Double elevator palsy(DEP) is characterized by monocular limitation of upgaze in both abducted and adducted position. It is often associated with hypotropia, blepharoptosis, and pseudoblepharoptosis of the affected eye. The authors experienced a case of primary inferior rectus restrictive type of DEP, which has showed hypotropia of 40 prism diopters, and blepharoptosis on the right eye. Examinations revealed poor Bell's phenomenon, and forced duction test showed the limitation of elevation on the right eye. Surgery was performed with 6mm recession of the right inferior rectus. Postoperatively the elevation of glove was satisfactory, Bell's phenomenon was improved and primary position was also orthophoric. Correction of blepharoptosis with frontalis slinging could safely performed in the presence of adequate Bell's phenomenon after the inferior rectus recession.
Blepharoptosis* ; Elevators and Escalators* ; Paralysis*

Double elevator palsy(DEP) is rare paralytic anomaly of ocular motility due to monocular paresis of both elevator muscles. Clinically, DEP is classified into the pure paralytic, restricted and mixed types. The authors describe the clinical experiences of 2 cases of purely paralytic type of DEP and 2 cases of restricted type of DEP treated at Department of Ophthalmology, Pusan Pail, Hospital, Inje Medical College from January 1988 to January 1991. The results were as follows: 1) In the pure paralytic type of DEP, the hypotropia was below 30 prism diopters in the primary position and in the restricted type, greater than 60 prism diopters preoperatively. 2) Preoperatively, the pseudoptosis was shown in 2 cases of purely paralytic type of DEP and it was disappeared postoperatively. The Bell's phenomenon was shown the negative result in 2 cases of restricted type of DEP. 3) For the pure paralytic type, the both vertical and horizontal deviation were corrected completely in primary position by the transposition and recession of the horizontal rectus muscles at one surgery and the limitation of ocular motility remained more and less in the elevation postoperatively but no limitation in the adduction and abduction. For the restricted type, the tenectomy of the inferior rectus muscle corrected about 40 prism diopters of hypotropia without the limitation of the infraduction.
Busan ; Elevators and Escalators* ; Muscles ; Ophthalmology ; Paralysis* ; Paresis

Although a patient with lost inferior rectus (IR) muscle woud be done infratransposition of the horizontal recti to control hypertropia, this procedure only could control ocular deviation at primary position, but could't improve the limitation of the downgaze markedly and could cause limitation of abduction and adduction. Authors tried to correct lost IR with anterior transposition of the inferior oblique muscle(IO) with marginal myectomy in the theoretical base that the anterior transposition of the IO can convert IO a depressor from an elevator. A 66 year-old female patient received trauma on her left IR muscle by sickle, then primary deviation of left eye was hypertropia of 50 prism diopters, exotropia of 35 prism diopters and secondary deviation was hypertropia 60 prism diopters, exotropia of 40 prism diopters and the degree of limitation of infraduction was -4. We performed anterior transposition of the IO with marginal myecctomy of 6.0 mm and lateral rectus (LR) 6.0 mm recession and medial rectus (MR) 4.5 mm resection of the left eye. The postoperative ocular alignment at primary position was exotropia of 10 prism diopters and degree of limitation of infraduction was -2 and limitation of supraduction was -2. The anterior transposition of IO with marginal myectomy was simple and effective in correcting the hypertropia and ocular motility in a case of lost IR.
Aged ; Elevators and Escalators ; Exotropia ; Female ; Humans ; Strabismus

Double elevator palsy (DEP) is an unusual anomaly of ocular motility in which both elevator muscles of the same eye are weak with a resultant inability or reduced ability to elevate the eye and hypotropia. This anomaly is occured congenitally, but occasionally occured as an acquired form. Congenital DEP, which is main cause of the monocular elevation paralysis, is characterized by the progressive deterioration and the absence of diplopia. The etiology is obscure, but is thought to be supranuclear lesion. We observed DEP of the same side of eyes in two patients who were brothers. The limitation of elevation and hypotropia were improved after Knapp's transposition procedure or Jensen's procedure.
Diplopia ; Elevators and Escalators* ; Humans ; Muscles ; Paralysis* ; Siblings*

We built a mathematical model of the eye based on the method of Robinson and improved it. It was programmed with C language. With this model several types of paralytic strabismus including superior oblique paralysis, oculomotor nerve paralysis and double elevator paralysis were simulated. Then we performed various surgical procedures such as recession, resection of horizontal recti, transposition, myectomy. Scott's procedure on these simulated squints and analyzed the results. We tried to show the usefulness and limitation of simulation.
Elevators and Escalators ; Models, Theoretical* ; Oculomotor Nerve Diseases ; Paralysis ; Strabismus*

We built a mathematical model of the eye based on the method of Robinson and improved it. It was programmed with C language. With this model several types of paralytic strabismus including superior oblique paralysis, oculomotor nerve paralysis and double elevator paralysis were simulated. Then we performed various surgical procedures such as recession, resection of horizontal recti, transposition, myectomy. Scott's procedure on these simulated squints and analyzed the results. We tried to show the usefulness and limitation of simulation.
Elevators and Escalators ; Models, Theoretical* ; Oculomotor Nerve Diseases ; Paralysis ; Strabismus*

PURPOSE: Isolated inferior oblique weakening procedure is an effective treatment for patients with superior oblique muscle palsy who had up to 15 prism diopters (PD) of vertical deviation in the primary position, but 2-muscle surgery is needed for patients with larger deviations. Herein, we report the surgical results of simultaneous 2-extraocular muscle surgery for large primary position hypertropia 16 PD or more caused by superior oblique palsy. METHODS: This study was a retrospective review of the records of patients who presented with central gaze hypertropia 16 PD or more and underwent simultaneous 2-extraocular muscle surgery between January 2003 and June 2014 in Severance Hospital. The patients were divided into 3 groups: 43 patients who underwent inferior oblique (IO) myectomy and contralateral inferior rectus (IR) recession (Group 1), 10 patients who underwent IO myectomy and superior rectus (SR) recession (Group 2), and 8 patients who underwent SR recession and contralateral IR recession (Group 3). Criteria for success included correction of head posture and a primary position alignment within 5 PD of vertical deviation. RESULTS: Mean preoperative alignment at primary gaze was 25.5 ± 7.1 PD (range, 16-60 PD) compared to the postoperative value of -1.3 ± 6.8 PD (range, -20~25 PD) (p < 0.001). Surgery was successful in 49 (80%) patients. Nine (15%) patients were overcorrected and the other 3 (5%) patients were undercorrected. Success rate was the highest in subjects who underwent IO myectomy and contralateral IR recession. Among the 24 patients who did not receive combined horizontal muscle surgery, horizontal deviations decreased from 10.4 ± 2.7 PD to 1.5 ± 5.5 PD (p < 0.001) CONCLUSIONS: Two-muscle surgery can be effective in patients with large hypertropia 16 PD or more. Additionally, horizontal deviations are more likely to be resolved with vertical muscle surgery alone. However, IO myectomy combined with ipsilateral SR recession can cause overcorrection postoperatively, so surgical dose should be reduced when performing weakening procedure of two elevators in one eye.
Elevators and Escalators ; Head ; Humans ; Jupiter ; Paralysis* ; Posture ; Retrospective Studies ; Strabismus*

PURPOSE: To report the effectiveness of adding distal fibular external rotation stress test on the traditional lateral stress Cotton test in evaluating distal tibiofibular syndesmotic injuries. MATERIALS AND METHODS: We evaluated syndesmotic injuries with intraoperative stress test during treating ankle fractures from March 2009 to September 2010. External rotation of distal fibula using small elevator was added on traditional stress test in case of suspicious syndesmotic injury. We retrospectively reviewed and compared the results of each test in 44 cases for which we tried both tests. RESULTS: In 9 cases of positive traditional lateral stress tests, positive results were obtained in all cases by additional external rotation tests. In 21 cases of negative traditional stress tests, additional stress tests results were also negative. But there were 10 cases of positive additional tests and 4 of negative additional tests in equivocal results cases by the traditional stress tests. CONCLUSION: Using additional external rotation stress test in case of equivocal test result by the traditional lateral stress Cotton test for evaluation of syndesmotic injury during operation for ankle fracture can be a supplemental method to clarify syndesmotic injury needs fixation.
Animals ; Ankle ; Elevators and Escalators ; Exercise Test ; Fibula ; Retrospective Studies

The philtral unit plays a key role in the appearance of the upper lip. And making the philtral column is extremely important in unilateral cleft lip repair for natural looking lip. Previously, we have been satisfied with the well matched white line & cupid bow, even though that is flat lip. But symmetrical upper lip and symmetrical philtral unit is necessitated So author analysed philtral column anatomy and cleft lip anatomy to make a symmetrical philtral unit, Ipsilateral orbicularis oris fiber attached to the philtral column, labial levator muscles including levator labii superioris and thickened dermis of philtral column area have the major role to make a philtral column. And in the cleft lip anatomy, deviation of septum and lateral muscle bulge were the obstacles to make a philtral cloumn in primary cleft lip repair. Author tried to make a philtral column in secondary cleft lip with several methods and concluded that it is not easy to get a satisfactory result. Based on upper trial and experience, author hypothesized two considerable points(prerequisites) in making a philtal column. 1) Relief of tension 2) Skin excess over the repaired muscle of the lip. To relieve tension, author used intraoral orthopedic appliance to narrow alveolar gap. The deviated septum was dislocated and fixed to the midline point and cinching was done. Supraperiosteal dissection near the pyriform apperture was also done. Above mentioned techniques are the solving way to fill the two prerequites. In the primary cleft lip repair, to get symmetrical philtral unit, author tried weakening of non-cleft side philtral column and formation of cleft side philtral column. To weaken the prominent philtral column, septum transfer to midline and cinching were performed. To prevent making nostril sill depression, the author performed lengthening technique of nasal lining flap of nostril sill area for reconstruction of the philtral column. lengthening of nostril sill area. Regarding lateral muscle bulge, spreading of muscle suturing are needed. Supraperiosteal dissection to release of insertion of labial elevator muscles and beveled incision of vertical incision has the effect of philtral column formation. We performed 462 cases of unilateral cleft lip repair from 1990 to 1999. In most cases, we did not get flat lip in the repaired cases and we could get good appearing of philtral unit. Author think primary repair is the optimal time and Millard technique and above mentioned methods are the method of choice to make a philtral column.
Cleft Lip* ; Depression ; Dermis ; Elevators and Escalators ; Lip ; Muscles ; Orthopedics ; Skin

Double elevator paralysis is a syndrome in which the superior rectus and the inferior oblique muscle of the same eye are paralyzed. The authors have experienced a case of double elevator paralysis with 35 prism diopters hypotropia and 20 prism diopters exotropia on the right eye. The patient was 19 years old female who visited our hospital because of poor cosmetic appearance. Knapp procedure was performed primarily to correct hypotropia, but 20 prism diopters hypotropia remained. 5 months later, a second operation was performed consisted of 7.5 mm recession of the left lateral rectus and 5mm recession of the right inferior rectus in order to correct the exotropia and residual hypotropia. After the second operation, ocular position in primary position was nearly orthophoric and upward movement of the right eye was considerably improved.
Elevators and Escalators* ; Exotropia ; Female ; Humans ; Paralysis* ; Young Adult