The authors report two cases with vertical deviations. The first patient had right exotropia and hypotropia and left inferior oblique overaction and was treated with left inferior oblique muscle weakening and bilateral lateral rectus muscle recession. The second patient had chin-up posture and right dissociated vertical deviation and was treated with bilateral superior oblique posterior tenotomy. [J Pediatr Ophthalmol Strabismus 2014;51:e78–e81.]
From the Department of Ophthalmology, Medical Faculty, Ondokuz Mayis University, Samsun, Turkey (LN); and the Department of Ophthalmology, Medical Faculty, Osmangazi University, Eskisehir, Turkey (HHG, HB).
The authors have no financial or proprietary interest in the materials presented herein.
Correspondence: Leyla Niyaz, MD, Department of Ophthalmology, Medical Faculty, Ondokuz Mayis University, Samsun, Turkey. E-mail:
Received: October 23, 2014
Accepted: October 30, 2014
Posted Online: December 12, 2014
The actions of the superior oblique muscles are incyclorotation, depression, and abduction. The in-cyclorotation is produced by the tendon’s anterior fibers, whereas the posterior fibers mediate depression. Superior oblique posterior tenotomy can weaken the depressor effect without inducing excyclotorsion.1 It is used in the correction of superior oblique overaction in A-pattern strabismus, small vertical deviations, and dissociated vertical deviation (DVD) in association with superior oblique overaction matching a defect in the contralateral eye, and in Brown’s syndrome with a small deviation in the primary position.2–8
In case of superior oblique palsy, the most widely performed corrective procedure is the surgical weakening of the inferior oblique muscle.9 Patients with superior oblique palsy who preferentially fixate with the non-paretic eye present with hypertropia of the paretic eye, whereas patients who fixate with the paretic eye may show hypotropia of the non-paretic eye. If a patient fixates with the paretic eye, the contralateral superior rectus muscle is inhibited and the non-paretic eye will appear hypotropic in the primary position. Prolonged hypotropia of the non-paretic eye may lead to contracture of the inferior rectus muscle of this eye.10
We report one case of hypotropia and one case of DVD, both treated with oblique muscle surgery.
A 12-year-old boy presented to the eye clinic with the complaint of deviation in his right eye for 8 years. He had a history of falling from a swing in his early childhood. Family history was unremarkable. On his ophthalmological examination, the Snellen best-corrected visual acuity was 1/10 in the right eye and 10/10 in the left eye. Cycloplegic refraction was −11.25 −5.75 × 35° in the right eye and −3.0 −1.25 × 140° in the left eye. Anterior segment was normal in both eyes. Fundus examination revealed slight pallor of the optic disc head, wide peripapillary atrophy and retinal pigment epithelial atrophy on the right, and normal fundus on the left. Bilateral excyclotortion was present. He had 30 prism diopters (PD) exotropia and 20 PD hypotropia on the right, V-pattern, and 2+ inferior oblique overaction on the left (Figure 1). A slight inferoplacement of lateral rectus muscles was noted intraoperatively. Bilateral 6.5-mm lateral rectus muscle recession with half tendon superior transposition and left inferior oblique muscle recession were performed. V-pattern exotropia and hypotropia resolved after surgery (Figure 2).
Right exotropia, hypotropia, V-pattern, and left inferior oblique overaction in case 1.
Resolution of V-pattern exotropia and hypotropia after surgery in case 1.
A 15-year-old boy presented to the eye clinic with the complaint of transient superior deviation of the right eye. Family history did not reveal any ocular or systemic pathology. On his ophthalmological examination, Snellen visual acuity was 8/10 in both eyes. Cycloplegic refraction was +0.75 × 110° in the right eye and −0.25 −0.25 × 160° in the left eye. Anterior segment and fundus examinations were normal in both eyes. He had a chin-up posture and revealed 16 PD of DVD on the right on cover test, A-pattern, and bilateral superior oblique overaction (1+ on the right and 3+ on the left) (Figure 3). Bilateral superior oblique 7/8 posterior tenotomy was performed. DVD and head posture resolved after surgery (Figure 4).
Chin-up posture, right dissociated vertical deviation, A-pattern, and bilateral superior oblique overaction in case 2.
Resolution of dissociated vertical deviation and head posture after surgery in case 2.
The first patient had exotropia and left inferior oblique overaction possibly due to the left superior oblique paresis. Because visual acuity was poor in the right eye, the patient preferred to fixate with his left eye. According to the Hering and Sherington principles, left eye elevation and excyclotortion due to inferior oblique overaction led to decreased innervation of the right superior rectus muscle and resulted in greater activity of the right inferior rectus muscle, ending up with right hypotropia and extortion. Left eye inferior oblique muscle weakening and bilateral lateral rectus muscle recession corrected hypotropia and exotropia in the right eye.
Surgical weakening of the inferior oblique muscle is the most widely performed corrective procedure for patients with unilateral or bilateral inferior oblique overaction. Previous studies have reported successful outcomes of inferior oblique weakening with respect to head tilt and associated vertical deviation. However, there are numerous reports of patients with persistent head tilt who require additional surgery. Lau et al. reported 30% significant residual torticollis after inferior oblique weakening surgery for superior oblique palsy.11 Our patient did not have torticollis because the visual acuity in his right eye was low due to high myopia and binocularity was absent. However, left inferior oblique overaction led to right hypotropia, which resolved with the left inferior oblique weakening procedure.
Kishimoto et al. evaluated the usefulness of inferior oblique weakening surgery in the paretic eye of patients with unilateral superior oblique palsy and concluded that inferior oblique weakening in the paretic eye is effective irrespective of the preferred eye for fixation on primary position and head tilt.10 A similar result was observed in our patient. V-pattern exotropia might be linked to the inferoplacement of lateral rectus muscles, which was observed during surgery. Bilateral recession and half tendon superior transposition of lateral rectus muscles in conjunction to the inferior oblique weakening resulted in complete resolution of V-pattern and horizontal deviation. The second patient had asymmetric bilateral superior oblique overaction. A greater amount of superior oblique overaction in the left eye led to left eye intortion and depression, which in turn caused decreased innervation of the right inferior rectus muscle and increased function of right elevators that led to right DVD. In this case, bilateral superior oblique tenotomy was preferred because the patient had a chin-up posture and A-pattern that further supported the evidence of bilateral superior oblique overaction. Bilateral 7/8 posterior tenotomy corrected right DVD, A-pattern, and chin-up posture.
Velez et al. compared three different surgical procedures for DVD and A-pattern strabismus and advised weakening of superior recti in DVD, superior oblique muscles in moderate A-pattern, and all oblique muscles in patients with large A-pattern.7 McCall and Rosenbaum12 described 4 patients with DVD associated with superior oblique overaction who underwent superior oblique posterior tenectomy combined with superior rectus recession surgery. They found that the amount of DVD, A-pattern, and DVD asymmetry was reduced remarkably postoperatively. In our patient, DVD was attributed to the asymmetric superior oblique overaction and we achieved a successful result with only superior oblique tenotomy without superior rectus recession. A-pattern, chin-up posture, and DVD resolved after surgery.
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