|Year : 2016 | Volume
| Issue : 4 | Page : 161-166
Graded recession with or without anterior transposition of the inferior oblique muscle for treatment of unilateral congenital superior oblique palsy
Rasha El Zeiny1, Tharwat Mokbel1, Hisham El Srougy1, Hanem Kishk1, Oliver Ehrt2
1 Department of Ophthalmology, Mansoura University, Mansoura, Egypt
2 Department of Ophthalmology, Ludwig Maximilians University, Munich, Germany
|Date of Submission||07-Dec-2016|
|Date of Acceptance||15-Oct-2016|
|Date of Web Publication||19-Apr-2017|
Rasha El Zeiny
Department of Ophthalmology, Mansoura University, Egypt, El Gomhorrya Street, Mansoura
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the efficacy of graded inferior oblique muscle recession (8–10 mm) and inferior oblique recession with anterior transposition (12 mm) in adult unilateral congenital superior oblique palsy patients with good binocular vision (strabismus sursoadductorius).
Patients and methods
This study included 53 patients who presented with pure unilateral strabismus sursoadductorius and stereopsis [mean age: 39.8 (SD±17) years] during the time period between 2011 and 2014. Graded inferior oblique recession (8–10 mm) was performed for 26 patients with vertical deviation (VD) of less than 15° in adduction. Maximal recession with anterior transposition to the temporal side of the inferior rectus muscle insertion was performed for 27 patients with VD of more than 15° in adduction. Horizontal deviations and VD were measured using the alternate prism cover test in five directions of gaze preoperatively and 3 months after the operation. Moreover, subjective quantitative assessment of the angles of deviation, including horizontal deviations, VD, and cyclodeviation, was carried out using Harms’ tangent screen.
The median effect of the operation on VD in 25° adduction increased from 6° with 8–10 mm recession to 10.5° with maximal recession and anterior transposition to the lateral side of inferior rectus muscle insertion. This was related more to the amount of preoperative VD in adduction than to the amount of inferior oblique recession. The incyclorotatory effect of both procedures was small and not significantly different between the two groups. Three patients had a postoperative hypotropia (2°–5°) with limited elevation. Four patients were planned for further surgery (8%) because of undercorrection in three cases and the appearance of contralateral strabismus sursoadductorius in one case.
Graded recession of the inferior oblique muscle (8–10 mm) is effective for patients with mild-to-moderate strabismus sursoadductorius. Maximal recession with anterior transposition of the inferior oblique muscle is an ideal approach for patients with marked strabismus sursoadductorius. The rate of undercorrection as well as overcorrection that necessitated reoperations was low.
Keywords: diplopia, field of binocular single vision, inferior oblique muscle, strabismus sursoadductorius, superior oblique palsy, tangent screen
|How to cite this article:|
El Zeiny R, Mokbel T, El Srougy H, Kishk H, Ehrt O. Graded recession with or without anterior transposition of the inferior oblique muscle for treatment of unilateral congenital superior oblique palsy. J Egypt Ophthalmol Soc 2016;109:161-6
|How to cite this URL:|
El Zeiny R, Mokbel T, El Srougy H, Kishk H, Ehrt O. Graded recession with or without anterior transposition of the inferior oblique muscle for treatment of unilateral congenital superior oblique palsy. J Egypt Ophthalmol Soc [serial online] 2016 [cited 2020 Jul 13];109:161-6. Available from: http://www.jeos.eg.net/text.asp?2016/109/4/161/204727
| Introduction|| |
Superior oblique paresis is the most common cause of isolated vertical diplopia. It may be congenital or acquired .
Strabismus sursoadductorius (congenital superior oblique palsy) is a complex eye movement disorder, with excyclodeviation and overelevation of the affected eye, which increases in adduction and on ipsilateral head tilt. Affected patients may suffer from vertical (or torsional) diplopia, asthenopia, a compensatory head posture (mostly head tilt or face turn to the contralateral side), or from the cosmetically disfiguring large hypertropia in the primary position and adduction .
The disorder may remain latent, compensated for by the abnormal head posture or the large vertical fusional amplitude, and manifest itself with diplopia in adulthood when the fusional reserve is exceeded .
The cause for this congenital motility disorder is not uniform. Aplasia or hypoplasia of the superior oblique muscle is found in some patients. Others may have a pure functional relative overaction of the inferior oblique muscle resulting from supranuclear oblique muscle imbalance. Abnormalities of the insertion have also been discussed .
Surgical treatment is the only therapy as prism correction often fails because of the incomitance pattern of the angle of deviation and the associated cyclodeviation (CD) .
The surgical approaches for the treatment of strabismus sursoadductorius include weakening the muscle strength of the inferior oblique muscle ,, strengthening the muscle power of the superior oblique muscle ,,, or a combination of both ,. A combination of inferior oblique muscle and vertical recti muscle recession operation (ipsilateral superior rectus and contralateral inferior rectus surgery) may be needed ,.
Inferior oblique recession is considered the gold standard primary procedure for managing congenital cases of superior oblique muscle palsy , even without checking the laxity of the superior oblique muscle tendon .
Until now, the efficacy of inferior oblique muscle recession and transposition could not be clearly demonstrated such as for operations on the recti muscles. A standardized protocol of treatment and secured dosage guidelines for operations on the inferior oblique muscle for the selective correction of vertical and torsional deviation in strabismus sursoadductorius, respectively, do not exist yet ,,.
We aimed in this study to analyze the dose–response relationship for inferior oblique muscle recession with or without anterior transposition operation in cases of typical strabismus sursoadductorius (congenital superior oblique palsy) and compare our results with the previous literature.
| Patients and methods|| |
In the pediatric ophthalmology and strabismus clinic at Ludwig Maximilians University, Munich, 53 patients presented with pure unilateral strabismus sursoadductorius (congenital superior oblique palsy) and stereopsis and underwent recession or recession with anterior transposition of the inferior oblique muscle during the time period from 2011 to 2014. Only the patients old enough to complete Harms’ tangent screen examination were included in this study. Exclusion criteria were previous eye muscle surgery, dissociated vertical deviation (VD), associated horizontal strabismus, trauma, noncompliance, or unreliability of the Harms’ tangent screen examination.
Data collection and study design followed the principles of Declaration of Helsinki and were approved by Hospital Ethics Committee.
All patients were examined 1 day preoperatively and 3 months postoperatively, using the alternate prism cover test in five directions of gaze to measure the objective horizontal deviation (HD) and VD. Subjective HD, VD, and CD in nine directions of gaze (each 25°) as well as on 45° head tilt to the right or left shoulder were measured with Harms’ tangent screen with dark red glass in front of the fixating eye for dissociation of binocular vision. The field of binocular single vision is also performed at the Harms’ tangent screen for patients complaining of diplopia.
The amount of head tilt and face turn, which the patient spontaneously adopts while fixating on a distant optotype at eye level, was measured using a Goniometer and documented in degrees.
The operative procedure was performed by O.E. The surgical planning depended on the amount of VD measured in maximum adduction. In all, 26 patients underwent graded inferior oblique recession operation (8–10 mm) in which the anterior one-third of the inferior oblique muscle was reattached to the sclera with a recession of 8 mm if VD in maximal adduction was less than 10°, or 10 mm if VD was 10°–15° (group A).
Twenty-seven patients underwent maximal inferior oblique recession with anterior transposition to the lateral border of the inferior rectus muscle insertion if VD in maximal adduction was more than 15° (group B). This corresponds to a recession of 12 mm combined with an anterior transposition of the inferior oblique for further weakening its vertical function (elevation). The posterior part of the muscle was not sutured to the sclera but left attached to the posterior check ligament.
Statistical analysis was performed using the software package SPSS, version 20 (SPSS Inc., Chicago, Illinois, USA). Normal distribution of the data was tested using the Shapiro–Wilk test. Thereafter, data were compared using the Mann–Whitney U-test and Wilcoxon signed-rank tests for nonparametric data. Correlations were performed using Spearman correlation coefficient (ρ). Univariate and multivariate linear regression analyses were performed. Linear relationship was confirmed when the correlation coefficient r was higher than 0.5 (R2>0.25). The significance level was set at P less than 0.05 for all tests.
For reasons of clarity and easier statistical analysis, all values of left strabismus sursoadductorius are converted as if they were right sided.
| Results|| |
The study included 53 patients, 19 of whom were female and 34 of whom were male. The mean age at the time of operative interference was 40 (SD±17) years. All patients were examined with Harms’ tangent screen preoperatively ([Figure 1]), 1 day postoperatively ([Figure 2]), and 3 months postoperatively ([Figure 3]).
|Figure 1 Preoperative median deviations in nine positions of gaze, assessed using Harms’ tangent screen. Horizontal deviation (HD) is noted in the top left square, vertical deviation (VD) in the top right square, and cyclodeviation (CD) in the bottom square for each direction of gaze. All measurements are in degrees. Median values (range) are given for each gaze direction. For HD, (+) means esodeviation and (−) means exodeviation. For VD, (+) means right hypertropia and (−) means left hypertropia.|
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Preoperatively, the median VD in 25° adduction increased from +9° in group A to +13.5° in group B ([Figure 1]). There was no significant incomitance of the VD on looking upward or downward in adduction, but marked incomitance was noted in horizontal gaze [when moving from the abduction (least) to primary position and then to adduction position (maximum)]. The median subjective CD was small (3°–5°), with no significant incomitance and no difference between the two groups. The V-pattern was 2°–2.5°, respectively, and thus physiologic. One-day postoperative examination and 3-month postoperative examination are illustrated in [Figure 2] and [Figure 3], respectively.
Matched pair analysis shows that the final postoperative values for vertical and torsional deviations were significantly reduced in all groups and in all directions of gaze. However, the HD was nonsignificantly changed.
Three months postoperatively the reduction of VD was maximum in adduction in both groups, increasing from 6° (0.68°/mm) in group A to 10.5° (0.88°/mm) in group B. This effect decreases significantly from 1 day postoperatively to 3 months postoperatively in group A but not in group B in which there is some increase. The incyclorotatory effect was small (median 3°), with no significant difference between groups A and B. The torsional effect also decreases significantly from 1 day to 3 months in both groups in all gaze directions except for the primary position and abduction (not statistically significant).
[Figure 4] shows a strong positive correlation between the preoperative angle of VD in adduction and the operative effect in both groups.
|Figure 4 Relationship between the effect of inferior oblique recession (with or without transposition) 3 months postoperatively on vertical deviation (VD) in adduction and the preoperative VD in adduction (measured using Harms’ tangent screen).|
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A residual VD in adduction of at least 5° was noted in 24% of the patients on Harms’ tangent screen. Only two patients (from group A) and one patient (from group B) were planned to undergo reoperation due to disturbing diplopia. One of them (from group A) had already undergone inferior oblique revision operation. Eleven percent of the patients had a postoperative −VD (overcorrection) in primary position or adduction. Only one patient had a postoperative −5°, which needed reoperation for a contralateral strabismus sursoadductorius. Four patients needed reoperations during a 3-year follow-up period.
The preoperative V-pattern was slightly reduced.
The field of binocular single vision was examined preoperatively and postoperatively in those patients complaining of diplopia (33 patients): 16 patients were from group A and 17 patients were from group B. Preoperatively, most patients had restricted field of binocular single vision (most evident in adduction direction and downgaze). Postoperatively, a marked widening of the field of binocular single vision, especially in the area of useful field of binocular vision was noted in most patients ([Figure 5]).
|Figure 5 Graphic representation of the field of binocular single vision drawn with the Harms’ tangent screen before and 3 months after the operative interference in groups A and B of unilateral strabismus sursoadductorius.|
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The field of binocular single vision of all patients were superimposed as white area (fusion) in grey surrounding (diplopia). The brighter the area, the larger the number of patients (n=) with binocular single vision in this area.
Many studies in the literature have reported the effectiveness of graded inferior oblique muscle recession with or without anterior transposition in the treatment of decompensated cases of congenital superior oblique palsy ,,,,,,,,,,.
Moreover, in our study, the effect of the inferior oblique weakening procedure was most evident in decreasing hypertropia in adduction. Hypertropia in primary position was decreased by half the amount. The incyclorotatory effect was nearly equal in all gaze directions and was not dependant on the amount of inferior oblique muscle’s recession. Therefore, inferior oblique muscle’s anterior transposition weakens the vertical action of the muscle (elevation) to a greater extent without an increased effect on the rotatory action of the muscle (incyclorotation). Inferior oblique muscle’s recession did not affect the horizontal alignment.
Our results for the reduction of VD in adduction correlate well with those of inferior oblique recession of Kolling , Boergen and Müller , and Steffen and Kolling . Bekl  showed less effect on VD with the maximum inferior oblique recession than that achieved in our study. Other studies achieved a higher effect on VD in adduction compared with ours , or in adduction and upgaze .
There was a decrease in the effect on the reduction of VD in adduction from 1 day postoperatively to 3 months postoperatively in group A (without transposition), but not in group B (where there is some increase). This is in contrast to the findings of Metten et al. , who could find an increase in the operative effect on the VD in both groups (with and without anterior transposition).
There was a decrease in the torsional effect in primary position from the first day postoperatively to 3 months postoperatively in both groups A and B. The decrease in this initial overcorrection on torsional deviation in abduction was only proved for group A (not B). This is similar to that found by Metten and colleagues , for the anterior transposition group, also by Mataftsi and colleagues , for the inferior oblique recession group.
The study of combined operation of superior and inferior oblique shows a clearly greater effect on the reduction of the angle of VD in adduction (mean: 15°–23°). However, there is an increased incidence of postoperative Brown syndrome and elevation deficit with diplopia. A complete elimination of the angle of VD is not necessary to relieve all patients’ complaints ,,.
The change in VD and CD depends primarily on the measured preoperative angle of deviation, not on the amount of inferior oblique recession ,,,.
Twenty-four percent of patients had some degree of undercorrection (≥5°). Mostly, they are not symptomatized from the residual angle of VD due to their characteristic large vertical fusional range in this congenital variety of superior oblique palsy. Only three patients were planned for further surgery but two of them did not present again for reoperation. Schmidt et al.  also found that undercorrection into a small residual well-compensated stage gives a satisfying result.
Three patients from group A (not B) had postoperative hypotropia with limited elevation. Only one of them needed reoperation due to contralateral strabismus sursoadductorius. Most patients achieved a reduction in the VD nearly equal to the preoperative VD in adduction. A self-adjusting effect of the operative procedure is due to our technique in which the inferior oblique muscle’s posterior part is not sutured to the sclera. There was no overcorrection or primary position hypotropia in group B (with anterior transposition) as found in other studies ,,,,,. This could be related to our operative technique of suturing the inferior oblique muscle next to the lateral border of inferior rectus muscle insertion (not anterior to it) and suturing the anterior end only.
Comparison between inferior oblique muscle recession and inferior oblique myectomy is difficult because most studies on inferior oblique myectomy used semiquantitative scale for elevation in adduction. Parks stated that recession gives less overcorrections and less undercorrections compared with inferior oblique myectomy . Bahl et al.  conducted a study comparing inferior oblique recession with myectomy in unilateral superior oblique palsy; he found both procedures to be equally effective (in the correction of diplopia and compensatory head posture) except for a higher rate of undercorrection in the recession group, which necessitated reoperation (14.3% of his recession group, which is much higher compared with the percentage in our study).
Graded inferior oblique recession is suitable for mild-to-moderate strabismus sursoadductorius, whereas maximal recession of the inferior oblique muscle (with anterior transposition) is an effective operation in cases of marked strabismus sursoadductorius. Unlike combined operative procedures on the superior and inferior oblique eye muscles, there is no need for general anesthesia in adult patients and no significant postoperative Brown syndrome.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]