Selective management of double elevator palsy by either inferior rectus recession and/or knapp type transposition...

Double elevator palsy (DEP) is a monocular elevation deficiency in abduction and adduction characterized by hypofunction of the superior rectus (SR) and inferior oblique muscles. Only a limited number of studies are published on the management of this problem. Therefore, we studied and report and add our experience with emphasis on the indications and types of surgery for DEP.

The records of 18 patients with DEP out of 3612 strabismic cases (0.5%) were reviewed. Fourteen underwent surgery. Inferior rectus (IR) recession was performed in cases with positive forced ductions (Group 1, n=6). In patients with negative forced duction test (Group 2, n=8) and in patients whose vertical deviation was not corrected with IR recession, transposition surgery (Knapp or modified Knapp procedure) was performed. A hypotropia of less than 5 PD postoperatively was considered a "successful" outcome.

In Group 1, "IR recession only", the mean preoperative vertical deviation was 29.2 PD +/-3.8 PD SD. The vertical deviation was adequately corrected after IR recession in only one patient; the other 5 patients then underwent transposition surgery at 6 months postop'. After the second operation, the mean corrected deviation for Group 1 overall was 25.8 PD +/-5.6 PD with an overall 33% surgical success rate. In Group 2, "primary transpositions", the mean preoperative vertical deviation and the mean corrected deviation were 23.9 PD +/-6.7 PD and 18.6 PD +/-4.4 PD respectively, and the surgical "success" rate was 63%. The mean corrected deviation for all cases was 21.7 PD +/-4. 9 PD and the overall surgical "success" rate was 57%.

Surgical intervention should be selective according to DEP clinical features. The surgical effect of transposition surgery may be enhanced by IR recession.