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

The Effects of Modified Graded Recession, Anteriorization and Myectomy of Inferior Oblique Muscles on Superior Oblique Muscle Palsy.

BACKGROUND: The aim was to investigate the effect of inferior oblique (IO) operation (IO myectomy or graded recession and anteriorization) for unilateral and bilateral superior oblique muscle palsy (SOP); Methods: A total of 167 eyes undergoing IO surgery by a single surgeon between 2008 and 2015 were retrospectively reviewed. The method for treating symmetric bilateral SOP was bilateral IO myectomy (n = 102) and the method for treating unilateral SOP or non-symmetric bilateral SOP was IO-graded recession and anteriorization (n = 65). Associated clinical results and other factors were analyzed; Results: Head tilt, vertical deviation, IO overaction, SO underaction degree and ocular torsion angle were all clearly changed, but there was no statistically significance between these two procedures. Mean preoperative torsional angle was 15.3 ± 6.4 degree, which decreased to 5.3 ± 2.7 degree after surgery. Preoperative torsional angle, IOOA and SOUA degree were all significantly affected in postoperative torsional angle (p = 0.025, 0.003 and 0.038). Horizontal rectus muscle and IO muscle operation did not interfere with each other's results (p = 0.98); Conclusions: Symmetric bilateral SOP could be treated with bilateral IO myectomy and IO-graded recession and anteriorization should be reserved for unilateral SOP or non-symmetric bilateral SOP.

A Rare Case of Cyclotorsion Due to Medial Rectus Displacement Following Orbital Trauma.

We describe a rare case of cyclotorsion likely secondary to medial rectus and inferior rectus pathology in a patient with orbital trauma. Sequential orthoptic measurements including Hess charts are presented alongside relevant sections of the orbital CT scans over the course of the patient's treatment. Following the insertion of a plate to repair an orbital floor fracture, the patient developed cyclotorsion. A combined approach of sequential orthoptic assessment and imaging revealed the likely underlying mechanism. Inferior rectus mechanical restriction combined with displacement of the medial rectus pulley appear to be the likely culprits. Once the orbital plate was exchanged for a smaller sized plate the patient's symptoms and clinical features resolved. Although orbital plate malpositioning is not an uncommon event, medial rectus deviation as a cause of cyclotorsion has not previously been described. We discuss the alternative differentials for patients with similar orthoptic findings and how they were excluded.

Influence of eye dominance on objective and subjective excyclotorsion in unilateral superior oblique muscle palsy: objective cyclotorsion measured by fundus photography.

PURPOSE: To study the effect of eye dominance on excyclotorsion in unilateral superior oblique palsy (USOP). STUDY DESIGN: Retrospective clinical study METHODS: Objective excyclotorsion was measured as the disc-to-fovea angle by fundus photography OU. Subjective excyclotorsion was determined with a major amblyoscope based on the difference in the earth vertical and subjective visual vertical. Eye dominance was determined by the hole-in-the-card method. A p-value ≤ 0.05 was considered statistically significant. SUBJECTS: Data of 24 USOP patients were retrospectively collected. The diagnosis was mainly made by the Parks 3-step method, history and the presence of characteristic excyclotorsion. When possible, orbital magnetic resonance imaging findings were obtained. RESULTS: The median angle of objective excyclotorsion in the paretic eyes was significantly larger than in the nonparetic eyes. Both median angles of objective/subjective excyclotorsion in the dominant eye were significantly smaller than those of the non-dominant eye. Patients were subdivided into two groups: group A, those whose paretic eye was the dominant eye (n = 13); group B, those whose paretic eye was the non-dominant eye (n = 11). The objective/subjective excyclotorsional angles of the paretic eye were significantly larger than of the non-paretic eye only in group B. CONCLUSION: In USOP the angle of excyclotorsion in the dominant eye is smaller than in the non-dominant eye. This may imply that the vertical sense of visual space is mainly adapted to the dominant eye, keeping the subjective vertical close to the earth vertical.

Two cases of acquired bilateral trochlea nerve palsy treated by simultaneous inferior rectus muscle nasal transposition and inferior oblique muscle myectomy.

PURPOSE: To report two cases of acquired bilateral trochlea nerve palsy with large torsional deviation successfully treated by simultaneous bilateral inferior rectus muscle (IR) nasal transposition and inferior oblique muscle (IO) myectomy. OBSERVATIONS: Case 1 was of a 54-year-old man with torsional diplopia after a traffic accident. He showed 32° and 38° excyclotorsion in the primary and downward gazes, respectively. Case 2 was of a 56-year-old woman with torsional diplopia after a brain tumor operation. She showed 25° and 33° excyclotorsion in the primary and downward gazes, respectively. We simultaneously performed bilateral IR nasal transposition and IO myectomy in these two cases. Postoperatively, case 1 presented with improved excyclotorsion, with 2° and 7° excyclotorsion in the primary and downward gazes, respectively; case 2 similarly presented with improved excyclotorsion, with 4° and 12° excyclotorsion in the primary and downward gazes, respectively. CONCLUSIONS AND IMPORTANCE: Simultaneous bilateral IR nasal transposition and IO myectomy are effective for treating large-angle torsional deviations, especially in downward gaze, requiring only one operation. A new surgical approach is suggested for the successful treatment of large torsional deviations, requiring only one operation.

Effect of unilateral inferior oblique weakening on fundus torsion in bilateral eyes of children with congenital superior oblique palsy.

AIM: To study the change of torsion in both eyes after unilateral inferior oblique (IO) weakening on children with congenital superior oblique palsy (SOP). METHODS: This retrospective study enrolled all patients diagnosed with unilateral congenital superior oblique palsy (UCSOP) accompanied by inferior oblique overaction (IOOA). A total of 120 eyes of 60 patients were divided into group 1 (more extorted paretic eye) and group 2 (more extorted nonparetic eye). The degree of fundus torsion was evaluated before and 1mo after the IO weakening procedure. The torsion of the fundus was recorded by measuring the disk-foveal angle (DFA) using fundus photography. RESULTS: Group 1 included 26 cases and group 2 included 34 cases, thus the rate of extorsion was insignificantly higher in the nonparetic eye (P=0.10). The preoperative DFA in the paretic and nonparetic eyes was 13.21±5.95, 7.97±4.25 in group 1, and 4.65±3.79, 13.16±5.35 in group 2 (both P<0.001). The postoperative DFA in the paretic and nonparetic eyes was 8.57±4.87, 7.32±4.27 in group 1 (P=0.24), and 3.85±6.00 and 9.94±5.45 in group 2 (P<0.001). The amount of postoperative reduction of the DFA in the paretic and nonparetic eyes was 4.64±3.90, 0.65±0.76 in group 1 (P=0.002), and 0.80±0.81, 3.21±5.50 in group 2 (P=0.01). The difference in the amount of reduction of DFA in the more extorted eye in group 1 (paretic eye) vs group 2 (nonparetic eye) was insignificant (P=0.30). CONCLUSION: Excyclotorsion in the nonparetic eye has a similar probability in the paretic eye in UCSOP children, and weakening of the ipsilateral IO has a more obvious effect on the decrement of extorsion in the more extorted eye regardless of which eye is paretic.

Comparison of excyclotorsion following graded inferior oblique recession for primary versus secondary inferior oblique overaction.

AIM: To compare the changes in excyclotorsion after inferior oblique (IO) recession in patients with primary and secondary inferior oblique overaction (IOOA). METHODS: We retrospectively analyzed the data obtained from patients with IOOA who underwent graded IO recession. The patients were followed up for at least 3mo after surgery. Fundus photographs were taken pre- and postoperatively, and the sum of the angles of torsion in both eyes was used to analyze changes in excyclotorsion. Patients were divided into two groups: those diagnosed with primary IOOA were enrolled in the 1'IOOA group, and those diagnosed with secondary IOOA caused by superior oblique palsy (SOP) were enrolled in the 2'IOOA group. Excyclotorsion before and after surgery were compared between the two groups. RESULTS: A total of 78 patients were enrolled in this study: 34 eyes in the 1'IOOA group and 44 eyes in the 2'IOOA group. In the 78 patients, torsional angle significantly decreased from 15.31°±7.40° to 12.11°±6.53° after IO recession (P<0.001). Mean preoperative torsional angle was larger in the 2'IOOA group than in the 1'IOOA group (P=0.03). In both groups, excyclotorsion significantly decreased after IO recession (P=0.001 and P<0.001, respectively); however, there was no significant difference in the amounts of changes in excyclotorsion between the two groups. CONCLUSION: Excyclotorsion is significantly larger in secondary IOOA than in primary IOOA, and a significant decrease in the torsional angle occurs after IO recession in both types of IOOA.

Modified Anterior Superior Oblique Tuck: A Case Series.

PURPOSE: Selection of the ideal procedure to correct symptomatic excyclotropia depends on several factors including the degree of torsion and associated vertical, horizontal and pattern deviation. Selective tuck of the anterior temporal torsional fibers of the superior oblique (SO) tendon is an alternative procedure to the classical Harada-Ito. The purpose of this study is to report its stability and results. METHODS: Retrospective review of all consecutive patients with symptomatic excyclotorsion of at least 5º (degrees) treated by selectively splitting and tucking the anterior temporal fibers of the SO tendon. Torsion in primary position was measured using the double Maddox Rods. Patients with additional symptomatic vertical or horizontal diplopia underwent simultaneous surgery on other extraocular muscles. RESULTS: Five patients were studied. Mean age was 60 ± 8 years (47-67). Mean postoperative follow-up was 10 ± 8 months (3-21). The mean preoperative torsion of 11º±4º (7º-15º) significantly decreased to 3º±2º (p = .03) at the first postoperative visit (16 ± 9 days) and 3 ± 2º during the last visit (P = .03). The procedure corrected 1.4º±0.9º per mm of tuck. Postoperatively no patient complained of torsion. No undesirable vertical or horizontal deviations were noted. CONCLUSION: This technique is a simple alternative to manage symptomatic excyclotorsion, with significant and stable relief of moderate amounts of torsion and without inducing unexpected vertical or horizontal deviation.

Bilateral Fundus Excyclotorsion in Unilateral Superior Oblique Palsy Confirmed by MR Imaging.

PURPOSE: To determine whether bilateral fundus excyclotorsion is helpful in distinguishing bilateral superior oblique palsy (SOP) from unilateral SOP by investigating bilateral fundus excyclotorsion in unilateral SOP and comparing the features with bilateral SOP using fundus photographs. METHODS: This retrospective cohort study included a total of 212 subjects who were diagnosed with unilateral SOP with hypoplasia of a single superior oblique (SO) muscle and 7 subjects with clinically diagnosed bilateral SOP. Fundus excyclotorsion angles using modified fovea-disc angles, inter-eye differences in cyclotorsion angles (the difference in fundus excyclotorsion angles: (paretic eye (or hypertropic eye in primary gaze)-fellow eye)), and subjective torsion were compared between groups of unilateral SOP with bilateral fundus excyclotorsion (SOPBE) and bilateral SOP. RESULTS: Bilateral fundus excyclotorsion was found in 18 out of 212 patients (8.5%) in the unilateral SOP group, and 7 out of 7 patients (100%) in the bilateral SOP group. Among the 25 patients with bilateral fundus excyclotorsion, the mean angle of excyclotorsion and the inter-eye differences were not significantly different between the unilateral SOPBE and bilateral SOP groups (mean angle of excyclotorsion in paretic eye, or hypertropic eye in the primary position, 5.7° ± 4.7° vs. 7.6° ± 4.3°, p = 0.125; the inter-eye differences, 0.7° ± 3.6° vs 0.5° ± 5.8°, p = 0.615). The degree of subjective excyclotorsion was significantly larger in the bilateral SOP group compared with the unilateral SOPBE group (16.0 ± 5.5 vs 4.6 ± 4.3, p = 0.002). CONCLUSION: Bilateral fundus excyclotorsion was demonstrated not only in bilateral SOP, but also in unilateral SOP at a rate of 8.5%. Bilateral fundus excyclotorsion alone did not prove to be a specific sign in distinguishing bilateral SOP from unilateral SOP.

Clinical measurements of normative subjective cyclotorsion and cyclofusion in a healthy adult population.

PURPOSE: To investigate normative subjective cyclotorsion values and cyclofusion ranges in a healthy adult population. METHODS: A cross-sectional investigation was performed in 120 healthy, non-strabismic adults, 60 men and 60 women in the age range of 18-69 years. All subjects were assessed for cyclotorsion using the synoptophore and the single Maddox rod (SMR) methods. Cyclofusion was investigated with the synoptophore in 60 of the subjects. RESULTS: All age groups showed low values of subjective torsion, mainly excyclotorsion with mean values of -1 degree for both methods. Reference ranges of cyclotorsion were between -0.7 and -1.5 degrees for the SMR method and between -0.7 and -1.4 degrees using the synoptophore method. There were no significant differences between gender (p = 0.48), but the effect of age was significant for both methods (p = 0.026) demonstrating a slight increase in excyclotorsion with age. Cyclofusion showed a total mean amplitude of 16 degrees, the fusion range was +7 degrees of incyclotorsion to -9 degrees of excyclotorsion. CONCLUSIONS: Subjective reference ranges for cyclotorsion and cyclofusion reveal that low values of torsion are to be expected upon clinical investigation in non-strabismic adult individuals. Values outside of the reference range may be indicators of possible binocular abnormalities or physiological variations. The cyclotorsional measurements and prevalence in this adult population group can be regarded as normative data in clinical settings.

Clinical characteristics according to the laterality of ocular torsion in unilateral superior oblique palsy.

BACKGROUND: To compare clinical characteristics according to the laterality of objective ocular torsion in patients with unilateral superior oblique palsy (SOP). METHODS: This retrospective study included all patients with a diagnosis of unilateral SOP. They were classified into subgroups according to correspondence between the paretic eye and the extorted eye using fundus photography. Ocular alignment and muscle action were tested by the prism and alternate cover tests and 4-scale movement measure. Various clinical factors, including the amount of preoperative ocular torsion and change in ocular torsion postoperative, were compared between the accordance and disaccordance groups. RESULTS: A total of 70 Asian patients (140 eyes) were included and underwent fundus photography preoperatively. Excyclotorsion in the paretic eye was defined as accordance (45 patients), excyclotorsion in the nonparetic eye was defined as disaccordance (25 patients). The presence of horizontal strabismus was detected in 28 (62%) patients in the accordance group and only 8 (32%) patients in the disaccordance group (p = 0.024). All horizontal strabismus observed in the accordance group involved exodeviation. The proportion of horizontal strabismus surgery was also significantly larger in the accordance group than the disaccordance group (p = 0.039). Among those patients, there were 26 who underwent fundus photography postoperatively. There was significant reduction in ocular excyclotorsion postoperatively in the accordance group (p = 0.001), but no significant reduction postoperatively in the disaccordance group (p = 0.270). There was no significant correlation between the amount of torsional reduction and the amount of vertical deviation reduction (p = 0.979). CONCLUSIONS: In cases of preoperative excyclotorsion in paretic eyes, careful consideration of combined horizontal misalignment which may require surgical correction is helpful to manage unilateral SOP.

Clinical Features and Surgical Results in Harada-Ito Surgery Patients.

Symptomatic excyclotorsion is an important clinical problem, especially in acquired superior oblique muscle palsy. Excyclotorsion can disrupt the fusion and cause torsional diplopia. Harada-Ito surgery (HI) is a widely used method for treating excyclotorsions. This method relieves the torsional diplopia by increasing the effect of the incyclotorsion. In this study, we aimed to report the clinical features of patients with torsional diplopia due to acquired trochlear nerve palsy and the results of HI surgery in these patients.

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.

Torsional Diplopia.

BACKGROUND AND PURPOSE: Torsional diplopia can result in failure of fusion in an individual without a measureable strabismus. When presented with a patient with complaints of binocular diplopia, physicians and orthoptists should consider cyclovertical muscle dysfunction when the source of the complaint is not readily apparent. METHODS: A thorough review of the literature combined with the author's own personal experience in treating adult patients with strabismus was used to evaluate the different potential causes of torsional diplopia. Predisposing factors, diagnostic techniques, and strabismus diagnoses are considered. RESULTS: The most common cause of torsional diplopia is a superior oblique palsy. Other more common causes include thyroid-related orbitopathy and skew deviations. CONCLUSIONS: Torsional diplopia is a common cause of undiagnosed strabismus in the adult patient population. Proper consideration of the most common causes should be made.

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.

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.

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.