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Purpose: To evaluate the surgical outcomes for patients with superior oblique paralysis (SOP) who underwent the inferior oblique weakening and the graded partial inferior rectus muscle tenotomy in the contralateral eye., Methods: Medical records were retrospectively reviewed for those SOP patients who had hyperdeviation of 4 △ -20 △ in the primary position and 8 △ -25 △ in the downgaze position. Patients were subdivided into three subgroups according to their vertical deviation angle in the downgaze position. They underwent an ipsilateral inferior oblique muscle recession and a graded partial tenotomy of the contralateral inferior rectus muscle. The vertical deviation angles, abnormal head position, and fundus torsion were compared statistically before and after operations. All patients were followed up at least 1 year., Results: Forty-seven patients were included in this study. The mean follow-up period was 17.2 months after surgery (ranging from 12 to 28 months). The vertical deviation angle was averaged preoperatively to 7.74 △ ± 3.23 △ in the primary position and 15.30 △ ± 5.92 △ in the downgaze position and reduced postoperatively to 0.85 △ ± 1.15 △ in the primary position and 1.53 △ ± 1.49 △ in the downgaze position ( P < 0.001). All patients had an abnormal head position preoperatively and had improved significantly postoperatively. Fundus extorsion had been improved significantly postoperatively., Conclusion: The surgical procedure of IO weakening combined with contralateral graded partial inferior rectus muscle tenotomy is a successful intervention for the correction of small deviation in primary position of SOP., (Copyright © 2024 Indian Journal of Ophthalmology.)

Purpose: Evaluate and analyze the efficacy of inferior oblique belly transposition (IOBT) in treating adult patients with diplopia and small-angle hypertropia caused by mild to moderate inferior oblique overaction (IOOA) secondary to acquired superior oblique palsy (SOP)., Methods: Nine adult patients with diplopia and small-angle hypertropia associated with mild to moderate IOOA secondary to unilateral acquired SOP were included in the current retrospective study. All patients received the IOBT procedure between February 2019 and May 2023 at The Second People's Hospital of Jinan and were followed up for more than 6 months after the surgery. During the procedure, the belly of the inferior oblique muscle was fixed to the sclera at 5 mm posterior to the temporal insertion of the inferior rectus muscle. The following indicators were reviewed pre- and post-surgery: the vertical deviation (VD) in the primary position and in the Bielschowsky test, the fovea disc angle (FDA) of the affected eye, changes in IOOA, and diplopia., Results: After IOBT, the VD in the primary position decreased from 7.22 △  ± 1.72 △ (range 4 △ -10 △ ) to 1.22 △  ± 1.30 △ (range 0 △ -3 △ ). The VD in the Bielschowsky test decreased from 13.00 △  ± 1.80 △ to 3.22 △  ± 1.09 △ . The FDA decreased from 10.02° ± 3.34° to 6.26° ± 1.91°. The grade of IOOA was reduced from 2.00 (1.00, 2.00) to 0.00 (0.00, 1.00). All changes were statistically significant (P < 0.001 or P = 0.006). Diplopia was resolved completely for all patients., Conclusions: IOBT can effectively treat adults with diplopia and small-angle hypertropia caused by mild to moderate IOOA secondary to acquired SOP., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To investigate the surgical outcomes of small superior oblique (SO) tuck-denoting minimal tendon laxity-in patients with unilateral SO palsy., Methods: The medical records of consecutive patients treated with ≤6 mm SO tuck from 2000 to 2018 at Kellogg Eye Center, University of Michigan, were reviewed retrospectively. Tendon tucks were performed to a fairly uniform tension in an amount that just eliminated slack in the tendon. Pre- and postoperative motility measurements were compared. Patients were excluded if they had a history of prior strabismus surgery or concurrent vertical rectus or inferior oblique surgery., Results: A total of 27 cases (14 males) met inclusion criteria. The median age at surgery was 47 years (range 3-74 years). The mean SO tuck (total, both arms of tuck) was 4.9 mm (range, 2-6 mm). After surgery, median hypertropia decreased from 9 Δ to 1 Δ in primary position and from 20 Δ to 4 Δ in the SO field of action (contralateral downgaze). Lateral incomitance (difference in hypertropia between contralateral and ipsilateral gaze) decreased from 10 Δ to 2 Δ (P < 0.001 in each case). Six patients had diplopia in upgaze postoperatively that was not symptomatic enough to require reoperation. Six patients had residual hypertropia requiring additional surgery., Conclusions: Small SO tuck provided disproportionate correction of hypertropia in the SO field of action and nearly eliminated lateral incomitance without producing unacceptable iatrogenic Brown syndrome. Even in the absence of tendon laxity, SO tuck was a good surgical option for SO palsy in our cohort where there was marked lateral incomitance and the greatest deviation was in the SO field of action., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate the clinical findings of patients with SOP who underwent surgery., Methods: This historical cohort study was performed on 1057 SOP patients managed with surgery in Farabi Hospital, Iran, from 2011 to 2022., Results: There were 990 (93.7%) patients with unilateral SOP with the mean age of 21.8 ± 14.8 years. Of these, 715 patients (72.2%) were diagnosed with congenital SOP, and 275 patients (27.8%) had acquired SOP (P < 0.001). In contrast, 67 (6.3%) patients were diagnosed with bilateral SOP, with the mean age of 19.4 ± 15.6 years. Among these, 18 cases exhibited the masked type. The mean angle of vertical deviation in primary position at far in unilateral and bilateral cases was 15.6 ± 8.3 and 13.3 ± 9.1 △, respectively (P < 0.001). In unilateral cases, abnormal head posture (AHP) was detected in 847 (85.5%) patients and 12 (1.2%) had paradoxical AHP. Amblyopia was found in 89 (9.9%) unilateral and 7 (10.3%) bilateral cases. Solitary inferior oblique myectomy, was the most common surgery in both unilateral (n = 756, 77.1%) and bilateral (n = 35, 52.2%) patients. The second surgery was performed for 84 (8.6%) unilateral and 33 (49.3%) bilateral cases (P < 0.001). The prevalence of amblyopia and the mean angle of horizontal deviation were significantly higher in patients who needed more than one surgery (all P < 0.05)., Conclusion: Congenital SOP was more than twice as frequent as acquired SOP and about 90% of unilateral and 50% of bilateral cases were managed with one surgery. Amblyopia and significant horizontal deviation were the most important factors for reoperation., Trial Registration: The Institutional Review Board approval was obtained from the Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1400.012) and this study adhered to the tenets of the Declaration of Helsinki and HIPAA., (© 2024. The Author(s).)

Purpose: To investigate the distinction between sagging eye syndrome (SES group) and acquired unilateral trochlear nerve palsy (Trochlear group) in the Bielschowsky head tilt test (BHTT)., Methods: Fifteen patients in the SES group (mean age 74.6 ± 5.2 years) and 14 patients in the Trochlear group (55.2 ± 15.9 years) visited the Department of Ophthalmology, Hyogo Medical University Hospital between November 2016 and October 2022 for treatment of their diplopia. Eye position was measured with the alternate prism cover test, and values for fixation of the dominant eye, or unaffected eye, were used. Cyclodeviation was measured with the synoptophore and the Glaucoma Module Premium Edition of the SPECTRALIS optical coherence tomography. In the BHTT, eye position was measured in three head postures: primary position (PP), head tilt to the side with hypertropia (Hyper), and head tilt to the side with hypotropia (Hypo). The differences in vertical deviation between PP and Hyper (Hyper - PP), PP and Hypo (PP - Hypo) and Hyper - Hypo were measured and compared., Results: Vertical deviation in primary position was 7.3 ± 4.5 PD in the SES group and significantly larger (17.1 ± 8.4 PD) in the Trochlear group (p = 0.002). The vertical deviation in Hyper was significantly larger in the Trochlear group with 7.7 ± 4.7 PD and 22.1 ± 9.4 PD, respectively (p < 0.001), whereas the that in Hypo was not significantly different between the two groups with 6.5 ± 3.4 PD and 8.4 ± 6.6 PD, respectively (p = 0.725). The SES group showed no significant difference according to the 3 head postures (p = 0.311), while the Trochlear group showed a significantly different with smaller mean values in vertical deviation in Hypo (p < 0.001). The difference in the vertical deviation for the 3 head postures was the largest in Hyper - Hypo (1.7 ± 2.1 PD and 13.6 ± 7.1 PD, respectively), and the accuracy of SES was at the cutoff value of 6 PD, and it was considered not to be SES if the value was 6PD or higher. The accuracy of SES determination was 100% sensitivity and 100% specificity, and the area under the curve was 1.0., Conclusion: The difference in Hyper - Hypo in the BHTT may be the most useful index in differentiating SES from acquired unilateral trochlear nerve palsy; if the difference was more than 6 PD, the probability of SES was very low., (© 2023. The Author(s).)

Purpose: Congenital trochlear nerve palsy is the most common cause of vertical strabismus. The goal of this study was to investigate surgical outcomes after superior oblique tendon plication with or without inferior oblique recession in children and adults with unilateral congenital trochlear nerve palsy., Methods: Data and outcomes were collected in patients with a diagnosis of unilateral congenital superior oblique palsy during a retrospective single-center study conducted at the University Hospital of Tours. A reproducible, standard ophthalmological and oculomotor examination was performed pre- and postoperatively at 1 year, including presence or absence of diplopia, vertical and horizontal deviations, and compensatory head posture. Surgical success, defined as an endpoint including absence of diplopia in primary position, absence of head tilt, and vertical deviation at distance fixation<5 prism diopters (PD), was analyzed., Results: A total of fifty-seven patients (median [IQR] age of 11 years [5-42]) were analyzed. Patients experienced a significant reduction in vertical distance and near deviations (p<0.001), compensatory head tilt (p < 0.001), and diplopia after surgery (p < 0.001). Surgical success was higher in adults (17/24, 70.8%) than in children (15/33, 45.5%), although this did not reach statistical significance (p=0.0657)., Conclusion: This study suggests that plication of the superior oblique muscle tendon, with or without recession of the inferior oblique muscle, can be effective in treating unilateral congenital trochlear nerve palsy. Further studies are necessary to compare surgical procedures and investigate their efficacy in adults compared to children in the short and long term., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Purpose: To analyze the surgical results of patients treated for superior oblique palsy with coexisting exotropia., Methods: The medical records of patients with superior oblique palsy and exotropia who underwent inferior oblique weakening and simultaneous lateral rectus recession by a single surgeon from 1996 to 2022 were reviewed retrospectively. Demographics, pre- and postoperative vertical and horizontal deviation, and presence of diplopia were recorded. Surgical success was defined as horizontal deviation <10 Δ and vertical deviation ≤4 Δ without overcorrection or diplopia. The decision to operate for the horizontal deviation was made based on fusion in free space when the vertical deviation was offset with a prism., Results: A total of 27 patients were included. Mean age was 26.1 ± 22 years (range, 26 months to 78 years). Preoperatively, mean vertical deviation was 15.2 Δ ± 7.5 Δ (range, 4 Δ -30 Δ ); mean exodeviation, 17 Δ ± 5.5 Δ (range, 10 Δ -35 Δ ). Of the 27 patients, 25 underwent unilateral and 2 underwent bilateral lateral rectus recession, according to the magnitude of the horizontal deviation. Mean follow-up was 3 ± 3.8 months (range, 2 weeks to 17 months). Postoperative mean vertical alignment was 3.0 ± 5.9, and horizontal alignment was 3.4 Δ ± 5.2 Δ (esotropia of 7 Δ to exotropia of 12 Δ ; P < 0.0001). Nineteen patients (70%) had a successful result; 2 patients had residual exotropia of >10 Δ , 2 had vertical overcorrection (range, 3 Δ -4 Δ ), and 6 had residual vertical deviation ≥4 Δ (range, 5 Δ -20 Δ ). None had secondary esotropia >10 Δ . Horizontal deviation was corrected successfully with no consecutive esotropia in 25 patients., Conclusions: In our study cohort, patients with superior oblique palsy and exotropia in whom fusion required both horizontal and vertical prism correction had a high likelihood of successful horizontal alignment after lateral rectus weakening in combination with inferior oblique surgery., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the effect of inferior oblique (IO) myectomy on ocular torsion according to the absence of the trochlear nerve in unilateral congenital superior oblique palsy (UCSOP)., Methods: We retrospectively reviewed the clinical data of patients who had been diagnosed with UCSOP and underwent ipsilateral IO myectomy (n = 43). Patients were classified into the present and absent groups according to the absence of the trochlear nerve and superior oblique hypoplasia on magnetic resonance imaging (MRI). For quantitative analysis of ocular torsion, disc-fovea angles (DFA) were collected in both eyes using fundus photographs taken within three months before surgery and one month after surgery., Results: DFA of the paretic eye did not differ according to the absence of the trochlear nerve (9.4±5.6° in the present group vs. 11.0±5.4° in the absent group, p = 0.508). However, the present group had a larger DFA in the non-paretic eye than the absent group (14.1±6.7° in the present group vs. 8.0±5.0° in the absent group, p = 0.003). The change of ocular torsion after IO myectomy in the paretic eye was -5.3±3.7° in the present group and -4.8±3.5° in the absent group, respectively (p = 0.801). In the non-paretic eye, the change in DFA was -1.5±3.0° in the present group, which was larger than that in the absent group (0.7±2.6°, p = 0.047). In the multivariate analysis, the change in DFA was correlated with only the preoperative DFA (standardized β = -0.617, p<0.001 in the paretic eye, and standardized β = -0.517, p<0.001 in the non-paretic eye)., Conclusions: In the paretic eye, there was no significant difference in the change of ocular torsion between both groups, whereas in the non-paretic eye, the present group had a larger change in DFA after IO myectomy than the absent group. However, in the multivariable analysis, the change in ocular torsion was significantly correlated with preoperative excyclotorsion but not with the presence of the trochlear nerve itself., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Moon, Lee. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: To assess the preliminary outcomes of inferior oblique (IO) disinsertion-distal myectomy and tucking combined with superior oblique (SO) full tendon advancement in patients with Knapp II or III superior oblique palsy., Methods: This single-centered retrospective study included 16 eyes from 13 patients with Knapp Class II or III SO palsy. All patients underwent IO disinsertion-distal myectomy and tucking combined with SO full tendon advancement while under general anesthesia. Pre- and post-operative levels of vertical deviation in the primary position, abnormal head position, IO hyperfunction and SO hypofunction, torsion, as well as the presence of diplopia, were all measured, and the differences were statistically compared., Results: Pre-operatively, 12 patients had abnormal head positions, and two had diplopia. The pre-and post-operative levels of IO hyperfunction and SO hypofunction, as well as a vertical deviation in the primary position and torsion, all differed statistically significantly (p < 0.01)., Conclusions: Inferior oblique disinsertion distal myectomy and tucking combined with SO full tendon advancement surgery appears to be an effective procedure in patients with congenital and acquired Knapp Class II or III SO palsy., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To investigate types of surgeries performed to treat a presumed congenital superior oblique palsy (SOP) and the reoperation rate., Methods: This was a population-based retrospective cohort study using claims data from the United States. Patients who underwent strabismus surgery for a presumed congenital SOP with ≥ 3 months of continuous enrolment after the initial surgery were included. We investigated age, surgical methods and the time interval between the initial surgery and reoperation. The hazard ratios for reoperation were estimated according to the surgical methods using Cox regression analysis., Results: A total of 3,998 patients underwent surgery for presumed congenital SOP; 2,981 (74.6%) on only one vertical muscle (excluding superior oblique). Reoperation was performed on 427 patients (10.7%). Compared to patients who underwent unilateral surgery on one vertical muscle (excluding superior oblique muscle), patients who underwent surgery that included the superior oblique muscle (unilateral 2.08; 95% CI, 1.61-2.67, p < 0.001; bilateral 2.44; 95% CI, 1.40-4.28, p = 0.002) and two or more vertical muscles (excluding the superior oblique muscle) (unilateral 2.99; 95% CI, 2.00-4.49, p < 0.001; bilateral 1.68; 95% CI, 1.23-2.28, p = 0.001) had increased hazard ratios for reoperation. The median period between the initial surgery and reoperation was 168.0 [Q1-Q3 84.0-407.8] days and negatively correlated with patient age at initial surgery (r = -0.199, p < 0.001)., Conclusion: The reoperation rate for presumed congenital SOP was 10.7%. Patients who underwent surgery on two or more vertical muscles or the superior oblique muscle had an increased risk of reoperation., (© 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: This study evaluated the prognosis of patients with traumatic unilateral superior oblique palsy (SOP) and clinical factors associated with spontaneous resolution., Methods: Medical records of patients with traumatic unilateral SOP who visited two hospitals (Yeungnam University Hospital and Daegu Catholic University Medical Center) between January 2015 and June 2020 were reviewed retrospectively. When traumatic unilateral SOP did not recover within at least 1 year of follow-up, no spontaneous resolution was considered. Both traumatic and ocular factors were evaluated to evaluate their association with spontaneous recovery., Results: Fifty-nine patients (mean age, 52.6 years; 48 male patients) were enrolled in this study. The mean interval from trauma to initial presentation was 3.9 months. The mean vertical deviation at initial presentation was 6.34 ± 5.22 prism diopters (PD) (range, 0-25 PD). During the mean 24.1-month follow-up period, 28 patients (47.5%) achieved spontaneous resolution of SOP. Thirteen patients underwent surgical treatment for SOP. Vertical deviation <6 PD at the initial visit and low fundus torsion in the nonparetic eye and both eyes were significantly associated with spontaneous recovery (p < 0.05, logistic regression analysis). Traumatic factors, including the trauma type, presence of intracranial lesion, loss of consciousness, and Glasgow Coma Scale score, were not associated with spontaneous recovery., Conclusions: In this multicenter study, spontaneously recovery was achieved in 47.5% patients with traumatic unilateral SOP. Even mild head trauma can lead to permanent SOP. Ocular factors, including the angle of deviation and fundus torsion, may better predict spontaneous resolution than traumatic factors in patients with traumatic unilateral SOP.

We present the case report of a patient who presented with intermittent diplopia and left hypertropia associated with an apparent left superior oblique palsy. After dissociation with cover testing, he showed conjugate rhythmic vertical eye movements present in all gazes, thought to represent rapid rhythmically alternating fixation. The vertical rhythmic movement resolved after strabismus surgery., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Congenital superior oblique (SO) palsy is often associated with anomalies of its tendon, increased tendon laxity being the most common. Rarely, the tendon lies in an abnormal location nasal to the superior rectus (SR) muscle, either attaching to the sclera or to Tenon's capsule. We describe a case of a child who presented with abnormal head posture and exotropia. The orthoptic evaluation revealed a left hypertropia and V-pattern exotropia. The motility pattern and the Parks three-step test were suggestive of left-sided SO palsy. Intraoperatively, the left SO tendon was very lax and was absent from its usual insertion. Further exploration revealed it to be inserted entirely to the nasal border of the SR muscle, with no scleral attachment. This tendon was advanced to its normal attachment to the sclera, and 11 mm inferior oblique recession was also performed. Postoperative alignment was satisfactory., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: To investigate preoperative clinical features and postoperative results according to the correspondence between excyclotorsion and the paretic eye in patients with congenital unilateral superior oblique palsy (USOP)., Methods: A retrospective review of medical charts was performed. The patients were divided into the accordance (ocular excyclotorsion in the paretic eye) and disaccordance (ocular excyclotorsion in the non-paretic eye) groups. The degree of excyclotorsion (scale, 0-4) was measured. Age, sex, hypertropia at the primary position, fixation preference, inferior oblique overaction, and degree of excyclotorsion were measured., Results: Ninety-eight patients were included in this study. There were 70 (71.4%) and 28 patients (28.6%) in the accordance and disaccordance groups. Sixteen patients (22.9%) in the accordance group and 12 patients (42.9%) in the disaccordance group were aged under 2 years (p = 0.04). A fixation preference of the paretic eye was observed in 2 (2.9%) and 8 (28.6%) patients in the accordance and disaccordance groups (p < 0.01). The postoperative degree of excyclotorsion in the accordance group (0.14 ± 0.39) was lower than that in the disaccordance group (0.28 ± 0.71) (p = 0.01). The residual postoperative excyclotorsion (> 1) were observed in the disaccordance group (14 patients, 50%) and accordance group (16 patients, 22.9%) (p = 0.01)., Conclusion: Preoperative disaccordance between excyclotorsion and the paretic eye was observed in patients who were under 2 years of age and preferred fixation of the paretic eye. The postoperative degree of excyclotorsion was lower in the accordance group., (© 2022. The Author(s).)

Background: Few reports have shown that superior oblique myokymia (SOM) may result from vascular compression of the trochlear nerve and may be curable using microvascular decompression (MVD)., Objective: To report the clinical characteristics and surgical treatment of 2 cases of SOM and provide a review of the related literature., Methods: Two patients with SOM were treated using MVD with the lateral supracerebellar infratentorial approach. The patients underwent diagnostic magnetic resonance imaging and three-dimensional fusion imaging preoperatively. A lateral suboccipital craniotomy was performed in the park-bench position. The trochlear nerve and branches of the superior cerebellar artery were confirmed after opening the cerebellomesencephalic fissure over the tentorial surface of the cerebellum. The vessel, which compressed the root exit zone of the trochlear nerve, was transposed far from the nerve and attached to the surface of the midbrain using Teflon felt and fibrin glue., Results: The first case showed compression on both the ventral and rostral sides of the trochlear nerve root exit zone, and the second showed compression only on the ventral side. Large bridging veins on the tentorial surface of the cerebellum complicated the approach in the second case. Postoperatively, both patients had immediate and complete resolution of symptoms without recurrence at the 24-mo and 17-mo follow-ups, respectively. Five previous reports described the complete resolution of SOM after MVD., Conclusion: A presentation of an intermittent fluttering ocular sensation should prompt magnetic resonance imaging for ipsilateral trochlear nerve compression. The lateral supracerebellar infratentorial approach allows safe and efficacious MVD for SOM., (Copyright © Congress of Neurological Surgeons 2021. All rights reserved.)

Purpose: To evaluate the effectiveness of inferior oblique recession with contralateral partial temporal inferior rectus recession in patients with decompensated congenital unilateral superior oblique palsy (SOP) in correcting moderate vertical deviations in primary position., Methods: The medical records of patients with SOP who underwent inferior oblique recession with contralateral partial temporal inferior rectus recession were reviewed retrospectively. Vertical deviation in primary position, subjective torsion, diplopia, residual deviation, and the deviation decrease were evaluated., Results: Four patients (three males and one female, age range 29-56 years) with congenital unilateral SOP and mean vertical deviation of 21.0 ± 5.3PD (range 14-25D) in primary position were included. Mean correction of hypertropia in primary position with this technique was 15.5 ± 5.3PD (range 10-20PD). The mean hypertropia on gaze to the contralateral side changed from 30.0 ± 10.8D before surgery to 9.3 ± 7.9D after surgery. Torsion had a mean change of 4.8° of incyclodeviation. Preoperatively, all patients had head tilt and diplopia, which was resolved in all but one patient, who will need surgery. Patients were followed an average of 18 months. No adverse events were reported in any subjects., Conclusion: When performing recession of inferior oblique muscles in SOP associated to a full recession of the contralateral inferior rectus, there is a risk of overcorrection in those with moderate angles. Performing a partial recession in the contralateral inferior rectus eye corrected up to 20PD in primary position in our series, reducing this risk.

Background: Adjustable bilateral Harada-Ito procedures have been described, sometimes with asymmetric adjustment used to correct vertical misalignment when coexisting with torsional strabismus. We investigated the causes of significant postoperative torsional incomitance noted in some patients undergoing these procedures., Methods: The medical records of patients who underwent bilateral Harada-Ito procedures for bilateral trochlear nerve palsy between 1980 and 2018 were reviewed retrospectively. Cases with simultaneous operation on any other oblique or vertical rectus muscle were excluded. Surgical results, especially using Lancaster red-green (Lan R-G) plots, were correlated with the procedures performed., Results: A total of 17 patients were included. At their last follow-up visit (mean, 12 months after surgery), 9 were diplopia free. Of the 8 with continuing diplopia, 2 had undercorrection and 1 had Brown syndrome. In 5 patients with continuing diplopia, there was relative intorsion of the eye movement paths in upgaze and relative extorsion of these paths in downgaze, a type of torsional incomitance. Asymmetric adjustment with tightening of one superior oblique tendon, and often loosening of the contralateral superior oblique tendon, had been performed in those 5 cases. Only 1 of the successful cases had the same type of asymmetric adjustment. There was a positive association between the severity of the preoperative Lan R-G pattern and postoperative diplopia., Conclusions: Asymmetric adjustment of bilateral Harada-Ito procedures when attempting to correct the coexisting vertical misalignment can cause significant torsional incomitance with incomplete correction of extorsion in downgaze and intorsion in upgaze. This pattern may result in postoperative diplopia that is surgically challenging to correct., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Schwannomas of the trochlear nerve are relatively rare, and most patients present with preoperative diplopia because of trochlear nerve palsy. We describe the case of a 61-year-old male patient with a trochlear nerve schwannoma and no pre- and postoperative diplopia, despite his trochlear nerve being cut during the operation. We aimed to investigate the frequency of postoperative diplopia associated with intraoperative trochlear nerve disturbance by reviewing previous case reports, wherein postoperative diplopia did not occur after the trochlear nerve was cut intraoperatively. We recorded the frequency of diplopia because of intraoperative trochlear nerve disturbance, such as the trochlear nerve being cut, in cases without pre- and postoperative diplopia. We searched the PubMed, Medline, and Google Scholar databases for works published from 1976 to 2020 and followed the preferred reporting items for systematic reviews and meta-analyses guidelines. We reviewed 36 publications and found 92 cases of trochlear nerve schwannoma. Surgical resection was performed for 43 patients, of whom 40 were kept under observation and 9 were treated with radiation therapy. Of the 43 cases, 9 without preoperative diplopia underwent gross total resection. We analyzed ten cases (including ours) without preoperative diplopia to check for postoperative diplopia. In total, four cases, including ours, did not display postoperative diplopia despite the trochlear nerve being cut. This may be attributed to the preoperatively acquired motor and sensory fusion in the patient's vision because of tumor progression. Our findings may benefit neurosurgeons who treat patients with schwannomas and help them predict patients' outcomes.

Purpose : To evaluate the effect of augmented inferior oblique recession (recession +5 mm loop) on the vertical deviation in primary position (PP) and the inferior oblique overaction (IOOA) in patients with unilateral congenital or acquired superior oblique palsy. Patients and methods : The medical records of patients who underwent unilateral inferior oblique recession with 5 mm loop during 2012 and 2019 were retrospectively reviewed. All patients had small to moderate manifest or intermittent hypertropia in PP and overaction of the inferior oblique muscle of +2 or +3 in lateral gaze. Patients who had combined inferior rectus surgery of the contralateral eye or who had previous vertical muscle surgery were excluded. Results : A total of 26 patients were included. Of these, three patients had combined horizontal muscle surgery. In 22 patients, the superior oblique palsy was congenital or longstanding, in 4 it was acquired and stable for more than 9 months. The mean preoperative vertical deviation in PP at distance and near was 14.7Δ and 11.2Δ, respectively. The mean postoperative vertical deviation was 5.7Δ and 4.1Δ after a mean follow-up of 19 months. The IOOA improved in all patients, 16 patients had an improvement of +2 and 10 patients had an improvement of +1. Conclusion : Inferior oblique recession with a 5 mm loop is a simple and quick technique to correct small to moderate hypertropia in primary position and inferior oblique overaction in contralateral gaze in patients with congenital, longstanding or acquired superior oblique palsy without risk of overcorrection.

Background: Conventional treatment options for trochlear pain arising from trochleitis or primary trochlear headache include oral anti-inflammatory medications and/or local injection of corticosteroids and local anesthetic. Trochleaectomy is an additional option to consider for monocular patients with intractable trochlear pain., Methods: We report 3 patients undergoing trochleaectomy for refractory trochlear pain syndromes., Results: Trochleaectomy resulted in resolution of their periocular discomfort., Conclusions: Trochleaectomy is an effective procedure to treat trochlear pain syndrome in functionally monocular patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by North American Neuro-Ophthalmology Society.)

Purpose: The rectus inferior myopexy is often used in vertical incomitant deviations without significant deviation in primary position. We analysed the long-term results in different pathologies., Methods: Retrospective study of patients operated on rectus inferior myopexy between 1984 and 2018. Vertical and torsional deviations were measured in primary position (PP) and 25° downgaze and the field of binocular single vision (FBSV) was evaluated with the Harms tangent screen, establishing a functional score. Postoperative follow-ups took place at 1 month, 6 months and long term (1 - 24 years)., Results: 62 patients were included (mean age 41 years, 28 women and 34 men). 47 presented a fourth nerve palsy (group 1) and 15 a reduced depression of other origins (group 2). 31 patients had undergone previous operations and 34 contemporaneous operations with the myopexy. In group 1, preoperative mean vertical deviation was 6.4° in PP and 12.3° on downgaze, postoperative 4° and 7.2°. In group 2, the value decreased from 3.3° in PP and 11.5° on downgaze to 1.2° and 6.6°. Over the years, there has been a decrease in the effect, particularly in group 1. The torsion was hardly influenced in both groups. The median functional score of FBSV improved in group 1 from 10% preoperatively to 39% postoperatively and in group 2 from 25 to 69%., Conclusion: The inferior rectus myopexy shows an effective way to reduce the incomitance of vertical deviation without significant influence on torsion. Over the years, there has been a decrease in the effect, particularly in patients with superior oblique paresis. We do not consider inferior rectus myopexy as a classic surgical treatment of superior oblique paresis. We have only used it in special cases., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: To compare the effectiveness of inferior oblique myectomy and anterior transposition for correction of hypertropia in trochlear nerve palsy., Methods: This retrospective study compares the surgical outcome of 40 patients with hypertropia secondary to trochlear nerve palsy who underwent either a unilateral myectomy or anterior transposition of the inferior oblique muscle. The primary outcome measure was the change in vertical deviation in primary gaze., Results: A total of 40 patients with a mean age of 41 years were included. There was no statistically significant difference between groups (near preoperative hypertropia, P = 0.134 [Mann-Whitney test]). Of these, 19 underwent anterior transpositions and 21 myectomies. Both surgical techniques were successful at reducing levels of vertical deviation (anterior transposition, 89%; myectomy, 76%). However, the relative percentage reduction showed a statistically significant difference in postoperative outcomes, with anteriorization being more effective (anteriorization, 82%; myectomy 48%; P = 0.003)., Conclusions: In this study cohort, anterior transposition was more effective than myectomy at correcting vertical deviation in patients with inferior oblique overaction secondary to trochlear nerve palsy., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the angle of deviation in various gaze positions as a risk factor for overcorrection of moderate-angle unilateral trochlear nerve palsies treated with two-muscle surgery., Methods: The medical records of consecutive patients with presumed unilateral moderate-angle trochlear nerve palsy who underwent two-muscle surgery were retrospectively reviewed. Patients with overcorrection, defined as reversal of hyperdeviation by prism alternate cover testing at distance (straight ahead) or near measured at 6 weeks, were compared to non-overcorrected patients for their preoperative torsion and ocular alignment at near and distance., Results: A total of 45 patients (age range, 12-77 years; 24 [53%] males) with deviation ranging from 14 Δ to 25 Δ in primary position underwent two-muscle surgery, of whom 8 (18%) experienced surgical overcorrection by 6 weeks' follow-up. The preoperative angle of deviation was similar between overcorrected and non-overcorrected patients for eight of nine cardinal distance positions and near gaze; however, patients with smaller deviations in ipsilateral gaze were more likely to be overcorrected with two-muscle surgery (8.5 vs 16.0 [P = 0.029]). Cut point analysis determined that an ipsilateral gaze of ≤9 Δ was significantly associated with overcorrection. Greater lateral incomitance also trended toward overcorrection (15.0 vs 9.0 [P = 0.059]). Torsion was not a clinically significant indicator of overcorrection (3.5 vs 6 [P = 0.083])., Conclusions: A preoperative ipsilateral angle of ≤9 Δ was associated with overcorrection in patients undergoing two-muscle surgery for moderate angle unilateral trochlear nerve palsies., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: This report presents the third case of trochlear schwannoma arising from the pineal region and the first case to be resected using a paramedian infratentorial supracerebellar approach. Schwannomas of cranial nerves have traditionally been thought to arise from the transitional point where the axonal envelopment switches from glial cells to Schwann cells; however, recent temporal bone histopathologic evidence from vestibular schwannomas challenges this view. Of the 38 cases of pathology-confirmed trochlear schwannoma in the literature, there are only 2 cases arising from the pineal region, where the nerve sheath transition zone is located. Here, we discuss an unusual case of trochlear schwannoma arising from this transition zone., Case Description: A 65-year-old man was admitted to our institute after a traffic accident. He complained of headache and dizziness, and a computed tomography scan revealed an isodense mass in the pineal region with obstructive hydrocephalus. Magnetic resonance imaging with contrast showed an enhancing mass in the pineal region. The tumor was subtotally resected using a paramedian infratentorial supracerebellar approach, and pathology confirmed the diagnosis of trochlear schwannoma., Conclusions: Trochlear schwannoma should be considered when a mass is identified in the pineal region. This diagnosis should still be entertained for mass lesions along the free tentorial edge because the tumor may arise distant from the glial-Schwann transition zone located by the dorsal midbrain. We propose a treatment algorithm for this rare tumor that seeks to maximize functional outcome., (Copyright © 2020. Published by Elsevier Inc.)

Purpose : To evaluate the efficacy of single or combined superior oblique tendon (SO) advancement for selected cases of unilateral superior oblique palsy (SOP). Methods : The medical records of 14 patients who underwent single or combined superior oblique tendon advancement in one institution from May 2017 to October 2018 were reviewed. All subjects with a diagnosis of unilateral SOP who underwent single or combined SO tendon advancement surgery were included. The goal of the surgery was to correct the hypertropia and head tilt. The single or combined SO tendon advancement surgery was selected based on the amount of hypertropia or head tilt and the Knapp classification of the SOP. The information recorded included pre- and postoperative deviation angle and ocular motility findings. The degree of upshoot in adduction was graded pre- and postoperatively. Results : Fourteen patients between the age of 3 and 52 years with unilateral superior oblique palsy were selected to undergo SO tendon advancement. Single SO tendon advancement was carried out in eight acquired Knapp class II or residual SOP patients. SO tendon advancement combined with contralateral inferior rectus recession was carried out in two acquired Knapp class II patients. SO tendon advancement combined with ipsilateral inferior oblique myectomy was carried out in four congenital Knapp class III patients. The changes in pre- and postoperative hypertropia at primary gaze in single SO tendon advancement patients were from 6.25 ± 2.12 prism diopters to 0.86 ± 1.46 prism diopters. The changes in degree of upshoot in adduction were from +1.86 to +0.21. Conclusions : SO tendon advancement worked well as single or combined muscle procedure to treat unilateral superior oblique palsy.

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., Competing Interests: None

Purpose: To identify clinical characteristics, etiologies, and treatment implications of sudden-onset, acquired cases of superior oblique palsy., Methods: The medical records of patients diagnosed with trochlear nerve palsy between January 2010 and January 2018 were reviewed retrospectively to identify cases of acquired trochlear nerve palsy with a specific date of onset of acute symptoms or specific causative incident. Patients with congenital palsies or an uncertain date of onset, history of other strabismus, concomitant oculomotor or abducens nerve palsies, or history of strabismus surgery were excluded., Results: Of 214 patients with superior oblique palsy, 23 had sudden-onset, acquired palsies. There were 14 cases of unilateral palsy and 9 cases of bilateral palsy. Patients with unilateral palsy presented with vertical diplopia, while those with bilateral palsy complained of either torsional (4/9 patients) or vertical (5/9 patients) diplopia. The most common etiologies were severe trauma associated with traumatic brain injury, followed by central nervous system neoplasm and stroke. Fifteen patients underwent surgical intervention, 3 of whom required more than one surgery., Conclusions: Patients with acute superior oblique palsy invariably complain of vertical and/or torsional diplopia. Neuroimaging should be considered in cases of acquired superior oblique palsy without a known traumatic cause. Bilateral cases of acquired superior oblique palsy are more challenging to manage surgically because of symptomatic torsional diplopia., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: We describe successful surgical treatment of superior oblique myokymia, which had recurred after superior oblique tenectomy., Methods: Single case report., Results: The distal stump of the superior oblique tendon was extirpated by stripping it from the globe. The ipsilateral superior rectus muscle also was recessed, to correct a hypertropia that had resulted from the original superior oblique tenectomy., Conclusions: Complete removal of the distal superior oblique muscle tendon provided definitive relief of superior oblique myokymia. Superior rectus muscle recession, combined with previous inferior oblique myectomy, compensated effectively for loss of superior oblique function.

Purpose: To evaluate the results of surgical treatment in a large group of patients with trochlear nerve palsy, with emphasis on the self-grading effect of a standardized recession of the ipsilateral inferior oblique muscle., Methods: All patients who underwent first-time surgery for trochlear nerve palsy in the period 2005-2014 in our department (n = 114) were retrospectively evaluated regarding pre- and postoperative data, surgical procedure, and the need for reoperations. Mean follow-up time was 8.5 ± 13.8 months., Results: Among the 114 patients, 73 (64.0%) had a congenital palsy, 31 (27.2%) an acquired palsy, while in 10 cases (8.8%) the type of palsy was uncertain. A standardized recession of the ipsilateral inferior oblique muscle with reattachment at the lateral border of the inferior rectus muscle was carried out in 97.3% of the congenital palsies and in 80.5% of the acquired/uncertain group. In the total patient material, further surgery was needed in 15.8%. Among the patients who underwent a single standardized recession of the inferior oblique muscle, a significant correlation between preoperative vertical angle of deviation and the postoperative change in deviation was demonstrated (correlation coefficient -0.70, p < 0.001), confirming the self-grading nature of this procedure. Subjectively, 97.1% in the congenital and 91.4% in the acquired/uncertain group reported complete/near complete resolution or significant improvement of their symptoms at the final control examination., Conclusion: In the majority of patients with trochlear nerve palsy, a favourable outcome may be achieved after a single, standardized recession of the ipsilateral inferior oblique muscle., (© 2018 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Trochlear schwannomas typically present with diplopia and are extremely rare benign intracranial neoplasms that require the combined expertise of neurotologists and neurosurgeons for surgical excision. A combined petrosal approach offers a surgical route for removal of growing and/or symptomatic tumors. A study of a trochlear nerve schwannoma that demonstrated rapid growth but was otherwise asymptomatic was presented in this study.

Purpose: The information about superior rectus (SR) recession in cases with SR contracture coexisting with superior oblique palsy (SOP) is very limited in previous literature. The aim of this study is to evaluate the effect of SR recession, as a combined procedure with inferior oblique (IO) disinsertion, in long-standing SOP with secondary SR contracture., Methods: The medical records of the 145 patients operated for SOP were retrospectively reviewed and 15 patients who underwent SR recession met the inclusion criteria. The mean follow-up was 50.4 months., Results: The preoperative angle of deviation was within the range of 16-35 prism dioptres (PD) with a mean of 23.0 ± 5.03 PD. In all of the cases, SR recession was performed in combination with IO disinsertion. Adult patients (12) underwent adjustable SR recession. Postoperative overcorrection developed in 3 cases (20%), and in 12 patients, the postoperative vertical deviation was within the range of 0-5 PD with a mean of 1.41 ± 1.88 PD. The overcorrected three patients underwent botulinum toxin A (BTXA) injection into the ipsilateral inferior rectus muscle. The deviation is well controlled by BTXA injection in two patients, whereas the other one was considered as masked bilateral SOP and underwent IO disinsertion in the other eye., Conclusion: Our results suggested that SR recession in combination with IO disinsertion is an effective procedure to control large vertical deviations in SOP with SR contracture in the majority of cases. However, the risk of overcorrection should be considered despite adjustable SR weakening and BTXA injection seems efficient to rescue overcorrections in long term.

Purpose: To report the surgical outcomes of the superior oblique tuck procedure in the management of superior oblique palsies performed at a single centre over a 25-year period., Methods: A retrospective study of superior oblique tuck performed as a primary and secondary procedure by a single surgeon over a 25-year period between 1992 and 2016. We evaluated patient demographics, the angle of deviation pre- and post-surgery in prism dioptres (PD), amount of muscle tuck surgery performed (mm), complications (iatrogenic Brown's Syndrome) and improvement of diplopia post-operatively., Results: 162 eyes from 162 patients were identified. Gender = 108 male patients (66.67%). Mean age at the time of surgery = 45.94 years; laterality = 85 left eyes (52.47%). 110 patients (67.90%) = congenital superior oblique palsy. Mean post-op follow-up time = 7.5 months. Mean pre-operative angle of deviation = 15.88 PD (range = 4-35 PD); mean post-operative angle of deviation = 5.09 PD (range = 0-20 PD; p < 0.0001). 157 patients (96.91%) displayed a reduction in angle of deviation post-operatively. Overall mean reduction in the angle of deviation = 10.79 PD (range = 0-34 PD). Mean amount of muscle tucking = 9.75 mm (range = 3-20 mm). 24 patients (14.82%) experienced post-operative iatrogenic Brown's syndrome but only two of these required further corrective surgery. 138 patients (85.19%) experienced improvement of diplopia post-operatively. Overall, 54 patients (33.33%) required additional extraocular muscle surgery to reduce diplopia further., Conclusions: This large series of superior oblique tuck procedures performed over a 25-year period, displays excellent surgical outcomes with regards to reduction of the angle of deviation, diplopia and limited complications.

Purpose: To determine the efficacy of isolated inferior oblique myectomy on hypertropia in primary position, side gazes, and tilts, and its effect on comitancy and abnormal head posture in unilateral superior oblique palsy., Methods: Thirty-nine patients with unilateral superior oblique palsy who had inferior oblique overaction underwent inferior oblique myectomy. The hypertropia was measured in primary position, side gazes, and tilts preoperatively and postoperatively. Abnormal head posture was also assessed. Success was defined as primary position hypertropia of 5 prism diopters (PD) or less., Results: The mean distance hypertropia was 15.7 ± 7.7 PD (range: 3 to 30 PD) preoperatively and 1.5 ± 3.3 PD (range: 0 to 16 PD) postoperatively (P < .001). The mean reduction of distance hypertropia postoperatively was 14.2 ± 7.8 PD (range: 3 to 30 PD). The contralateral gaze hypertropia decreased from 21.7 ± 9.0 PD (range: 5 to 45 PD) preoperatively to 3.6 ± 5.1 PD postoperatively (range: 0 to 20 PD) and ipsilateral head tilt hypertropia decreased from 21.9 ± 8.4 PD (range: 8 to 40 PD) preoperatively to 5.0 ± 5.9 PD (range: 0 to 24 PD) postoperatively (P < .000 for both). Incomitance (contralateralipsilateral gaze hypertropia) decreased from 15.0 ± 7.4 PD (range: 3 to 35 PD) preoperatively to 2.8 ± 4.1 PD (range: 0 to 16 PD) postoperatively (P < .001). The success rate between the two groups of patients who had hypertropia of 15 PD or less and greater than 15 PD in primary position was not statistically different (94.7% vs 85%). Two patients underwent a second operation for residual hypertropia. There was no overcorrection. Thirty-two patients had abnormal head posture, which resolved postoperatively in 29 cases., Conclusions: Isolated inferior oblique myectomy is an effective procedure in resolving hypertropia up to 30 PD due to unilateral superior oblique palsy, with a minimal risk of overcorrection and low risk of undercorrection. It decreases incomitancy, is a self-titrating procedure, and resolves abnormal head posture efficiently. [J Pediatr Ophthalmol Strabismus. 2019;56(1):23-27.]., (Copyright 2018, SLACK Incorporated.)

Purpose: To evaluate the effects of isolated inferior oblique (IO) muscle recession in patients with superior oblique palsy (SOP) and persistent hypertropia in abduction., Methods: Retrospective review of patients with unilateral SOP who were treated with isolated IO recession by a single surgeon (MCB) between January 2008 and December 2017. We included patients with congenital and acquired fourth nerve palsies, with a hyperdeviation of less than 20 prism diopters in primary position and at least 4 prism diopters in abduction by prism and alternate cover test (PACT) during distance fixation. A minimum follow-up of 4-6 weeks was required. Age at surgery, etiology, presence of head tilt, motor alignment in primary and secondary gaze positions at distance and near using PACT, versions, ductions, and torsion were recorded from the patients' chart., Results: Seven patients with SOP were included in this study. Four (57.14%) males, with a mean age at presentation of 41.86 years (range: 6-66 years). Mean follow-up was 13.25 months (range: 1.3-52.2 months). A decrease in mean central gaze hypertropia from 11.4 to 1.71 PD was found. A mean contralateral gaze hypertropia that decreased from 22.28 to 5.71 PD and an ipsilateral gaze hypertropia that improved from 5.86 to 1.14 PD were also noted. Torsion had a mean change of 3.4° of incyclodeviation at the final examination., Conclusions: This study confirms the efficacy of isolated maximal IO recession for the treatment of unilateral SOP that is accompanied by a modest hypertropia of the paretic eye in abduction.

Purpose: The aim of this study was to investigate the quantitative effect of inferior oblique (IO) 10- and 14-mm recession on postoperative horizontal deviation., Methods: Patients (22 men and 18 women) who underwent IO recession were divided into two groups for comparison studies: group 1 (10-mm IO recession, 15 patients) and group 2 (14-mm IO recession, 25 patients). Preoperative and postoperative horizontal deviations were measured, and the resulting horizontal deviations from the 10- and 14-mm IO recession surgeries were compared. The effects of superior oblique underaction, IO overaction, and combined exodeviation on postoperative horizontal deviation were analyzed., Results: Although group 1 did not show a significant horizontal deviation change after surgery (1.9 ± 4.5 prism diopters [PD], p = 0.452), group 2 had a meaningful horizontal change after 14-mm recession (2.2 ± 3.8 PD, p = 0.022). Both groups showed a significant esodrift in horizontal deviation (group 1, p = 0.017; group 2, p = 0.030) in patients with exodeviation over 8 PD. The mean change in horizontal deviation was 6.0 ± 5.4 PD for group 1 and 9.0 ± 5.0 PD for group 2. Although the amount of superior oblique underaction did not affect the extent of change in horizontal deviation, patients with severe IO overaction showed a significant change in horizontal deviation after 14-mm IO recession., Conclusions: Fourteen-millimeter IO recession could make a statistically significant change in horizontal deviation after surgery. In addition, esodrift should be considered after IO recession in patients with a preoperative exodeviation greater than 8 PD or severe IO overaction., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2018 The Korean Ophthalmological Society.)

Purpose: The clinical feature of unilateral decompensating strabismus sursoadductorius (dSSA; often called congenital superior oblique palsy, CSOP) is not an etiologically uniform entity. Hypotrophy of the superior oblique muscle (HMOS) is a frequent and immediate cause of dSSA/CSOP. In this study, clinical characteristics of dSSA/CSOP with and without HMOS are compared., Patients and Methods: Twenty-five consecutive patients (age 14 - 69 years; median 43 years) were included in this study, 14 with 3T MRI-proven HMOS (group 1) and 11 without HMOS (group 2). HMOS was defined as a reduction of the medio-lateral (ML) as well as based on ML and cranio-caudal (CC) diameter calculated area = (ML · CC/4) · π of the affected superior oblique muscle (SOM) < 80% in comparison to the contralateral SOM (measured on the single coronal image on which the muscle has its greatest extent). The two groups were compared in terms of head tilt, cyclo- and vertical deviation and the Bielschowsky head tilt test. Patients were classified according the Knapp's classification., Results: Both the incidence of head tilt with 14/14 vs. 5/11 (χ 2  = 0.003) and its degree: 11.1 ± 4.5° vs. 3.2 ± 4.1° (p < 0.001) was higher in group 1 than in group 2, as well as the Bielschowsky head tilt test: 9.3 ± 4.3° vs. 3.8 ± 4.9° (p = 0.008). The average amount of hypertropia was larger in group 1 than in group 2 during adduction: 16.7 ± 5.3° vs. 9.3 ± 3.4° (p < 0.001) as well as during adduction and downgaze of the affected eye: 14.6 ± 7.1 vs. 7.2 ± 3.7° (p = 0.03). In the sagittal plane, the increase of vertical deviation was larger in group 1 than in group 2: 2.8 ± 7.8 vs. - 2.4 ± 4.2 (p = 0.04); the excyclodeviation was larger in group 1 in all three planes (sagittal plane, adduction and abduction) in comparison to group 2: 1.3 ± 4.1 vs. - 2.9 ± 2.8 (p = 0.006), 2.4 ± 5.2 vs. - 2.2 ± 2.9 (p = 0.01), 0.5 ± 3.8 vs. - 2.7 ± 3.9 (p = 0.05). Knapp's class II was found in 6 of 15 patients in group 1 and only in this patient group (χ2 = 0.03)., Conclusions: In both groups, the vertical deviation showed a great dispersion. In patients without HMOS (group 2), vertical deviation in adduction did not exceed 15°. Patients with HMOS (group 1) do not show the typical features of a later acquired trochlear palsy due to an early developed compensating innervation. A vertical deviation in adduction of more than 15°, increasing excyclodeviation towards downgaze in all three planes (sagittal plane, adduction and abduction) and Knapp's class II are relatively reliable predictors of a hypoplasia of the SOM. An internationally uniform term for this group of patients, such as superior oblique weakness or superior oblique hypotrophy, would be desirable., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To determine the incidence of and to identify characteristics predicting significant superior oblique palsy (SOP) after adjustable superior oblique suture spacer surgery for treatment of Brown syndrome., Methods: The medical records of patients treated for unilateral Brown syndrome with adjustable suture spacers (2005-2016) were reviewed to identify possible association of age at surgery, spacer length, surgeon performing procedure, severity of Brown syndrome, preoperative hypotropia in primary position and affected side gaze, and reduction in Brown restriction on postoperative superior oblique function. "Good" postoperative superior oblique function was defined as absence of hypertropia and diplopia in primary position and no more than intermittent diplopia in downgaze comfortably fused with ≤4 Δ base-down or head tilt of <10°. Presence of postoperative hypertropia in primary position with increase in downgaze met criteria for significant SOP. Postoperative Brown restriction of ≤ -2 indicated resolution of Brown syndrome., Results: Median age at surgery was 59 months, interquartile range (IQR) was 32-82 months, and median spacer length was 6 mm (range, 2-7 mm) for 19 included patients. Preoperative median hypotropia was 9 Δ (IQR, 0 Δ -12 Δ ) in primary position and 18 Δ (IQR, 5 Δ -22 Δ ) in affected side gaze. Of 19 patients, 16 (84%) achieved sufficient resolution of Brown syndrome, but 6 (32%) developed significant SOP. Modest preoperative hypotropia in affected side gaze was the only predictor of significant SOP (likelihood ratio test = 7.11; P = 0.008). Logistic regression modeling enabled estimation of risk of significant SOP based on preoperative side gaze hypotropia., Conclusions: Suture spacer surgery can result in significant SOP. Risk may be predicted by magnitude of preoperative side gaze hypotropia., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the clinical outcomes of bilateral superior oblique posterior 7/8th tenectomy with inferior rectus recession on improving chin-up head positioning in patients with horizontal nystagmus., Methods: Medical records were reviewed from 2007 to 2017 for patients with nystagmus and chin-up positioning of 15° or more who underwent combined bilateral superior oblique posterior 7/8th tenectomy with an inferior rectus recession of at least 5 mm., Results: Thirteen patients (9 males and 4 females) were included, with an average age of 7.3 years (range: 1.8 to 15 years). Chin-up positioning ranged from 15° to 45° degrees (average: 30°). Three patients had prior horizontal muscle surgeries, 1 for esotropia and 2 for horizontal null zones causing anomalous face turns. Ten patients underwent other concomitant eye muscle surgery: 3 had esotropia, 1 had exotropia, and 2 had biplanar nystagmus null point requiring a horizontal Anderson procedure. Four patients underwent simultaneous bilateral medial rectus tenotomy and reattachment. All patients had improved chin-up positioning. Eight patients had complete resolution, whereas 5 had minimal residual chin-up positioning. Three patients developed an eccentric horizontal gaze null point with compensatory anomalous face turn with onset 2 weeks, 2 years, and 3 years postoperatively. Average follow-up was 42.7 months. No postoperative pattern deviations, cyclodeviations, or inferior oblique overaction were seen. No surgical complications were noted., Conclusions: Bilateral superior oblique posterior 7/8th tenectomy in conjunction with bilateral inferior rectus recession is a safe and effective procedure for improving chin-up head positioning in patients with horizontal nystagmus with a down gaze null point. [J Pediatr Ophthalmol Strabismus. 2018;55(4):234-239.]., (Copyright 2018, SLACK Incorporated.)

Background: Schwannomas of the parasellar region may arise from the trigeminal, oculomotor, trochlear, and abducens nerves., Objective: To define the tumor origin, location, and dural relationship (extradural vs extra-intradural vs cisternal) on preoperative magnetic resonance imaging (MRI), in order to plan the best surgical approach (purely extradural vs extra-intradural)., Methods: Twenty-four patients with parasellar schwannomas who underwent surgery were retrospectively analyzed. Twenty arose from the trigeminal nerve (7 intracavernous and 13 within the Meckel's cave), 3 from the oculomotor nerve, and 1 from the abducens nerve. The preoperative identification of the tumor location (extradural vs extra-intradural vs cisternal) and the nerve of origin was defined on MR sequences. All patients were operated on through a pterional approach (extradural or extra-intradural route)., Results: The tumor location was correctly defined on MRI in 22 out of 24 cases (92%) and the nerve of origin in 22 (92%). An extradural approach without intradural exploration was performed in all 5 intracavernous trigeminal schwannomas, in 11 out of 13 of the Meckel's cave, and in 2 schwannomas of the oculomotor nerve. Two schwannomas of the Meckel's cave with transgression of the medial dural wall, 1 of the oculomotor nerve, and the abducens nerve schwannoma required an extra-intradural approach. Complete tumor resection was obtained in 19 out of 24 cases (80%)., Conclusion: The pterional extradural approach is sufficient for Dolenc type I and II trigeminal schwannomas, excepting for those transgressing the inner dural layer. Schwannomas of the oculomotor and abducens nerves with cisternal location require an extradural-intradural approach.

Objectives: The schwannoma of the trochlear nerve is rare and originates mostly from the distal parts in the interpeduncular cistern. A lesion on the proximal segment in the inferior pineal region is extremely rare. Because of the rarity of the disease, the surgical approach to this region for the resection of trochlear nerve schwannoma has not been well documented in the literature. We herein describe a novel approach to successfully resect the trochlear nerve schwannoma., Methods: A 12-year-old boy presented with occipital headache, abnormal gait, and disturbed conjoined eye movement. He was diagnosed with a lesion in the inferior pineal region compressing the superior medullary velum into the roof of the fourth ventricle. A bilateral midline suboccipital craniotomy was performed, and the fourth ventricle was exposed. The lesion was approached through the fourth ventricle superior medullary velum (transventricular transvelar approach). The lesion was totally resected, and his histopathology examination revealed trochlear schwannoma., Results: The patient's symptoms resolved, and he had no recurrence at 12-year follow-up with normal eye movement and vision., Conclusion: The transventricular transvelar approach is feasible and safe to treat a lesion of the lower part of the pineal region being pushed through the superior medullary velum., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To identify preoperative factors associated with the surgical corrective effect of contralateral inferior rectus recession (IRR) for vertical deviation in patients with congenital superior oblique palsy (SOP)., Methods: This retrospective study included 20 treatment-naïve patients with unilateral congenital SOP (age range, 6-79 years) who underwent contralateral IRR according to our basic policy to select IRR for paretic eye fixation. The corrective effect (°/mm) of IRR was defined as the difference in the vertical deviation at the primary gaze position between before and 6-18 months after surgery per distance of recession. We also measured the preoperative vertical deviation at primary and secondary gaze positions, and vertical deviation with head-tilting, and calculated the difference in vertical deviation between these positions. We analyzed the correlation between the corrective effect of IRR and these study parameters., Results: The mean corrective effect of IRR was 2.4 ± 1.6°/mm, which had a significant correlation with preoperative differences in vertical deviation between the primary gaze position and the downward (P = 0.004, r = -0.61) and contralateral gaze positions (P = 0.03, r = -0.48); and the presence of preoperative stereopsis (P = 0.02, r = -0.51). After excluding a statistical outlier, the correlation between the corrective effect and the difference between the primary and contralateral gaze positions was no longer significant (P = 0.07), while the other two relationships remained significant., Conclusions: Our findings suggest that preoperative differences in vertical deviation between the primary and downward gaze positions and the presence of preoperative stereopsis are important considerations prior to performing IRR for congenital SOP, particularly with paretic eye fixation.

Superior oblique palsy (SOP) has many anatomic variations, and the accompanied paralysis generalization could stimulate the secondary changes of other extra-ocular muscles. Therefore, the clinical manifestations of SOP can be various, and the surgical design is complicated and changeable. It is necessary to understand the clinical development, stages and types of SOP correctly, and to take into account the developmental characteristics of the superior oblique muscle and select the individualized treatment plan. In this article, the SOP manifestations, imaging features, clinical examination and personalized treatment options are discussed, in order to provide some reasonable treatment options for SOP surgery. (Chin J Ophthalmol, 2017, 53: 881-884) .

Purpose: The purpose of our study was to determine whether ocular sighting dominance may influence the ocular torsion in patients with unilateral congenital superior oblique palsy (UCSOP)., Methods: This retrospective study included 22 UCSOP patients with radiologic evidence of unilateral superior oblique muscle hypoplasia on orbital magnetic resonance imaging and 66 healthy individuals with normal ocular motility as controls. Ocular torsion was assessed both quantitatively and qualitatively using digital fundus photography. The disc-fovea angle (DFA) was measured quantitatively using image software on a computer screen. All fundus photographs were qualitatively graded as normal torsion, extorsion, or intorsion in all subjects, based on the location of the optic disc relative to the fovea, according to the Bixenman and von Noorden's criteria. Ocular sighting dominance was assessed by the hole-in-the-card test and the pointing test. The Mann-Whitney U test and Fisher's exact test were used to determine the association between the ocular sighting dominance and the ocular torsion., Results: The median DFA was significantly larger in the eyes of patients with UCSOP (9.1° in the paretic eyes and 9.3° in the non-paretic eyes) than the eyes of the control group (4.3°, p < 0.001 for both). Ocular dominance tests displayed that, among 22 patients, 11 were paretic eye dominant and the other 11 were non-paretic eye dominant. The sighting-dominant eyes demonstrated significantly smaller median DFA than the non-dominant eyes (8.3° and 10.7°, respectively, p = 0.033), regardless of which eyes were paretic. Ten eyes of ten patients had extorsion, none had intorsion, and all the eyes of remaining 12 patients had no abnormal torsion, qualitatively. All the eyes showing extorsion in fundus photography were non-dominant eyes, regardless of whether the eyes were paretic or non-paretic., Conclusions: Our findings illuminate the importance of considering ocular sighting dominance for properly assessing ocular torsion in patients with UCSOP. Ocular sighting dominance may have an influence on objective ocular torsion in a way that decreases the torsion in the dominant eye, thereby hindering the abnormal ocular torsion from appearing in that eye.