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Rhabdomyosarcoma (RMS) originates from undifferentiated mesenchymal cells that give rise to striated muscles. The symptoms of para-meningeal RMS often resemble those of allergic rhinosinusitis, including nasal congestion, mucus discharge, headache, and occasional nosebleeds. We report a child with atypical clinical presentation of ocular hypertropia secondary to para-meningeal RMS. A child presented with an upward deviation of the left eye. He had a history of blunt trauma to the face before 5 days. Computed tomography (CT) of the head revealed a soft tissue density involving the left maxillary sinus. The magnetic resonance imaging (MRI) showed a 37.6 mm x 38.4 mm lesion within the left maxillary sinus extending to the orbit, nasal cavity, and premaxillary and retro maxillary areas with a heterogeneous signal and mild heterogeneous enhancements. A biopsy and histopathology confirmed alveolar RMS. The child was treated with chemotherapy and radiotherapy. Pediatric RMS with orbital extension mimicking benign conditions is challenging to diagnose and manage. Hypertropia following eye trauma can obscure severe underlying conditions, such as para-meningeal RMS. The inferior rectus lesion mimicking inferior rectus palsy stresses a thorough evaluation, including imaging and biopsy. Early and accurate diagnosis is crucial for the effective management of children with such aggressive malignancy.

PurposeTo analyze the differential transcriptome expression in hypertrophic ligaments flavum (HLF) compared to normal ligaments.MethodsA case–control study was conducted that included 15 patients with hypertrophy of LF and 15 controls. Samples of LF were obtained through a lumbar laminectomy and analyzed by DNA microarrays and histology. The dysregulated biological processes, signaling pathways, and pathological markers in the HLF were identified using bioinformatics tools.ResultsThe HLF had notable histological alterations, including hyalinosis, leukocyte infiltration, and disarrangement of collagen fibers. Transcriptomic analysis showed that up-regulated genes were associated with the signaling pathways of Rho GTPases, receptor tyrosine kinases (RTK), fibroblast growth factors (FGF), WNT, vascular endothelial growth factor, phosphoinositide 3-kinase (PIK3), mitogen-activated protein kinases, and immune system. The genes PIK3R1, RHOA, RPS27A, CDC42, VAV1, and FGF5, 9, 18, and 19 were highlighted as crucial markers in HLF. The down-expressed genes in the HLF had associations with the metabolism of RNA and proteins.ConclusionOur results suggest that abnormal processes in hypertrophied LF are mediated by the interaction of the Rho GTPase, RTK, and PI3K pathways, which have not been previously described in the HLF, but for which there are currently therapeutic proposals. More studies are required to confirm the therapeutic potential of the pathways and mediators described in our results.

Purpose: To evaluate the correlation between the angle of deviation in different gazes and the amount of head tilt in patients with congenital unilateral superior oblique muscle palsy (SOP). Methods: This case series study was performed on 20 consecutive SOP patients with head tilt. Based on the Bielschowsky three-step test, the angle of deviation was measured in different gazes. Furthermore, the hypertropia difference between the two lateral gazes (gaze difference) and the two head tilt sides (bilateral head tilt difference) was calculated. For measuring head tilt, close-up pictures from 40 cm with a habitual abnormal head position were captured and analyzed by the Corel Draw X7 software. Results: The mean age of patients was 13 ± 9 years (range, 2.5-31 years). The mean angle of hypertropia in ipsilateral and contralateral head tilt was 24.5 Δ ± 7.1 Δ and 6.5 Δ ± 4.2 Δ, respectively (P < 0.001), and in ipsilateral and contralateral lateral gaze positions, it was 8.2 Δ ± 5.5 Δ and 22.5 Δ ± 6.1 Δ, respectively (P < 0.001). The mean of bilateral head tilt hypertropia difference was 18 Δ ± 5.3 Δ and gaze hypertropia difference was 14.3 Δ ± 6.16 Δ. There was a positive correlation between bilateral head tilt hypertropia difference and the amount of head tilt (R = 0.609, R2 = 0.371, P = 0.004, the amount of head tilt = 0.39 × [Bilateral head tilt hypertropia difference] +1.77). The amount of head tilt also had a positive correlation with the gaze hypertropia difference (R = 0.492, R2 = 0.242, P = 0.028, the amount of head tilt = 0.27 × [gaze hypertropia difference] +4.81). Conclusion: In SOP patients, the amount of head tilt had a positive correlation with bilateral head tilt hypertropia difference and also gaze hypertropia difference.

Purpose Evaluate and analyze the efficacy of inferior oblique belly transposition (IOBT) in treating adult patients with diplopia and small-angle hypertropia caused by mild to moderate inferior oblique overaction (IOOA) secondary to acquired superior oblique palsy (SOP). Methods Nine adult patients with diplopia and small-angle hypertropia associated with mild to moderate IOOA secondary to unilateral acquired SOP were included in the current retrospective study. All patients received the IOBT procedure between February 2019 and May 2023 at The Second People’s Hospital of Jinan and were followed up for more than 6 months after the surgery. During the procedure, the belly of the inferior oblique muscle was fixed to the sclera at 5 mm posterior to the temporal insertion of the inferior rectus muscle. The following indicators were reviewed pre- and post-surgery: the vertical deviation (VD) in the primary position and in the Bielschowsky test, the fovea disc angle (FDA) of the affected eye, changes in IOOA, and diplopia. Results After IOBT, the VD in the primary position decreased from 7.22 △  ± 1.72 △ (range 4 △ –10 △ ) to 1.22 △  ± 1.30 △ (range 0 △ –3 △ ). The VD in the Bielschowsky test decreased from 13.00 △  ± 1.80 △ to 3.22 △  ± 1.09 △ . The FDA decreased from 10.02° ± 3.34° to 6.26° ± 1.91°. The grade of IOOA was reduced from 2.00 (1.00, 2.00) to 0.00 (0.00, 1.00). All changes were statistically significant ( P  < 0.001 or P  = 0.006). Diplopia was resolved completely for all patients. Conclusions IOBT can effectively treat adults with diplopia and small-angle hypertropia caused by mild to moderate IOOA secondary to acquired SOP.

Background Neuromuscular hamartoma is a very rare tumor; with only five cases reported in the orbit. It often occurs in infants and young children and involves large peripheral nerves, but there has been only few reports of occurrence in the orbit and adults. Case presentation This paper describes a 70-year-old man with an incidental orbital mass detected by an imaging test and who later developed associated symptoms. The mass was diagnosed as neuromuscular hamartoma. Superior rectus muscle recession and inferior rectus muscle resection were performed in the right eye for hypertropia secondary to postoperative inferior rectus muscle palsy. Hypertropia in the right eye and diplopia improved after surgery, and regular follow-up is underway. Conclusion This is the first case of an incidentally detected orbital mass diagnosed by histologic examination as a neuromuscular hamartoma in an older patient whose proptosis progressed after a long period of inactivity.

Background Inferior oblique anterior transposition (IOAT) is indicated in patients with incomitant dissociated vertical deviation (DVD) larger in adduction. In general, bilateral surgery is recommended in patients with DVD unless there is deep monocular amblyopia. The purpose of this study is to evaluate the results of asymmetric IOAT in patients with asymmetric incomitant DVD larger in adduction. Methods Retrospective chart review of the records of all patients with incomitant asymmetric DVD associated with inferior oblique (IO) overaction who underwent asymmetric IO weakening procedure. In all patients, the eye with more DVD in adduction underwent IOAT to the temporal corner of the insertion of the inferior rectus (IR) muscle, and the eye with less DVD underwent IOAT to a position 3–4 mm posterior to the insertion of the IR. No other muscles were operated simultaneously. No patient had previous surgery on any cyclovertical extracular muscle. Results Fourteen patients were included. Mean age at surgery was 10.3 ± 8.8 years (range 4–33). Primary position DVD preoperatively was 18 ± 2 PD in the eye with the larger DVD compared to 1.1 ± 1.0 PD postoperatively ( p  < 0.0001). DVD asymmetry between the lateral gaze with the largest DVD and the lateral gaze with the smallest DVD was 9.8 ± 3.1 PD (range 5–14 PD) preoperatively vs 1.1 ± 1.0 PD (range 0–2 PD), ( p  < 0.0001). Ten patients had preoperative V-pattern >10 PD (24.7 ± 8.7 PD, range 12–50 PD) preoperatively vs no patients postoperatively (mean V-pattern 4.4 ± 2.0 PD), ( p  < 0.0001). Postoperative follow up was 1.6 ± 0.7 years (range 1–3 years). Conclusion In patients with asymmetric incomitant DVD, asymmetric IOAT improves lateral incomitance without increasing the risk of antielevation, limitation in upgaze rotation, or hypertropia, or worsening the DVD in the eye with less deviation preoperatively.

Purpose To highlight the key clinical features of various aetiologies of adult hypertropia and to discuss the diagnostic approach towards evaluation of vertical double vision. Methods This is a retrospective cross-sectional study. A total of 300 consecutive patients with vertical diplopia were evaluated by a single neuro-ophthalmologist and strabismologist in a tertiary care setting from 2005–2008. The medical records of all patients with vertical diplopia coded with one of the following diagnoses; hypertropia, diplopia, thyroid eye disease, fourth nerve palsy, ocular myasthenia, congenital strabismus, and third nerve palsy were reviewed. The main outcome measures were determination of aetiologies of hypertropia. Results Fourth nerve palsy and thyroid eye disease were the most common causes of vertical diplopia in our series and comprised more than 50% of patients. The other causes of vertical diplopia were ocular surgery, orbital fracture, neurosurgery, childhood strabismus, skew deviation, third nerve palsy, myasthenia gravis, and decompensated hyperphorias. Ocular motility deficits were seen in 33% of the cohort of whom thyroid eye disease comprised the largest group. Orbital ultrasonography was sensitive in detecting thyroid orbitopathy. Conclusion In the majority of patients, the aetiologies of hypertropias can be ascertained by history and careful ophthalmic examination alone. Fourth nerve palsy and thyroid eye disease were the most common causes of vertical diplopia in this series.

The differential diagnosis and management of dissociated vertical deviation (DVD), inferior oblique overaction (IOOA), and skew deviation are reviewed. As with other types of strabismus, there is no universal consensus on the exact treatment methods of these hyperdeviations. Management is guided by the clinical context and the magnitude and frequency of the deviation. Some patients are observed with optimal refractive correction; others undergo surgical intervention when clinically indicated. Superior rectus recessions are typically performed to treat significant DVD. In cases of DVD with concurrent IOOA, anterior transposition of the inferior oblique insertion may be considered. Primary IOOA, as is commonly seen in association with infantile esotropia, is typically managed with inferior oblique recession or myectomy. In cases of secondary IOOA, correction of the primary problem should be considered in order to control the IOOA. Hyperdeviations that have patterns different from those of a cranial nerve palsy, DVD, or oblique dysfunction are known as skew deviations and are notoriously difficult to manage and may require evaluation with neuroimaging.

A 10-year-old patient experienced acute onset of vertical binocular diplopia with a right hypertropia, worse on gaze to the left and right head tilt, consistent with a right fourth cranial nerve palsy. Vertical fusional amplitudes were 10 PD characteristic of congenital cases. VoR

Unilateral or bilateral surgery Rectus muscle recessions and resections Rectus muscle recessions and resections are the most common strabismus surgeries performed in the pediatric age range, specifically horizontal rectus muscle surgery for esotropia and exotropia. Unilateral or bilateral surgery may be performed, depending on the preoperative evaluation and indications for the procedure. Considerations when performing vertical rectus muscle surgery are also discussed in this chapter. The adjustable suture technique, transpositions, partial tendon procedures, and reoperations are addressed in subsequent chapters. VoR