A nasal approach to a superior oblique tuck in the management of longstanding superior oblique palsy.

INTRODUCTION

Superior oblique palsy (SOP) is the most common cyclovertical muscle palsy, often presenting with vertical misalignment, excyclorotation, and abnormal head posture. The superior oblique tuck (SOT) is a widely accepted treatment option, though carries risks such as iatrogenic Brown syndrome. While a temporal approach is conventionally used, this case presents an alternative nasal approach to the SOT in a patient who had already undergone a temporal SOT.

METHODS

A 71-year-old female presented with persistent diplopia and a left head tilt. Examination revealed right hypertropia and excyclorotation in primary gaze, consistent with right SOP. Initial management with inferior oblique disinsertion yielded little improvement, and a subsequent temporal SOT also failed to correct the misalignment. Given persistent symptoms, a revision SOT was performed, using a nasal approach due to extensive scarring temporally.

RESULTS

Six months postoperatively, diplopia improved significantly in primary and downgaze. Vertical deviation in the left eye reduced from 7Δ BD pre-operatively to 1Δ BU in primary position and from 21Δ BD to 4Δ BD in laevodepression and excyclorotation improved. A mild iatrogenic Brown syndrome resulted, though this improved over time.

DISCUSSION/

CONCLUSION

In conclusion, this case highlights the nasal SOT as a viable surgical option in the management of SOP where alternative treatment options have been exhausted.