1. Congenital SO palsy vs Acquired SO palsy
I’m a 3rd yr resident Kim EK. This case is supervised by associate Professor Sin sun young.
R3 김은경/ AP. 신선영

2. Case 1 C.C) Diplopia associated with head trauma Onset : 1 month ago
- Struck on the head by a soccer ball
Onset : 1 month ago
Systemic disease(-)
Trauma Hx.(+)
A 24 year old male visited our clinic with diplopia which had been developed since he was struck on the head by a soccer ball. This picture was taken at the fisrt timing of the visit. He had no history of systemic disease

3. RSO palsy RIO overaction RSO underaction
He presented with right hypertropia in the primary position, and his right eye showed overaction of inferior oblique and underaction of superior oblique. Right hypertropia was more in the left down gaze. Form this 9 - cardinal photos we could suspect he had RSO palsy.
RSO underaction

4. Congenital RSO palsy vs Acquired RSO palsy
After then we had to differentiate congenital or acquired type of RSO palsy in order to decide whether brain imaging was required or not.

5. Other Clues Final Diagnosis Congenital Rt. SO palsy
1. Facial asymmetry (+)
2. Old photo : Head tilt to left shoulder
3. Large vertical fusional amplitude
As you can see, facial asymmetry was present and may be result of chronic head tilt , and large vertical fusional amplitude was also present. These findings are suggestive of a congenital RSO palsy.
Final Diagnosis
Congenital Rt. SO palsy

6. Case 2 F/64 C.C) Head tilt to right shoulder
Blurring caused head tilt to Lt. shoulder
Onset : 5 ~6 months ago
Gradual progression
Facial asymmetry(+)
DM(-), HBP(-)
Trauma Hx.(-)
A 64 year old female visited our clinic complaining of head tilt to right shoulder and blurring vision caused head tilt to the Lt.shoulder over the previous 6 months. Her symptoms had gradually developed, and facial asymmetry was present at the timing of the first visiting. She had no history of DM & HBP & head trauma.

7. LIO overaction Mild LSO underaction
She presented with 16 prism dioptor left hypertropia in the primary position, and her left eye showed over-action of inferior oblique and mild underaction of superior oblique. Left hypertropia was more in the right down gaze.
Mild LSO underaction

8. Excyclotorsion
Fundus photos showed excyclotorsion.

9. Parks’ 3 step test LSO palsy 20Δ LHT 16Δ LH(T) 10Δ LHT
20 Δ LH Δ LHT Δ LHT
Lt.eye
SR IO
IO SR
Rt.eye
For identifying the paretic muscle, the Parks three test was used. Left hypertropia increased in downgaze and right gaze and also on left head tilt. These findings indicate a paretic oblique muscle is LSO.
IR SO
SO IR
LSO palsy

10. Impression r/o Acquired Lt. SO palsy r/o Decompensated
congenital Lt. SO palsy
Again we had to differentiate congenital or acquired type of LSO palsy.

11. Clues Final Diagnosis Congenital Lt. SO palsy 1. Facial asymmetry (+)
Hypoplastic Rt.facial structrue
2. Gradual progression
3. No Hx. of head trauma
4. Large vertical fusional amplitude
Even though she had no history of head trauma, considering of her age we decided to perform bain imaging. CT images showed hypoplasty of Rt.facial structure and atrophy of LSO muscle. According to her history , diplopia had developed gradually and large vertical fusional amplitude was present , we could guess she had congenital LSO palsy.
Final Diagnosis
Congenital Lt. SO palsy

12. Case 3 C.C) Binocular diplopia Head tilt to right shoulder
M/14
C.C) Binocular diplopia
Head tilt to right shoulder
Onset : 4 months ago , suddenly
Facial asymmetry(-)
DM(-), HBP(-), Systemic disease(-)
Trauma Hx.(-)
A 14 year old male complained of sudden onset of diplopia and head tilt to right shoulder over the previous 4 months. He had no facial asymmetry at the timing of visiting and he had no history of DM & HBP & head trauma.

13. LIO overaction LSO underaction
He presented with 12 prism dioptor left hypertropia in the primary position, and his left eye showed over-action of inferior oblique and underaction of superior oblique. Left hypertropia was more in the right down gaze.
LSO underaction

14. Fundus photos showed excyclotorsion.

15. Parks’ 3 step test LSO palsy 16Δ LHT 12Δ LHT 8Δ LHT 25Δ RHT 10Δ RHT
Lt.eye
SR IO
IO SR
Rt.eye
Left hypertropia increased in downgaze and right gaze and also on left head tilt. These findings imply a paretic oblique muscle is LSO.
IR SO
SO IR
LSO palsy

16. decompensated congenital SOP
In this patient,
Small vertical fusional amplitude
Old photo : no head tilt
decompensated congenital SOP
Recommend
BMRI
In this patient , since he presented with small vertical fusional amplitude, and there was no head tillt in his old photos, we could exclude decompensated congenital SOP , so we decided to perform braing MRI.

17. Final Diagnosis Acquired Lt. SO palsy due to 4th nerve palsy
Carvernous hemangioma in midbrain
Brain MRI of confirmed carvernous[kǽvərnəs] hemangioma[himæ̀ndƷióumə] in mid brain. So the following diagnosis was acquired LSO palsy associated with brain tumor.
Final Diagnosis
Acquired Lt. SO palsy due to 4th nerve palsy

18. Thank you !

19. “Cause & Clinical features”
Review
Congenital SO palsy vs
Acquired SO palsy
“Cause & Clinical features”

20. Anatomy Origin : orbital apex above AZ
Trochlea (tendon: longest, 26 mm length)
Insertion : sup.temp. Q of eyeball
Primary action: intorsion (ant. 1/3)
Secondary action: depression & abduction (post. 2/3)
 Paresis: excyclotropia , hypertropia , esotropia

21. The Four Golden Rules of the patient with a vertical strabismus
A vertical strabismus is caused by a superior oblique palsy until proved otherwise.
A superior oblique palsy is congenital until proved other wise.
A superior oblique palsy is traumatic if not congenital
If the superior oblique palsy is not congenital, decompensated congenital or traumatic in origin, a neurologic consultation to exclude intracranial neoplasm and other acquired lesion is essential

22. Superior Oblique Palsy
Cause
Superior Oblique Palsy

23. Superior Oblique Palsy
Congenital SOP
Approximately 3/4 of SOP cases
Cause
Unknown
SO tendon abnormalities
SO muscle volume reduction

24. Superior Oblique Palsy
Acquired SOP
Cause
Trauma: most common
Inflammation
Infection
Vascular malformation
Infarction
Tumor
Myasthenia gravis
Surgery : ethmoidectomy, orbital surgery, blepharoplasty

25. Superior Oblique Palsy
Clinical Features
Superior Oblique Palsy

26. Superior Oblique Palsy
Clinical features
Congenital vs Acquired
Congenital : greater vertical deviations
little or no subjective torsion
* Decompensated congenital SO palsy
: aging  weaken fusional control
 manifest tropia, diplopia
- Acquired : smaller vertical deviations
relatively larger degree of excyclotorsion
나이가 들어감에 따라 fusional control 약화

27. congenital vs. acquired
Duration of symptom
long
short
Vertical fusion amplitude
large
small
Diplopia
+/- +
Head tilt
if covering each eye
Facial asymmetry: hemifacial hypotrophy
IOOA/SOUA
Severe/mild
Old photo(Head tilt)
yes no

28. Superior Oblique Palsy
Clinical features
“ Fusional vergence amplitude (FVA) “
The difference in the power needed
to turn the eyes from their far point
to their near point of convergence
Also called fusional amplitude
, vergence ability

29. Superior Oblique Palsy
Clinical features
“ Fusional vergence amplitude (FVA) “
Congenital
- large fusional amplitude, average 16 PD (some, 30 PD or more)
- symptomatic (diplopia) : age-related reduction in FVA
Acquired
- very little fusional amplitude

30. Superior Oblique Palsy
Clinical features
“ Diplopia “
Vertical diplopia
Some degree of horizontal or torsional diplopia
- Vertical : worse in gaze directed toward the uninvolved eye
associated with IOOA
common in acquired cases
congenital cases: 25%
- Torsional : most pronounced on down gaze(in the field of action of SO)
bilateral SO palsy

31. Superior Oblique Palsy
Clinical features
“Head tilt”
- head tilt to sound eye, 70%
* Paradoxical head tilt
head tilt to affected side
wide separation of double image
* Absence of head tilt
inabilty to obtain SBV by any head position
presence of large fusional amplitude
reduced VA in one eye

32. Superior Oblique Palsy
Clinical features
“Facial asymmetry”
Secondary to chronic head tilting
¾ of patients with congenital SO palsy
Head tilt away from the affected side
Not specific for SO palsy
lateral canthus
shallow
edge of mouth
midfacial hypoplasia on the side of head tilt

33. Thank you !