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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 106  |  Issue : 4  |  Page : 259-262

Ocular cyclovertical deviations among strabismic patients attending Ophthalmology Department in Minia University Hospital


Ophthalmology Department, Faculty of Medicine, Minia University, Minia, Egypt

Date of Submission10-Oct-2013
Date of Acceptance05-Nov-2013
Date of Web Publication28-Apr-2014

Correspondence Address:
Sahar T Abdelrazik
MD, Ophthalmology Department, Minia University Hospital, Minia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.131618

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  Abstract 

Introduction
Small residual hyperdeviations following surgical alignment of horizontal strabismus are of special clinical significance as they cause permanent problem in patient's binocular function. Once the correct diagnosis has been made, medical and surgical management of these deviations does not present any problems.
Objective
This study was designed to detect the prevalence of vertical deviation among patients suffering from strabismus, attending Minia University Hospital.
Design
This retrospective study was conducted in the Ophthalmology Department, Minia University Hospital during the period from January 2008 to January 2013.
Patients and methods
We reviewed our medical records at the Paediatric Ophthalmology Unit to evaluate the data of 1456 patients who attended the clinic from January 2008 to January 2013 and who were suffering from strabismus. They were subjected to complete history taking about birth history, trauma, abnormal head positions, and examination of old images. Complete ophthalmologic and orthoptic examination were performed. Detected cases of vertical strabismus were recorded and all data of the patients were subjected to statistical analysis.
Results
We reported that 87.5% of strabismus patients in the study had only horizontal deviation and 12.5% had vertical deviations either pure vertical or in association with horizontal deviations; 58.8% of these vertical deviations were inferior oblique overaction.
Conclusion
Vertical deviations had a considerable prevalence in strabismic patients and they should be in mind for good diagnosis and management of strabismus patients.

Keywords: Strabismus, horizontaldeviation, inferior oblique overaction, vertical deviations


How to cite this article:
Abdelrazik ST, Khalil MF. Ocular cyclovertical deviations among strabismic patients attending Ophthalmology Department in Minia University Hospital. J Egypt Ophthalmol Soc 2013;106:259-62

How to cite this URL:
Abdelrazik ST, Khalil MF. Ocular cyclovertical deviations among strabismic patients attending Ophthalmology Department in Minia University Hospital. J Egypt Ophthalmol Soc [serial online] 2013 [cited 2020 Jul 12];106:259-62. Available from: http://www.jeos.eg.net/text.asp?2013/106/4/259/131618


  Introduction Top


Diagnosis and management of vertical deviations represent great challenges for most of the ophthalmologists because there are several disorders that on the first impression appear similar clinically but differ widely in etiology and management. Correct diagnosis is very important, as operation performed on the basis of wrong diagnosis of the underlying problem may cause permanent consequence to the patient's binocular function [1].

Vertical deviations differ from horizontal deviations in several aspects, as amblyopia and abnormal retinal correspondence are less frequent, comitance is rare and the deviation is smaller in magnitude [2].

Cyclovertical deviations are classified into five groups: Purely comitant vertical deviations, vertical deviations of paretic origin, deviations with unilateral overaction of the inferior oblique muscles, dissociated vertical deviations, and vertical deviations combined with features of several of the other groups [3]. Some authors added other causes to overshooting in adductions other than inferior oblique overaction [1].


  Objective Top


The aim of the study was to detect the prevalence of vertical deviation among patients suffering from strabismus, attending Minia University Hospital.

Design

This retrospective study was conducted in the Ophthalmology Department, Minia University Hospital during the period from January 2008 to January 2013.


  Patients and methods Top


We reviewed our medical records at the Paediatric Ophthalmology Unit to evaluate the data of 1456 patients who attended the clinic from January 2008 to January 2013 and who were suffering from strabismus.

All of our patients were evaluated thoroughly, including complete history taking with respect to birth history, trauma, abnormal head positions, and examination of old images.

Complete ophthalmologic and orthoptic examinations were the standard in evaluating a patient with strabismus and included the following:

  1. Visual acuity examination using Snellen's chart for adult or Kay pictures for children.
  2. Anterior segment examination for any corneal opacity or cataract.
  3. Cycloplegic refraction and fundus examination.
  4. Cover-uncover, alternate cover, and prism cover tests for evaluation of strabismus angle and detection of latent element of strabismus.
  5. Hirschberg and Krimsky tests for detection of strabismus angle.
  6. Evaluating the motor state of the eye including extraocular muscle motility in the six cardinal directions to detect any incomitance in ocular movement either because of paralysis or restrictions.
  7. Evaluating the sensory state using the Worth four-dot test and the Maddox rod test for binocular functions.
  8. Special tests were performed for certain cases, such as:

    1. Park's three-step test for cyclovertical muscle paralysis and the double Maddox rod test for detection of any torsional abnormalities.
    2. Active force generation test and forced duction test to differentiate muscle paralysis from restrictions.
    3. Lees screen for cooperative patients with incomitance to detect the affected muscles.


The data of 1456 patients were coded, entered, and processed using SPSS statistical program (version 19). P value less than 0.05 was considered the cutoff value for significance.

  1. Description of qualitative variables was represented as number and percentage.
  2. Z test of proportion was used to compare two proportions.



  Results Top


The age of our patients ranged from 6 months to 63 years and the mean age was 19.67 ± 4.23 years [Table 1],[Table 2],[Table 3] and [Table 4].
Table 1: Prevalence of vertical and horizontal deviations

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Table 2: Frequency distribution of vertical deviation patients

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Table 3: Cases of primary and secondary inferior oblique overaction

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Table 4: Dissociated vertical deviations with and without horizontal deviations

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  Discussion Top


Small residual hyperdeviations following surgical alignment of horizontal strabismus are of special clinical significance as it may cause diplopia or blurring of vision because of the small amplitude of vertical fusional vergence [1].

We designed this study to detect the prevalence of vertical deviations among strabismus patients to be aware of their frequency, which may help in their diagnosis and subsequent management.

In our study, we reviewed the results of 1456 patients suffering from strabismus; 41.5% were male patients and 58.5% were female patients, and the age of the patients ranged from 6 months to 63 years with a mean age of 19.67 ± 4.23 years.

Pure horizontal deviation represented 87.5% of the patients and 60% of these patients were female.

The patients with vertical deviation represented 12.5% of the total number of the studied patients and this percentage included both groups of patients with isolated vertical deviation (5.84%) and those with combined vertical and horizontal deviations (6.66%).

Vertical deviation in our study was slightly more in male patients (56.59%).

Our results are similar to those obtained in 2005 by Abbas et al. [4] in their study in Pakistan that included 924 patients of strabismus, where they reported that 11.4% of the patients had a vertical deviation but only 2% had pure vertical deviation as compared with 5.84% in our study.

In addition, Scobee [5] reported a vertical component in 43% of the 457 patients with esotropia.

This high percentage of vertical ocular deviation was observed because Scobee restricted his study to the esotropic patients only and the number of patients in his study was about one-third of that of our study.

White and Brown [6] in their study in 1939 that included 2000 patients observed a higher ratio of these vertical deviations; approximately half of their patients had isolated vertical deviations and another third (37%) had combined horizontal and vertical muscle problem.

These results are widely different from ours and the explanation could be racial differences and a different referral system that enabled him to see more patients with vertical deviation and fewer patients with horizontal strabismus.

In our study, we encountered six different types of vertical deviations [Table 2].

The most frequent type is inferior oblique overaction that represented 58.8% of patients with vertical deviation in our study. In about 45% of patients, inferior oblique overaction was primary, bilateral, and associated with infantile esotropia and in the other 55% it was secondary to fourth nerve palsy. We did not detect any case of fourth nerve palsy without inferior oblique overaction. These findings are in agreement with the study by many authors who reported that superior oblique palsy is the most common cause of isolated vertical deviation [7],[8].

Thyroid eye disease with hypotropia was the second prevalent type after inferior oblique overaction, with 11% of vertical strabismus patients. In contrast with other causes of vertical deviation in our study, only thyroid eye disease with hypotropia and dissociated vertical deviation are more common in female individuals.

Dissociated vertical deviation in our study represented 10.4% of patients with vertical deviation (1.3% of the total number of strabismus patients enrolled in this study); 31.6% of these patients were isolated type without any horizontal deviation, whereas the other 68.4% were associated with either esotropia or exotropia. However, Helveston [9] recorded 11% of dissociated vertical deviation in his 1000 consecutive patients with strabismus and nystagmus, which is about 10-fold of what we encountered in our study.

We detected that 7.7% of patients with vertical deviation had double elevator palsy, which is a significant percentage that we cannot ignore, although Bell et al. [10] consider it as unusual anomaly of ocular motility.

Third nerve palsy patients with hypotropia had the same percentage of double elevator palsy; most of the patients were acquired, although congenital patients were encountered.

The least frequent of all vertical deviations was unilateral Brown syndrome, which represented 4.4% of vertical strabismus patients (0.55% of all strabismus patients) in our study; however, Crosswell and Haldi [11] reported only six patients (0.23%) with this syndrome in their review of 2583 consecutive strabismus patients.


  Conclusion Top


Vertical deviations should be searched thoroughly in every patient with strabismus, as they represent 12.5% of all strabismus patients; half of the patients were isolated and the other half were associated with horizontal deviation, and the inferior oblique overaction is the most frequent vertical deviation (58.8%).


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Von Noorden GK. In: Von Noorden GK, editor. Cyclovertical deviation. Binocular vision and ocular motility: Theory and management of strabismus. 6th ed. St Louis: Mosby; 2002. 377-396.  Back to cited text no. 1
    
2.Anderson JR. Ocular vertical deviations and nystagmus. London: British Medical Association; 1959.  Back to cited text no. 2
    
3.Bielschowsky A. Disturbances of the vertical motor muscles of the eyes. Arch Ophthalmol 1938; 20 :175.  Back to cited text no. 3
    
4.Abbas M, ur Rahman H, Butt IA, Ghani N. Prevalence and mode of presentation of vertical deviations in squint patients. RMJ 2005; 30 :79-81.  Back to cited text no. 4
    
5.Scobee RG. Esotropia: Incidence, aetiology and results of therapy. Am J Ophthalmol 1951; 34 :817.  Back to cited text no. 5
[PUBMED]    
6.White JW, Brown HW. Occurrence of vertical anomalies associated with convergent and divergent anomalies. Arch Ophthalmol 1939; 21 :999.  Back to cited text no. 6
    
7.Plager DA. In: Rosenbaum AL, Santiago P, editors. Superior oblique palsy and superior oblique myokymia. Clinical strabismus management: Principles and surgical techniques. Philadelphia, PA: WB Saunders Co.; 1999. 219-229.  Back to cited text no. 7
    
8.Von Noorden GK, Murray E, Wong SY. Superior oblique paralysis. A review of 270 cases. Arch Ophthalmol 1986; 104:1771.  Back to cited text no. 8
[PUBMED]    
9.Helveston EM. Dissociated vertical deviation: A clinical and laboratory study. Trans Am Ophthalmol Soc 1980; 78 :734.  Back to cited text no. 9
[PUBMED]    
10.Bell JA, Fielder AR. Viney S. Congenital double elevator palsy in identical twins. J Clin Neuroophthalmol 1990; 10 :32.  Back to cited text no. 10
    
11.Crosswell HH, Haldi BA. Superior oblique tendon sheath syndrome. A report of two bilateral cases. J Pediatr Ophthalmol 1967; 4 :8.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  In this article
Abstract
Introduction
Objective
Patients and methods
Results
Discussion
Conclusion
Acknowledgements
References
Article Tables

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