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. 2025 Jul 1;25(1):389.
doi: 10.1186/s12886-025-04205-6.

Evaluating ocular torsion following inferior oblique weakening in superior oblique palsy: a pilot study using color fundus photography and spectral domain optical coherence tomography

Kaveh Abri Aghdam  1 , Afsane Katiraee  1 , Samira Chaibakhsh  1   2 , Mostafa Soltan Sanjari  1 , Arezoo Miraftabi  1 , Fateme Nadjafi  1 , Ali Sadeghi  1 , Vahid Zare Hosseinabadi  1 , Amin Zand  3
Affiliations

Evaluating ocular torsion following inferior oblique weakening in superior oblique palsy: a pilot study using color fundus photography and spectral domain optical coherence tomography

Kaveh Abri Aghdam et al. BMC Ophthalmol. .

Abstract

Purpose: To compare spectral domain optical coherence tomography (OCT) and color fundus photography (CFP) for assessing ocular cyclotorsion in unilateral congenital superior oblique palsy (SOP) before and after inferior oblique disinsertion.

Methods: This prospective pilot study evaluated 18 patients (36 eyes) with unilateral congenital SOP. Disc-foveal angle (DFA) was measured preoperatively and 3 months postoperatively using CFP (analyzed with ImageJ) and Spectralis OCT (with FoDi software). Contralateral nonparetic eyes served as controls.

Results: Preoperative hypertropia (14.31 ± 4.15 prism diopter, PD) significantly improved postoperatively (1.46 ± 1.98 PD, P < 0.001). CFP measurements showed significantly greater cyclotorsion in paretic versus nonparetic eyes preoperatively (P = 0.001), while OCT revealed no inter-eye difference (P = 0.295). In paretic eyes, CFP-derived DFAs were significantly higher than OCT values both preoperatively (12.26 ± 4.72° vs. 8.87 ± 4.56°, P = 0.002) and postoperatively (7.25 ± 5.18° vs. 4.33 ± 3.98°, P = 0.005). Nonparetic eyes showed no significant inter-method differences at either timepoint (all P > 0.05). Inter-method reliability was moderate preoperatively (ICC = 0.693 paretic, 0.657 nonparetic) and improved postoperatively (ICC = 0.718 and 0.921, respectively). Bland-Altman analysis demonstrated narrowing limits of agreement postoperatively (nonparetic: 8.48° to 4.40°; paretic: 7.97° to 7.50°), with no systematic bias.

Conclusion: Spectralis OCT with FoDi software provides a clinically useful alternative to CFP for cyclotorsion assessment in congenital SOP, though it may systematically underestimate DFA values in paretic eyes.

Keywords: Congenital superior oblique palsy; Disc-foveal angle; FoDi software; Fundus photography; Inferior oblique weakening; Ocular torsion; Spectralis OCT; Vertical strabismus.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was approved by the Ethics Committee of Iran University of Medical Sciences (ethics code: IR.IUMS.REC.1401.421). The research adhered to the ethical guidelines stipulated in the Declaration of Helsinki. Prior to enrollment in the study, written informed consent was secured from all participants. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Objective ocular torsion measurements in a patient with left unilateral superior oblique palsy, comparing color fundus photography (CFP) and Spectralis optical coherence tomography (OCT). (A) Preoperative CFP image demonstrating disc-center fovea angle (DFA) measurements, (Ө˚), defined as the angle between: (1) the line connecting optic disc center and fovea, and (2) the horizontal reference line through the disc center. (B) Corresponding preoperative Spectralis OCT image analyzed using the fovea-to-disc (FoDi) software. (C) Postoperative CFP and (D) postoperative Spectralis OCT images from the same patient. DFA measurements were obtained for both eyes at each timepoint
Fig. 2
Fig. 2
Bland-Altman analysis of agreement between Spectralis optical coherence tomography (OCT) and color fundus photography (CFP) measurements (in degrees) for ocular torsion in nonparetic and paretic eyes. Plots compare preoperative and postoperative measurements. The y-axis displays the difference between OCT and CFP values (OCT-CFP), while the x-axis shows the mean of both measurements. The solid blue line indicates the mean difference (MD) or bias between methods, with dashed black lines showing 95% limits of agreement (MD ± 1.96 SD). SD = standard deviation
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