Surgical outcome of graded Harada-Ito procedure in the treatment of torsional diplopia ‒ a retrospective case study with long-term results

Figures & data

Figure 1. The graded modified Harada-Ito procedure in a left eye when transposing and reinserting the anterior segment of the superior oblique (SO) tendon, the dosage scale for the advancement position and the estimated effect, in degrees, on cyclodeviation is shown in enlargement (S.Flodin).

Table 1. Basic characteristics of all the patients operated using a dosage scale approach to the modified Harada-Ito procedure

No	Sex	Age yrs.	Etiology of cyclodeviation	Op eye	Op dose scale	Cyclofusion pre-op (min; max)	Pre-op torsion, degrees SMR right eye/left eye	Post-op torsion, degrees SMR right eye/left eye	Other strabismus surgery
Unilateral involvement
1	F	65	Idiopathic	LE	4	−15; −20	0 /-18	−1/-8	HV
2	M	34	Trauma/RTA	RE	3	−10; −15	−10 /-5	−5/0
3	F	73	Idiopathic (breast cancer)	LE	4	−15; −20	−10 /-5	1/-2
4	M	73	Mechanical/post-op retinal detachment,	LE	3	−13; −15	−3 /-11	0/-4
5	M	70	Trauma/fall	LE	3	−8; −12	−8 /-9	3/-2
6	M	60	Idiopathic	RE	2	−6; −9	−6 /-3	0/-6
7	M	66	Idiopathic	LE	4	−10; −19	−9/-11	0/0
8	F	66	Idiopathic (breast cancer)	LE	1	−10; −11	−5 /-10	−2/-2
9	F	55	Trauma/RTA	LE	4	−10; −20	−10 /-10	−3/-6
10	M	80	Idiopathic	LE	4	−12; −20	−10 /-12	0/0	V
11	M	53	Trauma/RTA,	LE	3	−8; −12	−2 /-5	0/0	HV
12	M	54	Trauma/RTA	LE	4	−11; −15	−5 /-5	0/-3	V
13	F	51	Intracerebral hemorrhage	LE	4	−18; −22	−10/-25	−2/-8	V
14	M	52	Trauma/fall	RE	3	−10; −15	−0 /-20	0/-8
15	M	66	Trauma/fall	LE	3	−8; −15	−5 /-10	−1/0
16	F	56	Cancer/brain tumor	RE	4	−10; −18	−8 /-10	0/0
17	M	46	Idiopathic	LE	2	−8; −10	0 /-10	2/-10	H
18	M	53	Idiopathic	RE	3	−9; −12	−5 /-15	0/-4	V
19	F	50	Cancer/brain tumor	RE	4	−12; −15	−18 /-3	−5/2
20	F	81	Trauma/fall	RE	4	−12; −15	−5 /-12	4/-4
21	M	45	Trauma/RTA	RE	5	−20; −30	−14 /-22	−3/-14	V
Bilateral involvement
22	F	49	Trauma/RTA	BE	3 + 3	−20; −30	−10/-10	3/-3
23	M	49	Trauma/fall	BE	4&5	−15; −30	−14/-15	−2/-1
24	M	54	Subarachnoid hemorrhage	BE	4&5	−20; −30	−30/-30	−4/-8	V
25	M	22	Mechanical/ cranio facial deformity	BE	2 + 2	−15; −20	−5/-20	0/0
26	F	45	Trauma/RTA,	BE	3 + 3	−18; −20	−10/-8	−2/-5	HV
27	M	72	Idiopathic	BE	1 + 3	−10; −17	−5/-16	0/0

BE = both eyes right and left; F = female; H = horizontal; HV = horizontal and vertical; LE = left eye; M = male; N/A = data not available/no measurement recorded; RE = right eye; RTA = road traffic accident; SMR = single Maddox rod test; SPH = synoptophore; V = vertical; + = two procedures at same time; & = two procedures at different times.

Table 2. Torsion as measured in degrees using the single Maddox rod test (SMR) in unilateral surgeries (n = 21), showing surgical procedures performed, pre-and post-operative values and the change/effect per surgical dose

Torsion Op eye Unilateral cases (n = 21)
Dose scale	No.	Pre-op	Effect size	Post-op	Effect size	Change from pre-op to post-op	P-value
1 (1/3)	1	−10		−2		8
2 (1/2)	2	−8 (2.8) -8 (−10; −6)	2.86	−5 (7.1) -5 (−10; 0	0.70	3 (4.2) 3 (0; 6)
3 (2/3)	7	−7.1 (3.9) -9 (−11; 0) (−10; −5)	1.82	−1.6 (2.1) 0 (−5; 0) (−4; 0)	0.76	5.6 (3.1) 5 (0; 10) (5; 7)	0.003
4 (1/1); full	10	−11.7 (6.7) -10.5 (−25; −5) (−18; −5)	1.75	−3.2 (3.3) -2.5 (−8; 0 (−6.5; 0)	0.97	8.5 (4.9) 8.8 (2; 17) (3.8; 12.3)	<0.0001
5 (>1/1); enhanced	1	−14		−3		11
Overall	21	−9.8 (5.5) -10 (−25; 0) (−11.5; −5)	1.78	−2.8 (3.2) -2 (−10; 0) (−5.5; 0)	0.88	6.9 (4.2) 7 (0; 17) (4.5; 9.8)	<0.0001

Mean (SD)/Median (Min;Max)/(Q1;Q3).

Table 3. Torsion as measured in degrees using the single Maddox rod test (SMR) in Bilateral cases (n = 6), Uni- and bilateral cases (n = 27) and all surgeries/eyes operated on (n = 36) showing pre-and post-operative values and the change/effect after surgery

	Torsion Op eye Pre-op	Torsion Op eye Post-op	Change before to after surgery (effect)	P-value within group
Bilateral cases (n = 6) Surgeries performed (n = 15)	13.7 (8.6) -10 (−30; −4) (−20; −5)	−5.4 (6.8) -3 (−20; 0) (−8; 0)	8.3 (5) 8 (0; 20) (5; 10)	< 0.0001
All cases (n = 27)	−10.4 (6.5) -10 (−30; 0) (−12; −5)	−2.70 (5.4 –2 (−20; 10)	7.72 (3.7) 8 (0; 17) (6.3; 9.2)	< 0.0001
All surgeries/eyes operated on (n = 36)	−11.5(7.1) -10 (−30; 0) (−15.8; −5)	−3.9 (5.1) -2 (−20; 0) (−6; 0)	7.5 (4.6) 7.5 (0; 20) (5; 10)	< 0.0001

Mean (SD)/Median (Min;Max)/(Q1;Q3).

(95% CI for Mean using the inversion of Fisher’s non-parametric permutation test).

Figure 2. Bland Altman plot of change in the Synoptophore (SPH) and the SMR test from pre-operative to post-operative measurements, dotted lines show Mean and Limits of agreement.

Figure 3. Scatterplot showing the outcome effect of surgery on torsion per dose in 21 individuals after unilateral surgery.