How Successful is Combined Superior and Inferior Oblique Muscle Surgery in Young Children with Superior Oblique Underaction Presenting in Infancy with a Severe Head Tilt?

BACKGROUND/OBJECTIVE: To evaluate the success of combining ipsilateral inferior and superior oblique muscle surgery in young children with congenital unilateral superior oblique under action who present in infancy with a large socially noticeable head-tilt. METHODS: A consecutive retrospective case series of young children was analysed. The success of surgery in eliminating the head-tilt was evaluated by pre- and post-operative ocular motility assessment focusing on the vertical misalignment in primary position and downgaze, the magnitude of the head-tilt in degrees and the status of the superior oblique tendon. RESULTS: Five children had a mean age at first surgery of 41 (range 25-63) months, a mean primary position vertical deviation of 26 (25-30) prism dioptres, a head-tilt of 30 (20-35) degrees and a mean post-operative follow up of 24 (8-43) months. While there was a uniform surgical plan, nonetheless each operation required individualisation based on a spectrum of per-operative superior oblique tendon findings. The head tilt was eliminated in 40% and reduced in the remainder, to a mean of 7 (0-18) degrees and with a mean post-operative primary position vertical misalignment of 3 (range 0-10) and of 10 (range 0-40) prism dioptres in downgaze. CONCLUSION: Combined, ipsilateral oblique muscle surgery reduced the severe head tilt and primary position alignment to a psychosocially and functionally acceptable level. For the majority, the outcome was stable or associated with further decremental improvement. A persistent downgaze vertical tropia occurred in children with macroscopically abnormal superior oblique tendons but these cases were not identifiable clinically pre-operatively.

A Post-Surgical Stereovision Surprise in an Adult With an Exotropia Since Infancy Previously Managed, at Two Years With Surgery.

AIM: To describe an unexpected sensory outcome in an adult male who is seeking ocular re-alignment for a psychosocially symptomatic large non-specific exotropia with suppression. The primary diagnosis was infant onset exodeviation of unclear diagnosis, was managed with bilateral strabismus surgery at two years of age, little memory of follow-up. RESULT: Measurable binocular single vision (BSV) was demonstrable following surgery at 17 years of age, albeit slowly between two weeks and six months postoperatively and subsequently enhanced. His newly acquired sub-optimal BSV led to symptomatic occupation-associated asthenopia. Following two subsequent operations over a 15-year period, he has stable, symptom-free ocular realignment within three prism diopters of orthophoria and performing tasks that require extended periods of near-vision activity. CONCLUSION: Delayed high levels of stereovision were unexpectedly achieved in an adult with infant onset exotropia with pre-operative sensory suppression that was surgically aligned to near orthophoria. The re-establishment of BSV in such a clinical scenario has to attain a level that is robust enough to meet an individual's social and occupational needs.