1. Analysis of Results of Various Surgeries on the Superior Oblique
KOWAL L
MAHINDRAKAR A
RVEEH, MELBOURNE

2. Preamble
Superior oblique surgeries are infrequent in Anglo-American strabismus
Reputation for being difficult and prone to complications
AIM: To examine the results of various superior oblique surgeries (single surgeon)

3. Methods
Records of 27 patients who had SO surgeries* and who were seen between were analysed
*some had their surgeries outside this period

4. 1. Superior oblique paresis / palsy SOP
Diagnostic groups
1. Superior oblique paresis / palsy SOP
2. Hypotropia
3. Brown’s
4. A pattern

5. Typical Pre-op case

6. RIO +, RSO -, RIR -
Typical changes of ‘chronic’ true SOP. RSO UA, RIO OA, and RIR UA from the tight SR seen after ‘chronic hypertropia’

7. SOP Full tendon width strengthening operation considered if:
Intra- op FDT shows significant unequivocal floppiness [‘..just keeps going’]
Usually: Coronal scan shows atrophy
Usual operation: advancement / insertion till mild Brown’s created [can elevate 6 o’clock limbus ~3mm above the intercanthal horizon]

8. Results – 4 pts with SO plication
2 unilateral cong. SOP
1 bilateral cong. SOP
1 bilateral acquired SOP due to post. fossa lesion

9. Unilateral Cong. SOP n=2 Both had SO plication and Parks’ IO recess
One required re-plication
Both have improved AHP 3 yrs later
One has good ROSV with 100” stereo

10. Bilateral cong SOP n=1 Bilateral SO plication Has large ROSV at 1 year
Torsion corrected from 10° excyclo to < 5° incyclo
Minimal residual hypertropia in R gaze (pre-op 20∆); none in L gaze (pre-op 12∆)

11. Bilateral SOP 2ary to post. fossa lesion n=1
Unilateral plication + bilateral IO recession + vertical R-R OU [!]
13 years follow-up: good ROSV
SO plication corrected 10° of excyclotorsion (8° residual)

12. In selected cases, a reliable and safe operation
Plication for SOP
In selected cases, a reliable and safe operation

13. 2. Hypotropia Diagnostic groups
1. Superior oblique paresis / palsy SOP
2. Hypotropia
3. Brown’s
4. A pattern

14. Hypotropia n=4 1-2y follow-up
n = 2 Tenotomy
corrected hypo (7∆ and 15∆)
improved A pattern from 25 to 12 ∆ in one pt.

15. Hypotropia n=4 1-2y follow-up
n =2: Recession – [posterior] transposition to 13mm from limbus & 2mm nasal to SR (Souza Dias)
corrected hypo (15 and 14∆)
improved A pattern from 25 ∆ to < 5∆

16. 3. Brown’s Diagnostic groups 1. Superior oblique paresis / palsy SOP
2. Hypotropia
3. Brown’s
4. A pattern

17. Results - Brown’s 6 patients Spacer, Tenotomy, Recession
1-2 years follow-up

18. Results - Brown’s Spacer → no improvement (1 pt.) FDT was negative
SO tenotomy + IO recession → no improvement (1 pt.)
SO tenotomy + IO Rc + LR Rc → Good range of movement (1pt.)

19. Results - Brown’s
SO tenotomy + IO rec. + other SR faden → improved appearance (1 pt.)
SO spacer (later removed) + IO rec. + other SR faden → No AHP; large ROSV (1 pt.)
SO recession ~12mm → corrected AHP (1 pt.)

20. Brown’s These results are not as good as published series
Pathology may vary
2ary effects [eg tight verticals] may come to dominate the clinical picture and obscure the original pathology

21. 4. A pattern Diagnostic groups 1. Superior oblique paresis / palsy SOP
2. Hypotropia
3. Brown’s
4. A pattern

22. A pattern n=14
10 : Partial tendon weakening operation : bilateral SO posterior tenectomy [SOPT]
4 : full tendon width weakening operation
1 full tendon width tenotomy
1 spacer
2 recession – transposition
1-3 y follow-up
10 had a PARTIAL tendon width operation, the SO PT operation

23. Posterior tenectomy SO

24. Posterior tenectomy NOTE: WIDE SCATTER OF RESULTS
OVER HALF HAVE AN UNDERCORRECTION!
From Souza Dias & Praeto Diaz

25. Posterior tenectomy NOTE: WIDE SCATTER OF RESULTS
OVER HALF HAVE AN UNDERCORRECTION!
From Souza Dias & Praeto Diaz

26. SO Post. Tenectomy n=10 1-4 years follow-up
2/10 patients improved completely
Max. correction 20 ∆

27. SO Post. tenectomy 5/10 had partial or complete correction
3/10 patients had partial correction
Improvement varied from 10 – 12 ∆
5/10 had partial or complete correction

28. SO Post. tenectomy 3 patients had no improvement
2 patients : A pattern worse

29. ‘A’ pattern – complete tenotomy n=1
2 years follow-up
‘A’ pattern improved from 25 ∆ to 12 ∆
Also corrected hypotropia of 7 ∆

30. ‘A’ Pattern – SO spacer n=1
1 year follow-up
AHP resolved

31. ‘A’ Pattern Recession – Transposition n=2
One had correction of 70 ∆ !!
One had improvement in ‘A’ from 25 ∆ to < 5 ∆ + correction of 14 ∆ hypo

32. Recession - transposition
FAIRLY
TIGHT
RESULTS

33. SO surgeries
One abandoned as no tendon was found

34. Complications
One spacer: chronic inflammation and recurrence of Brown’s after temporary improvement
No lid problems

35. Conclusions Palsy → plication reliable [if well selected]
Hypotropia → good results from tenotomy, recess / transpose
‘A’ pattern → Full tendon width procedure better than PTSO
PTSO → not reliable for ‘A’ pattern
Brown’s → mixed results

36. Pre-op (Centofanti Rec- trans)

37. Pre-op (dula – tenotomy)

38. Pre-op (dula tenotomy)