 Morning everybody we're going to get started So we we have two presenters this morning The second one who I'm not going to come back up and introduce is Lloyd Williams He's back there. He's going to show some pictures and share some stories from his recent trip with to the South Sudan And the first presenter I wanted to introduce Dr. Mariel Young She recently gave a talk to the residents and invited us to call her Mimi I don't know if that invitation is open to everyone or not, but She's shaking her head. Yes She is one of our new faculty in the pediatric ophthalmology division and She is from here originally she went to East High School and went to medical school here at the University of Utah So some of you may know her Completed her residency at UCSF and and then recently completed her pediatric ophthalmology fellowship at the Children's Hospital of Boston She's excited to be here. She's been seeing patients out at the Riverton primary children's location and we look forward to her talk Thanks Grant. I'm going to talk about ocular torsion today and how we diagnose and treat it I Did my fellowship at Children's Hospital Boston and did a lot of adults so I do like seeing adults as well as children and this talk kind of Centers a little bit more on the adults to business part of my practice so I'm kind of gonna center my talk around a case and this is a Woman from fellowship and this is a 61 year old woman who came in complaining a different vision in both eyes She didn't really describe it as double vision But when you talked to her a little bit more it was clear that that was she was she was talking about but just said She had a really hard time sometimes when she had moved her eyes into different positions of gaze and Was really bothered by this particularly with walking and looking down and going downstairs This had come up since she had a motor vehicle accident eight months prior. This is a pretty severe injury that After which she wound up in coma and was in the ICU for a couple of months On exam in the clinic. She had really excellent vision in each eye and just minimal refractive error Her pupil examination was normal Her slit lamp exam just showed a little bit of cataract and her dilative funnest exam was pretty unremarkable Here's just a look at her ocular motility. You can see just briefly looking at it doesn't seem like there's anything grossly wrong Just looking initially just at her straight-ahead position. She actually looks pretty orthotropic here Just I know many people get Anxious when they see big pictures like this and have a hard time Initially looking at them or breaking them down, but if you just look at her Start by looking at her horizontal gaze. You can see that when she looks to the right Perhaps maybe her left eye is just a little bit higher So maybe she's got a little bit of inferior oblique over action going on here, but but pretty mild And if you look this way you can see that she has her left When she looks into left gaze her right eye is just a tiny bit higher, but maybe even a little bit less so Also just breaking it down into her vertical Gases here. You can see when she looks down. She maybe has a little bit of esotropia She looks up maybe a little bit less so but these are pretty mild overall Nothing that really jumps at you. She also has seems to have a little bit of a Deviation in primary gaze they could still be pretty debilitated by What's what they have a down gaze because you do so many things in down gaze you read in down gaze You go up and downstairs and down gaze so this is a really important thing to check because it can really be difficult for people to deal with You can also see that she has a right hypertrophy on right head tilt no left hypertrophy on left head tilt So just kind of breaking this down. We have a woman by the V pattern esotropia What looks like on right gaze a left hypertrophy and I'm left gaze a right hypertrophy Any thoughts on what she could have Yeah, exactly exactly So in these patients who come in with a vertical deviation story like this It's really important a really important part of the puzzle is Assessing their ocular torsion because even though they have a small amount of deviation They can have quite a bit of ocular torsion that can be difficult for them to fuse and we could do that a couple of different ways In this woman With double mattox rod testing she had about 12 degrees of x-cycle a torsion which can be more than most people can fuse Usually we can fuse up to about eight degrees And then another way we can assess it is anatomically just looking at their fundus and she had Quite a bit of x-cycle torsion a little bit more in the right eye than the left eye And I'm gonna talk a little bit more about that So I'm probably gonna talk about the anatomy of the eye and how it relates to ocular torsion how we assess ocular torsion using the head tilt test double mattox rods looking at the fundus Conditions in which we see abnormal torsion such as superior bleak palsy skewed deviation and then briefly at the end about Some surgical considerations come back to my case so torsional strabismus is the abnormal rotation of the eye around the visual axis and is usually caused by the malfunction of the Cycle vertical muscles Like I said before patients can usually compensate for about eight degrees of x-cycle torsion or in in cycle torsion either way We more commonly see x-cycle torsion than in cycle torsion and as I said before it's a very important part of the examination And any patients with vertical strabismus even when they don't have torsional complaints Even when they don't say I see one image and then I see another that's tilted It's important to assess for it because it can be an important part of your management It's caused by either the malfunction of cycle vertical muscles or by Anatomic orbital pathology such as in patients with craniocynostosis where they really have x-cycle Rotated orbits usually these patients don't really complain of it, but they can but they can have findings on Dilated exam So just briefly to remove to review our superior muscles in tort the eye So some people say the superior people are in the in-crowd so our superior rectus superior obliques in tort whereas our inferior muscles X tort The head tilt test and is a is an important part of the three-step test and three-step test is something We often see on OCAPs and boards and things like that and I'm just going to explain a little bit about how that head tilt test works So tilting your head simulates torsion. So when you tilt your head to the right your right eye in torsion To compensate You have two muscles that are Torsionally acting there so your superior bleak and your superior rectus are both in toward in your eye These muscles also have vertical action. So while the superior bleak is in toward of your eye It's also pulling your eye down whereas your superior rectus is You know in towarding your eye and also pulling your eye up in a normal eye These are you know counterbalanced and key and But in an eye that has a palsy such as the superior bleak palsy like in this patient here You can see that the superior rectus is going to overwhelm and pull up harder than the palsy superior bleak is going to pull down So when you're tilting this head to the when she's tilting her head to the right She's going to have a right eye that's higher than her left eye Whereas when she tilts her head the other way those same tortors are going to relax and Gonna let the right eye X tort So you can see that when she's tilting to the right. She's got a right hypertrophy of it when she tilts to the left She looks pretty straight The three-step test is an important test to identify an isolated acute vertical muscle weakness so doesn't really work in complex deviations doesn't really work in old deviations that become comatine over time and Doesn't really work in so well in patients who have vertical muscle contracture So just briefly to go over the three-step test if you have a right hypertrophy You want to circle the muscles that either pull the right eye down or the left eye up So that would be the and this is kind of you're looking at a patient here. So this is the Right inferior rectus right superior bleak left inferior oblique or left superior rectus Then you look at either their gaze right or gaze left And if it becomes more in their gaze right then you want to circle the muscles on the patient's right here And then finally you assess which side is worse on their head tilt And if the deviation is worse on their tilt went to the left Then you're going to tilt your circles to the patient's left and this is again your patient looking at you So in this patient only one muscles Circle three times and that would be the inferior rectus here So in this case you would be looking at a right an isolated paracetam of the right inferior rectus Superior bleak palsy is the most common cycle vertical muscle palsy that we see can be congenital or acquired Unilateral bilateral those bilateral cases are often missed Because there can be even straight in primary position And it's often associated with an abnormal head posture You can see and some of these kids who come in if you just review their family albums You can see that they're always tilted that way They have an it's lateral hypertrophy that improves with a contralateral head tilt And this is often associated with some facial asymmetry So this kid here has a left superior oblique palsy and you can see that he's tilting to the right a little bit And then he also has this side of his face is just a little bit smaller too That's we see that pretty commonly these congenital cases skew deviation is a comatent vertical deviation That's caused by injury to the posterior fossa structures It's caused by a loss of super nuclear input from the utricle and sacula of the inner ear Causes an ocular tilt reaction where the eyes rotate toward the lower ear on head tilt which is different Well, which from what we said before on head tilt, you know when you tilt your head to the right your right I should Intort so it should rotate towards your upper ear. So that's a different In these patients their deviation doesn't really change when they when they go on head tilt They have complementary torsion where their higher eye is in toward it their lower eye is X toward it And it diminishes in the supine position So you can have them look straight ahead measure their vertical deviation then lay them back in the chair have a look at something On the wall and see and recheck their vertical measurement. It should decrease So we look at torsion either objectively or subjectively and the way we objectively We can't really assess it using external markers You can't really look at the outside of the eye and see that it's really toward it But we can't estimate it when we look inside and look at the fundus Subjectively we have the patient kind of tell us how much torsion they think they're seeing So indirect ophthalmoscopy is a good way to look at anatomic torsion. You can also use fundus photography The phobia is usually found in the lower third of the optic nerve this can vary a little bit And the normal intraocular distance is usually less than a quarter of a disc diameter So this is an indirect view of the right eye and you can see that this eye is pretty severely in toward it This is a view we're most Used to looking at is indirectly when we see our patients in clinic looking at the right eye You can see that it's really in toward it a lot the phobia should really be up here this X But the eye is really severely in toward it here We can assess subjective torsion using either double mattocks rods where you have the patients Rotate lenses to align them with either the horizontal or the vertical meridian and you can also use Len Lancaster red-green testing which is more much more cumbersome to do but can be more accurate and sidegazes and looks at looks at horizontal vertical and torsional deviations Double mattocks rod testing just a few little tips for doing that I usually have the patients obliquely orient their lenses at the beginning and then Rotate them to get them to I usually have them Align them with the Prism the rods are aligning vertically, but the line they see is horizontally Sometimes you have to use a base-down prism over one eye too because they start fusing the image of making it into one You can improve this a little bit by darkening the room to eliminate any fusional cues And what you see is what you it what it is meaning when you look at them and they've twisted it And they're a little bit out They are extorted Some disadvantages of double mattocks rod testing. It's useful pretty much only useful in the primary position And the head position is critical which could be tough in these patients because they have such Such a tendency to want to tilt that it's hard to hold their head straight Hold the fenn off and explain to them how to use the little Twisters to get to twist them on also the torsion may localize to the wrong eye. They may localize it to the other eye Lancaster red-green testing is Where we make a diagram of their horizontal vertical and torsional deviations and then nine positions of gaze We use flashlights to project streaks on a calibrated screen. Here's two people performing the test Actually, this is the woman giving the test. Here's the patient taking the test wearing the goggles She shines a flashlight and he kind of lines up his flat lines up a flashlight with hers and One limitation they must have normal retinal correspondence for it to work So here's actually a I don't know my other diagram Here's actually a diagram of a leg Lancaster red-green testing and you can see that this patient has a right inferior rectus contracture Well, and she has a large secondary deviation meaning that when she's fixating with her right eye The deviation is much greater and see that she has a large right Hypotropia and this gets worse in down gaze. Sorry. Yeah, it gets worse in down gaze She also has an isotropia that gets worse in down gaze and mild to moderate X torsion here You can see that it's much better when she's fixating with her left eye. So back to our patient again She had quite a bit of torsion just a little bit of deviation in primary gaze She had more of an ET in down gaze and just to talk a little bit about bilateral superior oblique policy as we've said before It's easily misdiagnosed as they may not have a shift in primary position These patients usually have greater than 10 degrees of X cycle torsion, which means that they can't use it And it can be pretty debilitated by it commonly associated with the V pattern and a chin down posture Sorry, chin down posture to try to put them into a sweet spot So as far as our surgical treatment options For a patient with bilateral superior oblique palsy, you can consider an inferior oblique weakening Which is really good in cases of unilateral superior oblique palsy But not usually enough in patients with bilateral superior oblique palsy can do an inferior rectus recession, which is the inferior rectus as you'll recall is the yolk muscle of the superior oblique so This could be useful in mild cases Superior oblique tuck Which in our patient would be great because it would solve her torsion solve her It would help with her V pattern Also help with her Incommodence where she has a right hypertrophy and left gaze and a left hypertrophy and right gaze the big risk of this procedure is inducing an iatrogenic Brown syndrome, which is not insignificant Mediorectus transposition and you can combine this with a mediorectus recession is also another possible procedure This would help with the esotropia help with the V pattern can with when you transpose it can also help with some of the torsion and the Lateral incompetence and and then lastly the Herata eto procedure, which is a procedure that Mostly just concentrates on solving the torsional problems and doesn't so much deal with the horizontal deviation This patient actually we decided to do a horse on a Herata eto procedure And this is where we advanced the anterior fibers of the superior oblique muscle There's the ones that are thought to be more responsible for torsion Whereas the posterior fibers are more responsible for depressing and abducting the eye So the goal of this procedure is to intuit the eye without significantly changing the vertical alignment And here's actually some pictures I stole from Ken Wright's Atlas where you see you just take that kind of third About a third of the superior oblique muscle and move it over to the superior edge of the lateral rectus muscle to really And tie it down here to change the vector the try to intuit the eye These photos don't turn out well at all But you can see this these are the interoperative photos of the patient and they show pretty significant fundus x torsion here prior to the Herata eto and then after you can see that they can't see but They it's corrected and it looks it looks pretty pretty normal Two months after the surgery she was very pleased. She was now able to walk comfortably without closing one eye She still did have some see some double in extreme down case. So wasn't totally fixed Here's some pictures of her you can see that she has a little bit less of that inferior oblique overaction her She doesn't have as much It doesn't appear in these photos out that she has as much lateral incompetence or as much of a V pattern You can see on her numbers here. She still has some however However, she only has us, you know a small e and her ET is less Although she still does have some ET in down gaze, which is gives does still give her some symptoms So it's kind of your typical strabismus case. We didn't fully solve the problem, but we did make it better She and the big thing here is she now has she's we've flipped her a little bit She has some in-cycle torsion, but she has much less and she's able to fuse that so in summary just Torsion can provide important information in cases of vertical strabismus even in the absence of torsional complaints It's an important part of the exam an important thing to assess both their subjective torsion and their Anatomic torsion we assess anatomic torsion by using indirect ophthalmoscopy We can assess subjective torsion using either double mattox rods or Lancaster green testing And finally, this is my mentor who Many questions say it again. Sorry This way you mean Yeah, it's the superior. It's that it's after the tent. It's after it Hits the troll play is that what you mean here? Yeah, kind of this way it's it's the superior bleak. So you're just taking this the About a third of the muscle here and moving it laterally, but this is a superior bleak I've never heard of them doing it on the inferior bleak at all And come up. Yeah, particularly a problem in people who fuse No, she got in a bad mode. She got a bad MBA and she was it was a dramatic bilateral superior bleak policy I can't remember how long after it was she had stabilized over about six six months Eight months. Yeah, so she had been in ICU two months and then she had been stable for about six months after that Well, thank you very much. Nice to meet you