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How to diagnose and recognize vertical deviations

Double image recreated by pt.. Superior Oblique Palsy. . . . Dr. G.Vicente. Unilateral Superior Oblique Palsy. If the misalignment is worse on left head tilt then the patient will walk into your office with a

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How to diagnose and recognize vertical deviations

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

    3. Superior Oblique Palsy

    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

    6. Torticollis patch test

    7. Torticollis patch test

    8. Torticollis patch test

    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 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

    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

    17. Congenital Superior oblique palsy surgery to shorten floppy tendon

    18. Congenital Superior oblique palsy surgery to shorten floppy tendon

    19. Congenital Superior oblique palsy surgery to shorten floppy tendon

    20. Congenital Superior oblique palsy surgery to shorten floppy tendon

    21. Congenital Superior oblique palsy surgery to shorten floppy tendon

    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

    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

    27. Harada-Ito Anterior displacement of ½ SO tendon

    28. Harada-Ito Anterior displacement of ½ SO tendon

    29. Harada-Ito Anterior displacement of ½ SO tendon

    30. Superior Oblique Palsy

    31. Superior Oblique Overaction

    32. 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.

    33. Superior Oblique Overaction “A” pattern

    34. Superior Oblique Overaction Down shoot

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