title: Double elevator palsy, subtypes and outcomes of surgery.
abstract: OBJECTIVE
  To describe the clinical manifestations of subtypes of double elevator palsy and to report the outcomes of surgery in these patients.
  
  
  METHODS
  This retrospective study was conducted on hospital records of patients with double elevator palsy at Labbafinejad Medical Center over a ten-year period from 1994 to 2004. Patients were classified into three subgroups of primary elevator muscle palsy (9 subjects), primary supranuclear palsy with secondary inferior rectus restriction (4 subjects) and pure inferior rectus restriction (7 subjects) according to forced duction test (FDT), force generation test (FGT) and Bell's reflex. Patients in the first group underwent Knapp procedure, the second group received Knapp procedure and inferior rectus recession simultaneously and in the third group vertical recess-resect or mere inferior rectus recess operation was performed. Success was defined as final residual deviation ≤5 PD and ≥25% improvement in restriction after all operations.
  
  
  RESULTS
  Overall 20 subjects including 10 male and 10 female patients with mean age of 12.6±9.3 (range 1.5-32) years were operated during the mentioned period which included 9 cases of primary elevator muscle palsy, 4 patients with primary supranuclear palsy and secondary inferior rectus restriction, and 7 subjects with pure inferior rectus restriction. Mean follow-up was 22.0±20.0 (range 3-63.5) months. Mean pre and postoperative deviation was 32.0±8.0 PD and 3.8±8.0 PD (P<0.001) respectively, and mean restriction before and after the operation(s) was -3.5±0.7 and -2.3±1.2 (P<0.001), respectively. Success rate was 77% for correction of deviation and 80% for improvement in muscle restriction.
  
  
  CONCLUSIONS
  Surgery for double elevator palsy must be individualized according to FDT, FGT and Bell's reflex. The outcomes are favorable with appropriate surgical planning.
authors.affiliation: Ophthalmic Research Center, Labbafinejad Medical Center, Shahid Beheshti University MC, Tehran, Iran.
authors.forename: Abbas
authors.initials: A
authors.lastname: Bagheri
authors.forename: Ramin
authors.initials: R
authors.lastname: Sahebghalam
authors.forename: Mohammad
authors.initials: M
authors.lastname: Abrishami