Superior oblique tendon sheath syndrome

Introduction to superior oblique tendon sheath syndrome Superior oblique traction tendon sheath syndrome (superiorobliquetendonsheathsyndrome) refers to the upswing movement of the inferior oblique muscle due to congenital anatomic abnormalities or excessively thickening or adhesion of the superior oblique muscle tendon and sheath due to trauma or surgery. Causes the eyeball to be fixed in a state of downward gaze. Brown first described the characteristics of the disease in 1950, and believed that this patient had a shortening of the condylar tendon of the congenital superior oblique muscle tendon, so that the eyeball could not be rotated when it was indexed internally, and passively pulling the eyeball upwards during internal rotation. When the tendon sheath is separated by surgery, the tension disappears, so it is called Brown syndrome. basic knowledge Sickness ratio: 0.05% Susceptible people: no special people Mode of infection: non-infectious Complications: endocrine eyeballs

The cause of superior oblique tendon sheath syndrome

Effects of factors such as acquired inflammation or trauma (30%):

The disease is a comprehensive symptom, the exact cause is not clear. The existence of the superior oblique tendon sheath has been controversial in the past. Some authors have dissected 30 adult eyelids and confirmed the existence of the superior oblique tendon sheath. The fascia of the superior and superior rectus muscles and the intermuscular compartment between them, the upper oblique fascia and the Tenon's sac part fibers are also involved in the formation of this fibrous sheath, in which the fibrous sheath is lined with a slick fluid sheath, thus Factors such as congenital developmental defects, acquired inflammation or trauma can affect the function of the superior oblique muscle, causing the disease.

Abnormal tendon sheath (15%):

The muscle sheath of the superior oblique muscle starts at the trochlear part and ends at the sclera at the attachment point of the superior oblique muscle. The average length is (18.39±0.33) mm. If the congenital tendon sheath is short and tense, the intraocular position is reversed. Only the eyeball can be pulled downward. Under normal circumstances, the superior oblique muscle acts as a ligament for the inferior oblique muscle. It is also believed that this syndrome is caused by adhesion between the tendon and the tendon sheath. In this case, the surgical separation of the tendon sheath Often it will achieve excellent results.

Abnormal tendon (10%):

Abnormal anomaly of the superior oblique muscle tendon affects its activity in the trochlear part. It can be seen in the tendon of the tendon caused by trauma, inflammation, scars, etc. In this case, use the indicator to gently press the pulley part and let the patient's eyeball turn up. Sometimes, the movement of the tendon through the part of the trochle can be felt, or the squeaking sound. At this time, the eyeball cannot be turned up, so some scholars call it the superior oblique muscle snoring syndrome.

Abnormalities of the inferior oblique muscle and its adjacent tissue (10%):

The adhesion point of the inferior oblique muscle adheres to the wall of the eyeball, or the bursting fracture of the sacral floor causes the inferior orbital tissue to be incarcerated, which may also cause the upturn to be restricted when the intraocular position is transposed. Girard describes the formation of an abnormal ligament of the superior oblique muscle. Causes pseudo-obshale palsy.

Contradictory innervation (5%):

Some people think that this disease is similar to the eyeball regression syndrome. Ferig-Seiwerth and Celic found that one of the three patients with Brown syndrome had contradictory innervation. Therefore, it is suggested that congenital Brown syndrome may be related to central nervous system disorder. In patients with contradictory innervation, when the eyeball is in the internal rotation position, the superior oblique muscle can not relax, so the traction test is positive. It is also reported that the electromyogram confirms this hypothesis, but most scholars disagree with this opinion.

Caused by surgery (5%):

More common in the superior oblique muscle folding, usually due to excessive folding, if the amount of folding is less than 10mm, rarely occurs, even if it occurs, the symptoms are lighter, and can be relieved.

Secondary to sciatic paralysis (5%):

Some authors believe that after long-term sciatic paralysis, the superior oblique muscle can be contracted and fibrotic, but most people do not recognize this view, because postoperative internal rotation can be normal, EMG shows that the lower oblique muscle has normal discharge activity, and then Individual oblique palsy is also rare.

Prevention of superior oblique tendon sheath syndrome

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Complications of superior oblique tendon sheath syndrome Complications endocrine ocular protrusion

Other lesions in the fundus.

Symptoms of superior oblique tendon sheath syndrome Common symptoms Tendon sprains Eyeballs Deviated tendon sheaths Dry eye movements Deviation Torsional strabismus Eyeballs can not be arbitrarily moved up and fixed

Classification

(1) congenital superior oblique tendon sheath syndrome (congenital superior oblique tendon sheath syndrome): refers to the congenital tendon sheath shortening and tendon hypertrophy affecting the normal activities of the trochlear, or abnormal anatomical dysplasia due to abnormal ligaments of the inferior oblique muscle The resulting up-turning of the intraocular lens is limited. This type of eye movement abnormality is constant and cannot be self-healing, so it is called true Brown syndrome.

(2) acquired superior oblique tendon sheath syndrome (acquired superior oblique tendon sheath syndrome): also known as acquired Brown syndrome, refers to local swelling of the superior oblique tendon sheath due to trauma, inflammation or surgery, hypertrophy, tendon sheath contraction or Similar to stenotic tenosynovitis, the intraocular transposition is limited in up-regulation, such eye movement is abnormal, and some cases can be relieved by themselves and the symptoms disappear. Therefore, this type of case is called intermittent Brown syndrome or pseudo-Brown synthesis. Sign.

2. Clinical features

(1) In the case of binocular or monocular exercise test: the degree of up-regulation is the same when there is an intraocular transfer, and there is a limit to the upward pull test when attempting to perform the internal transfer.

(2) When the patient has an intraocular position, the patient is inclined.

(3) When the eye is in the first eye position and the external position: the upturn is normal or close to normal, and the healthy eye may appear as an upslope in the first eye position.

(4) The superior oblique muscle is too strong.

(5) A V-shaped exotropia occurs when looking upwards.

(6) There is often no double vision in the first eye position or downward gaze or external rotation: but the patient may have a head position abnormality or maintain a head position, and the eye is oblique in the first eye position.

(7) Double vision is caused when the patient turns in the eye.

(8) Extraocular muscle EMG examination: the inferior oblique muscle is normal.

3. Clinical grading Eustis stipulates the grading criteria for the severity of Brown syndrome based on the clinical features of Brown syndrome.

(1) Mild: Only when the eyeball is turned inside, the upturn is limited, without the lower strabismus and the internal squint is not accompanied by the lower strabismus.

(2) Moderate: Upward rotation is limited during internal rotation, and strabismus is accompanied by internal rotation, but there is no strabismus in the first eye position.

(3) Severe: When the internal rotation is limited, the upper eye position and the internal rotation have obvious squint.

Examination of superior oblique tendon sheath syndrome

Upper oblique tendon sheath syndrome examination project:

Electromyography, ultrasonography of the eyeballs and eyelids, CT examination of the eye and temporal region, eyelid muscle force meter, and eye function examination.

The inferior oblique muscle was normal when the extraocular muscle electromyography (EMG) was examined.

Electromyography is a means of assisting the examination of diseases through myoelectricity. The use of electronic instruments to record the electrical activity of muscles at rest or contraction, and the application of electrical stimulation to examine nerve and muscle excitation and conduction functions. English referred to as EMG. Through this examination, the functional status of peripheral nerves, neurons, neuromuscular junctions, and muscles themselves can be determined.

Diagnosis and differentiation of superior oblique tendon sheath syndrome

Diagnostic criteria

1. When the patient is in the eye, the patient can't go up, but in the first eye position or the external position, the upturn is normal.

2. When the eye is in the internal position, the pull test is positive.

3. When the patient is in the eye, the patient is inclined.

4. Electromyography examination of the lower oblique muscles.

Differential diagnosis

1. The lower oblique palsy Brown syndrome is often positive in the intraocular transposition, which can be differentiated from the inferior oblique paralysis. In addition, Brown syndrome is characterized by an oblique deviation of the affected eye during the internal rotation, on the same side. The oblique muscles and the contralateral superior rectus muscles function normally. V-external slant appears when gazing upward, while the lower oblique palsy has no such sign. EMG is weaker in the inferior oblique paralysis, and Brown syndrome is normal.

2. The bursting of the sacral floor fracture is limited in the reduction of the sacral floor fracture, not only in the internal rotation position, but also in the first eye position and the external rotation, the upturn can be limited, this point is only with Brown syndrome. The transfer position is limited.

3. Congenital extraocular muscle fibrosis syndrome due to inferior rectus muscle fibrosis, passive rotation test directly above, inner upper, upper and upper limits.

4. The early passive rotation test of the double-upper muscle paralysis was normal, and the inferior rectus muscle was tense in the late stage, and the resistance was up-turned, and the affected eye was up-turned, and the external rotation was limited.

5. Graves eye disease has limited restriction, with exophthalmia, upper eyelid retraction, eyelid swelling and other manifestations, CT and ultrasound show extraocular muscle hypertrophy.

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