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Year : 2021  |  Volume : 69  |  Issue : 1  |  Page : 198-199

Comments on: Surgical management of Helveston syndrome (triad of A pattern exotropia, superior oblique overaction, and dissociated vertical deviation) using four oblique procedure

Department of Ophthalmology, Guru Nanak Eye Center and Maulana Azad Medical College, New Delhi, India

Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Neha Sachdeva
Guru Nanak Eye Centre, Ranjit Singh Marg, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_478_20

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How to cite this article:
Pandey PK, Sachdeva N, Saraf P, Choudhury RB. Comments on: Surgical management of Helveston syndrome (triad of A pattern exotropia, superior oblique overaction, and dissociated vertical deviation) using four oblique procedure. Indian J Ophthalmol 2021;69:198-9

How to cite this URL:
Pandey PK, Sachdeva N, Saraf P, Choudhury RB. Comments on: Surgical management of Helveston syndrome (triad of A pattern exotropia, superior oblique overaction, and dissociated vertical deviation) using four oblique procedure. Indian J Ophthalmol [serial online] 2021 [cited 2021 Jan 23];69:198-9. Available from: https://www.ijo.in/text.asp?2021/69/1/198/303341

Dear Editor,

We read with interest an article by Agashe et al. titled Surgical Management of Helveston Syndrome (triad of A pattern exotropia [XT], superior oblique overaction [SOOA], and dissociated vertical deviation [DVD]) using four oblique procedure.[1] There seems precious little syndromic about the constellation of findings as the term, save some cases of intermittent/constant XT, may broadly encompass infantile XT with the variable presence of latent nystagmus (LN), dissociated horizontal deviations (DHD), and accompanying fundus intorsion with primary SOOA attempting to control the DVD in adduction resulting in A pattern and intorsion while DVD still being significant in abduction (incomitant DVD). Infantile deviations carry their own baggage of diagnostic and therapeutic challenges with infantile esodeviations being far more common than infantile XT and no less challenging, the syndromic underpinnings/triad XT needs to be seen in that backdrop.

While retrospectively collating data of six patients that simultaneously underwent anterior transposition of the inferior oblique (ATIO), posterior tenectomy of the superior oblique (PTSO) and recession / resection of horizontal recti for simultaneous correction of DVD, A pattern and XT, authors have rather been parsimonious in sharing seminal parameters relating to infantile deviations including LN, DHD, fundus torsion. Authors make no effort to evaluate DVD for incomitance in adduction/primary position and abduction, a standard protocol that dictates the surgical approach to be adopted and a quintessential parameter to measure surgical success in DVD. Symmetrical surgery has been done for asymmetrical DVDs with excellent results which are intriguing, contrary to the existing body of evidence.

Since its initial description, ATIO has been used extensively in the treatment of DVDs.[2],[3] Primary SOOA, A pattern, and intorsion may be rendered worse after ATIO, mitigating beneficial effects of PTSO, the authors neither evaluate these aspects nor grade SO and IO overaction/under actions.

The cohort is too small (6) for any tangible statistical analysis, nevertheless preoperative mean A pattern and DVD (in primary position) were moderate and improved by 16 PD and 10 PD respectively. In the absence of corroborative data on pre/post- operative fundus torsion, DVD incomitance, LN, DHD, and oblique overactions/under actions, the inferences drawn may well be contaminated by above-confounding factors and prone to bias and prejudice. ATIO alone is known to offer excellent results in DVDs up to 15 PD in multiple studies.[2],[3] In triad XT, Ha et al. reported 57% and 80% success rates with horizontal muscle surgery alone or horizontal surgery combined with SO weakening procedures respectively.[4] In triad XT, satisfactory results in A pattern and DVD have also been shown by lateral rectus recessions alone in a cohort of 3 children less than 3 years.[5] McCall and Rosenbaum reported satisfactory results in incomitant DVD with PTSO and SR recessions.[6] PTSO may putatively worsen DVD in adduction while ameliorating A pattern and sparing intorsion. A pattern, elevation in adduction and intorsion may get worse with ATIO. The authors take little cognizance of theses variables.

The authors selectively invoke torsional movements for justification for 4 oblique muscle surgery for DVD without documenting torsional change, superior results in DVD amelioration, DVD incomitance, LN, and DHD following surgery to support the veracity of the hypothesis. Authors offer no explanation for correction of A pattern by four oblique weakening, by extrapolation, it should work equally well for V pattern as well, the concept thus militates against the accepted precepts on pattern strabismus.

DVD remains an enigmatic condition that is only alleviated and almost never eliminated. Many other putative explanations have been advanced, that DVD is an adaptive response to Control LN of the fixing eye by intorsion and adduction and thus improving VA, the non-fixing eye extorting and abducting.[7] DVD, LN and primary oblique muscle overactions, all have been portrayed to correspond to subcortical reflexes that are operative in one plane of visual space in lateral eyed animals.[8] DVD has also been interpreted as an atavistic righting reflex, the dorsal light reflex gone wrong.[9] In order to conflate any coherence, data in the present study beg to be tempered by evaluation of pre/postoperative DVD incomitance, LN, DHD, the oblique muscle under actions/overactions and fundus torsion.

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There are no conflicts of interest.

  References Top

Agashe P, Doshi A. Surgical management of Helveston syndrome (triad of A- Pattern exotropia, superior oblique overaction and dissociated vertical deviation using Four oblique procedure. Indian J Ophthalmol 2020;68:170-3  Back to cited text no. 1
Burke JP, Scot WE, Kuschke PJ. Anterior transposition of the inferior oblique muscle for dissociated vertical deviation. Ophthalmology 1993;100:245-50.  Back to cited text no. 2
Kratz RE, Rogers GL, Bremer DL, Leguire LE. Anterior tendon displacement of the inferior oblique for DVD. J Pediatr Ophthalmol Strabismus 1989;26:212-7.  Back to cited text no. 3
Ha SG, Suh YW, Kim SH. Clinical features and surgical outcomes of triad exotropia. J Ped Ophthalmol Strabismus 2017;54:363-8.  Back to cited text no. 4
Park J, Kim S. Strabismus surgeries for triad exotropia in younger children. Korean J Ophthalmol Vis Sci 2010;9:8-12.  Back to cited text no. 5
McCall C, Rosenbaum AL. Incomitant dissociated vertical deviation and superior oblique overaction. Ophthalmology 1991;98:911-8.  Back to cited text no. 6
Christoff A, Raab EL, Guyton DL, Brodsky MC, Fray KJ, Merrill K, et al. DVD- a conceptual, clinical and surgical overview. J AAPOS 2014;18:378-84.  Back to cited text no. 7
Brodsky MC. Dissociated vertical divergence; cortical or subcortical in origin? Strabismus 2011;19:67-8.  Back to cited text no. 8
Brodsky MC. Dissociated vertical divergence, A righting reflex gone wrong. Arch Ophthalmol 1999;117:1216-22.  Back to cited text no. 9


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