Search Results (4)

Background/Objectives: To evaluate interocular retinal and choroidal microvascular alterations associated with compensatory head tilt in unilateral congenital superior oblique palsy (SOP) and to investigate their relationship with head tilt degree using optical coherence tomography angiography (OCTA). Methods: This retrospective cross-sectional study included 34 patients with congenital SOP and head tilt–dominant abnormal head posture. A paired-eye design compared the tilt-side eye with the opposite-side eye. Superficial and deep capillary plexus (SCP, DCP) vessel density, foveal avascular zone (FAZ) parameters, choroidal vascularity index (CVI), and subfoveal choroidal thickness (SFCT) were assessed. Interocular differences were defined as Δ = opposite-side eye − tilt-side eye. Correlation and multivariable regression analyses were performed to assess associations with head tilt degree. The interocular difference in CVI (ΔCVI) and its association with head tilt degree were defined as the primary outcomes, whereas retinal OCTA parameters, FAZ metrics, and SFCT were considered exploratory secondary outcomes. Results: CVI showed the most prominent interocular difference, being higher in the opposite-side eye than in the tilt-side eye (0.71 ± 0.04 vs. 0.68 ± 0.04; p < 0.001), whereas SFCT did not differ significantly (p = 0.395). SCP foveal vessel density and DCP inferior vessel density showed nominal differences in the unadjusted analyses but did not remain statistically significant after Benjamini–Hochberg false discovery rate correction. ΔCVI correlated positively with head tilt degree (ρ = +0.533, p = 0.001) and remained independently associated in multivariable analysis (p = 0.001). Conclusions: Compensatory head tilt in congenital SOP is associated with measurable interocular microvascular asymmetry, predominantly at the choroidal level. CVI demonstrated the strongest association with head tilt severity, whereas retinal OCTA findings were exploratory, suggesting that OCTA may provide objective insight into posture-related choroidal microvascular alterations. Full article

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. Full article

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 measured by modified fovea–disc angles and inter-eye differences in cyclotorsion angles (the difference in fundus excyclotorsion angles: paretic eye or hypertropic eye in primary gaze–fellow eye), and subjective cyclotorsion were compared between groups of unilateral SOP with bilateral fundus excyclotorsion (SOP_BE) 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 (5.7° ± 4.7° vs. 7.6° ± 4.3°, p = 0.125) and the inter-eye differences (0.7° ± 3.6° vs. 0.5° ± 5.8°, p = 0.615) were not significantly different between the unilateral SOP_BE and bilateral SOP groups. The degree of subjective excyclotorsion was significantly larger in the bilateral SOP group compared with the unilateral SOP_BE 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. Full article

Acute vertical diplopia requires an immediate neurological evaluation. The preliminary differential diagnosis is based on a few basic questions, which can be answered by simple clinical tests.The neurologist determines whether the lesion affects the optic, ocular motor, or vestibular system, and confirms that the problem is neural. Otherwise the patient is referred to the ophthalmologist. A thorough neurological assessment then allows concluding whether the lesion is within the central nervous system or peripheral. Photographs of the ocular fundus on both sides help to distinguish between trochlear nerve palsy and ocular tilt reaction or skew torsion. For a finer differential diagnosis, focused MR-imaging is always needed. The diagnosis of an optic disorder should be considered if the vertical diplopia is clearly monocular. If vertical diplopia is binocular, the neurologist first searches for typical oculomotor (III) or trochlear nerve (IV) palsies.While III-palsy is mostly due to ischaemia (pupil typically spared) or compression (pupil typically affected) of the nerve, IV-palsy is mostly due to head trauma. III- and IV-palsies that go together with retroorbital pain should lead to a careful evaluation for neoplasm,thrombosis, and inflammation of the cavernous sinus. One can never be absolutely sure whether a typical III- or IV-palsy is due to a problem along the nerve or within the brainstem, except if other signs clearly indicate a lesion within the ipsilateral orbit or cavernous sinus. Thus neuro-imaging should always include MR-imaging of the midbrain to detect lesions in the nuclei and fascicles of the oculomotor and trochlear nerves. If a suspected III-palsy does not include all of the four corresponding extraocular muscles (superior, inferior, and medial recti; inferior oblique), one should also consider myasthenia gravis, which can mimic any neural extraocular muscle palsy. Wernicke’s disease is always a valid differential diagnosis of binocular vertical diplopia, especially in the presence of pathological nystagmus and ataxia. If binocular vertical diplopia is associated with deficits of multiple cranial nerves, one should consider a demyelinating disease such as Miller-Fisher and Guillain-Barré syndrome. Skew deviation is a vertical misalignment of the two eyes resulting from disturbance of supranuclear inputs to the ocular motor neurons of the vertical-torsional eye muscles. If skew deviation goes together with ocular torsion towards the lower eye, so-called skew torsion, an imbalance in the vestibular system, mainly a unilateral lesion of “graviceptive”pathways, which combine otolith and vertical semicircular canal signals, is likely. Skew torsion combined with head roll towards the lower eye forms the triad of ocular tilt reaction (OTR). Consistent with the anatomy of the graviceptive pathways, ipsiversive skew torsion (ipsilateral eye lower, and ipsilateral binocular torsion) and ipsilateral OTR (ipsiversive skew torsion, and ipsilateral head tilt) will occur as a result of unilateral peripheral or pontomedullary lesions below the pontine crossing of the graviceptive pathways. In contrast, a unilateral pontomesencephalic brainstem lesion leads to contraversive skew deviation (contralateral eye lower) and contralateral OTR (contraversive skew deviation, contralateral binocular torsion, and contralateral head tilt). Lesions of cerebellar structures inhibiting the otolith-ocular reflex may also lead to skew torsion. Distinguishing between IV-palsy and OTR is sometimes difficult. In both conditions the head tilts away from the eye showing hyperdeviation. While the upper eye in IV-palsy is extorted, the upper eye in OTR is intorted. Furthermore, the lower eye in OTR is extorted and both eyes may show a torsional spontaneous nystagmus that beats opposite to the static ocular torsion. Full article