These thoughts and actions taken by Dr Muhammad Azeem, written with the help of ChatGPT.
Two Children, Two Stories, One Common Muscle
A Challenging Clinical Scenario
On the same day, two children visited me. They were very different in age and presentation, yet their conditions overlapped in an interesting and important way.
The first was a 7-month-old baby diagnosed with infantile esotropia. The second was a 10-year-old boy who complained of double vision, which improved when he tilted his neck. On examination, the most probable diagnosis in the older child was congenital superior oblique palsy.
At first glance, these diagnoses seem unrelated. One is an infant with a horizontal deviation, the other an older child with vertical diplopia. But clinically, they intersect.
Where the overlap begins
Both conditions commonly lead to hypertropia. And in both cases, treatment often involves weakening the inferior oblique muscle, usually by inferior oblique recession.
The reason they reach this same surgical pathway, however, is very different.
Infantile esotropia and DVD
In infantile esotropia, the primary problem lies in the horizontal muscles. If these horizontal muscles are treated surgically at the right time, ideally between 6 months and 12 months of age, many secondary problems can be prevented.
One such secondary problem is dissociated vertical deviation (DVD), where the eye elevates along with the horizontal deviation. DVD develops in nearly 80 to 90 percent of children with infantile esotropia.
The mechanism of DVD is complex. These children develop binocular single vision (BSV) late, or sometimes not at all. If horizontal alignment is delayed beyond the optimal age, DVD becomes more pronounced. At that stage, inferior oblique recession may be required to control the vertical component.
This is why timely horizontal muscle surgery before or around 12 months of age is so important. It can significantly reduce the severity of DVD and the need for additional muscle surgery later.
Congenital superior oblique palsy
The second child presented very differently. He was older and could clearly describe his symptoms. He reported diplopia that improved with neck tilt, a classic compensatory posture.
In such cases, diagnosis is often delayed. As the child grows, the neck tilt becomes more noticeable, and the certainty of symptoms increases.
Here, careful evaluation is critical. The double Maddox rod test and Parks three-step test are two important tools that help confirm the diagnosis. For small hypertropias, a trial of prism can sometimes relieve the double vision.
Once the diagnosis is clear, surgery becomes the next step. Inferior oblique recession is commonly performed to weaken the overacting muscle. Some surgeons also suggest inferior oblique myectomy.
The unanswered question
The goal of surgery in congenital superior oblique palsy is to improve double vision and reduce abnormal head posture. But an important question remains: will inferior oblique weakening fully resolve the diplopia and neck tilt?
In many cases, it helps. In others, some residual symptoms persist. This grey area is something every strabismus surgeon encounters and must discuss honestly with the family.
A shared lesson
These two children reminded me how different paths can lead to a similar anatomical problem. One highlights the importance of early intervention. The other emphasizes careful diagnosis and thoughtful planning.
Both reinforce the same lesson:
timing, observation, and understanding muscle balance are everything in pediatric strabismus.
#infantile_esotropia #surgery #time #DVD
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