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The information about superior rectus (SR) recession in cases with SR contracture coexisting with superior oblique palsy (SOP) is very limited in previous literature. The aim of this study is to evaluate the effect of SR recession, as a combined procedure with inferior oblique (IO) disinsertion, in long-standing SOP with secondary SR contracture.The medical records of the 145 patients operated for SOP were retrospectively reviewed and 15 patients who underwent SR recession met the inclusion criteria. The mean follow-up was 50.4 months.The preoperative angle of deviation was within the range of 16-35 prism dioptres (PD) with a mean of 23.0 ± 5.03 PD. In all of the cases, SR recession was performed in combination with IO disinsertion. Adult patients (12) underwent adjustable SR recession. Postoperative overcorrection developed in 3 cases (20%), and in 12 patients, the postoperative vertical deviation was within the range of 0-5 PD with a mean of 1.41 ± 1.88 PD. The overcorrected three patients underwent botulinum toxin A (BTXA) injection into the ipsilateral inferior rectus muscle. The deviation is well controlled by BTXA injection in two patients, whereas the other one was considered as masked bilateral SOP and underwent IO disinsertion in the other eye.Our results suggested that SR recession in combination with IO disinsertion is an effective procedure to control large vertical deviations in SOP with SR contracture in the majority of cases. However, the risk of overcorrection should be considered despite adjustable SR weakening and BTXA injection seems efficient to rescue overcorrections in long term.

A retrospective review of the Toxin Clinic database was carried out over an 18-year period. We identified 68 patients with esotropia of 20 prism dioptres and under who were treated with Botulinum toxin. There were 47 females and 21 males, with a mean age of 34 years (range 11-78 years). Thirty-two (47%) patients had residual esotropia, 20 (29%) had primary esotropia, 11 (16%) had consecutive esotropia, 4 (6%) had secondary esotropia and 1 (1.5%) had a decompensating esophoria. The mean pre-toxin angle was 16 prism dioptres (range 6-20). A total of 434 injections were given, with an average of 6 per patient (range 1-36). Forty-five (66%) patients underwent continued toxin treatment with an interval of 3 to 31 months. Thirteen (19%) patients achieved long-term benefit from only one injection. Seven were unable to demonstrate binocular vision pre-injection but demonstrated it post-injection. Following an initial injection, nine (13%) patients proceeded to surgery. Botulinum toxin was a successful treatment for these patients and was well tolerated, with no side effects. It appears to have a definite role in the treatment of small-angle esotropia.

We determined the vergence position of rest (horizontal component) in two sessions, 1 to 6 weeks apart. Each session contained 8 trials. Twenty observers with normal eyes looked through Risley prisms that allowed a continuous modulation of their strength. We asked the observers to look at a fully fusionable picture, and to adjust the prisms such that viewing appeared most relaxing. The viewing distances were 400 cm and 50 cm.The standard deviation among the 8 trials of each session, averaged over the two sessions, the viewing distances of 400 cm and 50 cm, and the 20 observers, was + or -1.4 prism dioptres (cm/m). From the first session to the second, many observers changed the preferred prism significantly. At a viewing distance of 400 cm, 10 of 20 observers changed their preferred prism by more than 1.0 prism diopter, up to 3.3 prism diopters. At a viewing distance of 50 cm, 11 of 20 observers changed their preferred prism by more than 1.0 prism diopter, up to 5.1 prism diopters.The prismatic strength estimated as being most relaxing can be very variable. Before considering a prescription, the practitioner should determine whether the preferred prismatic strength remains reasonably stable. To ascertain this consistency, more than one session seems to be necessary.