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American Orthoptic Journal Back ContentTo request a single copy of any journal article, contact us at: 608 263-0654 (voice), or journals@wwwtest.uwpress.wisc.edu (email). Articles will be photocopied and mailed within two business days. Please prepay with VISA or MasterCard. Articles up to 29 pages in length are priced at $15.00. Articles containing 30 or more pages are priced at $25.00. For article reprints in quantities of 25-500 please use our online reprint ordering system by clicking Reprint Orders.
Volume 41, 1992, p. 26–27 Reflections on the Superior Oblique Muscle I am honored and pleased to be included among your speakers on your 50th Anniversary program. My only complaints are why wasn't my C.O. included in the printed program and the subject of my talk, "Reflections on the Superior Oblique." Reflection in Webster's Dictionary is defined as (1) looking at one's reflection in a mirror, (2) reproach, blame or discredit as a reflection on this honesty, or (3) thought, especially of a meditative, backward turning nature. In spite of this, my association with certified orthoptists has been a very happy, instructive one starting with Elsie Loughlin in Iowa City, followed by Nancy Capobianco in Boston, when I was a fellow with Hermann Burian and then at Columbia-Presbyterian where she trained Sally Moore who has headed our Orthoptic Department for over 30 years. During this time Ms. Moore and I have had a close association as she saw all of my private patients before surgery and frequently after surgery.
One of our main problems was surgery of the superior oblique. One reason is that this was the era of A and V syndromes, now called patterns, that was instigated by Martin Urist,1 graphically named by Dan Albert and Frank Costenbader, and left to the rest of us to figure out how best to treat. I had seen a fair amount of inferior oblique surgery at Iowa City but saw superior oblique surgery first in St. Louis with Scobee in the winter of 1951. In 1952, when I started running the Monday Muscle Clinic at Columbia Presbyterian, I gradually got convinced that surgery on the superior oblique was necessary to treat these patterns successfully. Fortunately, I had Ray Berke to teach me how to weaken the action of the superior oblique by his intrasheath tenotomy operation,2 but I had to learn how to strengthen the superior oblique by reading from John McLean's AOS thesis.3 He preferred the tucking operation done on the temporal side of the superior rectus-his #3 procedure.
My first experience was a V pattern esotropia on a clinic patient. I did the tuck on the right side and then helped the resident on the left side. Fortunately, this worked out beautifully as it collapsed the V pattern and I was hooked. The problem with superior oblique surgery is that it is technically difficult and mistakes can be catastrophic. This led me to try vertically shifting the insertions of the horizontal recti to correct these patterns.4 This worked but was insufficient to correct the significant patterns with oblique dysfunction-so back to the superior oblique to work out operating procedures as bug-free as possible.
This led to treating IVth nerve palsies which have been a special interest of ours (Ms Moore and me). She saw cases fro the entire Medical Center whereas I only saw my private and clinic patients. Our clinic stresses measurements, particularly in the cardinal fields. This showed how the fresh, mainly from closed head trauma, cases spread into different patterns. This formed the basis for the classification of superior oblique palsies that was the first Scobee Memorial Lecture in 1970 at the Academy Meeting.5 At that time there were five classes and the various surgical options for each class.
In the next three years, two more classes were added: VIth or "bilateral," and VIIth "Canine Tooth." The Canine Tooth Syndrome results from direct trauma to the peritrochlear area producing a paresis plus a Brown's syndrome due to scarring. Three of the first seven cases followed dog bites-hence the name, but the most common cause is fronto-ethmoidal sinus surgery.6 The 8th class called "IV A," which was added by Jim Sprague last year for our course at the Academy, consisted of a large vertical deviation in all fields, frequently more on the non-paretic side. Meanwhile, Peter Fells7 had brought the Harada-Ito procedure to our attention from the Japenese literature. This procedure consists of altering the anterior half of the superior oblique tendon to correct torsion withou effecting the vertical deviation. Arthur Jampolsky8 had reintroduced adjustable sutures. Both were added to our therapeutic armamentarium.
Adjustable sutures have been particularly helpful in treating the dissociated factor that is present in nearly 90% of the early onset "congenital" IVth nerve cases according to Ms. Moore. The diagnosis of a dissociated vertical deviation may be obvious or subtle. In the obvious cases the deviation is much larger than the rotations would explain and frequently shows no torsion. Also, after neutralizing the paretic deviation with prisms, both eyes come down on alternate cover tests. The subtle cases show no torsion and in congenital cases the head tilt is opposite to what you would expect from the superior oblique paresis. Recession of the superior rectus, preferably on an adjustable suture, is the procedure of choice for these cases. Jampolsky9 also has introduced the concept that the spread across the bottom fields may be due to contraction of the ipsilateral superior rectus. Therefore, the ipsilateral superior rectus should be recessed in all these cases, preferably in an adjustable manner. My own feeling is that conjunctival recession superiorly should be done on all these patients and that the superior rectus should be placed on an adjustable suture in case you may need it.
With all these additional modifications we now feel quite secure in our ability to correct this problem until something new and different comes along.
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