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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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Presentation on theme: "How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington."— Presentation transcript:

1 How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

2 Double image recreated by pt.

3 Superior Oblique Palsy Dr. G.Vicente

4 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.

5 Torticollis patch test

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9 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?

10 Parks’ three step test algorithm Rt tiltLIO Rt gazeLt tiltRIR RHT Lt gazeRt tiltRSO Lt tiltLSR Rt tilt RSR Rt gazeLt tiltLSO LHT Lt gazeRt tilt LIR Lt tilt RIO

11 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

12 Think Bilateral If… V pattern is present Esotropia in downgaze Greater than 10 degrees of excyclotorsion on double maddox testing.

13 Add double maddox rod pic

14 Superior Oblique Palsy Surgical 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 >15PD, consider recession of contralateral inferior rectus. –If longstanding and the eye has poor depression, the superior rectus is likely contracted and should be recessed.

15 Floppy tendon tuck for Superior Oblique palsies

16 Congenital Superior oblique palsy surgery to shorten floppy tendon SR MR LR IR SR LR RM IR IO Dr. G.Vicente SO

17 Congenital Superior oblique palsy surgery to shorten floppy tendon SR LR RM IR IO Dr. G.Vicente SO SR MR LR IR

18 Congenital Superior oblique palsy surgery to shorten floppy tendon SR LR RM IR IO Dr. G.Vicente SO SR MR LR IR

19 Congenital Superior oblique palsy surgery to shorten floppy tendon SR LR RM IR IO Dr. G.Vicente SO SR MR LR IR

20 Congenital Superior oblique palsy surgery to shorten floppy tendon SR LR RM IR IO Dr. G.Vicente SO SR MR LR IR

21 Congenital Superior oblique palsy surgery to shorten floppy tendon SR LR RM IR IO Dr. G.Vicente SO SR MR LR IR

22 Acquired SO palsies Weaken the opposing muscle, inferior oblique –Recession. If vertical deviation is large >15PD, consider recession of contralateral inferior rectus. If longstanding and the eye has poor depression, the superior rectus is likely contracted and should be recessed.

23 IO recession and contralateral inferior rectus recession for large vertical deviations

24 Acquired Superior oblique palsy Surgery to improve torsion and vertical alignment SR MR LR IR SR LR RM IR IO Dr. G.Vicente Recess IO Recess IR (contralateral)

25 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.

26 Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente

27 Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente

28 Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente

29 Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente

30 Superior Oblique Palsy Dr. G.Vicente

31 Superior Oblique Overaction

32  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.

33 Superior Oblique Overaction “A” pattern Dr. G.Vicente

34 Superior Oblique Overaction Down shoot Dr. G.Vicente


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