Klainguti G, Lang J
Hôpital Ophtalmique Jules Gonin, Service Universitaire d'Ophtalmologie Lausanne.
Klin Monbl Augenheilkd. 1995 May;206(5):359-64. doi: 10.1055/s-2008-1035462.
Typically, bilateral superior oblique palsies manifest with small vertical deviation in primary position, reversing in lateral gaze, with a positive headtilt test on both sides, a V pattern, and a chin-down head position. In primary position, excyclotropia often exceeds 10 degrees and markedly increases in inferior gaze.
Retrospective study of 21 patients with bilateral SO palsy who underwent operations including various surgical techniques such as SO tucking, inferior oblique recessions and inferior rectus weakering procedures (recession, posterior fixation). Preoperative symptoms of this group of patients was compared to those of 60 patients with unilateral SO palsy.
No significant difference was found between cases operated with complete SO tucking and cases operated with specific surgery on the anterior part of the tendon when pre- and postoperative excyclotropia was compared. Severe excyclotropia in primary gaze, markedly increasing in downgaze, was found to be statistically significantly associated with bilateral lesions (p = 0.001).
Bilateral SO palsy, even when highly asymetrical, can be surely diagnosed by carefully measuring excyclotorsion in both primary and downgaze by using dissociating devices. To avoid iatrogenic postoperative Brown syndrome it is recommended to adjust the amount of bilateral superior oblique tucking peroperatively, according to the degree of tendon extensibility. In cases of very severe excyclotorsion such a procedure can be completed by mild bilateral simultaneous inferior oblique recessions.
典型的双侧上斜肌麻痹在第一眼位表现为小度数垂直斜视，向侧方注视时垂直斜视度数反转，双侧歪头试验阳性，呈V征，头位下颏。在第一眼位，外旋转斜视常超过10度，在下转注视时明显增加。
对21例接受手术的双侧上斜肌麻痹患者进行回顾性研究，手术包括各种手术技术，如双侧上斜肌折叠术、下斜肌后徙术和下直肌减弱术（后徙、后固定）。将该组患者的术前症状与60例单侧上斜肌麻痹患者的症状进行比较。
比较完全性双侧上斜肌折叠术和肌腱前部特定手术的患者术前和术后外旋转斜视度数，未发现显著差异。发现在第一眼位的严重外旋转斜视在下转注视时明显增加，与双侧病变在统计学上显著相关（p = 0.001）。
即使双侧上斜肌麻痹高度不对称，通过使用分离装置仔细测量第一眼位和下转注视时的外旋转斜视度数，也可明确诊断。为避免医源性术后Brown综合征，建议术中根据肌腱伸展程度调整双侧上斜肌折叠的量。对于非常严重的外旋转斜视病例，可通过轻度双侧同时下斜肌后徙术完成该手术。
