Decompensated Superior Oblique Palsy Secondary to Bilateral Nutritional Optic Neuropathy Following Bariatric Surgery

Optic neuropathy can occur secondary to nutritional deficiencies in patients who have undergone bariatric surgery. We present a unique case of a 39-year-old man, claiming to be generally healthy, who presented with intermittent vertical diplopia and bilateral decreased vision in each eye. Visual acuity was 6/18 in the right eye and 6/12 in the left eye. Ishihara testing was defective for both eyes. Automated visual fields showed a severe generalized reduction in sensitivity in both eyes. The patient had a left head tilt and a right intermittent hypertropia of 30 prism diopters in primary position. CT of the orbits revealed a right superior oblique of small caliber. On further questioning, the patient admitted to a history of bariatric surgery 7 years prior to presentation with failure to take any nutritional supplements. Blood work demonstrated deficiencies in folate, thiamine, and copper. Within 6 months of initiating nutritional supplements, the vision in each eye was markedly improved and the diplopia resolved. There was an associated normalization of thiamine and copper, but folate levels remained low. We believe that the nutritional deficiency caused a bilateral optic neuropathy and the resulting vision loss precipitated a manifestation of a congenital superior oblique palsy that had previously just been a phoria. The case emphasizes the importance of considering occult sensory etiologies of acquired strabismus.

Clinical Features of Excyclotorsion in the Non-Paretic Eye of Patients with Congenital Unilateral Superior Oblique Palsy

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).MethodsA retrospective review of medical charts was performed. The patients were divided into the accordance (ocular excyclotorsion in the paretic eye) and discordance (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.ResultsNinety-eight patients were included in this study. There were 70 (71.4%) and 28 patients (28.6%) in the accordance and discordance groups. Sixteen patients (22.9%) in the accordance group and 12 patients (42.9%) in the discordance 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 discordance groups (p < 0.01). The postoperative degree of excyclotorsion in the accordance group (0.14 ± 0.39) was lower than that in the discordance group (0.28 ± 0.71) (p = 0.01). The residual postoperative excyclotorsion (>1) in the discordance group were observed in the discordance group (14 patients, 50%) and accordance group (16 patients, 22.9%) (p = 0.01).Conclusion Preoperative discordance 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.

Effectiveness of Inferior Oblique Myectomy in Unilateral Superior Oblique Palsy Depending on Magnitude of Hyperdeviation

Purpose: To evaluate surgical outcome and effectiveness of inferior oblique (IO) myectomy on unilateral superior oblique palsy (SOP) as a primary treatment.Methods: This study is a retrospective review of the medical records of 99 patients who had undergone IO myectomy due to SOP as a first-line treatment. Sixty-five patients with hyperdeviation of 15 prism diopters (PD) or less were categorized into group 1, 22 patients with hyperdeviation between 16 PD to 20 PD into group 2, and 12 patients with hyperdeviation higher than 20 PD into group 3. Preoperative hyperdeviation, postoperative hyperdeviation, and improvement of head tilting were then compared between the 3 groups. Surgery was determined to be successful when the post-op residual hyperdeviation is less than 5 PD, or when the improvement of hyperdeviation and head tilting was noted, for the patients who had preoperative deviation less than 5 PD, and without hypercorrection.Results: All groups showed significant improvement of hyperdeviation, and the amount of correction was larger in group with larger preoperative hyperdeviation. 80.3%, 95.0%, and 90.9% of patients showed improvement of head tiling and success rate was 87.7%, 77.3%, and 50.0% in group 1, 2, and 3 respectively. Group 1 and 2, group 2 and 3 had no significant difference in success rate but only group 1 and 3 had significant difference.Conclusions: Considering success rate with improvement of head position, self-titrating and possibility of overcorrection, IO myectomy could be an effective option as a first-line surgical treatment for unilateral SOP with hyperdeviation of 20 PD or less. However, due to a 50% success rate in patients with hyperdeviation larger than 20 PD, a secondary operation must be considered following IO myectomy, or a two-muscle procedure must be considered as a primary treatment.

Clinical Features of Excyclotorsion In The Non-Paretic Eye of Patients With Congenital Unilateral Superior Oblique Palsy

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). A retrospective review of medical charts was performed. The patients were divided into the accordance (preoperative fundus ocular excyclotorsion in the paretic eye) and discordance (preoperative 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 at each visit. Ninety-eight patients were included in this study. There were 70 (71.4%) and 28 patients (28.6%) in the accordance and discordance groups, respectively. The mean age in the accordance and discordance groups was 9.2 ± 12.7 and 7.5 ± 8.9 years, respectively. Sixteen patients (22.9%) in the accordance group and 12 patients (42.9%) in the discordance group were aged under 2 years (p=0.04). A fixation preference for the paretic eye was observed in two (2.9%) and eight (28.6%) patients in the accordance and discordance groups, respectively (p < 0.01). The accordance group (2.3 ± 0.67) demonstrated a significantly higher degree of excyclotorsion than the discordance group (1.9 ± 0.64) (p = 0.03). The postoperative degree of excyclotorsion in the accordance group (0.14 ± 0.39) was lower than that in the discordance group (0.28 ± 0.71) (p = 0.01). The prevalence of residual postoperative excyclotorsion (>1) in the discordance group was significantly higher (14 patients, 50%) than that in the accordance group (16 patients, 22.9%) (p = 0.01).Twenty-eight percent of the patients with congenital USOP demonstrated excyclotorsion in the non-paretic eye. Preoperative discordance 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 significantly lower in the accordance group.

A single inferior rectus muscle surgery for treatment of congenital superior oblique palsy with small deviation in primary position

Purpose: To evaluate outcomes of one muscle surgery for treatment of congenital superior oblique palsy (SOP) with Knapp Class V. Methods: Medical records were retrospectively reviewed for the patients with the congenital SOP type V who underwent surgical treatment through one muscle surgery between July 2015 and September 2020. The surgical procedure was resection-recession on the contralateral inferior rectus muscle of the hypertrophic or paretic eye. Vertical alignment at nine cardinal gaze positions, and resolution of the abnormal head posture were evaluated pre- and postoperatively. The follow-up was scheduled regularly at postoperative day 1, 1 week, 1 month, and followed by 2-month intervals until 18 months. Results: Twelve patients were included in this study, with a mean age of 6.4 years (range from 3 to 10 years). The mean follow-up period was 10.5 months after surgery (range from 6 to 18 months). The average vertical deviation at primary position was 6.33△ ± 2.93△ preoperatively and 0.75△ ± 1.14△ postoperatively ( p < 0.05). The average vertical deviation at downgaze was 23.33△ ± 4.75△ preoperatively and 1.92△ ± 1.62△ postoperatively ( p < 0.05). All patients had an abnormal head position preoperatively. Postoperative results indicated that the patients’ abnormal head position had been improved significantly. Conclusions: The surgical procedure of resection-recession on a single inferior rectus muscle is a successful intervention for the correction of superior oblique palsy (SOP) with Knapp Class V.