Major article
Surgical treatment of upgaze palsy in Parinaud's syndrome

https://doi.org/10.1016/j.jaapos.2003.12.013Get rights and content

Abstract

Introduction

Upgaze paralysis due to supranuclear defects can cause significant visual symptoms. There are only a few reports on the treatment of this problem in the literature. Patients with Parinaud's syndrome may also have retraction nystagmus and convergence on attempted upgaze that further complicates the treatment.

Methods

We performed a retrospective review of 48 patients with Parinaud's syndrome. Eleven patients were not able to elevate to the primary position and underwent surgery for the upgaze defect. Surgical treatments included transpositions in 2 patients, inferior rectus recessions in 8, which was combined with a superior rectus resection in one.

Results

Preoperative duction measurements demonstrated an average limitation on upgaze to −19° (−10 to −30) below midline with zero representing midline. Postoperative measurements showed marked improvement to +19 degrees above midline (15 to 30). Inferior rectus recessions were as effective as transpositions in restoring function. In addition, there was a marked reduction in the retraction nystagmus and upgaze convergence as well.

Conclusions

Visually significant upgaze limitation can be relieved with bilateral inferior rectus recessions in Parinaud's syndrome. Retraction nystagmus and covergence movements are also markedly improved.

Section snippets

Patients and methods

After appropriate Institutional Review Board approval, a retrospective chart review identified 48 patients with Parinaud's syndrome seen between 1985 and 2000. All patients had upgaze defects, retraction nystagmus, and pupillary abnormalities of varying degree. Eleven of the 48 underwent surgery for upgaze defect requiring a chin-up head position, in combination with severe retraction nystagmus and convergence spasm on attempted upgaze. Those patients who had follow-up of at least one year

Results

A summary of the preoperative and postoperative measurements of vertical eye movements is shown in Table 2. Preoperatively the average amount of maximum vertical movement was only to 11.9° below midline. Downgaze movement was considered normal averaging almost 48°. After surgery the average movement upward improved to 19.4° degrees above midline with a range of 10° to 30° (P = .0003). Postoperative downgaze rotations were affected with an average reduction in downward movement of 13° (P =

Discussion

There are only isolated case reports in the literature on the treatment of the upgaze disorder associated with Parinaud's syndrome.5, 6 Surgical treatment options are limited and consist of either weakening the inferior rectus, enhancing elevation force by resecting the superior rectus, or creating an alternative force by superiorly transposing the medial and lateral rectus muscles. In the previous reports, patients underwent bilateral superior rectus resection5 and bilateral inferior rectus

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