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Joseph L Demer - One of the best experts on this subject based on the ideXlab platform.
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Surgical interventions for Vertical Strabismus in superior oblique palsy.
The Cochrane database of systematic reviews, 2017Co-Authors: Melinda Y Chang, Anne L Coleman, Victoria L Tseng, Joseph L DemerAbstract:Superior oblique palsy is a common cause of Vertical Strabismus in adults and children. Patients may be symptomatic from binocular Vertical diplopia or compensatory head tilt required to maintain single vision. Most patients who are symptomatic elect to undergo Strabismus surgery, but the optimal surgical treatment for Vertical Strabismus in people with superior oblique palsy is unknown. To assess the relative effects of surgical treatments compared with another surgical intervention, non-surgical intervention, or observation for Vertical Strabismus in people with superior oblique palsy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 13 December 2016), Embase Ovid (1947 to 13 December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 13 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 13 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 13 December 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 13 December 2016. We did not use any date or language restrictions in the electronic searches for trials. We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation. Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. We identified two randomized trials comparing four different surgical treatments for this condition, two methods in each trial. The studies included a total of 45 children and adults. The surgical treatments were all procedures to weaken the ipsilateral inferior oblique muscle. One study compared inferior oblique myectomy to recession of 10 mm; the other study compared inferior oblique disinsertion to anterior transposition (2 mm anterior to the temporal border of the inferior rectus insertion).We judged both studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Neither study reported data on the primary outcome of this review, which was the proportion of participants with postoperative surgical success, defined as hypertropia less than 3 prism diopters (PD) in primary gaze. However, both studies reported the average reduction in hypertropia in primary gaze. One study found that at 12 months' postoperatively the average decrease in hypertropia was higher in participants who underwent inferior oblique myectomy than in those who underwent recession, however data were not available for statistical comparison. The other trial found that after at least six months of follow-up, the mean decrease in primary position hypertropia was lower in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (mean difference (MD) -5.20 PD, 95% confidence interval (CI) -7.76 to -2.64; moderate-quality evidence).Both trials also reported the average postoperative reduction in Vertical deviation in adduction. One study reported that the average reduction in hypertropia in adduction was greater in participants who underwent inferior oblique myectomy than in those who underwent recession, but data were not available for statistical comparison. The other study found a lower decrease in hypertropia in contralateral gaze in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (MD -7.10 PD, 95% CI -13.85 to -0.35; moderate-quality evidence).Secondary outcomes with sufficient data for analysis included proportion of participants with preoperative head tilt that resolved postoperatively and proportion of participants who underwent a second surgery. These outcomes were assessed in the trial comparing inferior oblique anterior transposition to disinsertion; both outcomes favored anterior transposition (risk ratio 7.00, 95% CI 0.40 to 121.39 for both outcomes; very low-quality evidence). None of the participants who underwent inferior oblique anterior transposition or disinsertion developed postoperative hypotropia or reversal of the Vertical deviation. All participants who underwent inferior oblique anterior transposition developed elevation deficiency, which the authors deemed to be clinically insignificant in all cases, whereas no participants who underwent inferior oblique disinsertion experienced this complication. Additionally, the trial comparing inferior oblique myectomy to recession reported that no participant in either group required another Strabismus surgery during the postoperative period. The two trials included in this review evaluated four inferior oblique weakening procedures for surgical treatment of superior oblique palsy. We found no trials comparing other types of surgical procedures for this disorder. Both studies had enrolled a small number of participants and provided low-quality evidence due to limitations in completeness and applicability. We therefore found no high-quality evidence to support recommendations for optimal surgical treatment of superior oblique palsy. Rigorously designed, conducted, and reported randomized trials are needed to identify the optimal surgical treatment for Vertical Strabismus in this disorder.
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surgical interventions for Vertical Strabismus in superior oblique palsy
Cochrane Database of Systematic Reviews, 2016Co-Authors: Melinda Y Chang, Anne L Coleman, Victoria L Tseng, Joseph L DemerAbstract:Background Superior oblique palsy is a common cause of Vertical Strabismus in adults and children. Patients may be symptomatic from binocular Vertical diplopia or compensatory head tilt required to maintain single vision. Most patients who are symptomatic elect to undergo Strabismus surgery, but the optimal surgical treatment for Vertical Strabismus in people with superior oblique palsy is unknown. Objectives To assess the relative effects of surgical treatments compared with another surgical intervention, non-surgical intervention, or observation for Vertical Strabismus in people with superior oblique palsy. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 13 December 2016), Embase Ovid (1947 to 13 December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 13 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 13 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 13 December 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 13 December 2016. We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation. Data collection and analysis Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. Main results We identified two randomized trials comparing four different surgical treatments for this condition, two methods in each trial. The studies included a total of 45 children and adults. The surgical treatments were all procedures to weaken the ipsilateral inferior oblique muscle. One study compared inferior oblique myectomy to recession of 10 mm; the other study compared inferior oblique disinsertion to anterior transposition (2 mm anterior to the temporal border of the inferior rectus insertion). We judged both studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies. Neither study reported data on the primary outcome of this review, which was the proportion of participants with postoperative surgical success, defined as hypertropia less than 3 prism diopters (PD) in primary gaze. However, both studies reported the average reduction in hypertropia in primary gaze. One study found that at 12 months' postoperatively the average decrease in hypertropia was higher in participants who underwent inferior oblique myectomy than in those who underwent recession, however data were not available for statistical comparison. The other trial found that after at least six months of follow-up, the mean decrease in primary position hypertropia was lower in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (mean difference (MD) -5.20 PD, 95% confidence interval (CI) -7.76 to -2.64; moderate-quality evidence). Both trials also reported the average postoperative reduction in Vertical deviation in adduction. One study reported that the average reduction in hypertropia in adduction was greater in participants who underwent inferior oblique myectomy than in those who underwent recession, but data were not available for statistical comparison. The other study found a lower decrease in hypertropia in contralateral gaze in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (MD -7.10 PD, 95% CI -13.85 to -0.35; moderate-quality evidence). Secondary outcomes with sufficient data for analysis included proportion of participants with preoperative head tilt that resolved postoperatively and proportion of participants who underwent a second surgery. These outcomes were assessed in the trial comparing inferior oblique anterior transposition to disinsertion; both outcomes favored anterior transposition (risk ratio 7.00, 95% CI 0.40 to 121.39 for both outcomes; very low-quality evidence). None of the participants who underwent inferior oblique anterior transposition or disinsertion developed postoperative hypotropia or reversal of the Vertical deviation. All participants who underwent inferior oblique anterior transposition developed elevation deficiency, which the authors deemed to be clinically insignificant in all cases, whereas no participants who underwent inferior oblique disinsertion experienced this complication. Additionally, the trial comparing inferior oblique myectomy to recession reported that no participant in either group required another Strabismus surgery during the postoperative period. Authors' conclusions The two trials included in this review evaluated four inferior oblique weakening procedures for surgical treatment of superior oblique palsy. We found no trials comparing other types of surgical procedures for this disorder. Both studies had enrolled a small number of participants and provided low-quality evidence due to limitations in completeness and applicability. We therefore found no high-quality evidence to support recommendations for optimal surgical treatment of superior oblique palsy. Rigorously designed, conducted, and reported randomized trials are needed to identify the optimal surgical treatment for Vertical Strabismus in this disorder.
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The Cochrane Library - Surgical interventions for Vertical Strabismus in superior oblique palsy
Cochrane Database of Systematic Reviews, 2016Co-Authors: Melinda Y Chang, Anne L Coleman, Victoria L Tseng, Joseph L DemerAbstract:Background Superior oblique palsy is a common cause of Vertical Strabismus in adults and children. Patients may be symptomatic from binocular Vertical diplopia or compensatory head tilt required to maintain single vision. Most patients who are symptomatic elect to undergo Strabismus surgery, but the optimal surgical treatment for Vertical Strabismus in people with superior oblique palsy is unknown. Objectives To assess the relative effects of surgical treatments compared with another surgical intervention, non-surgical intervention, or observation for Vertical Strabismus in people with superior oblique palsy. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 13 December 2016), Embase Ovid (1947 to 13 December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 13 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 13 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 13 December 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 13 December 2016. We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation. Data collection and analysis Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. Main results We identified two randomized trials comparing four different surgical treatments for this condition, two methods in each trial. The studies included a total of 45 children and adults. The surgical treatments were all procedures to weaken the ipsilateral inferior oblique muscle. One study compared inferior oblique myectomy to recession of 10 mm; the other study compared inferior oblique disinsertion to anterior transposition (2 mm anterior to the temporal border of the inferior rectus insertion). We judged both studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies. Neither study reported data on the primary outcome of this review, which was the proportion of participants with postoperative surgical success, defined as hypertropia less than 3 prism diopters (PD) in primary gaze. However, both studies reported the average reduction in hypertropia in primary gaze. One study found that at 12 months' postoperatively the average decrease in hypertropia was higher in participants who underwent inferior oblique myectomy than in those who underwent recession, however data were not available for statistical comparison. The other trial found that after at least six months of follow-up, the mean decrease in primary position hypertropia was lower in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (mean difference (MD) -5.20 PD, 95% confidence interval (CI) -7.76 to -2.64; moderate-quality evidence). Both trials also reported the average postoperative reduction in Vertical deviation in adduction. One study reported that the average reduction in hypertropia in adduction was greater in participants who underwent inferior oblique myectomy than in those who underwent recession, but data were not available for statistical comparison. The other study found a lower decrease in hypertropia in contralateral gaze in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (MD -7.10 PD, 95% CI -13.85 to -0.35; moderate-quality evidence). Secondary outcomes with sufficient data for analysis included proportion of participants with preoperative head tilt that resolved postoperatively and proportion of participants who underwent a second surgery. These outcomes were assessed in the trial comparing inferior oblique anterior transposition to disinsertion; both outcomes favored anterior transposition (risk ratio 7.00, 95% CI 0.40 to 121.39 for both outcomes; very low-quality evidence). None of the participants who underwent inferior oblique anterior transposition or disinsertion developed postoperative hypotropia or reversal of the Vertical deviation. All participants who underwent inferior oblique anterior transposition developed elevation deficiency, which the authors deemed to be clinically insignificant in all cases, whereas no participants who underwent inferior oblique disinsertion experienced this complication. Additionally, the trial comparing inferior oblique myectomy to recession reported that no participant in either group required another Strabismus surgery during the postoperative period. Authors' conclusions The two trials included in this review evaluated four inferior oblique weakening procedures for surgical treatment of superior oblique palsy. We found no trials comparing other types of surgical procedures for this disorder. Both studies had enrolled a small number of participants and provided low-quality evidence due to limitations in completeness and applicability. We therefore found no high-quality evidence to support recommendations for optimal surgical treatment of superior oblique palsy. Rigorously designed, conducted, and reported randomized trials are needed to identify the optimal surgical treatment for Vertical Strabismus in this disorder.
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location and gaze dependent shift of inferior oblique muscle position anatomic contributors to Vertical Strabismus following lower lid blepharoplasty
Investigative Ophthalmology & Visual Science, 2015Co-Authors: Sun Young Shin, Joseph L DemerAbstract:Lower lid blepharoplasty is widely performed aesthetic surgery that corrects involutional changes.1 This surgery involves the region of the lower eyelid retractors, connective tissue bands extending from the region of the conjoined inferior rectus muscle (IR), and inferior oblique muscle (IO) pulleys. This region also includes Lockwood's ligament, a connective tissue structure that supports the globe. Complications of blepharoplasty have been reported, including diplopia due to Strabismus.2–8 While Vertical Strabismus is relatively infrequent, it is one of the most bothersome complications. The mechanism of this diplopia is not well understood. The lower eyelid has an intimate anatomic relationship with the IO and orbital bones.9,10 The IO pulley is partly coupled to the mobile IR pulley by elastic tissues. The lower eyelid normally moves in coordination with Vertical eye position by roughly the same amount, as does the globe surface. However, while the IO pulley is shifted by the IR's orbital layer, the IO pulley moves only half as far at the IO pulley and lower lid.11 This means that in infraduction, the IO pulley more closely approximates the lower lid skin surface than in other gaze positions. Elasticity of lower lid tissues contributes to the coordinated shifts of the lower lid, IO pulley, and eye. Fibrous adhesions of the IO-IR pulley to the orbital floor may produce restrictive hypertropia by hindering normal posterior pulley shift during infraduction.12 It is therefore plausible that milder changes in elastic mechanical forces in the eyelids following blepharoplasty might be transmitted to IR and IO so as to contribute to Strabismus following blepharoplasty. Such a putative effect would probably be related to individual variations in lid and bony orbital anatomy. We hypothesized that the lower lid blepharoplasty could affect IO position, since the lower lid is intimately coupled to the IO-IR pulley system. If such an effect were to occur, it should be most pronounced in patients who have shallow orbits or other anatomic features bringing the IO-IR pulley assembly into proximity with the skin. This could cause Vertical Strabismus following lower lid blepharoplasty. Therefore, this study sought to investigate, using high-resolution magnetic resonance imaging (MRI), the position of IO relative to the adnexa in subjects with Vertical Strabismus following lower lid blepharoplasty, comparing these with controls.
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Graded rectus tenotomy in small angle hypertropia due to sagging eye syndrome
Journal of American Association for Pediatric Ophthalmology and Strabismus, 2013Co-Authors: Zia Chaudhuri, Joseph L DemerAbstract:Introduction: SES is an orbital connective tissue degeneration in which adnexal laxity is associated with inferior shift of the lateral rectus (LR) and other rectus pulleys. Asymmetrical LR sag causes hy-potropia and excyclotropia in the more affected eye. We aimed to develop a surgical nomogram for graded rectus tenotomy (GRT), a minimally invasive surgery, in treatment of small angle Vertical Strabismus in SES. Methods: We reviewed a 3-year surgical experience in 21 patients with Vertical Strabismus
J. P. Burke - One of the best experts on this subject based on the ideXlab platform.
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Prioritising downgaze alignment in the management of Vertical Strabismus for thyroid eye disease: principles and outcomes
Eye, 2020Co-Authors: J. M. Jefferis, N. Raoof, J. P. BurkeAbstract:Objective To evaluate outcomes of surgery for Vertical Strabismus in thyroid eye disease (TED) employing a set of surgical principles aimed at avoiding reversal of downgaze deviation while restoring binocular single vision (BSV). Methods A retrospective review of consecutive patients undergoing Vertical Strabismus surgery for TED using a set of surgical principles between 2008 and 2017. Principle outcome measure was the presence of BSV in primary position and downgaze 3 months postoperatively and at latest follow-up. Results Thirty five patients (29% male) with a mean age of 58 years (range 31–83 years) were included. Median follow-up was 16 months. At presentation, 17 (49%) used monocular occlusion to avoid diplopia; the remainder used a prism and/or abnormal head posture. In 12 (34%), combined horizontal and Vertical muscle surgery was required. Median (inter-quartile range) preoperative Vertical deviations in primary position and downgaze respectively were 20 prism dioptres (Δ) (15, 30) and 18Δ (8, 22), which improved to 1Δ (0, 3) and 1Δ (0, 3) after the first operation. BSV in primary position and downgaze, without prism, after a single surgery was achieved in 29 (83%). Second surgery was required in 5 (14%) and one patient who had reactivation of her TED required a third surgery. At final follow-up (median 16 months), 32 (91%) were diplopia free without prisms; 3 (9%) used a small prism correction (range 2–12Δ); no patients were left with intractable diplopia. Conclusions Our management principles are characterised by prioritising downgaze alignment to avoid downgaze diplopia reversal, whilst limiting adjustable sutures and employing standard surgical dosing. They give favourable outcomes in TED associated Vertical Strabismus.
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prioritising downgaze alignment in the management of Vertical Strabismus for thyroid eye disease principles and outcomes
Eye, 2020Co-Authors: J. M. Jefferis, N. Raoof, J. P. BurkeAbstract:OBJECTIVE: To evaluate outcomes of surgery for Vertical Strabismus in thyroid eye disease (TED) employing a set of surgical principles aimed at avoiding reversal of downgaze deviation while restoring binocular single vision (BSV). METHODS: A retrospective review of consecutive patients undergoing Vertical Strabismus surgery for TED using a set of surgical principles between 2008 and 2017. Principle outcome measure was the presence of BSV in primary position and downgaze 3 months postoperatively and at latest follow-up. RESULTS: Thirty five patients (29% male) with a mean age of 58 years (range 31-83 years) were included. Median follow-up was 16 months. At presentation, 17 (49%) used monocular occlusion to avoid diplopia; the remainder used a prism and/or abnormal head posture. In 12 (34%), combined horizontal and Vertical muscle surgery was required. Median (inter-quartile range) preoperative Vertical deviations in primary position and downgaze respectively were 20 prism dioptres (Δ) (15, 30) and 18Δ (8, 22), which improved to 1Δ (0, 3) and 1Δ (0, 3) after the first operation. BSV in primary position and downgaze, without prism, after a single surgery was achieved in 29 (83%). Second surgery was required in 5 (14%) and one patient who had reactivation of her TED required a third surgery. At final follow-up (median 16 months), 32 (91%) were diplopia free without prisms; 3 (9%) used a small prism correction (range 2-12Δ); no patients were left with intractable diplopia. CONCLUSIONS: Our management principles are characterised by prioritising downgaze alignment to avoid downgaze diplopia reversal, whilst limiting adjustable sutures and employing standard surgical dosing. They give favourable outcomes in TED associated Vertical Strabismus.
R Becker - One of the best experts on this subject based on the ideXlab platform.
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Influence of viewing distance on Vertical Strabismus
Graefe's Archive for Clinical and Experimental Ophthalmology, 2004Co-Authors: Michael H. Gräf, Daniela Rost, R BeckerAbstract:Background Vertical Strabismus can be modulated by the viewing distance. We report on 19 patients with this disorder. Methods The following squint angles were measured by the alternate prism and cover test at a viewing distance of 5 m. At 0.3 m, measurements were taken with and without an addition of 3.0 D to the corrected refraction. Cases of a dissociated Vertical deviation were excluded. Fifteen patients underwent surgery. They were reexamined 3 months later. Results At a viewing distance of 5 m, the Vertical deviation ranged from 0° to 16° (median 7°). At 0.3 m, the deviation increased by 2°–15° (median 7°) in 15 patients and decreased by 3.5°–8° (median 4.5°) in 4 patients. Eleven patients had a Strabismus sursoadductorius and one had a Strabismus deorsoadductorius. Eye muscle surgery reduced both the Vertical deviation for distance fixation to 0°–14° (median 2°) and the difference between the deviations for distance and proximal fixation to 1°–6° (median 3°). Conclusions In certain cases, Vertical Strabismus can be modulated by convergence and accommodation. This condition is frequently associated with an incomitance of the Vertical deviation in side gaze. The baseline deviation can be reduced by appropriate eye muscle surgery. In cases of Vertical accommodative vergence, bifocal glasses can be helpful.
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influence of viewing distance on Vertical Strabismus
Graefes Archive for Clinical and Experimental Ophthalmology, 2004Co-Authors: Michael Graf, Daniela Rost, R BeckerAbstract:Background Vertical Strabismus can be modulated by the viewing distance. We report on 19 patients with this disorder.
Isabel Ribeiro - One of the best experts on this subject based on the ideXlab platform.
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Parinaud’s syndrome due to an unilateral vascular ischemic lesion
International Ophthalmology, 2015Co-Authors: Josefina Serino, João Martins, Ana Duarte, Liliana Páris, Isabel RibeiroAbstract:A 59-year-old man who complained of binocular Vertical diplopia after an exploratory laparotomy, complicated by cardiorespiratory arrest during anesthetic induction, was found to have Collier’s sign, anisocoria, complete paralysis of upward Vertical gaze associated with convergence-retraction nystagmus on attempted upgaze and skew deviation with hypertropia in the left eye without ptosis, and an absent Bielschowsky sign. Magnetic resonance imaging of the brain showed a small lesion in the left paramedian midbrain compatible with microvascular ischemic sequelae. This patient was diagnosed with Parinaud’s syndrome (dorsal midbrain syndrome) associated with a Vertical Strabismus from an unilateral vascular ischemic paramedian midbrain lesion.
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Parinaud's syndrome due to an unilateral vascular ischemic lesion.
International Ophthalmology, 2015Co-Authors: Josefina Serino, João Martins, Liliana P Paris, Ana Duarte, Isabel RibeiroAbstract:A 59-year-old man who complained of binocular Vertical diplopia after an exploratory laparotomy, complicated by cardiorespiratory arrest during anesthetic induction, was found to have Collier’s sign, anisocoria, complete paralysis of upward Vertical gaze associated with convergence-retraction nystagmus on attempted upgaze and skew deviation with hypertropia in the left eye without ptosis, and an absent Bielschowsky sign. Magnetic resonance imaging of the brain showed a small lesion in the left paramedian midbrain compatible with microvascular ischemic sequelae. This patient was diagnosed with Parinaud’s syndrome (dorsal midbrain syndrome) associated with a Vertical Strabismus from an unilateral vascular ischemic paramedian midbrain lesion.
Eric Eggenberger - One of the best experts on this subject based on the ideXlab platform.
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differentiating acute and subacute Vertical Strabismus using different head positions during the upright supine test
JAMA Ophthalmology, 2018Co-Authors: Joao Lemos, Adnan Subei, Mario Sousa, Cesar Nunes, Luis Cunha, Christopher C Glisson, Eric EggenbergerAbstract:Importance: Accurate clinical differentiation between skew deviation and fourth nerve palsy (4NP) is critical in the acute and subacute settings. Objective: To determine the sensitivity and specificity of the upright-supine test to detect Vertical misalignment changes using different head positions for the diagnosis of acute or subacute skew deviation vs 4NP. Design, Setting, and Participants: This multicenter study enrolled consecutive patients from Coimbra University Hospital Centre, Coimbra, Portugal, and Michigan State University, Lansing, within 2 months of presenting with Vertical diplopia and diagnosed as having skew deviation or acquired unilateral 4NP. The study used nonmasked screening and diagnostic test results from June 1, 2013, to December 31, 2016. Data were analyzed from January 1, 2017, to June 30, 2017. Main Outcomes and Measures: A 50% or greater change in Vertical misalignment between the upright and supine positions, with the head centered and tilted to either side. Measurements included the alternate prism and cover (APC) test, the double Maddox rod test, the APC test change index ([measurement upright - measurement supine] / [measurement upright + measurement supine]), and the APC test sensitivity and specificity. Results: Of the 37 included patients, the mean (SD) age was 58 (14) years, and 26 (70%) were male. We enrolled 19 patients (51%) with skew deviation and 18 (49%) with 4NP. Eighteen patients with skew deviation (95%) showed additional ocular motor and/or neurological signs. When moving to the supine position, only 1 patient with skew deviation (5%) showed more than a 50% decrease of hypertropia with the head centered (APC test: sensitivity, 5%; specificity, 100%). Three patients with 4NP (17%) showed more than a 50% decrease of hypertropia with the head tilted toward the hypertropic eye, and 10 patients with 4NP (56%) showed more than a 50% increase of hypertropia with the head tilted toward the hypotropic eye. Change indexes were different between the skew deviation and 4NP groups for head tilt to the hypotropic eye (difference, -0.33 prism diopters; 95% CI, -0.43 to -0.20; P < .001). Cyclotorsion worsened in the supine position only in patients with skew deviation (hypertropic eye: difference, -7.6 prism diopters; 95% CI, -13.00 to -0.75; P = .01; hypotropic eye: difference, 8.2 prism diopters; 95% CI, 0 to 15.75; P = .03). Conclusions and Relevance: The upright-supine test with the head centered is not a sensitive method to separate acute or subacute skew deviation from 4NP. Conversion of an incomitant Vertical deviation in the upright position to a comitant Vertical Strabismus in the supine position in all head positions, as well as the absence of additional ocular motor and/or neurologic signs, may constitute a more useful clue.
