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Isolated inferior oblique pareses

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Abstract

Purpose

To describe etiology, clinical characteristics, radiological features and management of isolated inferior oblique pareses.

Methods

A diagnosis of inferior oblique paresis was made after a thorough strabismus examination and neuroimaging. The patients were managed surgically with adjustable strabismus surgery, or conservatively. Surgical success was defined as average horizontal deviation within ≤ 10 prism diopters [PD] post-operatively and for vertical deviation, it was ≤ 5 PD, at last follow-up.

Results

Seven cases were congenital, 6 cases were bilateral, with esotropia in 6 cases; ‘A’ pattern in 7 cases and hypotropia in 3 cases. The mean preoperative horizontal deviation was 52.5 PD, and the mean postoperative horizontal deviation was 2.37 PD (p = 0.028). The pre-operative vertical deviation was 18 PD and post-operative vertical deviation was 5 PD. MRI showed reduced IO muscle size; average area being 11.27 mm2 in the affected eyes, with normal sized inferior recti (average: 24.63 mm2) and medial recti muscles (average: 30.08 mm2). Surgical success was seen in all six cases. Average follow-up was 265 days. The Parks’ three step test was not valid, except for one acquired unilateral case.

Conclusion

Isolated pareses of inferior oblique muscle exhibit defective elevation in adduction of the affected eye, ‘A’ pattern and fundus intorsion, and is confirmed by neuroimaging. These can be successfully managed surgically to correct the deviation.

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References

  1. Ela-Dalman N, Velez FG, Demer JL et al (2008) High-resolution magnetic resonance imaging demonstrates reduced inferior oblique muscle size in isolated inferior oblique palsy. J AAPOS 12:602–607

    Article  Google Scholar 

  2. Brown HW (1957–1958) Isolated inferior oblique paralyses: an analysis of 97 cases. Trans Am Ophthalmol Soc 55:415–54

  3. Castro O, Johnson LN, Mamourian AC (1990) Isolated inferior oblique paresis from brain-stem infarction. Perspective on oculomotor fascicular organization in the ventral midbrain tegmentum. Arch Neurol 47:235–237

    Article  CAS  Google Scholar 

  4. Nutt AB (1955) The significance and surgical treatment of congenital ocular palsies. The Hunterian Lecture. Ann R Coll Surg Engl 16:30–59

    CAS  PubMed  PubMed Central  Google Scholar 

  5. Guyton DL (1983) Clinical assessment of ocular torsion. Am Orthopt J 33:7–15

    Article  Google Scholar 

  6. Guyton DL (2008) Ocular torsion reveals the mechanisms of cyclovertical strabismus: the Weisenfeld lecture. Invest Ophthalmol Vis Sci 49:847–857. https://doi.org/10.1167/iovs.07-0739

    Article  PubMed  Google Scholar 

  7. Lyle TK, Cross AG (1951) Diagnosis and management of paralysis of the extrinsic extraocular muscles. Br J Ophthalmol 35:511–548

    Article  CAS  Google Scholar 

  8. Kushner BJ (1989) Errors in the three-step test in the diagnosis of vertical strabismus. Ophthalmology 96:127–132

    Article  CAS  Google Scholar 

  9. Hilton AF (1982) The diagnosis and management of isolated cyclo vertical muscle palsy. Aust J Ophthalmol 10:31–40

    Article  CAS  Google Scholar 

  10. Manchandia AM, Demer JL (2014) Sensitivity of the three-step test in diagnosis of superior oblique palsy. J AAPOS 18:567–571. https://doi.org/10.1016/j.jaapos.2014.08.007

    Article  PubMed  PubMed Central  Google Scholar 

  11. Muthusamy B, Irsch K, Peggy Chang HY et al (2014) The sensitivity of the bielschowsky head-tilt test in diagnosing acquired bilateral superior oblique paresis. Am J Ophthalmol 157:901–907. https://doi.org/10.1016/j.ajo.2014.01.003

    Article  PubMed  Google Scholar 

  12. Lee JE, Yang HK, Kim JH et al (2018) Diagnostic utility of the three-step test according to the presence of the trochlear nerve in superior oblique palsy. J Clin Neurol 14:66–72. https://doi.org/10.3988/jcn.2018.14.1.66

    Article  PubMed  Google Scholar 

  13. Coats DC, Olitsky SE (2007) Strabismus surgery and its complications. Springer, Berlin, pp 259–261

    Google Scholar 

  14. Bowing B (2016) Kanski’s clinical ophthalmology. A systematic approach, 8th edn. Elsevier, Beijing, pp 730–861

    Google Scholar 

  15. Yanoff M, Duker JS (2009) Ophthalmology, 3rd edn. Mosby, St. Louis, p 1342

    Google Scholar 

  16. Wu XF, Yan JH (2020) Diagnosis and surgical management of isolated inferior oblique palsy. Int J Ophthalmol 13:349–355. https://doi.org/10.18240/ijo.2020.02.21

    Article  PubMed  PubMed Central  Google Scholar 

  17. Almog Y, Ben-David M, Nemet AY (2016) Inferior oblique muscle paresis as a sign of myasthenia gravis. J Clin Neurosci 25:50–53. https://doi.org/10.1016/j.jocn.2015.08.026

    Article  PubMed  Google Scholar 

  18. Khawam E, Menassa J, Jaber A et al (1998) Diagnosis and treatment of isolated inferior oblique muscle palsy: a report of seven cases. Binocul Vis Strabismus Q 13:45–52

    CAS  PubMed  Google Scholar 

  19. Clark RA, Miller JM, Rosenbaum AL et al (1998) Heterotopic muscle pulleys or oblique muscle dysfunction? J AAPOS 2:17–25

    Article  CAS  Google Scholar 

  20. Pollard ZF (1993) Diagnosis and treatment of inferior oblique palsy. J Pediatr Ophthalmol Strabismus 30:15–18

    Article  CAS  Google Scholar 

  21. Wilson ME (1994) Diagnosis and treatment of inferior oblique palsy. J Pediatr Ophthalmol Strabismus 31:131 (Comment on: Diagnosis and treatment of inferior oblique palsy. J Pediatr Ophthalmol Strabismus. 1993)

    Article  CAS  Google Scholar 

  22. Lueder GT, Archer SM, Hered RW etal (2015–2016) Pediatric ophthalmology and strabismus. Section 6. Basic and clinical science course. American Academy of Ophthalmology, San Francisco, pp 148–170

  23. Wright KW (1999) Brown’s syndrome: diagnosis and management. Trans Am Ophthalmol Soc 97:1023–1109

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Hoyt CS, Taylor D (2013) Paediatric ophthalmology and strabismus, 4th edn. Saunders/Elsevier, Edinburgh, pp 802–810

    Google Scholar 

  25. Donahue SP, Lavin PJM, Mohney B et al (2001) Skew deviation and inferior oblique palsy. Am J Ophthalmol 132:751–756

    Article  CAS  Google Scholar 

  26. Wong AM (2010) Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy. J AAPOS 14:61–67. https://doi.org/10.1016/j.jaapos.2009.11.019

    Article  PubMed  PubMed Central  Google Scholar 

  27. Santiago AP, Rosenbaum AL (1997) Grave complications after superior oblique tenotomy or tenectomy for Brown syndrome. J AAPOS 1:8–15

    Article  CAS  Google Scholar 

  28. Kutschke PJ, Scott WE (1996) Postoperative results in inferior oblique palsy. J Pediatr Ophthalmol Strabismus 33:72–78

    Article  CAS  Google Scholar 

  29. Olivier P, von Noorden GK (1982) Results of superior oblique tenectomy in inferior oblique paresis. Arch Ophthalmol 100:581–584

    Article  CAS  Google Scholar 

  30. Scott WE, Nankin SJ (1977) Isolated inferior oblique paresis. Arch Ophthalmol 95:1586–1593. https://doi.org/10.1001/archopht.1977.04450090108009

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Ophthalmology, Fauji Foundation Hospital, Foundation University Islamabad, Defence Avenue, DHA Phase-I, Islamabad, 44000, Pakistan

    Nadeem Sana

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  1. Nadeem Sana
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The author was involved in conceptualization, methodology, diagnosis, surgical treatment, radiological measurements and formal analysis and investigation.

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Correspondence to Nadeem Sana.

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Dr. Sana Nadeem, Assistant Professor, MBBS FCPS ICO Fellowship in Pediatric Ophthalmology & Strabismus Trialect Fellowship in Glaucoma, Neuro-Ophthalmology, Cornea & Ocular Surface diseases

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Nadeem, S. Isolated inferior oblique pareses. Int Ophthalmol 42, 3165–3181 (2022). https://doi.org/10.1007/s10792-022-02316-3

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