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Pattern Strabismus and Torsion Needs Special Surgical Attention

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Pattern Strabismus and Torsion Needs Special Surgical Attention Eye (2015) 29, 184–190 & 2015 Macmillan Publishers Limited All rights reserved 0950-222X/15 www.nature.com/eye 1 1 2 CAMBRIDGE OPHTHALMOLOGICAL SYMPOSIUM Pattern strabismus R Kekunnaya , T Mendonca and V Sachdeva and torsion needs special surgical attention Abstract deviation is minimal. However, AHP may be absent if there is a large deviation in primary Pattern strabismus is relatively common in position. Patients often complain of asthenopia strabismus practice. Although it is classically and double vision, especially if the deviation is used to include A and V patterns, the term more in downgaze. has been expanded to include additional Clinical workup of patients with pattern vertically incomitant horizontal strabismus. strabismus includes: (1) measurement of This article reviews the clinical features, deviation in nine gaze with accommodation etiopathogenesis, and surgical options for the being controlled; (2) measurement of deviation patients with pattern strabismus. in 251 of upgaze (chin depression) and 351 of Eye (2015) 29, 184–190; doi:10.1038/eye.2014.270; downgaze (chin elevation); (3) careful published online 21 November 2014 assessment of overelevation and overdepression in adduction; and (4) objective assessment of Introduction fundus torsion with indirect ophthalmoscopy or The term pattern strabismus denotes a fundus photography. significant difference in the size of horizontal deviations in defined positions of upgaze and Uncommon subtypes of pattern strabismus downgaze. Classically, it includes A and V 1 Jasti V Ramanamma patterns, where by convention the difference Y pattern exists when the change in deviation is Children’s Eye Care Center, 4 minimal between primary and downgaze, and L V Prasad Eye Institute, KAR between upgaze and downgaze must be 10 campus, Hyderabad, India prism diopters (PD) and 15 PD for A and V occurs only in upgaze. It is highly characteristic patterns, respectively. However, in recent years, of bilateral inferior oblique overaction seen in 2Nimmagadda Prasad this term has been expanded to include the congenital esotropia or exotropia. It can also be Children’s Eye Care Center, other patterns with significant differences in the seen in Duane retraction syndrome (DRS) and L V Prasad Eye Institute, primary gaze and up/downgaze such as Y, X, Brown syndrome (Figures 1a and b).1 This GMRV Campus, pattern of strabismus offers advantage for Visakhapatnam, India arrow, and lambda patterns. A lesser degree of difference is accepted for A pattern, because binocular vision, especially if the primary Correspondence: convergence is more essential in downgaze. The position deviation is minimal. R Kekunnaya, Head, Jasti V exact mechanism of pattern strabismus is poorly X pattern is seen in long-standing exotropia and Ramanamma Children’s Eye understood even today. Cyclotorsion is a type 3 DRS patients. In both situations, a tight Care Center, Consultant, common feature of pattern strabismus and is lateral rectus muscle causes a leash effect and leads Pediatric Ophthalmology, to increased divergence in both up and downgaze. Strabismus and also proposed to be one of the etiological factors Neuroophthalomology, for A and V patterns. Various surgical options Overaction of all four oblique muscles was shown L V Prasad Eye Institue, for pattern strabismus include procedures on to be the cause for X pattern by Brandner et al2 Kallam Anji Reddy Campus, superior/inferior oblique muscles if there is using computer-based simulation model. L V Prasad Marg, Banjara associated oblique dysfunction or transposition Arrow pattern occurs when maximum Hills, Hyderabad 500034, convergence occurs in between the primary and India procedures on the rectus muscles in its absence. Tel: +91 40 3061 2632; downgaze. This is seen in cases of bilateral Fax: +91 40 2354 8271. superior oblique palsy. Clinical features E-mail: [email protected] Lambda pattern is the opposite of Y pattern or [email protected] Presence of pattern strabismus may result in an wherein, maximum divergence occurs between abnormal head posture (AHP) to maintain primary and downgaze. Such a pattern is seen Received: 1 October 2014 with bilateral superior oblique overaction3 or Accepted: 6 October 2014 fusion. For example, a patient with V pattern Published online: 21 exotropia may adopt a chin elevation (Table 1) inferior rectus underaction (over-recessed or November 2014 to keep the eye in downgaze where the slipped muscle). Pattern strabismus, A pattern, V pattern R Kekunnaya et al 185 Etiopathogenesis An imbalance of the cyclovertical muscles was also proposed to be one of the mechanisms for pattern In 1897, Duane described V pattern in a patient with strabismus. It was thought that, while an A pattern bilateral superior oblique palsy.4 Measurements of occurs when inferior rectus underacts and yoke superior deviation in up and downgaze was popularised by oblique overacts, a V pattern is noted when superior Urrets-Zavalia5 in 1948. The worldwide accepted term of rectus underacts and yoke inferior oblique overacts.10 A and V patterns was coined by Urist.6 The role of This theory has also been abandoned due to lack of oblique muscle dysfunction was described by Knapp7 in adequate evidence. 1959. He also recommended surgeries on oblique muscles to treat A and V patterns. About 12.5–50% of the patients with horizontal strabismus may have coexisting A and V patterns.3–5 Oblique muscle overaction or underaction Spina bifida was associated with A pattern in 31% of the This theory is most popular and widely accepted and cases.8 was put forward by Knapp7 in 1959. It is based on the Etiology of pattern strabismus has evolved through fact that abduction is the tertiary action of oblique many theories. Though there are various schools of muscles. Thus a primary or secondary overaction of the thought, there is no unanimity regarding the exact inferior oblique muscle leads to increased abduction, pathophysiology of pattern strabismus. Proposed especially when the eye is in elevation. This leads to a V etiological mechanisms can be mechanical (peripheral) pattern. Vice versa is seen when the superior oblique and neural (central).9 muscles are overacting. In clinical practice, usually this type of oblique muscle dysfunction is observed to be Mechanical factors associated with pattern strabismus. Classification of eye movement abnormalities and According to the theory of horizontal muscle overaction,6 strabismus (CEMAS)—a national Eye Institute sponsored an imbalance between the actions of the rectus muscles workshop referred superior oblique overaction as leads to pattern strabismus, for example the medial overdepression in adduction and inferior oblique rectus muscles overact in downgaze and lateral rectus overaction as overelevation in adduction.Therefore, muscles overact in upgaze giving rise to a V esotropia. ‘overelevation/overdepression in adduction’ is a Conversely, an A pattern arises when the medial rectus generalized term where oblique dysfuntion is one of the muscle underacts in downgaze and lateral rectus muscle causes for the same. underacts in upgaze. However, this theory has been disproved by electromyographic studies that showed that electrical activity of horizontal rectus is similar in pattern strabismus and other incomitant strabismus. Anomalies of orbital structures Anatomical factors like craniofacial anomalies, Table 1 Showing AHP in A and V pattern hydrocephalus, and heterotopy of muscle pulleys Chin up posture A esotropia, V exotropia demonstrate pattern strabismus owing to abnormal Chin down posture A exotropia, V esotropia vector force. Patients with mongoloid slant are seen to Figure 1 Preoperative (a) and postoperative (b) photographs of a patient who had Y pattern due to Brown syndrome, who underwent superior oblique tenotomy. Eye Pattern strabismus, A pattern, V pattern R Kekunnaya et al 186 have A esotropia and V exotropia, whereas patients with pattern strabismus and dissociated vertical deviation antimongoloid slant have V esotropia and A exotropia.11 (DVD). The ‘theory of sagittalisation of oblique muscles’ as a cause of pattern strabismus was put forward by Gobin12 Could A pattern strabismus be a special form of skew According to this theory, reduction in angle between deviation? visual axis and muscle axis results in cyclophoria that is compensated by contraction of respective cyclovertical Donahue and Itharat17 reported 13 cases of A pattern muscles, thereby resulting in overelevation or strabismus with neurologic abnormalities like overdepression in adduction. hydrocephalus, spina bifida, perinatal stroke, and global Pseudoparalysis of superior oblique and V pattern developmental delay. In all, 11 out of 13 patients had no may be seen in plagiocephaly owing to shallow orbit on difference in vertical misalignment during right and left affected side.13 Similarly pseudo A pattern may be seen head tilts. Hence, they proposed that in A pattern in patients with hydrocephalus.8 strabismus, damage to utricular pathways resulted in decrease in anterior semicircular canal input and increase Abnormalilties of extraocular muscle (EOM) pulleys in posterior semicircular canal input that causes increased bilateral depressor tonus of superior oblique EOM pulleys are condensations of posterior tenon’s and inferior rectus muscles. However, the superior capsule composed of collagen, elastin, and smooth oblique muscle is an incyclotorter and the inferior rectus muscles, which act as the functional origin of EOMs. muscle is an excyclotorter, which should
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