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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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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 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 >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 tuckfor Superior Oblique palsies
16. Congenital Superior oblique palsysurgery to shorten floppy tendon
17. Congenital Superior oblique palsysurgery to shorten floppy tendon
18. Congenital Superior oblique palsysurgery to shorten floppy tendon
19. Congenital Superior oblique palsysurgery to shorten floppy tendon
20. Congenital Superior oblique palsysurgery to shorten floppy tendon
21. Congenital Superior oblique palsysurgery 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 palsySurgery 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 OveractionDown shoot