الفهرس 
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Abstract
Superior oblique palsy is the most common vertical ocular muscle palsy that needs intervention to minimize vertical ocular misalignment, vertical or torsional diplopia and anomalous head posture (4).
There are many non surgical and surgical options to treat superior oblique palsy only used in symptomatic patients. Non surgical treatments as prisms for small vertical deviation and botulinum toxin injection of 2.5–5 IU in ipsilateral inferior oblique and contralateral inferior rectus muscles with electromyographic help under topical anesthesia that is used as a first line therapy for acquired superior oblique palsy diagnosed less than 4 months or more than 4 months with vertical deviation less than 6 PD in primary position or as complementary treatment for symptomatic under or overcorrection after surgery (46).
Surgical treatment is successful in decompensated congenital and acquired SOP of at least 6 months duration, Some authors recommend routinely operation on one muscle for first procedures and waiting before planning a second intervention to avoid overcorrections. Surgical options include ipsilateral superior oblique tendon tucking, ipsilateral inferior oblique recession, Ipsilateral inferior oblique myectomy, Ipsilateral anterior transposition of IO muscle, Ipsilateral superior rectus recession, Contralateral inferior rectus recession or Harada Ito to improve excyclotorsion.
The aim of our study is comparing the safety and efficacy of inferior oblique myectomy to those of anterior nasal transposition of inferior oblique 2mm nasal and 2mm posterior to nasal edge of inferior rectus muscle as two treatment options of superior oblique palsy.
This study includes 41 eyes of 30 patients of SOP divided in two groups group (A) of anteriot nasal transposition included 20 eyes of 15 cases with average Mean age was 11.3 ± 7 age (range 5-27) years6 males and 9 females and group (B) of myectomy included 21 eyes of 15 cases with average years Mean age was 10.3 ± 7.1 (range 4-33) years 6 males and 9 females.
The pre and post operative ocular alignment in all directions as evaluated in all our cases compare the efficacy of both techniques as treatment options for SOP, The preoperative vertical deviation in primary position of our patients was as follows
group A included 8 unilateral and 7 bilateral cases of SOP
• 6 cases were orthotropic.
• 9 cases showed vertical deviation 14-20 PD in primary position, 12-25PD in side gazes and 16-30PD in head tilt.
• IO overaction grade 2 in 5 cases, grade 3 in 8 cases and grade 4 in 2 cases associated.
• Preoperative V pattern range 15-20PD in 7 cases and no V pattern in 8 cases.
• Diplopia in 8 cases.
• AHP in 7 cases (46.7%).
• Maddox rod torsion range 5-10 degree in 7 cooprative cases
• Fundus torsion in all cases.
• Associated horizontal muscles surgery 2 cases BMR --,7 cases BLR--.
• Pre-operative Palpebral fissure range (8-11mm) rt eye and range (7-12) in lt eye. Postoperative there is improvent in vertical deviation in primary position mean 0.33 ± 1.04 range 0-4 PD (p>0.05), mean 0.4 ± 1.5 range 0-6 PD (p>0.05) in side gazes only in one case with previous vertical deviation 25PD, mean 0.53 ± 2 range 0-8 PD (p>0.05) in head tilt only in one case with previous 30PD with Io - in 8 cases, IO- - in 4 cases and residual IO+ in 3 cases and improvement in V pattern, maddox rod torsion, fundus torsion except minimal torsion in 3 cases with residual IO+ no significant change in palpebral fissure postoperative mean 10 ± 0.79 (Rt), 9.9 ± 1.6 (Lt) range (8-11mm) rt eye and range (7-12) in lt eye (p>0.05), post intermittent diplopia in 4 cases that improved within 3 months of follow up and no diplopia 60% of cases with improvement in AHP in all cases.
group B included 9 unilateral, 6 bilateral cases of SOP
• 6 cases were orthotropic.
• 9 cases showed vertical deviation in primary position range 0-20 PD, 8-18 PD in side gazes, 10-25 PD in head tilt, V pattern in 6 cases range (15-20 PD).
• Fundus torsion in all cases.
• Maddox rod torsion in 8 cooperative cases.
• Palpebral fissure mean 9.7 ± 1.2 (Rt) range 8-12 mm mean (lt) 8.8 ± 1.1 range 8-12 mm.
• Preoperative diplopia in 8 cases.
• AHP in 9 cases (60%)
• Associated horizontal deviation in 7 cases (4cases BLR--,3 cases BMR--) and IR (inferior rectus) muscle recession bilateral with IO myectomy in one case.
Postoperative vertical deviation range 0-4PD in one case in primary position, postoperative side gazes 0-6 PD in two cases with previous vertical deviation 20 PD, postoperative head tilt vertical deviation 0-8PD in two cases with previous vertical deviation 20 PD and previous IO overaction grade 2 (8 cases), grade 3 (5 cases), grade 4 (2cases). Improvement of V pattern, Maddox rod postoprtative (p>0.05), Io - in 9 cases, IO- - in 2 cases, residual Io+ in 4 cases and minimal change in palpebral fissure range 8-12mm bilateral (postoperative), fundus torsion improved except minimal deviation in 4 cases with residual IO+ postoperative, Intermittent diplopia in 3 casesthat improved within 3 months of follow up and no diplopia in 9 cases (60%) within 3 months of follow up.
Many studies were done before to detect benefit of anteriorization of the inferior oblique muscle but for management of DVD with IOOA not like the our current study in SOP.
The study carried out by Saleh M and Abdelhalim NE at 2018 to compare between Temporal Versus Nasal Anterior Transposition of the Inferior Oblique Muscle for management of Dissociated Vertical Deviation with Inferior Oblique over Action with two year follow up, The study included 50 eyes of 28 patients with DVD of at least 10 PD in the involved eye and the patients were divided into two groups ,group A (25 eyes of 15 patients) managed by temporal anterior transposition of the inferior oblique muscles and group B (25 eyes of 13 patients) managed by nasal anterior transposition of the inferior oblique muscles. The size of preoperative and postoperative angle of DVD, grade of IOOA preoperative and postoperative, need for repeated surgeries and complications were recorded and evaluated, The results group A the mean DVD angle was decreased in primary positions from 21.11±4.32 ∆ to 9.5 ±4.7 ∆ (P<0.001) and from 19.5±4.6 ∆ to 5.51 ±2.65∆ (P<0.001) in group B mean IOOA grade was decreased from +2.0 ±0.7 to +0.18±0.4 in group A (P<0.001) and from +2.5 ±0.7 to+0.1±0.5 (P<0.001) in group B with two patients developed hypotropia of 5 and 6 PD. Persistent IOOA (+1) was observed postoperatively in two eyes in each group. Limited elevation in abduction was found in 3 patients in group A, the incidence of recurrence rate after 24 months was 2 eyes 10% in group A and one eye 5% in group B (60).
Another study carried out by Arafa, Eltoukhy, et al at 2020 to detect the efficacy of anterior nasal transposition of Inferior Oblique to manage DVD and vertically incomitant horizontal strabismus (IO is an abductor so overaction of that muscle will result in less convergent and more divergent position in the upper gaze (V-pattern), primary IO overaction with congenital esotropia or exotropia or secondary to congenital SO palsy. This study included 60 patients who suffered from inferior oblique overaction. The participants were divided into two groups: group A had 30 patients with vertically incomitant horizontal strabismus while group B had 30 patients with dissociated vertical deviation. With follow up for six months and the measurements of ductions, versions and alignment in primary position were recorded. Results of this study were no pattern in 93.3% of cases postoperatively while 6.7% of cases developed insignificant V pattern (0.8 ± 2.9 ΔD), with statistically significant difference between the pre-and post-operative values (pvalue< 0.001) in group A, group B showed a complete resolution of DVD in 100% of cases with preoperative (DVD<15 ΔD) and in 20% of cases with preoperative DVD ≥ 15 ΔD, the remaining cases had residual DVD (3.6 ± 4.1 ΔD) (52).
There was study carried out by Ahmed awadien (2009) to compare the effects of myectomy and nasal transposition in patients with inferior oblique overaction, Study included 24 patients with bilateral nearly symmetric primary IO overaction, 14 patients of them treated with bilateral symmetrical inferior oblique myectomy and 10 patients of them treated with bilateral nasal transposition of inferior oblique muscles with follow up 3 months.There was marked improvement in the degree of the inferior oblique overaction in both groups. In patients who had inferior oblique myectomy 64% of the patients had no residual inferior oblique overaction on either side within 3 months follow up period. The remaining 36% has residual +1 overaction on one or both sides. None of the patients developed significant inferior oblique underaction. Patients who had nasal transposition of inferior oblique muscle, none of the patients has residual overaction on both sides at the end of the follow up. However 2 patients (20%) had limitation of elevation in adduction on one or both sides. Conclusion of this study was both myectomy and nasal transposition of inferior oblique muscle showed to be effective in improving inferior oblique overaction but nasal transposition was a more potent surgery with greater improvement in the degree of inferior oblique overaction, Overcorrection tended to occur more in patients who had nasal transposition of inferior oblique muscle so nasal transposition should be reserved to patients with marked inferior oblique overaction. (63).
The study carried out by Rohit Saxena, Medha Sharma, Digvijay Singh et al (2017) to detect the long term outcome of inferior oblique anterior and nasal transposition in superior oblique palsy with evaluation of alignment in primary gaze, contralateral gaze, upgaze including prism bar cover test and measurement of torsion for all cases. They found in one year postoperative follow up reduction in inferior oblique overaction and changes in fundus torsion in 12 patients who were included in the study (mean age at the time of surgery was 20.6 years) with three cases of them underwent horizontal muscle surgery. The median preoperative hypertropia was 21.5 PD (range 12 -36 PD) corrected to 4.5 PD (range 2 -10 PD) at 12 months postoperatively follow up (P = 0.002). Median inferior oblique overaction decreased from +3 (range +1 to +4) to 0 (range -1 to +1). Extorsion was eliminated and head tilt improved in all patients. No consecutive hypotropia or underaction in elevation was observed in 10 patients but 1 patient complained of torsional diplopia in upgaze. (64).
Study for twenty patients with IO muscle overaction due to superior oblique muscle palsy, absent SO muscle or Duane syndrome carried out by Stager, Beauchamp, Wright WW, et al, (2003). Before surgery each patient showed elevation in adduction, exotropia in up gaze, abnormal head posture and extorsion, Each underwent anterior and nasal transposition of the IO muscle with the new insertion typically 2 mm nasal and 2 mm posterior to the nasal border of the IR muscle insertion. Large improvements in ocular alignment, extorsion and head posture were found in most patients. In Duane syndrome, ANT corrects upshot but downshoot may get worse. Mersilene permanent sutures rather than dissolving suture material are recommended to avoid postoperative retraction of muscle fibers. This procedure seems particularly useful in patients with severe or recurrent congenital and acquired SO palsies, Extreme ANT may induce exotropia in the primary position. (65).
Study carried out by Hussein, stager, Beauchamp (2006) for patients with missing superior oblique tendons presented with overelevation, underdepression in adduction, abnormal head postures and V. These patients may have craniosynostosis, two cases with unilateral, 7 cases with bilateral absent SO tendons underwent anterior and nasal transposition of the inferior oblique muscles, some in combination with horizontal rectus recession for horizontal strabismus. They were evaluated 6 to 46 months postoperatively for alignment but cyclodeviations were not evaluated in most children. Postoperatively, all patients improved with no abnormal head posture, V pattern in bilateral cases had largely cleared although some symptoms remained as vertical deviation in side gaze (3 patients) and V pattern esotropia in downgaze (2 patients). Conclusions of this study were that anterior and nasal transposition of the IO muscle reduced overelevation in adduction, divergence of the eyes in upgaze but esodeviation may persist in downgaze and this procedure was most effective in unilateral absence of the SO tendon (66). Another study also carried out for congenital absence of the superior oblique muscle and treated with anterior and nasal transposition of the inferior oblique muscle by Park, Cha, Yoonae, et al (2010), two year old boy presented with hypertropia 18PD that increased to 35 PD in head tilt. The patient presented with orthotropia at distant and near with no vertical deviation shown on the Bielschowsky head tilt test three weeks after surgery and the abnormal head posturing was no longer observed (67).
There was study for iatrogenic superior oblique palsy following congenital ptosis surgery (levator excision and fascia lata brow suspension for Marcus Gunn jaw winking ptosis) carried out by Inez. Wong, Vincent Paris, Harold. Choi, et al (2011) using ipsilateral anterior and nasal transposition of the inferior oblique muscle instead of other conventional procedures to improve vertical and torsional diplopia. Strabismus surgery in this study was performed 1 year after ptosis surgery, preoperative patient had a left hypertropia of 20 PD that increased to 25 PD on both right gaze and left head tilt, Vpattern, SO underaction of -3 and IO overaction of +4 in the left eye. Testing of subjective torsion using double Maddox rod showed excyclotropia of 8° in primary position which increased to 14° on downgaze. The left IO was transposed nasal to the inferior rectus muscle. Postoperatively, the abnormal head posture was corrected, patient was orthophoric in both primary position and downgaze although there was a 6 PD left hypotropia on upgaze with limitated elevation more in adduction, diplopia free except in upgaze and the excyclotorsion was eliminated in primary position, with excyclophoria of 3° only in downgaze. These results were stable at 11 months (68).
Complications as safety element in group A there were lower lid fullness only in 5 cases (33.3%), eye puffiness in two cases (13.3%), lower lid retraction in one case (6.7%), Subconjunctival Hemorrhage in two cases (13.3%) (p>0.05). complications of group B were Subcojuctival Hemorrhge in 4 cases (26.7%), puffiness in one case (6.7%), Exposed tenon in one case (6.7%), wound cyst in one case (6.7%) (p>0.05).
Anterior nasal transposition of the inferior Oblique muscle is an effective procedure for cases with severe or recurrent inferior oblique overaction when other conventional procedures of inferior Oblique muscle fail. This procedure used to manage DVD as presented before in previous studies alone or combined with superior rectus recession if more than 15PD, primary bilateral IO overaction, IO overaction in missed So muscle or tendon, iatrogenic SOP post ptosis surgery as detected in previous studies, the current study used this procedure in treatment of unilateral or bilateral congential, acquired post 6 months SOP with secondary IO overaction in comparison to IO myectomy procedures.