed standard SOZT in canceling preoperative superior oblique overaction associated with A pattern anisotropia or V pattern in Brown’s syndrome. PATIENTS AND METHODS Sixteen consecutive patients with superior oblique overaction or Brown’s syndrome were treated by removal of a triangular piece of the superior oblique tendon near its insertion (augmented SOZT). Outcome was compared with 20 consecutive historical controls after standard SOZT. RESULTS The decrease in superior oblique overaction in the right and left eyes and fundus intorsion and the collapse of A pattern anisotropia were more significant for patients with superior oblique overaction (P = .003, P = .007, P = .05, P = .0015, respectively) and patients with Brown’s syndrome (P = .025, P = .03, and P = .05, respectively). No study patient with superior oblique overaction and A pattern anisotropia required reoperation compared with 5 of 14 controls (37.5%); rates for patients with Brown’s syndrome were 0 for the study group and 3 of 6 (50%) for the control group. CONCLUSIONS Augmented SOZT is superior to standard SOZT for correcting superior oblique overaction, intorsion, A or V pattern, and stereopsis. It is not associated with complications or reoperation. The size of the Z-tenotomy can be modified according to the intraoperative assessment to achieve symmetric results. [Ophthalmic Surg Lasers Imaging 2007;38:462-470.] AUTHORS From the Pediatric Ophthalmology Unit (MS, DB, DW, RA-S), Schneider Children’s Medical Center of Israel, Petah Tiqwa; the Department of Ophthalmology (MS, RF), Rabin Medical Center, Beilinson Campus, Petah Tiqwa; and the Sackler Faculty of Medicine (MS, RF), Tel Aviv University, Tel Aviv, Israel. Accepted for publication March 9, 2005. Address correspondence to Moshe Snir, MD, Pediatric Ophthalmology Unit, Schneider Children’s Medical Center of Israel, 14 Kaplan Street, Petah Tiqwa, 49202 Israel.

Rhombencephalosynapsis is a rare, sporadic, posterior fossa malformation characterized by agenesis of the cerebellar vermis, dorsal fusion of the cerebellar hemispheres, and fusion of the dentate nuclei and superior cerebellar peduncles. 1 Ophthalmologic findings in patients with rhombencephalosynapsis have not been described in detail. Optic nerve and chiasmal hypoplasia were reported in two patients. 2 , 3 Strabismus has been noted in several patients; however, specific details were not provided. 1 We describe the association of A -pattern strabismus and superior oblique overaction with rhombencephalosynapsis.

In this chapter, A- and V-pattern strabismus and oblique dysfunction are discussed, including management strategies. Under the category of A- and V-patterns, special subtypes are described. The section on oblique dysfunction includes the following: head tilt test, inferior oblique paresis and inferior oblique overaction, superior oblique paresis and superior oblique overaction, and Brown’s syndrome.

Purpose: To evaluate the effect of posterior tenectomy of the superior oblique on the correction of A-pattern, superior oblique overaction and the changes in torsion that occur in such cases. Patients and Methods: This prospective study included 15 consecutive cases of bilateral superior oblique overaction with an ?-pattern of more than 20 PD, a difference of deviation between 25° upgaze and 35° downgaze, and superior oblique overaction of 2+ to 3+ on a scale of 0 to 4+. Deviation was measured in the primary position, 25° upgaze, and 35° downgaze using the prism bar cover test, and torsion was measured using a Synoptophore, the double Maddox rod test, and fundus photographs. Measurements were obtained preoperative Iy and postoperatively at 1 week, 1 month, and 3 months. All case-patients underwent a standard temporal route posterior tenectomy of the superior oblique by a single surgeon. Results: Mean age was 11.2 ± 4.2 years with 14 cases of A-pattern exotropia. Mean superior oblique overaction was 2.60 ± 0.50 in the right eye and 2.26 ± 0.45 in the left eye, which decreased postoperatively to 2.20 ± 0.56 and 1.80 ± 0.41, respectively. The index of surgical effect was 0.84 in the right eye and 0.79 in the left eye. Postoperatively, mean correction of the ?-pattern was 1 7.53 ± 5.82 PD (index of surgical effect, 0.7). Subjective measurement of torsion was more consistent with the Synoptophore compared with the double Maddox rod test. Objective measurement of torsion (fundus photography) was higher compared with subjective measurement. Postoperatively, there was insignificant change in the amount of torsion in upgaze and primary position. Conclusion: Posterior tenectomy of the superior oblique results in significant and controlled weakening of the superior oblique and collapse of the ?-pattern with a clinically insignificant change in the amount of torsion. J Pediatr Ophthalmol Strabismus 2005;42:284-289.

Introduction: Superior oblique split lengthening (SOSL) is done for weakening of superior oblique. It corrects the superior oblique overaction (SOOA) and A pattern. Its effect on the torsion of the eye is not known. We present our data on the effect of this particular procedure on torsion. Materials and Methods: We did a study of 16 patients (32 eyes) who underwent bilateral SOSL and compared the disc foveal angle (DFA) preoperatively and postoperatively. The split lengthening was done from 4 mm to 7 mm depending upon the overaction of superior oblique. Results: The mean age was 15.3 ± 8.4 years. Mean preoperative DFA in the right eye (RE) was −3.9° and in the left eye (LE) was −2.9°. Mean postoperative DFA in RE was 0.2° and in LE was 0.9°. The mean change in the DFA for RE was 4.1° ± 1.3° and for LE was 3.8° ± 1.2°. All the patients were aligned horizontally within 6 prism diopter and no pattern and no diplopia postoperatively. The A pattern was corrected in all the patient postsurgery. For each mm of surgery, an improvement of 0.8° was seen in the DFA. Conclusion: We report the effect of SOSL on torsion. The SOSL reduces intorsion postsurgery and is, therefore, a valuable procedure in SOOA where both pattern and in torsion needs to be corrected.

Purpose: To evaluate two superior oblique weakening procedures, silicon expander (SE), and translational recession (TR), and their effects on correction of "A" pattern, vertical deviation in adduction and dorsoadduction, superior oblique overaction, and torsion. Method: In a prospective, institution-based study, 32 eyes of 16 patients having bilateral superior oblique overaction with significant "A" pattern (>10 prism diopters [?]) were evaluated. The parameters studied were: change in "A" pattern; effect on vertical deviation in adduction and dorsoadduction; superior oblique overaction; and torsion. Results: The index of surgical effect (ISE), showed 95% reduction in "A" pattern with SE and 92% reduction with TR, indicating equal effect in collapse of "A" phenomenon (p=0.78). The extorsion produced by TR was more than that produced by SE (P=0001). Conclusions: Both the SE and TR procedures offered controlled weakening of the superior oblique and caused a 95% and 92% reduction in the "A" pattern. The latter procedure caused a marked extorsiona! change, three times that which resulted from SE. Both the procedures leave residual superior oblique overaction. Journal of Pediatrie Ophthalmology and Strabismus 1999;36:189-195.

Two patients who presented with compensatory head postures and diplopia are described. They both had marked unilateral superior oblique overaction, in one patient due to a large, incomitant skew deviation. Each underwent a superior oblique tendon lengthening procedure using a segment of silicone 240 retinal band as an expander, in combination with a contralateral superior rectus recession. Both achieved an excellent result with an improvement of the compensatory head posture and an increase in the field of binocular single vision. This surgical procedure is proposed as an option in the management of superior oblique overaction, including certain cases of skew deviation.

Purpose: To assess the prevalence of A-V pattern strabismus and evaluate the clinical characteristics, surgical methods and outcomes. Methods: Among 825 patients who underwent horizontal strabismus surgery, the records of patients with A-V pattern strabismus were reviewed retrospectively. The prevalence and clinical characteristics of patients with A-V pattern strabismus were assessed and the surgical methods and outcomes of A-V pattern strabismus were evaluated. Results: Among 825 patients with horizontal strabismus surgery, 113 (13.7%) patients had A-V pattern. V exotropia was the most common (65.5%) and A esotropia was the least common (7.1%) pattern. A +1.9 inferior oblique overaction in 92.8% of the V-pattern patients and a +1.5 superior oblique overaction in 70.0% of the A pattern patients was found. Among the 113 patients, 64.6% patients underwent oblique muscle surgery and 35.4% patients underwent vertical transposition of horizontal muscle. Vertical incomitance was significantly reduced after surgery in all types of A-V pattern strabismus (p

EXCERPT A 6-year-old boy was referred to your office because his first grade teacher noticed that he holds his chin down when reading. In addition, he rotates his head from left to right while reading a line of text. Despite this, his parents report he is doing well at school and is in the top of his class. The parents did observe brief moments of a misalignment of the eyes when he was an infant, but this has not occurred for years. Responses to Last Issue’s Case To read last issue's case, please click here.

Six patients underwent bilateral superior oblique recession for ?-pattern strabismus with overacting superior obliques. The established technique was modified to permit the entire procedure to be carried out through a single nasal fornix incision. The amount of recession WBB graduated and measured both directly from the point of the original incision anteriorly and indirectly from the nasal of the corner of the superior rectus insertion based on anatomical measurements. A good correlation was found between the amount (measured directly) of recession performed and reduction in the ?-pattern. The relationship was linear. By extrapolation the first 8 mm of superior obliquesurgery had no effect but thereafter the- effect obtained was 2 diopters reduction in ?-pattern for every mm of superior oblique surgery. No similar correlation was found for the amount of recession performed measured indirectly. There was no correlation between reduction in superior oblique overaction and the amount of recession performed. This was believed to be due, at least in part, to an inaccurate eystem of measurement of superior oblique overaction. We now, therefore, measure superior oblique overaction in mm using the corneal light reflexes. There was, however, a good correlation between the amount of preoperative superior oblique overaction and the effect obtained.

Recession of the superior oblique was performed bilaterally in 12 patients with the A phenomenon and unilaterally in four patients with vertical imbalance. The results are discussed.

Surgical management of overaction of the superior oblique muscle is discussed with reference to such conditions as A-pattern, Brown's syndrome, torsional torticollis, and homolateral inferior oblique or contralateral inferior rectus paresis. The authors perform weakening of the superior oblique from the temporal side of the superior rectus for slight or moderate overaction. They prefer posterior tenectomy for mild overaction and scleral disinsertion of the tendon in moderate overaction causing A-pattern of no more than 25 pd. With 25-30 pd. they perform translation-recession of the muscle by the nasal approach.