Changes in Ocular Excyclotorsion According to Graded Inferior Oblique Recession

PURPOSE: To investigate changes in ocular excyclotorsion in patients with inferior oblique overaction (IOOA) according to amount of correction by graded inferior oblique recession and to compare the amount of excyclotorsion between primary IOOA and secondary IOOA. METHODS: This study included 54 eyes of 54 patients who were diagnosed with unilateral IOOA and underwent graded inferior oblique recession. Fundus photographs were taken pre- and postoperatively. The sum of angles of torsion of both eyes was used to analyze changes in excyclotorsion. The angle of excyclotorsion was analyzed using the ImageJ program. RESULTS: Eighteen eyes were grade 2, 24 eyes were grade 3 and 12 eyes were grade 4. Preoperative angle of excyclotorsion was 16.23 ± 5.96° for the patients with grade 2 eyes, 18.83 ± 5.76° for the patients with grade 3 eyes and 29.00 ± 10.23° for the patients with grade 4 eyes. Therefore, as the degree of IOOA increased, the amount of excyclotorsion became larger. There was no statistical significance between grade 2 and grade 3 (p = 0.467), however, there was a statistically significant difference between grade 3 and grade 4 (p < 0.001). Postoperative angle of excyclotorsion was significantly decreased in each group (grade 2: p = 0.020, grade 3: p < 0.001, grade 4: p = 0.041). The amount of surgical recession of inferior oblique muscle showed a positive correlation with a decrease in the angle of excyclotorsion, but was not statistically significant. The amount of excyclotorsion and the decrease of excyclotorsion after surgery were larger in secondary IOOA than in primary IOOA, but were not statistically significant (p = 0.260). CONCLUSIONS: As the preoperative degree of IOOA increased, the amount of correction of excyclotorsion became larger but there is no statistical significance. Correction of IOOA and excylclotorsion is expected after graded inferior oblique recession.

Clinical Evaluation of Excyclotorsion in Patients with Primary Inferior Oblique Overaction

PURPOSE: To evaluate the amount of excyclotorsion according to degree of inferior oblique overaction (IOOA) in patients with primary IOOA. METHODS: Fifty-nine primary IOOA patients who underwent inferior oblique muscle surgery were evaluated. Visual acuity, ocular movement test, prism cover test, Bielschowsky head tilt test, fundus photograph and photographic examination for excyclotorsion were performed. The correlation analysis was performed for the excyclotorsion according to the amount of IOOA (Control group; IOOA < 1, Group 1; 1 < or = IOOA < 2, Group 2; 2 < or = IOOA < 3, Group 3; 3 < or = IOOA < 4, Group 4; IOOA = 4). RESULTS: Excyclotorsion was 7.37 +/- 2.36degrees in the Control group, 9.29 +/- 3.79degrees in Group 1, 10.04 +/- 4.39degrees in Group 2, 17.98 +/- 4.62degrees in Group 3, and 24.70 +/- 4.61degrees in Group 4. The amount of IOOA and excyclotorsion showed a positive correlation (Pearson's correlation coefficient r = 0.675). Asymmetric IOOA was observed in 35 patients (59.3%) and symmetric IOOA was observed in 24 patients (40.7%). Asymmetric IOOA combined with hypertropia was presented in 9 patients (37.5%) and symmetric IOOA combined with hypertropia was presented in 3 patients (8.6%). Therefore, patients with asymmetric IOOA have a higher incidence of vertical diplopia. The amounts of IOOA and excyclotorsion were greater in primary IOOA with esotropia than in subjects with exotropia (p = 0.001). CONCLUSIONS: The excyclotorsion was proportional to the amount of IOOA in Group 3 and Group 4. The aspect of excyclotorsion was widely distributed in Group 1 and Group 2 compared to that in the Control group.

Surgical Results of Modified Harada-Ito Operation for Excyclotorsion

PURPOSE: We evaluated the efficacy of the modified Harada-Ito operation for excyclotorsion in acquired superior oblique palsy patients after trauma. METHODS: This study represents a retrospective review of 10 eyes in 9 patients who were surgically treated for excyclotorsion. Cyclotorsion was measured with the double maddox-rod test and fundus photographies preoperatively and postoperatively. RESULTS: The median measured change in excyclotorsion before and after the surgery in the primary gaze was reduced from 15.67 +/- 6.00 to 4.78 +/- 3.42 according to fundus photographies and from 12.30 +/- 6.27 to 2.45 +/- 3.73 according to the double maddox-rod test. Subjective and objective changes in excyclotorsion werer not significantly different. CONCLUSIONS: The Modified Harada-Ito operation is an effective treatment for correcting excyclotorsion. Although not statistically significant, the amount of excyclotorsion on fundus photography is exaggerated. This point should be considered to achieve effective surgery.

Analysis of Effect of Inferior Oblique Myectomy in Patients With Inferior Oblique Overaction

PURPOSE: To investigate the effect of inferior oblique (IO) myectomy by analyzing the correlation of the amount of inferior oblique overaction (IOOA), hypertropia and excyclotorsion before, between, and after IO myectomy in patients with various degrees of IOOA. METHODS: A total of 86 eyes from 59 patients with IOOA who underwent IO myectomy were enrolled in the present study. The correlation analysis was performed for the amount of IOOA, hypertropia and excyclotorsion before and after surgery, according to the preoperative amount of IOOA, hypertropia, and excyclotorsion. RESULTS: The IOOA decreased from +2.5 +/- 0.6 before surgery to -0.01 +/- 0.25 (p < 0.05) after surgery. The vertical deviation was 5.7 +/- 6.3 prism diopter (PD) and 2.3 +/- 5.2 PD (p < 0.05) postoperatively. The amount of cyclodeviation was 15.3 +/- 7.6degrees before surgery and 6.6 +/- 5.7degrees (p < 0.05) after surgery. The amount of surgical correction for IOOA and the hypertropia was significantly correlated with preoperative deviation (p < 0.05, p < 0.05). The amount of excyclotorsion before and after surgery was also positively correlated but was not statistically significant (p = 0.05). CONCLUSIONS: IO myectomy can correct any degree of IOOA, hypertropia, and related excyclotorsion.

Surgical Results of Classic Harada-Ito Procedure with Intraoperative Adjustment for Excyclotorsion

PURPOSE: We evaluated the efficacy of classic Harada-Ito procedure with intraoperative adjustment for excyclotorsion. METHODS: This study represents a retrospective review of 22 patients surgically treated for the diagnosis of excyclotorsion with abnormal head posture between January 1995 and August 2001. Head tilt, facial asymmetry, diplopia and excyclotorsion were measured preoperatively and postoperatively. Intraoperative adjustment was made by observing the torsional position of the fundus with indirect ophthalmoscopy. Cyclotropia was measured with the Maddox double-rod test or fundus photography with the eyes in primary and down gaze. RESULTS: Causes of excyclotorsion were congenital (7 patients, 32%), trauma (11 patients, 50%)and idiopathic (4 patients, 18%). Of the 22 patients, 19 patients had a head tilt toward the nonparetic side and the others paretic side. Head tilt was uniformly eliminated in 19 of 22 patients (86%). Six of 22 patients had facial asymmertry. After surgical correction, facial asymmetry gradually disappeared in 2 congenital patients. Preoperatively fourteen of 22 patients had diplopia. Postoperatively, eighth of patients had no diplopia and the others had improved of the symptom except one case. The median measured value change of excyclotorsion before and after the surgery in the primary position was reduced from 7.2+/-5.2degrees to 1.7+/-2.8degrees (76%) and 5.3+/-2.2degrees to 0.4+/-1.1degrees in congenital patients, from 8.9+/- 6.6degrees to 1.5+/-2.6degrees in trauma and from 6.0+/-3.4degrees to 4.3+/-4.2degrees in idiopathic. In downgaze, the median measured value change from 10.9+/-5.3degrees to 2.9+/-3.3degrees (73%) and 7.0+/-3.9degrees to 1.1+/-3.0degrees in congenital patients, from 13.2+/-5.7degrees to 3.2+/-3.0degrees in trauma and from 11.5+/-1.0degrees to 5.0+/-4.1degrees in idiopathic. CONCLUSIONS: Intraoperative adjustable classic Harada-Ito procedure was an effective treatment in correcting head tilt, facial asymmetry and diplopia.

Two Cases of Correction of Excyclotorsion Remained after Harada-Ito Procedure

Authors performed horizontal transposition of superior and inferior rectus muscle in 3.0 mm, to eliminate excyclotorsion of the 5 degrees which remained after Harada-Ito procedure in two patients with superior oblique palsy. The medial and lateral edges of the proximal part of tendon were reattached at the temporally and the inferior retus nasally. This operation was performed 3 or 4 months ater Harada-Ito procedure in 2 patients, respectively. The amount of horizontal transposition was made according the degree of excyclotorsion measured by double maddox rod test. The results showed no cyclotorsion at head tilt to the right and double maddox rod test. In conclusion, the horizontal transposition of vertical rectus muscles is effective in the elimination of excyclotorsion remained after Harada-Ito procedure for superior oblique palsy.

Clinical Feature and Diagnosis in Masked Bilateral Superior Oblique Palsy

The preoperative diagnosis of the masked bilateral superior oblique palsy (SOP) is very diffcult, so the clinical manifestation is very important. We studied to determine diagonostic criteria of the masked bilateral SOP. Among 24 patients. who were diagnosed as unilateral SOP preoperatively, 5 patients developed postoperative masked bilateral SOP. 2 patients had been diagnosed masked bilateral SOP preoperatively. We compared 17 cases of unilateral SOP with seven cases of masked bilateral SOP about V-shift, head tilt test and the degree of excyclotorsion. The mean V-shift of the masked SOP patients was 5.3PD and that of the unilateral SOP patients was 1.5PD(p=0.09). The mean excyclotosion difference between the primary position and downgaze was 9.7 degree in masked cases and 2.6 degree in unilateral ones respectively (p=0.35). The mean difference of hyperdeviation the right versus the left tilted head position was 22PD in masked cases and 18.1PD in unilateral ones (p=0.35). The cases of excyclotorsion difference over 5 degrees between primary and downgaze were five(71%) in masked cases but none in unilateral cases(p=0.0001). So above finding may be strongly suggested as diagnosing the masked bilteral SOP.