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How to diagnose and recognize vertical deviations

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

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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

  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

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

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

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

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

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

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

  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 SR SR LR RM MR LR IR IR IO IO Recess IR (contralateral) Recess IO Dr. G.Vicente

  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. 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 Dr. G.Vicente

  34. Superior Oblique OveractionDown shoot Dr. G.Vicente

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