To compare clinical characteristics according to the laterality of objective ocular torsion in patients with unilateral superior oblique palsy (SOP). 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. 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). 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.

To evaluate the manifestations of increased esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine in children with hyperopia and esotropia. We reviewed the medical record of 34 children with hyperopia and esotropia who underwent a prism alternate cover test before and after instillation of mixed eye drops containing 0.5% tropicamide and 0.5% phenylephrine between November 2014 and October 2015. Increased angle of deviation was defined as 10 prism diopters (PD) or greater deviation after cycloplegia. The factors related to increased angle of deviation were evaluated using univariable and multivariable logistic regression analysis. The median age was 5.0 years (interquartile range, 3.75 to 5.0) and 12 patients (35.3%) were male. The median manifested refractive (MR) was +2.13 diopters (D) (+0.92 to +4.47) and cycloplegic refractive (CR) was +3.50 D (+1.72 to +5.66). The median difference between MR and CR was +0.88 D (+0.50 to +1.28). Thirteen patients (38.2%) showed increased esodeviation under cycloplegia and all had accommodative esotropia. A larger difference between MR and CR was the only significant factor affecting increased esodeviation in both univariable (OR = 4.72, P = 0.029) and multivariable (OR = 5.22, P = 0.047) analyses. Children with hyperopia and esotropia often showed an increased angle of deviation after instillation of 0.5% tropicamide and 0.5% phenylephrine. This phenomenon reminded the clinicians that cycloplegics can have a different effect on esodeviation and suggested that increased angle of esodeviation may help to reveal the latent deviation in some patients with hyperopia and esotropia.

Direct damage to the superior rectus (SR) muscle insertion following upper lid blepharoplasty has not been reported. We document a rare case of vertical diplopia due to direct damage to the SR muscle insertion following cosmetic upper lid blepharoplasty. We describe a case of 24-year-old woman with Asian eyelid. The patient had already undergone multiple cosmetic upper lid surgeries and complained of vertical diplopia immediately after her most recent surgery (levator resection with skin approach). Preoperatively, large-angle right hypotropia and severe upgaze limitation were present and noticeable ptosis was observed in the right eye. Intraoperatively, the SR muscle fibers were observed to be detached at the insertion site and severe fibrosis and adhesion surrounding the muscle was noted. After strabismus surgery, vertical strabismus was improved. This case can provide valuable insight to surgeons performing ptosis surgery and blepharoplasty, particularly in cases of reoperation. Surgeons should be careful while manipulating the levator muscle or resecting deep tissues not to affect the SR muscle.

Noh H, et al. J Korean Ophthalmol Soc. 2019 Dec;60(12):1269-1274. https://doi.org/10.3341/jkos.2019.60.12.1269

Son KY, et al. J Korean Ophthalmol Soc. 2019 Dec;60(12):1275-1283. https://doi.org/10.3341/jkos.2019.60.12.1275