ORIGINAL CONTRIBUTION Surgical Management of Skew Deviation R. Michael Siatkowski, MD, Robert F. Sanke, MD, and Bradley K. Farris, MD Abstract: There are no published data on the outcomes of realignment surgery for skew deviation. A retrospective chart review disclosed 10 patients who had undergone sur- gical correction of skew deviation by three surgeons at a single institution between 1991 and 2002. Nine of 10 pa- tients had satisfactory relief of diplopia with an acceptable field of single binocular vision. Vertical rectus recession or resection was the most common procedure. Four patients required more than one procedure. For nonalternating hy- pertropias, resection of the inferior rectus muscle or reces- sion of the superior rectus muscle of the hypertropic eye was successful. For alternating hypertropia, resection of both inferior rectus muscles was successful. Oblique muscle surgery was not associated with good outcomes. (J Neuro-Ophthalmol 2003;23: 136–141) S kew deviation is a vertical ocular misalignment result- ing from damage to supranuclear areas controlling eye movements (1,2). Varying amounts of torsion and the ocu- lar tilt reaction may be present (3,4). Prisms may be useful in alleviating diplopia in some cases, but generally only if the misalignment is small and fairly comitant, and torsional diplopia is minimal or absent. If prisms are not effective, extraocular muscle surgery may provide symptomatic im- provement. However, a review of the literature yields no studies evaluating the outcomes of surgical treatment of skew deviation. We performed a retrospective review of 10 cases of skew deviation in which surgery was performed at a single institution by three surgeons over the past decade. METHODS After appropriate University of Oklahoma Health Sciences Center Institutional Review Board approval, charts from 30 patients who were diagnosed with skew deviation between January 1991 and January 2002 were ret- rospectively reviewed. The diagnosis of skew deviation was made based on the presence of vertical diplopia follow- ing an ischemic, inflammatory, traumatic, degenerative, or neoplastic disorder affecting the supranuclear vertical eye movement centers in the brain stem. Cases with concomi- tant oculomotor or trochlear nerve paresis or orbital pathol- ogy (n = 10) were excluded. Ten candidates were excluded because fusion could not be achieved in primary gaze with prism correction. Thus, surgical subjects had no preopera- tive evidence of symptomatic subjective torsional diplopia or central disruption of fusion. After exclusions, there were 10 patients who met study criteria (Table 1). Their charts were reviewed for age and gender of the patient, initial stra- bismic measurements, cause of the misalignment, surgical procedure or procedures performed, final ocular alignment, and the patients’ assessment of whether they were satisfied with the surgical results. All patients underwent surgery only after the mis- alignment had been stable for at least 6 months. Two au- thors performed procedures in nine patients (BKF, six cases; RMS, three cases); a third surgeon operated on one patient (patient #3). The selection of the procedure was at the discretion of each physician. In general, amounts of ver- tical rectus surgery were based on achieving 2 to 3 prism diopters of realignment for each millimeter of muscle re- cession or resection. Adjustable sutures were used in three cases (patients #5, 7, and 8). Surgical success was defined as complying with at least one of the following three crite- ria: (1) elimination of diplopia in primary and reading gaze; (2) conversion of the preoperative misalignment to a smaller and more comitant postoperative misalignment such that prisms could achieve single vision in primary and reading positions; and (3) patient report of satisfaction on the following scale: very satisfied, satisfied, neutral, or sur- gical failure. RESULTS The age range for the 10 study patients was 31 to 83 years, with a mean of 57 years (Table 1). Six patients were female. The causes of skew deviation were brain stem stroke (n = 6), mesencephalic mass lesion (n = 1), spino- cerebellar degeneration (n = 1), lithium toxicity (n = 1), and ethanol toxicity (n = 1). Dean A. McGee Eye Institute, Department of Ophthalmology, Univer- sity of Oklahoma College of Medicine, Oklahoma City, Oklahoma. Address correspondence to R. Michael Siatkowski, MD, Dean A. McGee Eye Institute, 608 Stanton L. Young Blvd., Oklahoma City, OK 73104, USA; E-mail: Rmichael-siatkowski@ouhsc.edu Supported by an unrestricted grant from Research to Prevent Blind- ness, New York, New York. Presented in part as a poster at the 2002 North American Neuro- Ophthalmology Society Annual Meeting at Copper Mountain, Colorado, February 9–14, 2002. 136 J Neuro-Ophthalmol, Vol. 23, No. 2, 2003