Analysis of Results of Analysis of Results of Various Surgeries on Various Surgeries on the Superior Obliquethe Superior Oblique

KOWAL LKOWAL L

MAHINDRAKAR AMAHINDRAKAR A

RVEEH, MELBOURNERVEEH, MELBOURNE

PreamblePreamble

Superior oblique surgeries are infrequent Superior oblique surgeries are infrequent in Anglo-American strabismus in Anglo-American strabismus

Reputation for being difficult and prone Reputation for being difficult and prone to complicationsto complications

AIM: To examine the results of various AIM: To examine the results of various superior oblique surgeries (single superior oblique surgeries (single surgeon)surgeon)

MethodsMethods

Records of 28 patients who had Records of 28 patients who had SO surgeries* and who were seen SO surgeries* and who were seen between 2004 -08 were between 2004 -08 were analysedanalysed

*some had their surgeries outside this period*some had their surgeries outside this period

Diagnostic groupsDiagnostic groups

1. Superior oblique 1. Superior oblique paresis / palsy paresis / palsy SOPSOP

2. Hypotropia2. Hypotropia3. Brown’s3. Brown’s4. A pattern4. A pattern

Typical Pre-op caseTypical Pre-op case

RIO +, RSO -, RIR -RIO +, RSO -, RIR -

SOPSOP

Full tendon width strengthening operationFull tendon width strengthening operation considered if:considered if:

1.1. Intra- op FDT shows significant unequivocal Intra- op FDT shows significant unequivocal floppiness [‘..just keeps going’]floppiness [‘..just keeps going’]

2.2. Usually: Coronal scan shows atrophyUsually: Coronal scan shows atrophy

Usual operation: Usual operation: advancement / plication @ advancement / plication @ insertion till mild Brown’s createdinsertion till mild Brown’s created [can [can elevate 6 o’clock limbus ~3mm above the elevate 6 o’clock limbus ~3mm above the intercanthal horizon]intercanthal horizon]

Results – 4 pts with Results – 4 pts with SO plicationSO plication 2 unilateral cong. SOP2 unilateral cong. SOP

1 bilateral cong. SOP1 bilateral cong. SOP

1 bilateral acquired SOP due to 1 bilateral acquired SOP due to post. fossa lesionpost. fossa lesion

Unilateral Cong. SOP Unilateral Cong. SOP n=2 n=2 Both had SO plication and Parks’ IO recessBoth had SO plication and Parks’ IO recess

One required re-plication One required re-plication

Both have improved AHP 3 yrs later Both have improved AHP 3 yrs later

One has good ROSV with 100” stereoOne has good ROSV with 100” stereo

Bilateral cong SOPBilateral cong SOP n=1 n=1 Bilateral SO plicationBilateral SO plication Has large ROSV at 1 year Has large ROSV at 1 year Torsion corrected from 10Torsion corrected from 10° °

excyclo to < 5° incycloexcyclo to < 5° incyclo Minimal residual hypertropia in Minimal residual hypertropia in

R gaze (pre-op 20R gaze (pre-op 20∆)∆); none in L ; none in L gaze (pre-op 12gaze (pre-op 12∆)∆)

Bilateral SOP 2ary to Bilateral SOP 2ary to post. fossa lesion post. fossa lesion n=1n=1

Unilateral plication + bilateral IO Unilateral plication + bilateral IO recession + vertical R-R OU [!]recession + vertical R-R OU [!]

13 years follow-up: good ROSV13 years follow-up: good ROSV

SO plication corrected 10SO plication corrected 10° of ° of excyclotorsion (8° residual)excyclotorsion (8° residual)

Plication for SOPPlication for SOP

In selected cases, In selected cases, a reliable and a reliable and safe operationsafe operation

Diagnostic groupsDiagnostic groups

1. Superior oblique 1. Superior oblique paresis / palsy SOPparesis / palsy SOP

2. Hypotropia2. Hypotropia3. Brown’s3. Brown’s4. A pattern4. A pattern

HypotropiaHypotropian=4 1-2y follow-upn=4 1-2y follow-up

n = 2n = 2 TenotomyTenotomy

corrected hypo (7corrected hypo (7∆ and 15∆)∆ and 15∆)

improved A pattern from 25 to improved A pattern from 25 to

12 ∆ in one pt.12 ∆ in one pt.

HypotropiaHypotropian=4 1-2y follow-upn=4 1-2y follow-upn =2:n =2: Recession – [posterior] transposition Recession – [posterior] transposition to 13mm from to 13mm from

limbus & 2mm nasal to SR (Souza Dias)limbus & 2mm nasal to SR (Souza Dias)

corrected hypo (15 and 14∆) corrected hypo (15 and 14∆) improved A pattern from 25 ∆ to < 5∆improved A pattern from 25 ∆ to < 5∆

Diagnostic groupsDiagnostic groups

1. Superior oblique 1. Superior oblique paresis / palsy SOPparesis / palsy SOP

2. Hypotropia2. Hypotropia3. Brown’s3. Brown’s4. A pattern4. A pattern

Results - Brown’sResults - Brown’s

6 patients 6 patients

Spacer, Tenotomy, RecessionSpacer, Tenotomy, Recession

1-2 years follow-up1-2 years follow-up

Results - Brown’sResults - Brown’s

Spacer Spacer →→ no improvementno improvement (1 pt.) (1 pt.)

FDT was negativeFDT was negative

SO tenotomy + IO recession SO tenotomy + IO recession →→ no no improvementimprovement (1 pt.) (1 pt.)

SO tenotomy + IO Rc + LR RcSO tenotomy + IO Rc + LR Rc → → Good range of movement (1pt.)Good range of movement (1pt.)

Results - Brown’sResults - Brown’s

SO tenotomy + IO rec. + other SR SO tenotomy + IO rec. + other SR faden faden → improved appearance → improved appearance (1 pt.)(1 pt.)

SO spacer (later removed) + IO rec. SO spacer (later removed) + IO rec. + other SR faden → No AHP; large + other SR faden → No AHP; large ROSV ROSV (1 pt.)(1 pt.)

SO recession ~12mm SO recession ~12mm →→ corrected corrected AHP AHP (1 pt.)(1 pt.)

Brown’sBrown’s

These results are not as good as These results are not as good as published seriespublished series

Pathology may varyPathology may vary 2ary effects [eg tight verticals] 2ary effects [eg tight verticals]

may come to dominate the may come to dominate the clinical picture and obscure the clinical picture and obscure the original pathologyoriginal pathology

Diagnostic groupsDiagnostic groups

1. Superior oblique 1. Superior oblique paresis / palsy SOPparesis / palsy SOP

2. Hypotropia2. Hypotropia3. Brown’s3. Brown’s4. A pattern4. A pattern

A pattern n=14A pattern n=14

10 : 10 : Partial tendon weakening operationPartial tendon weakening operation : bilateral SO posterior tenectomy [SOPT] : bilateral SO posterior tenectomy [SOPT]

4 : 4 : full tendon width weakening full tendon width weakening operationoperation

1 full tendon width tenotomy1 full tendon width tenotomy1 spacer1 spacer2 recession – transposition2 recession – transposition

1-3 y follow-up1-3 y follow-up

Posterior tenectomy Posterior tenectomy SOSO

Posterior tenectomyPosterior tenectomy

NOTE: WIDE SCATTER OF RESULTS

From Souza Dias & Praeto Diaz

Posterior tenectomyPosterior tenectomy

NOTE: WIDE SCATTER OF RESULTS

From Souza Dias & Praeto Diaz

SO Post. Tenectomy SO Post. Tenectomy n=10n=10

1-4 years follow-up1-4 years follow-up

2/102/10 patients improved patients improved completely completely

Max. correction 20 Max. correction 20 ∆∆

SO Post. tenectomySO Post. tenectomy

3/103/10 patients had partial patients had partial correctioncorrection

Improvement varied from 10 – 12 Improvement varied from 10 – 12 ∆∆

5/10 had partial or complete 5/10 had partial or complete correctioncorrection

SO Post. tenectomySO Post. tenectomy

3 patients had 3 patients had nono improvementimprovement

2 patients : A pattern 2 patients : A pattern worseworse

‘‘A’ pattern – complete A’ pattern – complete tenotomy tenotomy n=1n=1

2 years follow-up2 years follow-up

‘‘A’ pattern improved from 25 A’ pattern improved from 25 ∆ ∆ to 12 ∆to 12 ∆

Also corrected hypotropia of 7 ∆Also corrected hypotropia of 7 ∆

‘‘A’ Pattern – SO spacer A’ Pattern – SO spacer n=1 n=1

1 year follow-up1 year follow-up

AHP resolvedAHP resolved

‘‘A’ Pattern A’ Pattern Recession – Recession – Transposition n=2Transposition n=2

One had correction of 70 One had correction of 70 ∆ !!∆ !!

One had improvement in ‘A’ One had improvement in ‘A’ from 25 ∆ to < 5 ∆ + correction from 25 ∆ to < 5 ∆ + correction of 14 ∆ hypoof 14 ∆ hypo

Recession - Recession - transpositiontransposition

FAIRLY TIGHT RESULTS

SO surgeriesSO surgeries

One abandoned as no tendon One abandoned as no tendon was foundwas found

ComplicationsComplications

One spacer: chronic One spacer: chronic inflammation and inflammation and recurrence of Brown’s recurrence of Brown’s after temporary after temporary improvementimprovement

No lid problemsNo lid problems

ConclusionsConclusions

Palsy → plication reliable [if well Palsy → plication reliable [if well selected] selected]

Hypotropia → good results from Hypotropia → good results from tenotomy, recess / transposetenotomy, recess / transpose

‘‘A’ pattern → Full tendon width A’ pattern → Full tendon width procedure better than PTSOprocedure better than PTSO

PTSO PTSO → not reliable for ‘A’ pattern → not reliable for ‘A’ pattern [but will not ‘bite’ you] [but will not ‘bite’ you]

Brown’s Brown’s → mixed results→ mixed results

Pre-op (Centofanti Pre-op (Centofanti Rec- trans)Rec- trans)

Pre-op (dula – Pre-op (dula – tenotomy)tenotomy)

Pre-op (dula Pre-op (dula tenotomy) tenotomy)