How to diagnose and recognize vertical deviations

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How to diagnose and recognize vertical deviations

• Part II
• Superior Oblique Palsy
• G. Vike Vicente, MD
• Eye Doctors of Washington

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Double image recreated by pt.
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Superior Oblique Palsy
Dr. G.Vicente
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Unilateral Superior Oblique Palsy

• If the misalignment is worse on left head tilt
  then the patient will walk into your office with
  a
• Right head tilt
• How can you differentiate this from a neck
  torticollis?
• Patch one eye, the torticollis will improve in SO
  palsy pts.

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Torticollis patch test
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Torticollis patch test
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Torticollis patch test
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Torticollis patch test
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Congenital superior oblique palsy

• Usually unilateral
• Watch for contralateral hypoplasia
• Which came first the chicken or the egg?
• Is the face small on that side because of the
  torticollis or is there a superior oblique palsy
  because of abnormal facial bone structure?

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Parks three step test algorithm

• Rt tilt LIO
• Rt gaze Lt tilt RIR
• RHT
• Lt gaze Rt tilt RSO
• Lt tilt LSR
• Rt tilt RSR
• Rt gaze Lt tilt LSO
• LHT
• Lt gaze Rt tilt LIR
• Lt tilt RIO

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Adult superior oblique palsy

• Acquired? ie Cranial nerve 4 palsy
• Usually bilateral
• Traumatic
• Remember the long course of CN 4
• closed head trauma?
• MVA?
• loss of consciousness?
• Neoplastic, tumor
• 55 yo AF h/o breast CA, headache, chronic
  sinusitis (meningioma)
• Congenital but late onset, decompensation

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Think Bilateral If

• V pattern is present
• Esotropia in downgaze
• Greater than 10 degrees of excyclotorsion on
  double maddox testing.

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• Add double maddox rod pic

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Superior Oblique PalsySurgical treatment

• For congenital SO palsy,
• It is really more of a floppy tendon.
• Shorten, or tighten the superior oblique tendon.
• For acquired
• Weaken the opposing muscle, inferior oblique
• Recession.
• If vertical deviation is large gt15PD, consider
  recession of contralateral inferior rectus.
• If longstanding and the eye has poor depression,
  the superior rectus is likely contracted and
  should be recessed.

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Floppy tendon tuckfor Superior Oblique palsies
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Congenital Superior oblique palsysurgery to
shorten floppy tendon
SO
IO
IO
Dr. G.Vicente
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Congenital Superior oblique palsysurgery to
shorten floppy tendon
SO
IO
IO
Dr. G.Vicente
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Congenital Superior oblique palsysurgery to
shorten floppy tendon
SO
IO
IO
Dr. G.Vicente
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Congenital Superior oblique palsysurgery to
shorten floppy tendon
SO
IO
IO
Dr. G.Vicente
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Congenital Superior oblique palsysurgery to
shorten floppy tendon
SO
IO
IO
Dr. G.Vicente
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Congenital Superior oblique palsysurgery to
shorten floppy tendon
SO
IO
IO
Dr. G.Vicente
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Acquired SO palsies

• Weaken the opposing muscle, inferior oblique
• Recession.
• If vertical deviation is large gt15PD, consider
  recession of contralateral inferior rectus.
• If longstanding and the eye has poor depression,
  the superior rectus is likely contracted and
  should be recessed.

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IO recession and contralateral inferior rectus
recession for large vertical deviations
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Acquired Superior oblique palsySurgery to
improve torsion and vertical alignment
SR
SR
MR
LR
LR
RM
IR
IR
IO
IO
Recess IR (contralateral)
Recess IO
Dr. G.Vicente
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Acquired SO palsy

• If little vertical deviation but large
  extorsional component
• Consider Harada-Ito procedure
• Anteriorly displaced anterior half of the SO
  tendon.
• Tightening the whole tendon would cause a Brown
  syndrome.
• Lateralizing the anterior fibers intorts the eye.

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Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente
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Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente
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Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente
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Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente
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Superior Oblique Palsy
Dr. G.Vicente
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Superior Oblique Overaction
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Superior Oblique Overaction

• Usually primary since IO palsies are very
  uncommon
• Vertical deviation often present in Primary gaze!
  
• Ipsilateral hypotropia, worse on adduction.
• XT may be present as well.
• A pattern visible
• Tx SO recession or tendon elongation.

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Superior Oblique OveractionA pattern
Dr. G.Vicente
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Superior Oblique OveractionDown shoot
Dr. G.Vicente