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How to diagnose and recognize vertical deviations. Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington. Double image recreated by pt. Superior Oblique Palsy. Dr. G.Vicente. Unilateral Superior Oblique Palsy.
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How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington
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… • Right head tilt • How can you differentiate this from a neck torticollis? • Patch one eye, the torticollis will improve in SO palsy pts.
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?
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
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
Think Bilateral If… • V pattern is present • Esotropia in downgaze • Greater than 10 degrees of excyclotorsion on double maddox testing.
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.
SR SR MR LR LR RM IR IR Congenital Superior oblique palsysurgery to shorten floppy tendon SO IO IO Dr. G.Vicente
SR SR LR MR RM LR IR IR Congenital Superior oblique palsysurgery to shorten floppy tendon SO IO IO Dr. G.Vicente
SR SR LR MR RM LR IR IR Congenital Superior oblique palsysurgery to shorten floppy tendon SO IO IO Dr. G.Vicente
SR SR LR MR RM LR IR IR Congenital Superior oblique palsysurgery to shorten floppy tendon SO IO IO Dr. G.Vicente
SR SR LR MR RM LR IR IR Congenital Superior oblique palsysurgery to shorten floppy tendon SO IO IO Dr. G.Vicente
SR SR LR MR RM LR IR IR Congenital Superior oblique palsysurgery to shorten floppy tendon SO IO IO Dr. G.Vicente
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.
IO recession and contralateral inferior rectus recession for large vertical deviations
Acquired Superior oblique palsySurgery to improve torsion and vertical alignment SR SR LR RM MR LR IR IR IO IO Recess IR (contralateral) Recess IO Dr. G.Vicente
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.
Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente
Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente
Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente
Harada-Ito Anterior displacement of ½ SO tendon Dr. G.Vicente
Superior Oblique Palsy Dr. G.Vicente
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.
Superior Oblique Overaction“A” pattern Dr. G.Vicente
Superior Oblique OveractionDown shoot Dr. G.Vicente